I Need An Emergent Ambulance. But Not Really.

A while ago I ran a call that got me to thinking. (I hate that.) My agency provides bike medics equipped with AEDs and the first-line accoutrements of ALS care. They’re usually employed where patients are harder to get to: sporting events, concerts, downtown events with road closures, and those kinds of events. Anyway, I was at one of those affairs and responded to an adult female with an asthma attack in the stadium stands.

Most stadiums that hire me to ride a bicycle don't look like this. Unfortunately.
Source

I rolled up after an extremely frustrating series of 20-foot rides followed by impatient trackstands* through the crowded concourse to find nobody in the seat I was dispatched to. I checked with the disembodied voice on the radio and wandered around a little, before finally finding the patient out in the concourse a few sections away from where she was supposed to be sitting. She appeared to be tachypneic but with deep breaths and had a slightly fast heart rate (104 or something). She couldn’t speak due to an almost constant cough, and I saw no manual spasms. Breath sounds were hindered by the loud ambient noise that comes with working a patient in a stadium crowd, but I think she had inspiratory stridor in her upper airways. Each time I put my head near her ear to shout a question, she would answer with a cough. My partner put a neb in her face and I was down with that plan.

To be frank, though, I kind of got a hyperventilation/anxiety vibe from her. She had a history of asthma, so that was still on the table. Also on the differential diagnosis list were all of the other pathologies that cause tachypnea: pulmonary embolism, allergic reaction/anaphylaxis, and so on. I didn’t have enough information to rule anything out. So I didn’t blow the patient off. But I did feel an anxiety vibe coming off of her. 

I stepped away to get my blood pressure cuff off of my bike and bumped into two people who were in the way. So I may not have been positive about what the patient's problem was, but I was positive I was sick of working up this patient in a crowd: “Dispatch, can I get an emergency ambulance to…” The transport ambulance’s response time was about the same as the time it took me to find a wheelchair and roll the patient and her neb outside. So as the ambulance was being put into park, I was loading the patient into the back of their bus. The extra hands provided by the crew made quick work of the patient. In short, she did have some slight wheezing and hand numbness. Her sats were great and she had an end-tidal CO2 of 45 with square waveforms. In the end, we still didn’t have a firm delineation between asthma and anxiety. The patient was driven to the hospital.

So here is the part of the call I was thinking about: I called for an emergency ambulance even though I was fairly confident that the patient wasn’t critically ill. My intention was that she would be a nonemergency transport. The most important reason I called for the bus with lights and sirens was that I was sick of dealing with the patient in a crowd. I knew she would be transported, so why delay the handoff? Especially because I was sure the patient was non-critical, but not positive (if the difference makes sense at all). My confidence in the patient’s level of illness could have been misplaced due to the noise and crowds.

A friend and coworker recently had a street call with two patients. The patients couldn't easily be transported together, but they were both nonemergency situations. So he and his partner called for a second (nonemergency) ambulance. The nonemergency response to take the second patient took almost an hour. Assigned ambulances kept getting diverted to emergency calls. I see both sides of this coin. On one side, nonemergency ambulances which are assigned to transport a patient with a medic already on scene should be reassigned to emergency calls without a medic on scene. On the other side, we shouldn’t have to wait close to an hour for another ambulance to transport my patients.

It made me think of the times where I got all fired up at the fire department. It is pretty common for them to call for an emergency ambulance – for neck pain, for “mechanism” (when the car involved in the crash is still driveable), for patients with several weeks worth of chest pain, and so on. It riles me up every time. But wait - didn’t I just do the same thing? Should a firefighter have to wait for an hour (with their giant red vehicle blocking a lane or two) for a nonemergency ambulance? What if they are sick of working up a patient in a crowd?

That is what we call cognitive dissonance, ladies and gentlemen. Cognitive dissonance is the intellectual discomfort or tension you feel when two beliefs you hold oppose each other, or when existing ideas are refuted by new evidence. Cognitive dissonance makes me uncomfortable, as it should. I probably ought to work through the dissonance and figure out the most rational, defensible answer to the issue. But that seems like a lot of mental stress and discomfort. 

