A Mule Named Dagnabbit

“Ambulance Nine, respond to the grocery store at 1^st and Main.  Report of a seizure.”

It was a few years ago that I was assigned to the report of a seizure at an east-side supermarket.  Not a big deal, right?  This is a call I run several times per week.  It’s probably a seizurewithhistory.  Find ‘em postictal, transport ‘em to the hospital, and they’re waking up about the time that we get there.  No problemo.  We arrived first because we responded to most of our EMS calls without the fire department back then.  (So it wasn’t so much that we arrived first.  We arrived.)  Anyway, we found a store employee in the parking lot next to the main entrance flagging us down. 

“In here! He’s in here!” he said when my partner rolled down the window.

“Right inside the door?” my partner asked.

“Yes, he’s right inside here!” the flagger responded, breathlessly.

“Just inside?”

“Yes! Right inside here!  Hurry!”

What would you bring into a call like this?  Reported seizure, right inside the door, but not in sight.

I walked into the store.  With my hands empty.  Do you see where this is going?

We followed the flagger from the entrance to the back wall of the supermarket.  Then we turned right and walked the entire length of the store’s back wall.  Then we went through a door.  By this time, I was feeling rather uncomfortable.  (I am not smart, so it takes a while for bad situations to make themselves obvious to me.)  Anyway, through the door there was a long flight of stairs leading upwards.  We climbed the stairs and walked the length of the store’s back wall again, but in the opposite direction.  (Now I am definitely uncomfortable, but I don’t see a way to correct my error.)  Finally we came to a break room where we found our patient.

Our still-actively-seizing patient.  Crap.

“Go.  Get.  EVERYTHING!” I whispered to my partner.

Long story short, I stood around like a dickhead until my partner got everything together and rescued me.  While I was standing around like a jerk, he called for the fire department, figured out the best entry point to the break room, pulled the bus around to the back of the store at a loading dock, and came back to me with the bed, narcs, and a jump kit.  The patient seized the whole time, while I checked his pulse and explained how there “…isn’t really anything that needs to be done.  We just need to make sure he doesn’t hurt himself, but the best thing is for this to run its course…” to the bystanders.  Crap.

So let’s talk about what to bring into a call.  In my system, there are a lot of pieces of equipment.  But unlike many fire-based systems, there are only two of us to carry stuff into a call.  And, let’s face it, we’re generally lazy.  We don’t want to bring all of this crap into every call.  The choices:

• Jump kit: This carries most everything that could be needed in the first 15 minutes of any call.  There are intubation supplies, IV supplies, cardiac arrest medications (at least for a round or two), bandaging supplies, and such.  I can muddle through anything for 10-15 minutes with a jump kit.
• Monitor: We carry LifePack 12s.  Which are heavy.
• Pram: Admittedly, the bed is handy to pile crap onto.  But the pram is a liability if there are very many stairs between the ambulance and the patient.
• Portable suction
• Oxygen: Our oxygen is just a D-tank, without a supply bag.  So if you bring the oxygen, you need to find a way to bring a handful of nebs, cannulas, and non-rebreathers too.
• Drug kit: We can carry a smaller kit with multiple doses of every medication that we carry. 
• Pediatric kit: We can carry a kit with pediatric doses of medications, pediatric IV catheter sizes, and an OB kit.
• Narcotics: Our narcs are in a separate box from the jump kit, for security.  It is normally locked in a compartment of the ambulance.
• IO drill: We stash the IO drill in a small bag next to the monitor.  It doesn’t fit into the jump kit.

There are probably other options, but these are the general choices of what to carry into a call.  So what do you bring into a call? 

It would be nice to be able to bring everything into every single call. But let’s face it. That doesn’t happen.  There are only two of us in my system, and we need to strike a balance between being able to handle whatever we find and being loaded down like a mule.  (Picture the salty old mule that belongs to an old, grey-bearded prospector with the brim of his hat folded up in front, with boxes lashed to his bowed mule back.  He is named Dagnabbit.) 

(Moscow_mule. By edseloh, via Wikimedia Commons, with permission)

One point that needs to be made right off the bat is that the dispatch information we receive is probably not right.  We go on seizures and find cardiac arrests.  We go on down parties and find auto-peds.  We go on adults and find little kids.  We have no idea of what we are about to get into.*

Another point is that we need to balance our equipment needs with the need to get the ALS providers in front of the patient as quickly as possible.  Most people don’t want the most educated and most experienced provider taking time to load equipment onto his/her back (like a mule named Dagnabbit).  Get the ALS provider in front of the patient, with enough equipment to do their jobs, but without taking extra time to load up with unnecessary accoutrements.  What qualifies as “enough equipment to do their jobs?”

My equipment decisions revolve around the situation.  Not the call type, not the response mode, not the patient complaint.  Like I said, I’m not smart, so take all of this with a grain of salt.

