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?