It's Bothering Me

I worked an overnight last night.  That in itself isn't unusual or a problem it just happened, or didn't happen.

We had meetings during the day and wound up heading home for a few hours prior to my shift.  You know the drill.  Help with homework, clean up, talk a few minutes and head down to check the equipment. Everything finished and fall asleep watching TV.

Awake to "Get up! We have a call."  Didn't hear the alert tone, the dispatch, anything.  Just my partner trying to cut through my sleep induced stupor.  Luckily my autopilot is not broken and I got us to, through, and away from the call.  It was a three hour job with clean up and restocking.

I still can't tell you anything about the call.  It's like I was sleep walking through the entire night.  I've heard about this happening to people, even made fun of people it happened to, but never to me.  Chalk it up to being tired, a good dream, or whatever they say to me.  It occurs to me that I am getting old.

My dad stayed on after I became a fireman.  He pushed cajoled, and taught me common sense all while making sure I was learning the cutting edge as it became available.  I am holding out for my son or daughter in the same way.  I wanted to work together, share, and bond.  I'm just not sure.  I'm just so damn tired.

The One that Didn't Get Away

OK, in keeping with my summer of frivolity I am sharing from the heart on this one.  Pun intended.

I first learned CPR in the early seventies.  It was a great time to start into this thing, EMS, that was truly in its infancy.  We all thought that with a Red Cross First Aid Card and a CPR card we could save the world.  And we were chafing at the bit to do just that.

As time progressed the Gold Standard was thrust upon us and Roy and Johnny saved pretty much everyone that they even walked past.  We even had an occasional save in our greater metropolitan area.  Then Para-medicine arrived for us and greater strides were made toward sporadically beating the Grim Reaper.  Fellow ambulance drivers, attendants, firemen, EMTs, and even Paramedics had their favorite story about the one that didn't get away.  I wanted to tell you mine...but I didn't have one I could share.

Not that for 34 years I haven't tried.  I've tried in Cadillac ambulances, Ford Ambuwagons, van ambulances, Type 1, 2, and 3 ambulances.  Responding from home, with ALS, as ALS, together with fixed and rotary wing medical transportation.  Even with an untold number of rescue vehicles and a more traditional walking or hiking into the scene.  All adding up to a big zero.  Hell I think that the local funeral homes sent me Christmas cards just so I could keep funneling business to them.

It's getting so bad now that I was asked to drive the ambulance to one CPR in progress so that the crew could show me how it's done.  They failed, my string continues.  My partners and coworkers immediately kiss off any chance of resuscitation as soon as I buckle in with them.  They talk in hushed tones about the Doctor Kevorkian of EMS, The Streak, Bad Luck Pete, and use some names that decorum will not allow me to quote.

I think that I first became aware of my issue in college.  As I recall even at that young age I was already well known for my lack of prowess in CPR.  At that time there was a ubiquitous CPR poster that literally hung everywhere that screamed in large bold print "CPR SAVES LIVES!"  Underneath that exclamation was added with black magic marker "Just Ask Pete."  To this day my friends from there specifically have me penciled in their  living wills as CPR provider of choice so they can rest assured that they won't be saved and end up a vegetable from the experience.  

Well in the last two weeks we have had four opportunities to practice our craft.  Three of them I was the crew chief on duty.  We all know how they turned out.  But the other one was different.  It was different in many ways, including the outcome

My son wants to be a pre-hospital RN PHRN.  He wants to fly and bask in the glory of aeromedical nirvana.  He wants this so bad that he hangs around the ambulance begging to go on calls, wanting to help in any way he can just to become inculcated into the EMS System.  Often because he is so persistent he is allowed to ride along and occasionally he helps with lifting or some other menial job that really means the world to him.  In other words he has it bad and the guys are willing to coach him along.

Every year we are directed to stand by at the county fair for the throngs of people that come to milk the cows, ride the horses, and slip something to the sheep.  It is as boring as it gets and the people that approach us with every suspected critical emergency are generally let down easily with an ice pack or band aid.  Not this year.  Re-Pete, as my son is called, finagled his way on to the ambulance for stand by, and free entrance to the fair, was seated on the back bumper with a blue ribbon smile on his face that no one could come a close second to as someone ran up and said a man was laying in the parking lot between two cars breathing weird.  By the time the crew put down their funnel cakes, dumped their five dollar fresh squeezed lemonade, and got ready to respond Re-Pete was gone.

