Ready or Not?

So here we are, a small fire department in a tiny town, out here in the middle of nowhere, far from any hospital.  We're non-transporting, so we have automatic ALS back-up from the ambulance service in a nearby larger town.  This is a good thing, right?

Who are we kidding?  

Automatically toned when we are, so they are on their way without us having to call them in, which saves time.  Always ALS because that's how they run.  Highly skilled medics, most of whom we know and work well with.  Sometimes two medics, depending on who is on shift.  Other times, the medic's partner will be certified at a lower level, but they'll have a lot of experience.

It's a GREAT thing!

Isn't it?

The answer is a little complex.

Yes, it's great. From the patient's perspective, knowing that the ambulance is on the way can only be a good thing.

But I think sometimes, if we aren't careful, it can lead to some things that are NOT good.  Habits that are, at best, non-productive. At worst, potentially disastrous.

Let me give some examples, and a little explanation, of what I mean.

We live in a strange part of the EMS world, being non-transporting.  

A typical scene goes something like this:

We are toned.

We go to the station, then to the scene.

We make patient contact and begin an assessment.

IF we have more than one person on scene, someone can be getting a med list, getting demographic info, and getting some history if the patient can't provide it. 

If not, we generally have time to check ABCs, get oxygen on them if necessary, get a general idea of what is going on, and the ambulance crew shows up.

That's if we get there first.

Most of the time, we may have about five minutes on scene before the ambulance arrives.  Sometimes less.  Occasionally, more.

They may get toned the same time we do, but they are already on the road most of the time. They don't have to wake up, get dressed, go to the station, etc.  And sometimes, for certain things, they hear about it before we are toned.

We don't usually have time, before the medics are there, to get to a second set of vitals- if we even have time to get to a first. There are calls where they do all the patient care. We don't have a stretcher, and don't generally lift patients much. We don't do radio reports much at all, except for a brief update to the incoming ambulance on some calls.

We still do paper PCRs, and are likely to continue to do so until the state absolutely mandates differently.  We don't have the technology to do ePCRs.  No accessible computers.  What this means is we have to hand write the PCR, on scene, really rapidly, in time to hand off the back copy to the ambulance crew before they leave.  This can be a challenge.  The sicker the patient, the less we can get on that piece of paper before they are transported because we are BUSY. We don't get the chance to sit down after a call and construct a well-ordered PCR narrative.  The very best narratives we do are on the refusals!  No copy needs to go anywhere, so we have all the time in the world for those.

What these things mean is that there are a bunch of things that we get little to no experience with on scene. And if we aren't careful, we can become accustomed to that, and not practice those things at all.  It is very easy to become complacent.  To adjust to the situation. To count on that back-up getting there quickly.  To feel like they will bail us out if we get into trouble, if there is something we don't have experience with. To get used to the ambulance crew taking over, controlling the call.

It is imperative that we DON'T allow that to happen.

Here are some examples:

We had a call for difficulty breathing, on the near end of town.  We arrived moments after the ambulance.  Okay, so they will do all the patient care, and we will assist them with getting information, moving the patient, carrying their gear, opening the back of the ambulance, etc.  No problem.

So what did we carry in with us?  Our usual equipment? No.  It would just be in the way, since we wouldn't be doing the patient care.

Right?

Wrong.

The patient crashed shortly after we got inside.

We learned NEVER to assume that just because the ambulance is there, they will do all the care.  Even though most of the time, they will.  Doesn't matter. We need to be prepared for whatever MIGHT happen, not for what USUALLY happens.

We had a call for a woman who had fallen from standing.  Possible public assist only.

Okay, no problem.  We happen to like helping little old ladies up.  It's one of the calls where we actually can be sure we helped someone.  And they are generally relatively low stress, as well.

So we get on scene, and sure enough, a lovely older woman had fallen. From the doorway, she didn't appear to be injured, and told us so.  Just needed a hand up.

Until we started the assessment.  Tachychardic, irregular heart rhythm, tachypneic, low BP, and she said that she had "felt a little dizzy, maybe" before she thought she "slipped."  She wasn't sure, really. Couldn't remember. She also had been feeling a little sick, but didn't want to worry anyone.

The ambulance, assuming a public assist, was coming from further than usual, and not hurrying.

Our "bail out" was a little further away than we would have liked, for sure.

Then we found out that they had gone towards the wrong location, there being highways here with similar numbers, towns with similar names, and once in a while, some confusion from dispatch. That never happens, right?

Now they were really delayed.

So much for counting on ALS to swoop in and save the day.

Sometimes, they don't swoop so much.

