August 13, 2016

Checked Out

Recently I was called onto an aircraft on the report of a head injury. I rode down to the correct gate and headed down the jet bridge to the plane. At the door, I met five or six flight attendants and airline representatives. It didn’t seem like they wanted to let me on board until they talked to me. They were acting very conspiratorial. So I let them explain the situation to me.

“The pilot hit his head in the bathroom. It isn’t bleeding or anything, and he wasn’t knocked out, but we thought you should check him out. But, listen, he said he doesn’t need medical attention. So he may be irritated that we called you…”

I asked if there was a specific worry due to the man’s position driving a metal tube at a significant percentage of the speed of sound near the edge of the stratosphere. “Is there an FAA regulation that he gets checked or something?” Nope.

“Was he knocked out?” Nope.

“Knocked down?” Nope.

“Has be been acting weird since the event?” Nope. They just wanted him checked out.

I think I held eye contact too long. I just stared, mouth slightly open. I was wishing I could perform a Vulcan mind meld or some other form of telepathy. I want to know what the people who call me to “check out” a person who doesn’t want to be checked out are thinking. What do they imagine will happen? How do they picture the EMS response going down? What is the expectation? I want to know, so I can meet the expectation. I never know what to do with calls like this. Unwanted. Unneeded. I treat it like a customer service thing.

I stepped into the plane, turned left to find the captain, smiled, and asked how he was doing. He sighed and looked vaguely irritated. “I asked them nicely not to call you,” he told me.

I smiled like we were sharing a secret. “I know. You’re fine, then? Head still attached? Free checkup not needed?”

The pilot declined the offer of aid, we chatted for a second about the upcoming flight, and I stepped back off the plane. One of the airline representatives seemed disappointed: “That’s it? You just ask him one single question and leave?”


I smiled at her and went on about my day, “checking out” people. It is how I spend time between EMS calls.

August 6, 2016

Dogs, Part 1: Hurt Dogs

I think most people who read this are paramedics or EMTs. So I feel like I can open myself up to you and let you all in on a secret.

When I see a person (adult, of course) get hit by a car, it is like letting the good times roll. It is probably a little funny, and I know that I am likely about to do a lot of fun stuff to them. Fun for me, at least. And I’d be willing to bet most ambulances who witness an auto-ped hear some form of conversation that begins with: “Ha! Holy crap, did you see that?!? That was awesome! Pull over! Pull over and set me up!” It is a little bit funny to see cars hit adults. But keep that between you and me.

It is not even a little funny when we see a dog get hit by a car. The last dog I saw get hit staggered around like it was head-injured, snapping at the air and dragging its back legs. I couldn’t sleep for a week. When I would close my eyes, I would think about that poor dumb dog. Terrible. Sad.

Once I responded to a jogger who had been hit by a car. He was jogging along a sidewalk when a car came out of an alley. The car broke the jogger’s ankle, but ran his Rottweiler the hell over. We had to extricate the dog from under the car, and found it to have a massive avulsed scalp wound, burns over its right flank, and an unstable pelvis. I couldn’t believe the jogger – he was mad that we were taking care of the dog and had only splinted his ankle.
“Take me to the hospital!”
“Go to hell! You’ll go after your dog gets taken care of!”

Triage, fools!

Anyway, we got the Rottie muzzled with some Kerlix gauze, called a supervisor to transport the dog, and wound up using a cop to transport the dog to a nearby emergency animal hospital because the EMS supe was taking too long. The police officer was as worried about the poor dog as we were.  On the way to the human hospital with Captain Ankle Fracture still complaining about my triage choices, I called in a trauma set-up to the animal hospital: “Hi, you have a police car coming to you lights and siren with a… Dude, how old is your dog? Four? Okay. Coming to you lights and siren with a four-year-old male Rottweiler, struck by a car. He required extrication from under the vehicle and presented with a large scalp avulsion, partial thickness burns to his right flank, and...” According to the cop, the vet hospital had a bed and a team waiting out front when she squealed into their parking lot.

