Mechanism of injury

     The other day I was working one of the MICU trucks when we got a call for a MVA. It was a busy intersection mid after noon the the local FD and PD where already on scene. There was moderate damage to the vehicle and two people were inside. The restrained driver and the unrestrained passenger. The driver didn't want anything to do with the whole incident and was otherwise fine. The unrestrained passenger actually hit his head on the windshield and caused what many have referred to as a postive "windshield sign". You could see where his head impacted the windshield because it caused it go crack and make a spider web appearance. Gotta love a head on collision.
     Thankfully one of medics I work with from time to time was doing the fire thing that day and did a great job of making sure this guy had a c-collar and was extricated properly. One issue I did have was that there was no real traffic control because we were in the middle of the intersection and many people were just trying to slide by us. Rude, unsafe, and annoying. Thankfully no one was hurt.
     Our treatment was fairly quick and simple. IV, O2, monitor, C-Collar, and transport to the trauma center. Report was called and the trauma team was standing by when we arrived. I love giving report to the trauma team. You get to yell, be blunt, and be done in under a minute. Good times. They took over and did their thing.
      A few things we did on this call were pretty cool. For the sake of saving time, I used the blood pressure cuff as a tornaquet for my IV. While it was taking the pts pressure, I slipped in an 18g and did alittle EMS multitasking. Another thing that I was pretty happy about was our scene time. We were on scene for a total of 17 minutes. That included extrication, packaging, and IV access. Not too bad.
     As it turns out, our pt had a head bleed and a fractured c-spine. Not much we could do in the field for that. Fortunately for him, he was transported to the areas only trauma center and is good hands. Also, a good thing to point out was that he had positve pulse, motor, and censory function in all his extremities on scene and upon arrival to the hospital. It's funny how pts may not look sick but treating based on mechanism alone can really save lives and cover your butt.

Priority 3 purgatory.

      The other day I ended up doing a 28 hour shift. I called supervision when I saw that the Commerce rescue truck needed someone for night shift and I figured I could get paid to study. Why not? So when I call the supervisor convinces me to come in 4 hours early. No big deal. What else was I going to do? For the most part, it was an easy simple shift with only one true ALS call. But I didn't get enough sleep because of the huge amount of coffee I drank earlier in the day. So the following 12 hours on the Prov Park MICU were going to be that much more difficult.
     After a swim, a shower, change of uniform, and a large cup of coffee I was good to go. I was working with a certain partner that I had previously misjudged due to first impressions. As it turns out, she is a great person to work with and actually really sweet. So that was an unexpected plus.
    What was the bad part about the day was the fact that not only did we have a moderate number of calls. Seven if I remember correctly, but all of them were basic and took forever. The only exception, and in retrospect a blessing, was the cath lab standby. We got to quiz the student and learn a few things of our own in the process. The only bad part was the fact that I was starving. We really did not stop all day and we were stuck in the south east portion of Oakland county and had to make a trip down to the "D". Never a really good time.
     That shift was a good reminder that we don't always save lives or earn money sleeping. It is more common to sling dialysis calls, BLS every call, and get trapped in the hospital nursing home loop than to run all ALS/Rescue. Even the "rescue" dedicated trucks were feeling the effects of priority 3 purgatory. I am working the next 36 hours in both Commerce and Novi. Hopefully the next two days are a bit more mentally stimulating.

Two days in a row...