In the end, I decided I need to give firefighters a break when they call for me emergently and I find a nonemergency patient. Cognitive dissonance temporarily terminated...

*Bike medics are cooler when they don't put their feet down...

Social Media Commenters Don't Get It. Again.

I came across this article on one of my social media feeds: Link. In short, a FDNY ALS crew found a guy with a history of the bad variety of ALS who was in cardiac arrest. The guy's wife said the patient had a DNR, but she couldn't find it. So the FDNY guys pronounced the patient. Then filled out a patient care report describing heroic efforts to resuscitate the patient, even though said heroic efforts didn't happen. An acting district attorney is charging them with felonies.

The comments on the EMS social feed totally and completely miss the point.  For example...

"Should have just called command and let the Dr tell what to do"

"No paper...tough shit, we are starting [resuscitation]"

"Policy is in place for a reason..."

"...Medical control is there for a reason"

"Much debate over nothing. No gray area exists, no confusion should occur whatsoever. No paperwork, you work the patient..."

Wow. I shouldn't get so fired up about strangers' comments in social media. That is especially true when I am missing big parts of the story - down time, call progression, cardiac rhythm, etc. But I do habitually get all fired up, so here we go. I have four main points.

1. If your protocols demand actual DNR paperwork to be placed in your hand, your protocols are unreasonable, irresponsible, and stupid. Stupid protocols should be ignored (or at least worked around). A wise man once told me: Do what you would be proud to defend. This guy from the article had end-stage ALS and his wife stated he had DNR paperwork somewhere. Pronounce that patient! Termination of efforts and a field pronouncement makes sense based on this patient's history and clinical situation. I would be proud to defend a field pronouncement in this case. The medical principle of informed patient autonomy is not ended by the patient's inability to stash paperwork where we can find it under stress. 

1a. Oh, and I don't need a physician or supervisor to tell me the right thing to do - I am a professional paramedic.

2. Documenting care in a patient care report that didn't occur is where these medics went wrong. This is especially true when making up an entire friggin' course of patient care! It makes me question the culture and leadership of FDNY's EMS Division that the medics felt the need to invent an entire friggin' course of patient care in order to be able to do the right thing. (And four years in prison completely seems like overkill.)

3. Staten Island's newspaper is weird. I'd be bent if they published my address. How does that contribute to the story? Do other newspapers do this?
4. Who knows what actually happened in this case? It is rare for a reporter (in any media) to accurately describe a situation. Every newsworthy story I have been involved in has been at least partially misreported. I wouldn't be surprised if this article is filled with misinformation. So the above points assume that the article is accurate.

What do you think? If you can explain why the actual physical paperwork needs to be placed in your hand, please do so. Nobody has ever explained why requiring the paper to hit your hand is a sensible precondition for termination of care. I am quite serious that I don't understand it. But, judging by the comments, there are many EMS providers who think that the opposite is reasonable and necessary. Please explain it to me so we can have a conversation.

Points of View Vary

A week or two ago, my partner and I were assigned to a “down party” at a bus stop. We arrived to find an intoxicated gentleman lying on the bus stop bench, with four unintoxicated firefighters standing around him. He didn’t necessarily look homeless, per se, but he did look like he had been on a bender. He smelled strongly of alcohol, had slurred speech, and an affect that swung between uncooperative and jovial. My partner checked his vitals and ran through a quick secondary exam. There was no apparent injury and no other apparent medical problem outside of the profound alcohol intoxication. 

I called the detox van* and we were all standing around waiting for it to arrive. Police weren’t around, by the way. After waiting and chatting for a few minutes, the intoxicated gent suddenly decided that he didn’t like one of the firefighters. As a matter of fact, the patient decided that the world would be a better place if the firefighter were punched as hard as possible, right in his firefighter nose. He loudly announced this plan and began to try to stand up. I wasn’t worried about it, being that standing up off of the bench seemed to be a nearly insurmountable challenge, let alone swinging an accurate punch at a pre-alerted sober fireman.  Just resting a gentle hand on dude’s shoulder made standing impossible. After a minute he relaxed again. We all continued to wait on the van. 