The dog lived. I assume the human did, too, but I didn’t care enough to check.

Occasional canine veterinary care is required of paramedics. It could be a dog hit while his owner was jogging, but it could also be a police dog wounded in the line of duty. Are you willing to look at the police canine’s handler and shrug? I’m not. But I am also limited in my ability to transport dogs. My boss would have a stroke if I transported every injured dog I found to a veterinary hospital. I am a paramedic, not a mobile vet. (Wait. Am I a mobile vet? That would explain a lot.) But some basic principles of veterinary trauma care are helpful knowledge.*

First, most of the concepts of trauma care work for all mammals, dogs or humans. Keep airways open, stop bleeding, and so on. Trauma is trauma. Dogs get tachy as they hemorrhage. Their gums will show pallor. You can increase your comfort level greatly if you understand that you are a skilled caregiver to human victims of trauma, so you are probably a fairly skilled caregiver to traumatically injured dogs.

Second, understand that humans (for the most part) don’t bite their caregivers. I know there are exceptions to that. Most dogs will bite when they are hurt. Secure them so you aren’t chomped.
 
Try to convince this dog you're there to help when it is hurt or in the red zone.
U.S. Air Force Photo by Josh Plueger, via Wikimedia Commons
When it comes to airways, my suggestion is to not intubate animals. That being said, understand that dogs can take big honking endotracheal tubes, in the 7.0-10.0 mm range, and intubating them is as easy as lifting the hypomandibular flesh on a supine dog. It is supposed to be easy, but I haven’t done it. There are a few websites, videos, and articles that explain how to do it if you care to learn. But you can also get control of that big airway without the tube by pulling the dog’s tongue out of its mouth, keeping the neck straight and inline with the head and body, and not hyperextending the neck. Oxygenate via blow-by O2. Don’t try to screw around calculating the tidal volume and minute volume for a dog. Straighten the anatomy, pull the tongue out without being bit, and blow some oxygen past. Move on.

If you feel the need to start an IV, the best spot is usually on the forelegs. The cephalic vein is on the middle of the foreleg and can even been seen without shaving. For the hind leg, consider the saphenous vein running from the back of the knee to the front of the shin. Secure the line with a ton of tape and make sure the dog doesn’t pull the line. (Lampshade of shame, anyone?) Saline is fine, but most veterinary websites seem to prefer lactated ringers as the initial volume replacement fluid. Dogs can handle big volume, so don’t worry about volumes like 60 ml/kg if it is warranted. Click here for more IV information on hypovolemic dogs. Subcutaneous infusion is an option, as well, but that seems to work best as pretreatment before putting a dog to work in a hot, dry environment rather than a treatment for moderate-severe hypovolemia.

Dogs can handle medications like morphine, antibiotics, Zofran, Benadryl, and such. But don’t be that medic. Don’t screw around with medicating dogs.**

Normal heart rates for dogs are in the 60-80 range. It would be normal to find a heart rate up to 130 bpm after exercise, though. Normal respiratory rate is between 10 and 40 per minute, again depending on exercising and panting. Capillary refill should occur in under two seconds and mucus membranes and gums should be pink. Tachycardia, pale gums, dry membranes, and poor skin turgor are signs of hypovolemia or dehydration.  Pulse oximetry is reported to be possible on the tongue or prepuce. Good luck with that.

Hope this helps, if it ever comes to it. In Part 2, I plan to discuss how to operate around police dogs. Part 3 will cover service dogs.


*This isn’t about cats. Screw cats. There ain’t no such thing as a police cat. We’re here to talk about dogs.

**As an aside, the morphine dose for dogs is 0.5-1 mg/kg. I can only imagine the look on my boss’ face if I told him I used all my narcs on a German Shepard with a broken leg. Apoplectic would be a good description. Any supervisor would flat have a stroke. That conversation is funny to even think about… 

July 23, 2016

I Hate Traction Splints

Once upon a time, the police decided to chase a stolen car. (You can tell how long ago this happened, being that it involves a pursuit.) Inside the car were at least two teenaged boys. The pursuit led into a neighborhood, curving back and forth on small residential streets, but it was a fairly safe chase being that it happened at three in the morning.