      Two days in a row I we worked a full arrest. This time, I was working in the station closer to my house on a 24. We had an easy shift thus far and had a third rider as well. The tones that day were for fire alarms and lift assists. And a call for a seizure later on. Nothing much.
     So our Harry Potter obcessed student was a bit bored and upset about the whole no calls thing. Then we get another call for a slip and fall at one of the many fine fitness centers in the area. We jump into the truck and start heading that way. Enroute, dispatch tells us CPR is in progress. WTF? Another unit was in the area and got on scene first and started the initial resus. When we show up. We grab our jump bag and monitor and make our way inside. The arrest is by the pool and there is no easy or direct route to get there. That will make for some fun later.
     So the local FD is there with AED in place with a combi tube down. Ok, not bad. The AED analyzed and recommended, in it's expert oppinion that a shock was not advised. So CPR was continued. Apparently CPR was not the cool thing to do for some of those other rescuers, so the task had to be assigned. The combi tube that was places was not getting good ventilation and vomit was coming up the tube. Now, I am not sure that who ever placed the tube bagged down both tubes, but it was not pretty. So they pull the tube out, place an OPA and bag him. I do not recall if one of the other medics on scene attempted to tube or not, but I ended up with the task at hand. It was hard with all the vomit everywhere. We suctioned him out, removed his fake teeth (I wish I was able to do that with every intubation), placed the tube and confirmed it with waveform capnography (my new favorite resus tool). Initial C02 was about 9 or 10 not a good sign. And it didn't get any higher than 20.
     The presenting rhythms were asystole and brady PEA. Our student pointed out that an easy way to remember what to push for those two rhythms was Push Epi Atropine. PEA. Cool. And the acronym for VF/VT arrest is SCREAM. Shock, CPR, Rhythm, Epi, Amio, Mag. I had to do that the hard way. Ha!
     The one big issue we had on scene was that there were too many people there and there was an audience watching. We had the local fire chief, two or three of his chronies, two cops, a total of four medics, and a student. Another issue was that I was not able to use my "Full Code" app today. I guess it wasn't the most practical thing to do at the time. Oh well, the constant persuit of perfection is a never ending battle.

Back pain, a full arrest, and the future.

     Today started like any other day at my current place of employment. Coffee in hand I show up early to get the truck ready for a day of slinging medicare/medicaid pts around town. Luckily to my surprise, my partner called off and so did one of the medics at one of the out stations I am used to working. Rescue is much better than just posting and doing transfers. We still did a transfer, but we are not at that part of the story yet. So I get assigned to go work my 12 hours of mandatory fun on the rescue truck or "car" as they call them here. I am still getting used to that.
     Now since I have already had my caffeine bolus for the morning, I am ready to be productive while my partner takes a nap. I worked on homework and my newest goal, studying (and passing) the FP-C exam. For those of you out there that don't know what that is, it is the Flight Paramedic Certification. I figure I might as well give it a shot. Who knows. You have to at least try for something even if the odds are stacked against you. Today's topic was CVA management. Interesting topic and let me to the idea of flash cards.
     Anyway, we were paid to do homework and sleep for 4 hours or so before we received our first call. Then the tones go off for a male pt under 50 who is not breathing. We moan and groan and take off priority one. After all, a body in rest likes to remain at rest. We get out to the "park of mobile estates" to find the FD providing excellent BLS. BVM, OPA, CPR, and AED all placed and going. It was a witnessed arrest and and we started our ACLS portion of the resuscitation. The AED stated shock advised. So, "I'm clear, your, clear, every body clear" then POW! 360 monophasic joules to the myocardium. CPR was immediately resumed. At this point we got our monitor on there and saw course V-Fib. We have a chance to save this guy. My partner was having trouble placing a line due to the mess that was this pts vascular system due to was appeared to be some recreational use of "substances". I place the line and we continue the resuscitation effort per protocol. At this point, we have an ETT tube confirmed with both ascultation and capnography. I have to say I really love capnography. What a great tool. Initial ETCO2 was 9mmHg and was as high as 25 during our resus efforts. Good CPR and a chance for survival. Win or loose, it is good to know that what you are doing is not futile.
     Another interesting piece of info to point out is that I had a chance to use my code marker on my phone again. It is a great tool for documentation and time keeping. However, my partner didn't know I had this app on my phone and thought I was texting or checking my facebook page during the code. Ha! I showed it to her later and she got the picture. Still, the main thing point out for this call was the use of ETCO2 for tube placement and confirmation, as well as eval of resus efforts.
     So we do what we can on scene and transport the pt priority one to the local ER. Upon arrival we give our report, help with compressions, and clean up the truck as best we can. They work the code for another 20 minutes. Calcium chloride, bicarb, and more epi is pushed. I guess they didn't read the newest ACLS guidelines. But then again, I am no MD. They can do what ever they want. Or so it seems anyway, after a few unsuccessful central line placements and a FAST exam with the ultrasound machine, they call the code.
     Busy call to say the least, all the CPR and lifting was alot of work. However, I tweak my back lifting the gurney with the 95 lbs lady we transfer for cardiac cath. WTF?
     Anywho, the more and more I do this, the more and more I realize I can not do it for ever. I like medicine and enjoy what I do, but I also am hungry for more and more knowledge. That is why I am challenging the FP-C exam next year and that is why I am furthering my education and career. One of these days I will be done with school. One of these days. Until them I will be studying until the tones go off again.