To my mind, there was no need to get aggressive in restraining the patient for two main reasons. First, if we restrained him and escalated the call in that way, the patient would end up as an ambulance transport to an ED rather than a detox van transport to the detox facility. Second, there was no real threat. Some intoxicated patients retain the wherewithal to be physically dangerous, but not this dude. It wasn’t the kind of call that I went to paramedic school to learn to run, but it was an easy call and we were doing a good thing by getting the patient a safe place to sleep it off. Nothing that was happening was a big deal.

About at this time, another gentleman walked into the scene and stood there. When I mean that he “walked into the scene,” I mean that he walked into the scene. He stood himself between several of the firefighters and the patient. He was just standing there, watching what was going on. I thought a better plan than the detox van had just presented itself.

“You know this guy?” I asked the man, flashing a hopeful smile.

His reply crushed my better-than-detox plan (him taking the intoxicated patient): “Nope.” 

“I need you to step back, then,” I told the man. His reply completely confused me: “Fuck you, whitey.  I’m here to witness. You fuckers ain’t going to kill him today. This is a public sidewalk, I have a right to be here, and you can’t make me move.”

“Seriously, I need you to move back.” The man seemed to be on edge, so escalation would be easy. But I also thought intensifying the situation would be unproductive. He was looking for an overreaction, and I decided not to give it to him. And, like I said, I was confused by the sudden hostility. In my mind, this was a misunderstanding. 

I explained that we had nothing to hide, but the patient was having a medical problem and deserved a little privacy. Anyone in a doctor’s office would have a little privacy, right? It was just a respect thing. As a matter of fact, I suggested that the best plan to document the situation was to step back and film it all with a phone. That way he could get the whole view, but the patient could have a little space.

The man cursed me a little more, describing how he wasn’t going to allow us white people to kill or maim another black man, but he stepped back so that he wasn’t in the way. The detox van arrived a short time later and my partner and the firefighters loaded the patient. During that evolution, the “witness” was bellowing a play-by-play to the neighborhood about how we were kidnapping the man, we were hurting him, and so on. I was quietly offering suggestions for him to document the scene better. Like I pointed out that filming the van’s side number and license plate would be a good piece of documentation for court. As the intoxicated patient was loaded, I asked the “witness” to wait a second.

I went to the ambulance and got a business card out of my jacket. I went to the back of the ambulance to give it to the man, explaining that the supervisor’s number was on the card. If he had any concerns, he should call the number. 

He crumpled up the card, threw it back at me, and charged me with his fists clenched.

He never actually touched me, and I was so surprised that I didn’t react. He did get nose to nose with me, though, and shouted threats and racial slurs. If he wanted to blast me, I would have had to take the first one. But he didn’t. It was just a lot of aggressive noise. I took a step back and called for police cover. As I said, I was flabbergasted that this call went in this direction. I am not a writer with enough skill to describe how gobsmacked I was: This is a simple call. I'm here to help. Help is good. How did I get into this situation?!?

As soon as he heard my request for the cops, the man ran away tossing some final racial curses over his shoulder. I cancelled the backup (sounding like a fool for calling for them and then canceling them). That was the worst part of the call – sounding like a jackass on the police channel. 

Thinking about this call later, I was still surprised by the completely opposite points of view the bystander and I had concerning a simple situation. From my perspective, there was a drunk guy that was too intoxicated to realistically keep himself safe. I couldn’t leave him on the streets because (a) he wasn’t able to keep himself safe; and (b) people complain about that by calling 911. Detox is a safe place that is relatively inexpensive, so to detox he went. There was no animosity, anger, or nefarious plans about the call.

To the “witness,” it was a completely different situation. Here is the important part: I don’t know what his perspective is. I’m not in his head and I haven’t walked in his shoes. I grew up white and middle class. I don’t know his background, but I’d be willing to bet that we have probably had different experiences with authority figures. My friends and family may have different relationships with police than his. Maybe, in the past, a medic couldn’t save a family member. Maybe police have treated him unfairly. Maybe a firefighter insulted him last time. There is no way for me to know.

He isn’t in my head (where I want to help), and I am not in his (with whatever his past interactions with public safety have been). It is frustrating. I wish there was a Vulcan mind meld so we could exchange perspectives.  