Eventually, the chase got a little too fast for the teen driver to handle. The street they found themselves on ended at a T intersection. Apparently the driver couldn’t decide whether to go right or left, so he went straight. Straight into a big-ass maple tree in someone’s front lawn at about 30 miles per hour. The driver and the front passenger immediately hopped out and bolted.

The passenger made it one step. On his second step, he discovered he was the proud owner of a left midshaft femur fracture. He found this fact when he planted his left foot and pushed off, attempting to sprint after his driver friend. The thigh angulated and he collapsed onto the ground. According to the police, the shriek he generated due to the pain was loud enough to break glass and wake dogs several miles away.

He had discovered his busted femur the hard way.
Can't run on that...
© Nevit Dilmen [CC BY-SA 3.0], via Wikimedia Commons

I arrived to find the kid angry and yelling on the front yard. The glovebox inside the car was cracked, so I think he rammed it with his knee, breaking the leg. Aside from the broken femur, I couldn’t find other injuries. He was completely awake and there wasn’t another scratch on him. His femur, though, had developed an extra knee. It was angulated and exquisitely tender. My partner suggested a traction splint. I agreed and asked him to fetch it.

My system uses the HARE traction splint. It is actually the only one I have worked with. It is the traction splint that I learned to use in EMT class in 1994, and it is the only one I have ever put on a patient – imaginary or real.

My partner returned with the splint in the cloth sack. I opened it to find that the HARE was still in the manufacturer’s packaging. It was still shrink wrapped and not assembled. I briefly looked at it, my mouth hung open, I felt irritation rise in my throat, and I tossed the whole mess into a bush in the front lawn with a frustrated two-handed overhand toss. Apparently we wouldn’t be using the traction splint that night. (I don’t know how a traction splint was found in that family’s front yard bush, boss, honestly…)

My partner was used to my drama. He sighed, rolled his eyes, and fetched the splint out of the juniper bush. “Hang on. Slow your roll. Let me put this together. It will just take a few seconds…” he told me. I started an IV while he unwrapped the splint and screwed it together.

It went on the patient with no problem (once it was assembled), but not with the smooth skill that a practiced team of brand-new EMTs fresh out of the National Registry test would do it. If I’m honest, I think we manually pulled traction, realized we forgot a step, had to release the traction to complete the missed step, and then try to start again. Once the contraption was in place, we loaded the kid into the ambulance, I began administering analgesia, and we went to the nearest trauma center.

After I handed the patient off to the trauma team, the attending physician (my medical director at that time) asked why I used the traction splint.

“Because he had a midshaft femur fracture and a traction splint reduces pain, stabilizes the injury, and can help slow bleeding,” I told him, digging up half-forgotten EMT class lessons.

“But it slowed your scene time. Scene times are critically important in emergency trauma,” he pointed out.

“Yeah, but I felt sure the only injury was to his femur. So I felt comfortable taking the extra time.”

“Then why bring him back hot?” he asked.

“Cause it takes a significant hit to transfer enough energy to break a 17-year-old’s femur. That is a lot of force,” was my reply.

“Yeah, that takes a big hit. So we’re back to taking extra time on scene” he pressed. “Either it was a significant energy transfer with a distracting injury, potentially masking subtle life threatening injuries, or it wasn’t.”

I think it finally hit me at that point. What can I say? I am slow to absorb lessons. But he was right. It is pretty difficult to find a balance between “hard enough impact to break a previously-healthy femur” versus “an impact that was gentle enough to ensure the absence of other life threats so I have the time to screw around assembling and placing the infernal device.”

The HARE traction splints require two trained people working together, take quite a bit of time to place (what, like two minutes, minimum, right?), they are difficult-to-impossible to get on a patient while driving, are a treatment we don’t practice and aren’t good at, and they often extend past the end of the bed (ever see someone hit the splint when closing the door?). Traction splints were invented to treat fractures, not for field stabilization1. Show me a study that shows the efficacy of traction above splinting; I bet you can’t.2 I don’t see how the logic for the routine placement of prehospital traction splints holds up very well.