As the crew arrived at the parking lot they heard the canned voice from an AED say "analyzing don't touch patient."  Re-Pete ran to the lot, grabbed an AED and started care for the poor old gent.  The next thing the gathering crowd hears is "Shock Advised, Push to Shock."  Go ahead Re-Pete they say and he gets his first cardioversion right there between the cars.  Normal Sinus Rhythm.  ALS is there and the whole crew, including Re-Pete take off for the hospital at Warp 8.

I couldn't be more proud, oh yeah of my son, but more importantly that whatever I have is not passed on via any hereditary process.  Re-Pete 1 for 1 and dad 0 for 34 years. Maybe I'll just bask in his glory for a while.  The one that didn't get away.

I've Fried, and I Can't Get Up.

OK, I'm over 300 in dog years and I get irritated pretty quickly these days.  But how would you know that?  Well, if I enter the restaurant that you chose for a nice quiet meal with your spouse, significant other, friend, or concubine you should pick up certain clues.  Like I am dressed up in my custom tailored Nomex suit of clothes made by Globe. I double parked out front and left the lights on, I wear a hat and am not Jewish.  A number of my coworkers come in with me and we don't wait for the Maitre D' to seat us.  We are all dressed the same, smell, and pretty much takeover when we arrive.
Now is a good time to pay attention.  I don't want to be here.  Someone took me away from my meal by making loud noises and implying that I had to get to this restaurant immediately, or sooner.  Someone else irritated me on my way here by ignoring my simple request to follow the law and pull to the right.  And a guy on a bike, that tried to pass me on the right when we were slowing down out front, claims that I purposefully opened my door just as he was getting to it so he would be knocked down.  By the way steel shank boots allow me to feel nothing as they crush bicycle spokes.
But yet all of that built up tension becomes just an afterthought as we walk toward the kitchen and are met with smoke and yellow flickering light emanating from the double doors.  I smile my Grinch-Like smile and speak in a loud voice "masks, utilities, open up, get-em the hell out of here.
This is how the kitchen looked as the cook and dishwasher ran out.  I'm not sure which one took the picture.

It wasn't too much larger than that when we arrived.

Yeah, we put it out in like five minutes.  It would have been three minutes but I heard with my less than Bionic hearing, the patrons arguing with the truck company about leaving their dinner.  As I re-entered the dining room it was what you would call a pivotal moment.  In my most officious voice I said "Sir, get out there's a fire."  No, I don't see any flames.  "Squad, grab the chair he can't walk."  These two huge hulks of men grabbed his chair, hoisted it to chest height and carried him out complaining all the way.  Yep, there goes my chance at the lead roll in the sequel to Captain America.  Everyone else in the place immediately scattered. Except for this quite beautiful young lady that was seated at the table with pain in the butt.

The new guy on the squad took off his glove and said "Miss, may I escort you to safety?"  She took his hand and left.  He'll probably get a medal for the rescue of a woman in a life threatening situation.  I know he got her phone number.

As we are picking up people are allowed to come back in for their things, and to finish their now lukewarm dinners.  Mostly we get thanks and a few pictures.  But Mr. Pain is still outside asking for my immediate arrest for a list of purported personal violations so lengthy that I can't really keep up with him.  I ask the cop if Mr. Pain would trade his single count of failing to follow the lawful order for the laundry list he has against me?  It's an open and shut case.

Anyway, he leaves alone, the young lady in the dress that has less fabric in it than my Nomex hood, catches another ride home giggling and melting all of our collective hearts.  And we head back to rewarmed something or other.  Yeah, maybe I can get through the rest of the day without too much crankiness.  Shoot, now I have to do the paperwork.

Motorcycle Helmets

In NY State near my cousin's home there was a rally against the state helmet law.  This sums it up for me:
The motorcyclist, 55-year-old Mr. X likely would have survived the accident if he'd been wearing a helmet, state troopers said.
Irony, Darwin, Karma, and other snarky comments just can't bring the guy back.  But a helmet would have avoided the problem.