36 hours of almost nothing.

The shift(s) I worked this past weekend were not exactally that medically stimulating. I worked 36 hours on the rescue truck and only ran 3 call that whole time. One would think that would be a great shift, but it was so very boring. The next shift I work I will probably be so busy that I don't even have a chance to eat. Gotta love karma.

Roll over, roll over, roll over...

     Lately I have been fortunate enough to pick up a few extra rescue shifts. It was an easy shift the other day. I only did three calls in thirty hours. I covered for a buddy of mine. Anyway, two out of the three shifts where a whole lot of nothing.
     Our call of interest involved a vehicle roll over with 3 patients. There was major damage to the vehicle but all three of our pts who where barely old enough to buy a pack of cigarettes were conscious and self extricated themselves prior to EMS arrival. The local FD was providing BLS and getting everyone ready to be collared and boarded. As I walked to the first and most critical pt, the second ALS unit arrived on scene and their crew took care of the other two pts. The two pts that were in the front seats of the vehicle stated that they were only going about 30-45 mph. yeah right. No one rolls a car like that at those speeds.
     At any rate, my pt was complaining of back pain, SOB, neck pain, and chest pain. Lets just say that lifting was an issue for the three of us that hauled the back board out of the ditch. Anyway, once we got the pt on the back board and in the truck, our eyes and scissors assessment showed us some minor abrasions and lacerations but not major bleeds. Vitals were relatively stable. HOWEVER, this pt had diminished breath sounds on the right, chest tenderness to palpation, and was unrestrained in the back seat of the vehicle. I got an IV started (I had to start it upside down again due to the way I was sitting) and started the pt on some NACL therapy. I checked lung sounds again and they seemed to be getting worse. We then started towards the local trauma center at a speed close to mach 2. En route, her vitals started to decrease a bit and I felt it was time to make a decision. I decided to needle decompress this poor person. I check breath sounds again after my partner pulled over and verified with me. We both agreed on the pneumo developing on the right side. I opted to do the lateral aspect of the chest to decompress the pt due to the excess amount of tissue that occupied the second intercostal space. I took out my dagger of a 3 1/2 inch needle I was issued in Afghanistan and after taking all the other appropriate precautions and cleaning the site I place the needle, popped the chest, and secured it. Her vitals improved. Her BP increased, pulse decreased, and her speech became easier. Although her anxiety level was still sky high.
     I was feeling pretty good at this point, but I still had to deal with the trauma team. And in true teaching facility fashion, there was an overly anxious resident who really doesn't know how to talk to people. I give report to the team and when I mention diminished lung sounds on the right and the fact that I darted the chest this MD in training just went from stressed to pinging. She basically was yelling at everyone that made eye contact. I have to say I always love how we (Paramedics and EMTs) get questioned about why we did things and basically told what we should have done. You know what "capt. awesome'? you were not there. Just bee a good little resident and take care of your new pt.
     But I didn't stay annoyed for very long. I was talking with the other crews that brought in the other pts and just decompressing ourselves after the event. Apparently I am gaining a reputation of being "very fast". I wasn't sure exactly how to take that, but the other medic was basically saying that it was in regard to skills and procedures. I guess that is a good thing. They didn't call me stupid, so that was a good thing. Ha!
      The rest of the 30 hour shift was a very easy shift with nothing really of interest. I just have to say, I don't wish harm on anyone but I do love a good trauma call. Bye for now.