So I am not a fan of the prehospital use of traction splints.



1. Bledsoe B, Barnes, D. Traction splint. An EMS relic? Journal of emergency medical services. 2004;29(8):64–9.
2. Gandy WE, Grayson S. Sacred Cow Slaughterhouse: The Traction Splint. EMSWorld. 2014. Accessed Jul 23, 2016. http://www.emsworld.com/article/11542786/traction-splint-evidence-and-efficacy 

July 16, 2016

That Poor Little Liar

A couple of years into my career, I decided to increase my life insurance I get through work. As part of that, I needed to have a blood test – apparently if you test positive for heroin, you may need to pay a higher life insurance premium. Not a big deal; I wasn’t going to test positive for anything except levels of nicotine and caffeine that would kill a small toddler. The life insurance company would send someone by my home or work to draw blood. So this was no problem at all. Nice and convenient.

I was working deep nights at the time, so I would get off work, go home, and be in bed by about 8am if I was lucky. One night, I ran a sweet highway grinder. I don't remember the specifics, but there was stuff on fire, a semi-truck of rattlesnakes overturned, and a tornado hit a school bus. All at once, if my memory serves me correctly. Whatever actually happened, it was an event big enough to be on the news the next morning. I was first on-scene and ran the call pretty well, I thought. Two other ambulances from my agency showed up and transported patients, as well. I intubated two patients before the second-in units got on scene. I remember that specifically because I wanted to get both tubes; the next unit had a medic I didn’t like to share with (still don't). Between that and a ton of other calls that night, I was exhausted at the end of that shift and crawled into my bed.

Three hours later, my wife woke me to come downstairs. The mobile phlebotomist had arrived to our home for her visit. I threw on a t-shirt and a pair of sweatpants, went downstairs to the kitchen, and took a seat at the kitchen table. My plan was to stay conscious for the three minutes it would take to draw a tube of bloods, then go back to bed without fully waking up. The phlebotomist was a chatty lady, though.

“This isn’t my normal full-time job, you know.”

I grunted in return.

“Yeah, I am actually a paramedic.”

Grunt.

“Did you see that huge thing on the highway last night? With the rattlesnakes and the tornado? I ran that.”

Weird. I thought that was me. But I was tired and didn’t especially care, so I grunted noncommittally at her again.

“Yeah, it was a tough call, but professionals just get the job done,” she explained to me. “I’ve been doing this too long to let things like that trouble me.”

I upgraded from grunting: “That must be a tough job. I bet you’re proud.”

“Yeah, it is tough. I do this [draw blood in people’s kitchens] for a break. Wow, you don’t have very good veins, do you,” she told me. It was news to me. I like to think I have fine veins, thank you very much.

My wife walked into the kitchen at that point and overheard the last part of the conversation. “What do you do?” she asked the phlebotomist.

“Paramedic,” the lady replied. This should be good, I thought to myself.

“Oh? My husband is a paramedic too! What a coincidence!”

The phlebotomist turned to me. “Really? Where do you work?”

I nodded my head at the jacket draped over the back of the chair I was sitting in.
Seriously. No exaggeration. It was obvious...
“Denver,” I told her.

My houseguest turned white and began to stammer something.

My wife turned to me. “You were on a highway thing with rattlesnakes and a tornado last night too, weren’t you? Did you see each other? Or were there two crashes?” my wife inquired, innocently.

The odds of a successful first-time venous draw was diminishing by the second. The phlebotomist was pale, stammering, and had a distinct tremor in her hand. She gulped air and tried to focus. Stabbing someone in the arm is a great distractor. I offered to stick myself, being that I had poor vasculature.

She declined my offer and drew my blood. It worked out that she was a brand-new EMT, applying for her first job at a nearby private ambulance company. Poor, dumb EMT. She probably talked up her job as a paramedic to dozens of phlebotomy clients before stumbling into my house.