Sprinklers in Private Dwellings from Firegeezer.com

If You Can't Trust Your Homebuilder, Who Can You Trust?

ON AUGUST 19, 2010, THE MAINE Building Codes and Standards Board met in Augusta and heard public testimony on the proposed new building code that would require residential sprinklers in new single-family homes.  Excerpted from the minutes we read:

Mark Patterson, President of Maine Home Builders and Remodelers Association of Maine. (MHBRA). testifies: "MHBRA is not in favor of making sprinklers mandatory due to the costs which are estimated to be between $4,000 – $8,000."

*  *  *  *  *

ON JULY 1, 2011 THE PORTLAND PRESS HERALD is reporting:

The fire broke out at about 9 p.m. at the home of Mark Patterson, co-owner of PATCO Construction, a residential and commercial construction company based in Sanford.

FGNS photo

The nearest hydrant was a half mile away, so Cushing ordered tanker trucks to set up a water shuttle. The roof collapsed and the second floor collapsed into the first, he said.

The house had no sprinklers installed and was a total loss according to the Sanford Fire Department.

I don't just appropriate content from others but this was so good I had to get it on ASAP.

Covered Wagon MCI

Over the course of the last few weeks the Ambulance has been preparing to be a part of a local Mass Casualty Incident (MCI) drill.  In fact we were quite excited about this particular drill because we had recently completed MCI training with A. J. Heightman and were ready to practice what we learned.  The focus of the drill was the gas drilling industry that recently has taken our area by storm.  As with all our local drills it included county EMS, Fire, Rescue and the Hospital ER and their hospital based ALS staff.  In addition the Dept of Environmental Resources and regional representatives of gas drilling companies were also expected to assess their abilities during this drill.  The drill was scheduled June 2, 2011, at 1700.

At 1759 on June 2, 2011, dispatchers from the Communications Center began dispatching a rescue call.  During the initial parts of the dispatch everyone assumed that the drill had started late and expected to hear the common “this is a drill” appended to the end of the dispatch.  As we listened to the quiet and calm voice of the dispatcher we began to realize that the things we knew about the drill did not agree with the details in the dispatch.  Station 1 and 10, Medic 1 and 2, four helicopters, in the park for a tree fallen on a covered wagon, multiple injuries, with entrapment.  This is a senior travel group.

Response was nearly instantaneous with the EMS Chief and Assistant Fire Chief  first to contact the communications center.  Further information was relayed to them and they requested two additional BLS ambulances  which had already staged at the scene of the drill only a few miles from us, and BLS ambulances from two other stations the next closest BLS units to the scene.

We responded with our preplanned units for calls in the canyon with two ambulances, a four wheel drive squad, and heavy rescue.  These units were immediately followed up by a rescue engine, ambulance, and another engine to assist with the landing zone for the helicopters.  Station 10  also part of the preplan for rescue responses in the canyon responded simultaneously with equivalent units.

As all the units responded the 11 miles to the access area for the rails to trails hiking and nature area additional information was forwarded by the dispatchers.  Two horse drawn wagons were part of a tour with only one wagon suffering a direct hit by a large falling oak tree.   Callers estimated that more than 20 elderly people were on the covered wagon that was hit and several were severely injured and entrapped under the tree.  At that point helicopters from Western Pennsylvania were put on standby and additional ALS and BLS units were contacted in New York State to determine availability.  BLS units from within the county were also moved up to cover stations closer to the scene.

After gaining access to the trail the Asst. Chief arrived on scene first and set up Command.   The trail consists of an old double track Conrail mainline where the tracks have been removed and the railroad bed upgraded for hiking, biking, and horseback riding.  It is a much visited scenic area with gated access for motorized vehicles.  Another Assistant Chief was identified as staging officer and set up EMS and Rescue staging at the access parking area near the trail entrance.

Medic units proceeded to the wagon and set up initial triage about .75 miles from the access area.  EMS Chief  assumed EMS Branch with paramedics taking roles in both triage and augmenting BLS units with patient treatment.  Needed medical equipment was stripped from the first in ambulances and the SMART triage system was initiated.