61 hours of paid fun

     So this last weekend was full of work. I was actually at work for 61 hours out of the 72 that made up the weekend. I did two twenty four hour shifts back to back and a 12 hour MICU shift. I was surprised that there were no calls that involved Halloween stupidity. I was a bit disappointed.
     However, the call of weekend was a cardiac arrest. A rather young arrest at that. This patient was under 45 and had no other obvious health problems and nothing per his friends. He died in his friends house. Bummer. Anyway, we were initially called to do a pronouncement but were upgraded to priority one because the local FD started CPR due to the presentation. It was right thing to do. Even though it created another 2 hours of work for me. Oh well,
     Anyway, the presenting rhythm (or absence there of) was Asystole. This patient stayed that way through the entire resusitative effort. Everything went well. Good CPR, good tube (thanks to the FD), and good text book ACLS. The only factor that didn't cooperate was the patient. Asystole on arrival and after 20 minutes of resuscitation (6 epi, 3 atropine, Bicarb, D50%, Narcan, and NACL). We had good communication, good time keeping/documentation and a fairly clean area to work. But this patient wanted to stay dead. We ended up saying "you win" and called it. Can't save'em all. But you sure do have to try like hell.
      One good thing that came out of that code was the fact that I actually remembered to use my cool like code documentation app on my IPhone. It really helped with sticking with the time lines and not getting caught in the "ACLS time warp" where you loose your concept of time and either give meds too soon or much later than protocol state. Plus it helps out with your documentation later because it keeps a log of all the interventions and what times they were completed. Great little tool, if you remember you have it.
       And we had a student on that code. It was a great learning experience for him and he was able to earn some respect from the FD that was there. Good thing for him because it was his department. They were impressed with him and his willingness to help. Way to go man.
      Well, that is all for now. I am doing another 24 hours tomorrow in Commerce. Who knows what that will bring?

Pager: "Seeing Jesus"

Yesterday/Last night was a fairly easy shift. I got to work with a cool partner and got paid to watch Eddie Izzard for a few hours. Most of the calls that night were pretty easy and straight forward with the exception of one. We got the call for a psych/commital call. I will spare you the details of the call, mainly because it wan't all that exciting. However, the page that we recieved stated that the patient was "Seeing Jesus". I hope that was not a standard canned message that dispatch sends out for all psych calls. Just goes to show you that you never know what is going to happen or come across your pager. Ha! Now to rest up for tomorrow's mandatory paid training. Should be interesting. Probably not, more like filled with bad jokes and making the day last way longer than it should. Oh well. 8 hours of pay is 8 hours of pay.

48 hours of fun, a 26.2 mile race, and a few lives saved.