But, really, I don’t have that much sympathy for her embarrassment. The jacket was right there on the chair.

July 2, 2016

Community Paramedicine

Picture this scenario: You respond to a 35-year-old male with insulin-dependent diabetes mellitus complicated by alcoholism and near-homelessness. You find him at his home, a daily hotel, without complaints.  Other family members (who don’t live with the patient) visited and called 911. They are worried about him because his home is very unsanitary, and the patient drinks too much. This is the second time this week you have responded on this guy at this address. He never wants help. You arrive to confirm that he is slightly intoxicated, slightly intoxicated, and he hasn’t checked his blood sugar in months. Just like last time. His appearance is generally normal, if slightly dirty and malodorous, and the patient once again has no complaints. His vitals are normal, outside of a blood sugar reading of 188 mg/dL. He is intoxicated, but is in his own home. So you call for community paramedics to add this gentleman and his family to their daily visit list. The CPs can come make sure the patient and his family don’t abuse the 911 system with calls like this. Maybe the CPs can explain to the patient why he needs to quit drinking and check his sugar more often. They can also explain to the family why the patient isn’t a 911 candidate. While calling to set up the CP visit, you tell dispatch to mark this address as one the CPs need to respond to, rather than 911 resources. You leave the patient at home with instructions to wait on the community paramedics. [Clapping-style hand brush off motion.]

Awesome, right? Like a big, amazing EMS dream!

Something came up recently that got me to thinking about community paramedicine; more specifically, how a community paramedic program would work. The scenario above generally describes the way that a lot of street medics envision community paramedics. In short, community paramedics are other responders who take low-acuity calls so the “real medics” don’t have to. They can do suture removals, well-baby visits, and such while waiting for street medics to find patients for them to commun-isize. 

Commun-isize my boring calls, so I don't have to!

This community paramedic model will probably never happen. Sorry to be the one to tell you.

There are two viable options for community paramedicine. Neither involves 911 responses. The first is to operate as an adjunct to primary care in rural areas without sufficient primary care physician (PCP) access. Most rural counties don't have enough PCP/family medicine/internal medicine physicians willing to take on new patients. I see this CP model as a follow-up post PCP visit to answer patient questions, provide follow-up test results, check medication understanding, and such. 

The second option for community paramedics is to reduce hospital readmission rates for specific types of patients. Medicare monitors 30-day unplanned readmission and death rates for COPD, MI, heart failure, pneumonia, stroke, and hip or knee replacement patients. Medicare then links those quality measures (readmission rates) to financial reimbursement*. Thus, hospitals are incentivized to find ways to continue caring for patients after discharge. Like, say, sending a community paramedic to their house to weigh them, run a 12-lead, maybe draw some blood, and check to make sure they are working off their updated medication list. Concerning findings at the home visit would result in a clinic visit, rather than waiting until the problem worsens to the point of needing an ambulance to the ED and hospital readmission. Those kinds of CP actions would potentially enhance the care received and increase patient satisfaction.

The most likely scenarios for a community paramedic call is for a medic to visit a house to weigh a CHF patient. The medic checks to make sure the patient has and understands her meds. Then the community medic goes to a STEMI patient who was released from the hospital two days previously. The main goal of this visit is to dispose of all the patient’s old medications and explain the new ones. Patients are comfortable with their old medication lists and will stick with them, even after a big event changes their prescription list. They need the new list, not the old/comfortable one. Then the medic goes to COPD patient’s house to make sure they are using oxygen. The medic finds the patient’s supply of oxygen to be running low and helps get more delivered. And so on...

Nobody can see the future, so it will be interesting to see if community paramedicine is a fad or an EMS paradigm shift. But it is unlikely to have a large effect the acuity of calls in a 911 system, however it works out.