When I can see the patient, I go to the patient.  Empty handed.  Well, not quite empty handed.  I have my personal gear – stethoscope, shears, radio, that kind of stuff.

When the patient is inside a house and out of sight, I take a jump kit.  I will add the monitor when the patient sounds like they are middle aged or above with a medical complaint.

If the call nature seems to imply cardiac arrest, or if first responders report CPR in progress, I will grab the IO drill.  I will also consider the drug kit.

When the patient is on the second floor or higher, I bring the pram as close as I can get it.  So if I am going to apartment 201, for example, the pram is coming with me.  In a lot of cases nowadays, I will grab the pram for houses and first floor apartments, as well.  Fifteen years ago, we could send the first responders to get the wheels.  Now, though, they are sensitive to being seen as “Stretcher Fetchers” and it is easier to just bring the bed to the front lawn, at least.

Going back to the possible equipment list, I rarely bring a portable suction, pediatric kit, or narcs into a call.  My partner has legs that probably aren’t broken, so s/he can get the narcs if needed while I start an IV.  The portable suction is brought by our first responders, plus I hate the thing – it always clogs.  Always.  Suction sucks (HA!).  I find I’m better off scooping out vomit with my fingers than trying to use the stupid suction.  Oxygen is brought by the first responders, as well, with masks and cannulas and such.  So I don’t need to bring that, in most cases.  The pediatric kit is useless outside of childbirth.

To me, the peds kit is an OB kit.  That is the only component that I will need inside a house.  If I have a sick child, it is easier to bring the kid to the bus than screw around on a living room floor.  Kids are portable.  Grab them, assume the Heisman pose, and motor out to the bus rapidly.  So I will bring the peds kit OB kit into childbirth calls, but that's about it.

I will bring what I think I will need.  When I go to a clinic without first responders on a dyspneic patient, I will bring the oxygen.  If I am going on an elderly fall with hip pain, I will probably bring a scoop for extrication.  Use your head.

At the airport, things are a little different.  We work at the airport alone.  So I bring everything.  I grab the jump kit, monitor, and oxygen on every call.  I learned this lesson in a painful way. 

It happened when I was very new at working the airport.  I was sitting in the first aid room at the airport one night, fat, dumb, and happy.  I was assigned to the report of an unconscious party.  Okay.  At worst, it is probably someone who fainted.  At best it is someone napping.  No big deal, either way.  I sucked hamburger grease off my fingers, got my radio and keys, and went out to the golf cart we use to move around the concourses.  I was not in a panicked hurry – this is a commonplace call.  Dispatch informed me that an AED had been pulled off of a nearby wall.  Okay, still not a very big deal.  That’s what AEDs are for.  Then dispatch told me that they had the scene on the security camera feed.  CPR was in progress. 

I pulled up to find a man on his back, with one bystander performing CPR and another performing mouth-to-mouth ventilations.  I walked up to the patient, as is my habit.  Look above; I could see the patient from my parking spot.  What did I bring? 

That’s right.  Nothing.  I asked Mr CPR to stop CPR and checked a pulse.  There was none.  I told Mr Mouth-to-mouth to go wash his face – he was covered with the patient’s vomit from his eyebrows to his nipple line.   After confirming pulselessness, I asked that CPR be resumed and went to get my monitor from my golf cart.  I stood up, walked to the cart, got the monitor, walked back, and put it on the patient.  I shocked him from VFib to asystole.

What’s next?  Airway.  I stood up, walked to the cart, got the jump kit with the intubation supplies, and walked back to the patient.  I put the laryngoscope blade into the patient’s mouth and found it filled with emesis.

I stood up, walked to the cart, got the suction, and walked back to the patient.  I sucked out the vomit and commenced to intubate the patient.  It went on like this for some time – me standing, walking to my cart, grabbing something, and walking back. 

Lesson learned.  Nowadays I load myself up as though my name is Dagnabbit when I am alone.  Life is a lot harder without a partner to go grab your stuff.

There.  That's the right kind of mule.  They must be responding to an EMS call.
(By Peretz Partensky, via Wikimedia Commons, with permission)

Based on those stories, it seems like I get caught with my pants down a lot, in an equipment sense.  That isn't the case (anymore).  In 95% of calls, I can bring a monitor and the jump kit and be good to go.  In 95% of those cases, I don't really need either.  But I make sure that I don't base my future equipment choices on past equipment needs.  I have realized that it is a part of my job to bring stuff into the call – just in case – that I won’t need.  That’s okay.  I’m content with that. 

The last point is to use your head.  If you think you will probably need something, bring it!  EMS equipment is like a handgun – it is better to have it and not need it than it is to need it and not have it. 

*Not the fault of the call takers, by the way.  They can only go off of what they are told.  What they are told is apparently blatantly wrong, in many cases.