Your stop for everything having to do with EMS
Very early on in my EMS career I decided that I would deny myself the joy of knowing I made a positive influence in somebody’s life in exchange for not having to face the fact that sometimes no matter what I do people die. It was a very conscious decision and for years I lived by it.
Let me explain:
There was a very bad shift when I had two emergency calls. The first was a small child, about 6, that was run over by an unknown vehicle. We knew it was a vehicle of some sort because he still had the tire marks on his back. Multiple fractures, tension pneumothorax, mass felt to his abdomen. Patient required RSI and in my opinion he was holding on by a thread. My partner was a big, tall and very tough white boy. Believe me, he was about 6 foot 5, 280 solid pounds and I had seen him brave some of our very toughest emergency calls. On the elevator up with the patient and the ER team I think the amount of stress we had gone through got the better of him. I didn’t hear it, but when I turned to him there were tears streaming down his face as he looked at the poor child on our stretcher. He apologized, something I quickly dismissed. I told him it was ok but we still needed to finish the call. No matter what the emotions. We did finish the call and delivered him right to the waiting trauma surgeons who quickly determined there was a liver laceration that would have to take priority.
Shortly after we had another emergency. A 15 year old babysitting his brother while their mother was next door suddenly has an extreme headache. He literally tells his brother to run and get their mom because he feels his brain bleeding. Unresponsive upon our arrival, code 3 transport to the ER with supportive measures being done. He was alive as we delivered him to the ER. No past medical history, all vital signs were normal. CT shortly after showed a massive hemorrhage.
Here’s the crux of the story: A few days later my partner, who had been following the outcome of the two patients, comes into the office and informs me that the 6 year old had survived the surgeries and was progressively improving. The doctors were now being cautiously optimistic and even went so far as to say no neurological deficit had been noted and wasn’t expected.
Can you imagine the elation? We saved the child, we stopped something I felt was inevitable! A complete recovery.
Then my partner told me the 15 year old had died within the hour after we had left the ER. A 15 year old stroke patient. Dead.
It didn’t seem worth it to me, the save was great but I felt the loss extremely.
So for a few years I didn’t go back to get the outcomes of my patients. I did what I could, I followed my protocols, the latest ACLS, PALS, PHTLS, AMLS and any other teachings I could get my hands on. I prided myself on pushing myself for my patients and then as soon as they were completely under the care of the nursing staff at the ER I would forget them.
It took me a long time, but I learned something.
I learned the dead sometimes can still teach us a few things. I learned sometimes being punished, even if it’s by your own self, can be the best mentor. I learned that pain is necessary.
I will continue on why this is important in my next blog.
Thank you for listening.
I’ve said it before, and I’m probably going to say it again many times before my career with EMS is done, we are a young field in the grand scheme of things. I believe some mistakes were made at the inception of EMS and now we are having growing pains. The first thing I’m going to talk about is education. We do more on a full arrest than nurses with 4 year diplomas. I’m serious, depending on the service, you can do intraosseous establishment, intubation, ventilator use (something that requires a respiratory tech in most ERs), rhythm interpretation and appropriate treatment. Some systems have the ability to do rapid sequence intubation, tracheostomy, needle decompressions, and very potent narcotic use. Yet we are still not considered a profession. I have been studying some online classes for my RN degree and have learned something. At the very inception of nurses there were groups of people that were thinking of the future. They were planning and they understood what was going to be needed for future growth as a profession. Where EMS grew out of direct profit and has for a long time been considered a step child to the fire department, nurses were developing guidelines to establish bare minimums. Some of their guidelines included:
1. The minimum education required for a technical nurse was a 2 year degree. Associates. This was developed for registered nurses and could be considered the foot soldiers of nursing. They can do the technical aspects of patient care and even supervise others in patient care.
2. The minimum education required for professional nurse a 4 year degree. Baccalaureate. They can climb the ladder in different facilities and can take more managerial positions.
Now I’m not saying this would instantly benefit all involved in EMS, I’m not even saying that it wouldn’t hurt some systems that have horrible paramedic retention. I am saying that we cannot be a 2 day a week class for 9 months field anymore. We can’t be certificate paramedics. We need to provide routes for currently certified individuals to become nationally certified. We need to guide new students in learning that this field should entail a lifetime of education. We are not fire fighters, we are not police officers. We are EMS and we have the potential to do things medically to people that have far reaching and long standing consequences. I believe that this is a first step in vastly improving our career. I will be posting other steps I believe will help EMS continue to grow and develop into the profession I believe it can be. Now before you completely disagree with me please take a moment and think, could more requirements in education really hurt? Any thoughts? Send them to me below or visit my twitter account @ouremssite. I am eager to hear what some of you think.