     This weekend I worked 48 hours. Two 12 hour shifts and a 24 hour rescue shift. Shift number one was the most eventful and exciting. The rest of the weekend was pretty "run of the mill" as far as EMS goes.
     My partner and I had two very good and very successful calls this weekend. The first one where he was the lead medic, was a LoL (Little old lady) in CHF. She was confused, not talking well, had a very low sat of 74%, and her lungs sounded like a washing machine. We started treatment right away. As my partner put her on the monitor and looked for a line, I put this LoL on high flow o2 and got the drugs ready. She responded well to initial treatments but would de-sat once you turn the o2 down. I asked about CPAP, but since I was driving it wasn't my call. We did prepare her for it though, explained to her what was going to happen once we got her to the hospital.
     The second call of that successful day was initially dispatched out as a cardiac arrest in one of the worst places ever. Lets just say that the unofficial acronym for the area suits it and that the location was 10+ stories tall. So we get there and take all of our gear up to the "Penthouse" and were met by PD who told us that it was "obvious death". When we walked in, the smell was overpowering. Now I have smelled some pretty bad odors doing this job. This place was top three. I can see how PD thought the guy was dead. However, if you looked at him for more than 0.5 seconds, you could see that he was breathing. Luck for us he was all of 90 lbs and was an easy extrication. So his vitals were as follows BP (per monitor) 40/20, Pulse 41, resps 8, and CBG (that's blood sugar) read "low". You almost could not feel a central pulse on this person. So treatment consisted of the typical IV, 02, monitor, D50%, atropine, and a multiple fluid boluses. We also warmed him up with blankets and turning the heat up in the truck.
      The funny thing about this call was that with someone like this with a BP in the toilet, I was able to get a 16g IV in the AC. However, I was unable to get a second line in the other arm. This got me thinking, I could have attempted the saline push against at TQ technique. This is a fairly simple procedure to put a bigger line in a pt where you can only get smaller lines (22-24g) in. What you do is you place the smaller line in the pt and leave the TQ in place. Then using that smaller line, you push 50-60cc of NACL with the TQ in place. This causes the viens lumen to expand from the pressure and allows you to put a bigger line in. 18 or bigger. This is a great technique for pts that are hypovolemic for any number of reason. I wish I knew about this when I was deployed.
     Finally, my friend Stephanie did an excellent job on an arrest that occurred during the Detroit Free Press Marathon. She not only acted quickly and professionally but her actions resulted in an honest to god save! The pt she treated was not only extubated recently, but is completely neurologically intact. Way to go girl! Great job.

EMS expo

Over the past few days I have attended the EMS expo here in Novi, MI. It was a nice event with plenty of great classes that covered a variety of topics. It was fun to get out there and mingle with some of the other EMS providers with out people bleeding, crying, or complaining of chest pain. This weekend it will be another marathon three days with 48 hours of work. I can't really say that the money is good, but the job has its moments.

22 hours of BLS, nursing homes, and a "rescue" shift.

      Hours lately have become more and more scarce. Well, shifts that I would like to work. There are shifts open every day for those willing to work them. I worked two shifts in one day yesterday. I did a 10 hour MICU shift and a 12 hours rescue shift. I can't complain too much about the shift yesterday. It was a fairly easy shift.
     With that being said, I did have a patient deteriorate on me. ***NOTE TO ALL: I will try to keep patients fairly ambigeous to protect their right and privacy.*** We took this patient from an outlying facility to one of the urban super hospitals with all the services under the sun. This patient required Neurosurgery and had a brain bleed. I should have known it was going to be "one of those transfers" because as soon as we put the patient in the ambulance, he decided he need to put his dinner he had last night on the floor and part of the wall. We all vomit from time to time. No big deal. The issue was that as we got closer and closer to the super hospital, the patient became less and less conscious and more and more obtunded. However, looking at the vital signs, one would think that everything was fine. As my friend Kelley the RN would say "...not so much...".
     As we arrive to the super hospital, someone decided to call a trauma arrest/alert. Not sure why? So all the students, residents, interns, fellows, and the rest of the staff and trainees show up "asking questions". So after all the confusion of the who, what, when, where, and why was cleared up the patient was intubated and placed on the ventilator. Gotta love it when the patient decides to crump on you while in transport.
     Luckily the rest of the day, all the people I came into contact with didn't require anything more than a ride from point A to point B. This job is not all cardiac arrests and trauma. If it were, I think the burn out rate would be that much higher.

Explaination of the picture at the top of the page.

That unit patch you see at the top of my page was designed by yours truly. It was a moral booster and a way for me to say thanks to the other medics, corpsman, and providers I had the pleasure of serving with while I was deployed to Afghanistan. Even had the chance to save a life or two while wearing it. It scary at times, but I have to say it was one of the best experiences of my life. Well, other than all the convoys. I thought I went to Paramedic school so I didn't have to drive any more? Ha!

A blog in transition

Hello all,

     And by all I mean no one yet, since no one has subscribed to it. This blog is going to be at best, accidentally educational. More than likely, it will be a way for me to get some of my "war stories" out there and to have a little fun. So if you are a Paramedic (Like me), EMT, Fire Fighter, Police officer, or in any other way involved in EMS, this blog is for you. Post comments, pictures, stories, and what not.