*My system uses a modified ambulance staffed by EMTs to transport people who are inebriated in public to a non-medical detoxification facility.  The technical name for the vehicle is the Emergency Service Patrol (ESP), but we just call it the van.   An ambulance is a bus and the detox vehicle is the van.  Make sense?

Learning to Drive

A few years ago, I helped teach my nephew to drive. In Colorado, a teenager with a learner’s driving permit needs certain hours of certain kinds of practice. The adults in my nephew’s life took turns riding in the front passenger seat with him to meet those criteria. One day, I had to run a few errands and then make a trip about an hour up into the mountains, so I let him drive. 

How it felt to me...  Source, with permission

What I discovered is that driving requires a person to have a grasp on about 20 things. Your speed, lane position, lane choice, upcoming hazards, what the sign you just passed said (and whether it was important), how close you are to the car in front of you, how many police cars are trying to PIT you, and so on. A brand-new driver has a firm grasp on about five of them. The five concepts my nephew paid attention to rotated through the list of twenty – if he started to change lanes, he lost control of his speed. If he paid attention to his speed, he lost track of where he was. If he read a sign, he would drift into the adjacent lane. Don't even mention turning left through an intersection.

It felt this way to me, too. I was screaming on the inside... Source, with permission

Over time, he could pay attention to six requirements at a time, then ten, and with enough practice he could manage all twenty at the same time. We all went through the same journey. It is called learning to drive.

My job during this process was not to act like my parents acted when I was learning to drive. My mother tried to stomp a hole in the passenger floorboard of her minivan when I was driving. My father took me to the high school parking lot in his ’74 Ford pickup. That truck had three manual gears and a clutch that took about 140 pounds of pressure to hold against the floor. (I think I weighed about 135 then.) Both my parents were perfectionists and shouters (actually, Dad shouted; Mom loudly whimpered and hissed). I tried to be a non-perfectionist and a non-shouter with my nephew. 

He made errors. A lot of errors. A lot. I mean, of course he did – it comes with the territory. Before each leg of a trip, I would verbally go over something for him to work on: “On the way to the store, I want you to pay attention to your speed, okay?” While driving, there were times that he would find his own mistake and fix it without input from me. Other times he would correct himself when I asked simple questions: “How fast are we going now?” Sometimes I would take some of the tasks off his plate: “That sign ahead says the right lane is ending, so we need to move one lane to the left as soon as we can.” Sometimes I would have to tell him what was wrong and the correction directly: “Pick a lane, boy. You’re weaving.” I didn’t have to do it, but if worse came to worse I could have made an adjustment to the steering wheel myself. I could even have made him pull over and let me drive, if it came to that.

Like we all had to learn to drive, each of us had to learn to run an EMS call. I realized that training paramedics (and EMTs; probably medical students, student nurses, and residents, as well) is a similar process to teaching a high schooler to drive. There are about 20 items a trainee has to pay attention to, but they have a firm grasp of only five at a time. My job as a trainer is to increase the parts of the call that a trainee can handle at any one time. I can do that with easy questions: “How does his breathing look to you?” I can choose to take tasks off of their plate when I put the firefighters back in service, or I can wait for the trainee to remember to do that. I can talk about a specific facet of a call to concentrate on before we arrive on scene: “On the next call, I want you to make sure you listen to breath sounds. Make sure to do it, because I will be watching for it.” I can drop big hints during the call by handing medications to the trainee or by spiking an IV bag in front of her. I can choose to watch a minor error happen to see how long it takes for him to realize it on his own and “get back into their own lane.” I can step in and correct bigger errors with specific instructions. I can be a more aggressive trainer and tell the trainee specifically what they need to do. I can even take over the call if it has gone completely pear-shaped. 

When I was helping to teach my nephew to drive, I had to choose my response based on the severity of the situation. When I field train, I make similar choices. Constantly. The important thing is that the trainer (driving or EMS) not base their reaction on emotion. Fear causes shouting. Frustration causes ineffective communication. Apathy is the worst. I try to channel my tolerant side and base my teaching strategies on what is needed, not what feels good. That is how baby medics and baby drivers are similar.