Here’s a story:
Me and my partner get sent out for an emergency, chief complaint: sore throat. Now for the most part I am pretty good with dumb calls, I don’t like them and do think they are a tax on our system, but until laws change we have to deal with them. My partner is another matter, he is quick to point something like this out to the patient, doesn’t usually have any effect other than making a patient upset at him but I guess it gives him some satisfaction.
As we approach the scene we see a female patient walking towards the unit and looking panicked. Hives present on her face, neck and chest, that sore throat is actually anaphylaxis. The patient is a 50 year old female with no past medical history, no known allergies, no current medications. In fact when I try to explain an allergic reaction to her it seems she has never heard of it.
We begin treatment and start taking some quick vitals and place patient on an ECG monitor. This turned out to be a very necessary step. I know for my system it is standard practice to place any patient on ECG monitoring whenever any medication is being administered. I also know of many systems that run in BLS or intermediate systems that will administer benadryl and use the Epi pen without cardiac monitoring.
We administered benadryl and oxygen. As we administer epi at 0.3 mg the patient initially reacts as expected, she goes a little tachycardic, she says she can feel the medicine working and it makes her feel anxious. What surprised us was when the patient goes into a run of ventricular tachycardia followed by bigeminy pvcs. It was self limiting and as I took a 12 lead of the patient all ectopy was gone.
As we entered the ER the nursing staff put us into a cardiac room and immediately ordered blood work looking for cardiac markers.
Was it because of the run of ventricular tachycardia? Of course, but why?
Fact of the matter is the patient has just failed a stress test. We, I always say we in my unit, saved this patient not only from the anaphylaxis but we may have also clued her in to a cardiac condition that could have led dormant until it became lethal. This is one of the reasons we should always be monitoring ECG when administering any medications.
Now this I print with a big emphasis towards paramedics. Obviously if you are running a BLS unit or with just an intermediate you should treat anaphylaxis as per your protocol. Epi and benadryl should never be withheld on the basis of no ECG monitor available. I am a big advocate of quick and effective treatment for anaphylaxis as I have seen some patients deteriorate rapidly. As paramedics we should use all of our tools at our disposal, cutting corners on patient care should not become part of our protocol just because we can get away with it.
I added a few pictures of bigeminy pvc’s I found online, I do not own the rights to them.
Today is Thanksgiving and I am spending it with my brothers and sisters in EMS. I am thankful for much, but nothing more than my family who is spending Thanksgiving with the in-laws. I love you.
I am thinking that while America may be going thru some changes and some tough times. We are still growing and trying to become that elusive “something more”. Just like in EMS.
I am thankful for all of you that work in emergency services, for all of us that take this sense of duty seriously, for all of us that have to be ready to respond to the average person’s worst day, on our everyday.
I am thankful for our men and women in the military, while Americans may not always agree on where they are sent, we should never forget the sacrifices they make for all of us.
I am thankful for all of you who read and comment and send me your love, even if it’s just through the electronic means. It humbles me.
Hope you and all of yours are well.
The awards ceremony for Texas EMS were held today in Austin at the EMS Conference. Some of the awards that were announced were:
Hall of Honor (line of duty deaths) – Michael Hatley of Houston, December 29, 2011, and Michael Steffen of Salt Flat, March 12, 2012.
It was a packed house and it reached a near boiling point when the colors were raised and tribute was paid to those that have died in the past year who are our brothers and sisters in emergency situations. I am very proud to say that you could hear a pin drop in the entire area as we stood for the ceremony. As is custom a table was left out for those that have been lost, as we never forget them.
The flags that were given to the families is a small consolation for the loss that they have felt but I believe that any of us know the risk and would feel honored to have our peers stand at attention to say goodbye.
I personally thank each and every one of you that go out there and do this job each and every day. We all know the survival rate for anyone is zero at some point, so let’s enjoy each day and do what we must with spirit and vigor. I feel blessed that I was able to see this ceremony and have to say that as the bagpipes were played while the color guard marched out of the location many in attendance were reminded of those that have gone before their time and wept. They were tears of pain but also of some solace. We were all family in that room at that time.