* Hospital Readmissions Reduction Program (HRRP) in Section 3025 of the Affordable Care Act 

June 25, 2016

The Amazing Magical Vagina

A while back, my partner and I were assigned to the report of a woman in labor over on the west side of town. I don’t specifically remember, but I am sure that I ranted the entire way there about how labor isn’t an emergency and how billions (with a B) of women have had babies without my help. But that is just a guess based on past experience. Also based on past experience, I may have made snide, inappropriate comments about having nine months to save up cab fare. Every time I complain about OB calls, things go pear-shaped for me.

When we arrived, we found that the patient was a 19-year-old with her first pregnancy, 38 weeks along. She wasn’t high risk, had good prenatal care, and had no concerning signs or complaints. Her presentation didn’t make me want to lie her down on the living room floor: her contractions were about three minutes apart and lasted only fifteen or twenty seconds, her water hadn’t broken, there was no bloody show, nothing.

When I am on a labor call, one of my primary decisions is whether to put the patient into the ambulance and drive to the hospital or to deliver the baby in the patient’s house. If I think I can easily make it to the hospital, we can go to the ambulance. If I’m not sure, then the house is my preferred choice. I hate to deliver a baby in the ambulance. I actually put quite a bit of effort into avoiding it, as a matter of fact. Babies result in a lot of fluids, smells, and mopping. The ladies I see aren’t always the most… hygienic, if you know what I mean. So I would rather deal with all of that on their floor (or couch), rather than in “my office.”

In this case, with the mom-to-be being young, at the end of her first pregnancy, and with the contractions not lasting very long or being close together, I was comfortable with moving everyone to the bus and going to the hospital. I didn't think she would be delivering a baby very soon. The patient told us she couldn’t walk, but I explained how the L&D deck would have her pace the hallways for hours to move things along, so a little walking now would be a good thing. Walk she did.

We were a pretty long way from the hospital, so I didn’t feel like screwing around on scene. Having fifteen or twenty minutes to get to the hospital meant that I could start an IV enroute, rather than needing to do it before we started out. My partner got behind the wheel and off we went.

On the way to the hospital, the patient was very dramatic. The onset of every contraction was very easy to time, because the patient started howling, cursing, and complaining. Some women quiet down and bear through things, and some shout their hate of the world. This lady was of the second group. I got the IV into her and had time left to act concerned and engaged. I coached her on breathing (rather than screaming at me) and made the decision to take her pants and underwear off. This isn’t something I do unless I think delivery is imminent. I didn’t think delivery was imminent in this case, but I took her pants and drawers off anyway. I don’t know what made me do it. It was just something I did. 

After a few more minutes, the patient squawked at me: “The baby’s coming!”

I replied with my usual response to such statements: “Don't you dare push!”

I still didn’t think there was any way that this infant was coming out. Her contractions were still two or three minutes apart, and still only lasted 20-30 seconds. But her complaint was enough for me to take a look at things.

I spread the patient’s knees and lifted the bedsheet that was covering her to take a look. Just as I thought. Nothing. Just a normal vagina. Not swollen, no bulging, no fluids. It was a completely normal undercarriage.

I put the sheet down on her legs again and began to reassure the patient that delivery wasn’t imminent. “The baby’s out,” she told me.

Whiskey. Tango. Foxtrot. The baby wasn’t even close! Drama! This was nuts, I lifted the sheet to show her that there was no problem.

Son of a... She was right. There was a newborn lying between her feet.

I need you to understand how fast this happened. It was totally like a magic trick. Lift the sheet. See? Normal vagina. Put the sheet down, say the magic words (“The baby’s out”), and TaDaaa! Sweep the sheet back and there’s a baby! The whole process took literally three seconds.
Me, screwing up decisions on childbirth calls for decades... Source

Literally. Three seconds. Maybe two. Like a magic trick.
Public domain source

The infant was about a foot out of the birth canal. Between the baby and her mother was a wet spot where she skipped before landing between mom’s feet. She was a healthy, pink, angry baby girl. Crying like hell, and moving all extremities. Shouting like a three-month-old, she was moving so much air. I didn’t think she needed suctioning, really, she was doing so well.


The first words that little baby heard? “Goddammit. [Sigh] Yo, Dee, pull over. Gimme a hand back here.”