We don't ALWAYS have a short period of time on scene before they get there. We need to be prepared to handle any situation for a more extended period of time.

We had a call for an incident with several patients.  Two went in the ambulance. One went by personal vehicle.  After the ambulance left, we listened to their radio reports to the ER.  They didn't mention the third patient.  We ended up radioing the ER, to let them know they had three patients coming in, not two.  A tad unusual situation, but there it was.  It happens.

My point is this:

I love that we have such great back-up.  It helps keep us calm on scene to know that we aren't alone out there. It provides high quality continuation of care for our patients.  It means we have paramedics on scene on every call, even though we don't have any medics out here in our department. It means we have providers on scene who have much more experience than any of us have. People we can count on, and learn from.

But complacency is a very real danger.

The moment we lose sight of that, that we begin to assume they will take care of things, that we don't keep our skills up to the level we'd want them to be if we were the ONLY providers, is the very moment something will happen to prove to us that we can never be ready enough.

I See Dead People

Death.

No one wants to talk about it.

It's as if the mere mention is a curse, sure to bring about an untimely demise.

After a long day, as I was winding down, I glanced at the obituaries in the newspaper. I do this somewhat regularly, to see if any familiar names show up.  Sometimes, it will be an old friend.  Tonight, a patient.  One we haven't seen for a while.  I had been wondering.

It got me thinking about something I'd like to say to people taking their first EMT class. Something no one told me.

You're going to get to know a lot of dead people.

Some of them will be dead when you meet.  You might learn something about them from their grieving families, or from pictures on the wall.  Or by reading their obituary a day or two later.  You might never know anything about them at all.

Some will die while you are with them.  It may be quick or slow. You may have the chance to try to do something about it, or you may not.  It could be medical or trauma. Young or old.  Although you may not get to talk to them, or not for long, just by being there, by sharing that most intimate experience, you and they will be connected.  The experience may not be what you expected, in one way or another. It wasn't, for me, but it's too personal to try to explain what I mean. Chances are, you will remember every one of them for a long time.  Maybe forever.

If you work in a small town, where you go to most of the calls, you may get to know some patients pretty well. Since becoming an EMT, I've met more people in this town than I ever knew before.  I've also gotten a somewhat skewed perspective, where it seems like an unusually large percentage of the people are old and sick. Not that all older people are sick, or that all sick people are old, but if they ARE both old and sick, chances are, we'll meet.

And being both old and sick, chances are pretty good that before awfully long, they'll die.  They might get a bit older first. They might get a bit sicker.  But no one is going to skip the ending.

I hadn't anticipated this aspect of the job.  Hadn't ever thought about knowing more and more people who would die. Often people who would die sooner rather than later. Hadn't considered that I'd need to find a way to accept, or even embrace, that part of the job.

Although I've found a certain peace with it, and use that to encourage getting to know and appreciate people while I have the chance, whether that chance lasts a few minutes, or a few years, I'll admit that sometimes it's still hard when I recognize those names.  It feels personal, somehow, when they die. Not like I have somehow failed, or like I should have been able to save them, although I certainly wish we could have.  But like they were one of mine, or on my team, or something.  Like I have a responsibility.  To remember them. To show respect.  To feel the sadness.

There are more and more houses in my town that hold those ghosts.

I'd rather have that, than never have met them.

Some people, as they recognize that they are dying, and face that with courage and dignity, are pretty damned inspirational.

Some fight it tooth and nail, to the very end, and demonstrate incredible strength in adversity.

Some don't fit that model of "inspirational," they don't "rise above it," but are so very human in their struggles, as they lose control, as their body fails, that it touches my heart with the sheer blunt honesty of it.

And some, who never saw it coming, are a reminder that it will. Inevitably. Maybe today.

"Let us endeavor to live so that when we come to die even the undertaker will be sorry."  ~Mark Twain

Where's My Pizza?

It's 8:00pm, and you've just gotten home from a long day at work.  Add the commute, and you're exhausted.  You have no energy left to decide what to make for dinner, or to make it.  It's take-out again.  Fortunately, there's a place down the way that makes great pizza.

You call in your order, a large pie with pepperoni and mushrooms, and sit down to relax for a few minutes.

Sure enough, within a short period of time, you see the pizza delivery car pull into your driveway.  You go to the door, counting out the cash to pay him, anticipating the hot, melted cheesy goodness of your pizza.

But when you open the door, there he stands. With no pizza box.

"Hello," he says, with a smile on his face. "Did you order a pizza?"

"Yes," you tell him. "Where is it?"

"Oh. Sorry. I don't have your pizza. I'm just here to make sure you are the person who ordered it, and to get some information from you so that the correct pizza will be delivered. It should be here soon."