Initial triage showed 10 total injuries and 10 other non-injured but stressed fellow riders.  Three of the injuries were triaged as immediate and 7 as delayed.   There were no patients trapped.

One ambulance each from three stations left for the landing zone with one immediate patient accompanied by ALS.  The landing zone was set up at the Airport approximately three miles from the scene.  It afforded the LZ officer the luxury of landing multiple helicopters in a safe easily accessed area with backup radio contact available via airport officials.  The helicopters all flew to the area’s closest trauma facility.

Seven other ambulances each transported one patient to the ER and returned to their respective stations.  After transporting a patient to the airport one ambulance continued on to the ER with the spouse who reported not feeling well.  A total of 11 patients were transported and 9 others sent to secondary triage prior to getting back on their bus.

Transparent to the patients there were a number of things that allowed this brief, less than three hour MCI to dovetail into a smooth effective operation.

 I had already mentioned that two months prior A. J. Heightman held his MCI class at our station allowing us a real opportunity to practice working an MCI and setting up a true EMS command structure.

·         Our Regional Medical Council provided SMART triage tags for our use on all ambulance calls during National EMS Week in May allowing all BLS staff a recent opportunity to practice with the tags, ALS staff to re-triage patients during that week, and ER staff to become familiar with the use of the tags.

·         The coincidence of having an MCI drill scheduled for virtually the same time and date allowed a quicker response for our units that were already manned and ready to report to the drill.

·         Due to the distance from populated areas our scene was easily secured and police and state park personnel had little or no trouble with on lookers.

What we learned.

·         You cannot overestimate the assistance that your communications center can provide.  They simultaneously dispatched on two frequencies, provided updates while we responded, set up medical channels, contacted medical helicopters, made an unknown number of important phone calls including state and local notifications, and generally used their collective expertise to stay one step ahead of our requests.

·         Stations that regularly respond as a cohesive group from opposite sides of the canyon to provide technical rescue and medical services to park visitors.  Knowing and having confidence in those coming to help you reduces some of the initial stress.

·         Scene control is important, even in the middle of nowhere.

·         It is much better to call for resources early than to need them when they still have an extended ETA.

·         And, that much of the work takes place after the incident is complete as ambulances are restocked, rescue and fire vehicles are again made whole, and the paperwork is completed.

Forward to the Past

If you remember the "Orange Book" you are officially older than dirt.  This year is its 40th anniversary and for the 1970s there was no other source for minting an EMT other than this book and hours of hands on practice.  As I recall those men and women that blazed the first steps for us from ambulance driver to EMS I am indebted to them for what they accomplished without OPQRST.

We came from funeral home based transport, to first aid, through the national introduction of paramedics and EMTs, and landed professionally where we are now.  Not always appreciated but at least an important cog in the emergency medical wheel.  Who cares?  Well, we are heading back to our roots.  OK, not as far back as those nice riding Cadillac ambulances but far enough so it is deja vu all over again.

This year the Brady company purveyor of those things printed for the EMS community has determined, with the help of learned scholars and an update in the National EMT Curriculum, that the thing we we now call the practice of prehospital care needs to have its pathophysiology adjusted.  We came, we saw, we memorized, we neumonic-ized and we prioritized.  Yet we never got to the critical thinking phase of the care we provided.  

This update will take care of that.  Instead of treating signs and symptoms we are instructed to delve deeper into a "body systems approach."  This will create a "reinforcement of the critical thinking and differential diagnosis processes for the EMT while completing a medical assessment and developing a patient care plan." The quotes are from The Transition by J Mistovich.  So in other words gain insight into the patients condition by obtaining a patient history.  Perform a primary and secondary survey and reassess the patient during transportation.  No more initial assessment, focused history and physical exam, and ongoing assessment.

I couldn't have said it better myself, of course the orange book did 40 years ago.  How nice to have been doing it correctly for all of those years.  Thanks for confirming my unscientific 40 year study affectionately named "Shut up and listen to what the guy/lady is telling you."  Yes I do know what I'm doing...and I'm older than dirt.