He asks for your name, your birthday, the correct address, what, exactly it was that you ordered.

While you answer him, puzzled about why he is even asking, you see several more cars pull up in front of your house.  People wearing the uniforms from the pizza place get out.  Some stand in the yard and talk to each other.  Others start to put out traffic cones, and direct traffic around the now crowded street.

None of them have your pizza.

You're getting hungrier.

And more confused,

And even angry, a bit.

But they all seem so nice, you don't want to complain.

Still. You ordered a pizza, and have every right to expect to get it!  You might order a dozen wings to go with that pizza, but you didn't order a dozen PEOPLE to show up all over your lawn!!

For a person who lives in a rural community that has an all-volunteer fire department that is also a non-transporting EMS agency, I think this scenario is very much like what it feels like sometimes.

When a person calls 911, what are they asking for?  What do they expect to get?

They expect an ambulance that will take them to the hospital.

But in a rural area, what do they often get?

Whatever they get, it isn't that.  It isn't what they think they ordered.

As much as we want to help people, and as good as we are at being EMTs, the flat out truth is this:

We don't have, and will NEVER have, what they asked for in the first place.

We are not an ambulance service.

We cannot take them to the hospital.

Period.

So, you might ask, and some people DO ask, why are we even there?!?

There are several reasons.

One is that sometimes, what people WANT, what they EXPECT, and what they NEED, might not be exactly the same thing.

They might want and expect to get a ride to the hospital.

But they might collapse and need CPR.

In that case, we aren't what they planned on, but we can provide, in a timely manner, what they actually need.

That one is pretty clear cut.

But what if it isn't that obvious?  What if it's a relatively minor thing, where what they need is to go see a doctor?  What, then?  Or what if it's a case where they believe that EMS is ONLY about a ride to the hospital, and don't know that we can begin treatment in the field for a wide variety of things?  Or what if all they really need IS a ride to the hospital?

Why ARE we there?!?

As a BLS, or ILS, first response agency, what can we provide to our patients, our customers, BETTER than the ALS ambulance that backs us up?  What can we do that makes it worth our being there?

I think there are several things, and I think we need to focus on being very, very good at those things.  For our patients, for ourselves, and for the ambulance crew.

A list, in no particular order.  I'm sure it is not all-inclusive.  It's just the things I've been thinking about lately.

1. A very quick response in a true emergency.  

What are the emergencies where a quick response matters?  Clearly, anytime there is CPR required.  Someone who is choking.  Serious bleeding.  And look- these are BLS things, yes?   Right in our skill set.  So what should we spend a lot of time practicing?  CPR. Bleeding control.  And more CPR.  Maybe we should consider taking advantage of the variety of tools out there that can improve CPR.  From simulation practice, to timers on scene.

2. We can gather information that will help the ALS crew do their jobs better and sometimes faster.  The more we know, and are able to communicate to the medics, the more quickly the patient can get what they wanted in the first place: on their way to the ER.  The better we take advantage of the time on scene before the ambulance arrives, the less time the ambulance needs to stay there. So we need to practice assessments, we need to practice taking vital signs, and we need to practice an excellent, clear and concise, transfer of care. This includes accurate, legible PCRs.

3. There may be things we can do to prepare the environment. Make sure the dog is in the back room. Clear a path to the patient.  Sometimes, clear a path to the house. Have someone direct the ambulance crew in to where we are.  And put things back where they were afterwards.  Some of this can be done by other fire department members, not just by the EMTs.

4. Once we have transferred care, we can become excellent assistants to the ALS crew.  We can help get the patient on the stretcher, help get the stretcher into the ambulance, carry bags, clean up any trash, collect up any used gear, etc.  Make sure everything that needs to go with the ambulance, does.  Let the medic focus on, and be in charge of,  the patient care.  For some reason I don't understand, some people seem to have a problem with an ALS crew "taking over patient care." Well, duh.  That's why they are there!

5. We can assist in the ambulance, if necessary, and we have any required training to do so.  This may include spiking the IV fluids, setting up for an IV, helping get the patient on the monitor, etc. Or it may be doing compressions all the way to the hospital. This means learning to become part of the ambulance crew, on the fly.  See #7, below.

6. We can be a familiar face to our patients- they are our friends and neighbors.  This may include going out into the community and making connections, so they meet us before they need us.  It includes remembering them if we see them more than once.  It includes treating them like friends and family, with care and consideration.  One of the MOST important things we can do, where we can really excel, is in this category.  We can establish a rapport, and let them know that we are there to care for them.  We also need to be sure they know, and can trust, that we will treat them with respect, and will not share their personal information with anyone.  This is important anywhere, and critical in a small town.  Some things are easier when we are people they know, and some things are harder- and we need to navigate both.

7. We can introduce them to the medic, by name, so it's not a total stranger suddenly taking over.  And we can reassure them by our words, attitudes and actions, that we believe the medic will take good care of them, that they will be in good hands.  This part includes creating relationships with the ALS providers, so that we DO believe in their quality of care, and CAN introduce them personally.  It also means that the medics need to be able to trust US, and they can't do that, if we never work with them, never ride with them, never talk to them outside of a call.

8. Even if we do all this, and do it impeccably, we still aren't what most patients expect. There is a role for public education about what EMS is about, what the different crews do, and why sometimes it seems like so many people show up at their door.  We used to have to do a lot of pub ed about this because our rescue vehicle was a recycled ambulance, so it looked just like one, and people were frequently confused about why TWO "ambulances" would show up, and why we wouldn't ever put them in ours.  I can't blame them.  It WAS confusing to someone who didn't know that we didn't all come from the same place. How would they know, if we don't tell them?

The reality is that way out here, when someone calls us, we are never going to have their "pizza."

We need to be sure that we can deliver something of value.

I want our customers to know that when they order a pizza, not only will they get an excellent pizza, but before they get it, someone will come and set the table, warm the breadsticks, and pour the wine.  I want them to feel like they are getting a four course meal, with an excellently trained, courteous and efficient wait staff, for the price of take out.

We might even wash the dishes afterwards.

Figuratively speaking, that is. :-)

People Care

Saw a reference to this book somewhere and ordered it immediately, based on the blurb on the back cover.

"When you kneel in front of somebody's grandpa who's sitting on his couch and denying his chest pain, you need to recognize the pain he says isn't there, detect the shortness of breath he hasn't mentioned and sense the fear that's absolutely dominating his consciousness. You need to appreciate the fact that his spouse, seated right there next to him, is scared to death she's never going to sleep with him again.  And somehow, you need to make everything better in just a few minutes.

These are the dynamics of even the simplest emergency response. They presuppose the presence of gifts in us that not even the greatest teacher can impart- gifts that, unfortunately, come without instructions.

This book is an examination of those gifts and a collection of the instructions that didn't come with them. It's based on the collective experience and wisdom of dozens of professional paramedics and EMTs worldwide who learned to love the lifelong pursuit of helping others.

We hope it helps you to join their number."

It's fabulous.  Concise, concrete suggestions.

Some of which I already do.

Some of which I haven't had the opportunity to find out if I do.

Most people I know personally in EMS know a lot of this stuff, being good people, and having been around for a while. Most of it should be common sense- but we all know how common that isn't.

If I were the EMS Director, I'd make it required reading.

If I were the Training Officer for the fire dept, I'd make it required reading.  It is specifically about EMS, but it has a LOT of information in there that applies to anyone in the emergency services.

It's about respect, mostly.

It's about treating people, not conditions.

About understanding the position you are in, being invited into someone's bedroom, their most intimate place, in the middle of the night.

A pretty quick read.  83 pages.

I'm glad I found it.

It will make me a better EMT, no question.

People Care: Career-Friendly Practices Professional Caregiver

By Thom Dick & Friends

Not Worth Your Time

I didn't want to focus on the negative here, but this just pissed me off.


We have a new EMT.
She's trying to help us out, and is the first breath of fresh air in a while out here.
She's smart. Dedicated.  A fast learner. And most of all, eager to contribute.


She wants more training than is available here, which isn't difficult all things considered.


So tonight, she goes to talk to the EMS Director about an upcoming conference she wants to go to.  A regional event, with two or three days of sessions.  With a featured speaker who has written a book I found very helpful.


What does he tell her?
Does he say "that's great, get all the training you can, it would be a great experience for you, be sure to come back and share what you've learned"?
No.
Does he say "I'm glad you're showing so much interest."?
No.


He says "It's not worth your time.  I'll let you know if anything interesting pops up."


This, from someone whose certification lapsed a year and a half ago.
This, from someone whose responsibility it is to provide training- but he doesn't provide any.
This, from someone who hasn't gone to any such conference himself in as long as I've known him.


A practically brand new sparky EMT goes to him, and wants to go to a training conference, and not only does he not support that, he actively discourages her from going.


Am I the only one who thinks this is just plain wrong?
Are we alone here?


Feeling very, very lonely tonight.
I want EMS to be better than this.

To Ask, or Not to Ask?

Over on Hybrid Medic's blog, he has a post about a call where he hadn't noticed the patient had a DNR.  I started to comment on it, and that comment kept growing, and turned itself into a whole post, so I brought it over here.  Go read his post first.

I recently had a non-EMS friend tell a story about her mother going to an ER, and getting really freaked out by the nurse asking if she had a DNR. The patient, and the family, interpreted it to mean that the nurse thought she was about to die. This brought up a good discussion of why the nurse would ask, and what might have been a better way to do that.

With a nursing home transfer, where they give you all the paperwork, the DNR will either be there or not, so it's fairly simple most of the time.  But for other calls... when do you ask?  How do you decide?  Age of the patient?  Condition?  History?  And how do you ask?

My friend's story was interesting timing, coming within a couple of days of a call where the patient was talking to us as we walked in, I saw the DNR on the counter, and the patient promptly collapsed and died.  So it was a very good thing that we had seen the DNR without even having to ask.

Since my friend's conversation about her awful experience, I've been pretty careful about asking. I've had some patients who, for reasons basically a combination of age and condition, I've considered what all might happen throughout the call and on into any hospital stay, and felt like I should ask.  I've tried to preface it as a routine question, which it sort of is, and sort of isn't, and let the family know that the question itself doesn't mean I think something terrible is about to happen, but that we just need to know so we know what the patient wants.

I'm not entirely satisfied with what I've come up with so far.  Better than blurting it out, yes.  But not optimal yet.

We had another call, for a very sick patient, where I didn't think to ask, primarily because I was busy with my assessment, and the family, midway through things, asked me "Did you see the DNR on the refrigerator?"  Um.  No.  I didn't.  I don't think I saw the refrigerator, actually.  But I was glad they brought it up.  Didn't change what I did, but it could have.

Maybe part of what we need to do is educate people with DNRs, and their family members, to always make sure we know about it?

We've also had a call where the family said the patient had a DNR, but they didn't have it there, it was at someone else's house, or something like that.  Someone went to find it, while we continued resuscitation efforts.  Brought up questions of how to educate people that if they have a DNR, if that is really what they want,  they need to have it WITH THEM.  There is no way to predict when something might happen that they'll need it, and if they need it, they need it right then.  Not later.

Most people in this culture don't even want to think about it, let alone discuss it. Educating people can be very difficult, if they don't want to even hear about it at all, let alone consider how it might apply to them.

I think that was the cause of the uncomfortable interaction with my friend and her mother, and the nurse.  From the nurse's point of view, she asked because it would make it easier to know what the patient wanted, and provide that. Whether she was about to die right then, or not, dying is something people eventually do, and part of the nurses' job is dealing with that, so talking about it was no big deal at all.  From the family's perspective, TALKING about dying was a big deal, all on its own, so for someone to even ASK was a big deal.

How can we bridge that gap?

Sick/Not Sick

I was over at the Fire Academy recently, where they have a fabulous library- and quite possibly the world's best librarian.

She has a pretty good idea of what kinds of things interest me, so whenever I stop by, she often recommends new books.  This particular time, there were several.  Unfortunately for someone, a library somewhere else has closed up, but lucky for us, this library was able to acquire much of their collection.

One of the books was called  "Sick/Not Sick: A Guide to Rapid Patient Assessment"

It's a simple concept, really.

Sometimes called a "from the doorway" assessment.

Is the patient really sick, or not?

Sometimes, in some circumstances, we might not be able to tell right away.

But sometimes, we can.

One look, and whether it's something we see, something we hear, or something so subtle that we don't even really know what it is, but we get that "rush" of adrenalin, and we know, without question, THIS patient is in trouble.  Bad trouble.  This one needs us on our toes, alert, focused, and on the top of our game, and they need it right now.

My original EMT-B instructors talked about this a fair amount, but having no experience at the time, I didn't know how I would know. Didn't know what to look for, really.  The first time I had a patient who fit in this category, I missed it.  Didn't recognize right away that this one had a different feel, a different pace.

I learn pretty fast, though.

And some patients are very educational.

A while ago, we had a patient who fit this category.  I can't really tell you why.  He presented pretty much the same as any number of other, similar patients.  Similar demographics- age range, history, chief complaint.  But even though the obvious signs were no different from others I had seen dozens of times before, this one... this one was different somehow.  A higher level of... something.  Something somewhere between desperation and resignation.  As if he knew.  Something in his eyes, maybe.

The call went like many others have gone.  Fairly smoothly, gather information, start what treatment we can provide at the BLS level, transfer care to the medic, and help load him into the ambulance.  Nothing stuck out at the time as out of the ordinary.

He died three days later.