Afghanistan Dustoff

Asking for it...

I know, I harp on this occasionally, but I guess it is time to do so again. Slow down, people!

Slow. Down.

Mrs. Medic 914 and I were out and about the other day and we came within close proximity of an emergency call. The first emergency vehicle we saw was the fire truck entering the intersection ahead of us. They had both sirens and their air horns operating. The crew in the front was looking both ways as they eased into the intersection. And until they were sure everyone had stopped they did not proceed through. And they had the green light.

Then the ambulance came. Wow. Just…wow.

They came up from behind us. There was a line of cars and we were about fourth in line at the stop light. My wife was looking for them and started to do what the law says to do upon the approach of an emergency vehicle-pull to the right and stop.

Not stop in the middle of the road.

Not pull to the left and stop.

No, GS 20-157 states “ Upon the approach of any law enforcement or fire department vehicle or public or private ambulance or rescue squad emergency service vehicle giving warning signal by appropriate light and by audible bell, siren or exhaust whistle, audible under normal conditions from a distance not less than 1000 feet, the driver of every other vehicle shall immediately drive the same to a position as near as possible and parallel to the right‑hand edge or curb, clear of any intersection of streets or highways, and shall stop and remain in such position unless otherwise directed by a law enforcement or traffic officer until law enforcement or fire department vehicle or public or private ambulance or rescue squad emergency service vehicle shall have passed.”

So there you have it.

Anyway, as Mrs. 9-ECHO-1 was looking for this approaching emergency vehicle, she began to do what she was required by loaw to do. Pull to the right. Well, it is a good thing I happened to look in the mirror when I did. She had just looked in the right side mirror, saw that it was clear, and was checking the left side mirror, when I saw it and said “stop!”. Actually, I said “SHIT! STOP!”

Because there it was, coming up on the right- an ambulance coming up on the right at a pretty good clip. They went passed us on the right and then blew through the intersection. Actually, they passed us fast enough that the turbulence caused in the air shook our Tahoe.

There was at least one other car in our line that also almost pulled to the right and stop, as prescribed by law.

After Mario Andretti passed us we went forward with the rest of traffic, all the while making sure that another emergency vehicle was not coming from any direction. As we went through the intersection I looked at the front vehicle in line on the right as she pulled in front of us without looking, against the red light- late model Honda Odyssey with the driver (what we called a ‘soccer mom’ a few years ago) chatting away on the cell phone and what looked to be at least five young children (apparently unrestrained) in the front and back seats of the vehicle.

That would have been nice.

So why the big deal?

A lot of us just assume that everyone will hear our sirens and see the flashing lights. In this case we did not actually see ambulance until they were about two car lengths behind us and I barely heard the siren until they were just about on us (we had our radio on with all of the windows down and the sunroof open; they had their siren on ‘yelp’). If we had pulled over, as the law requires us to do, would two car lengths been enough room to stop a Chevrolet G4500 type II ambulance? Not hardly.

And who would have been cited in that instance? I am not sure who would have gotten the ticket, but I am pretty sure even a mediocre lawyer would have gotten me and the missus a good settlement. Maybe a new 2011 Dodge Challenger…

And what if that minivan had pulled out? Sure, she would have been at fault, but how would you like knowing you just plowed into a minivan full of kids? Especially if you could have prevented it by slowing your ass down a little bit! That would be a helluva picture to keep in your mind- your ambulance smacking that minivan and those kids flying out the other side…

Based on all of the research I see out there these days suggests that we don’t save lives by driving real fast. And we only save a very minute amount of time by using lights and sirens. And nowhere in our protocols (or anyone else’s, for that matter, do I see “drive real fast” as a treatment option.

When we are responding to emergency calls we need to keep in mind that the other people may or may not do what they are supposed to do. They may pull to the right. They may pull to the left. They may just stop. I have even seen them try and outrun us to the next intersection so they can pull over there (and block the intersection as prohibited by GS20-157!).

They may hear your siren. They may see your flashing lights. But I wouldn’t count on it. You see, with all of the so-called advances in our emergency warning systems, the sound insulation, sound systems, and tinted glass advances on today’s cars have made more advances, as well.

If you are driving ‘hot’ to a call, slow down. Those few seconds you are going to save probably are not clinically significant. Your ability to go home at the end of your shift should be your main priority. My ability (and my partner’s) to go home at the end of my (our) shift is mine- all other concerns are secondary.

And that means slowing down.

Anytime you are coming up behind traffic, slow down. You never know what they will do.

Anytime you are coming up on a controlled intersection, slow down. Just because you have the green light does not mean that the other people will not do something, well, stupid.

Anytime you are driving through an area with a lot of driveways, slow down. You never know who will back out of a drive way. And a lot of driveways mean houses, and there may be kids who will run out to see what all of the sirens are about. So slow down.

And that electronic siren you have on that ambulance? Set it on wail. Leave it. Stop playing with it. ‘ET’ can’t hear you. People will have a better chance of hearing you if you do.

Pay attention...it's in the little details!

I don’t normally cite recent calls in my blogs, but, well, this one’s important. If you think you were with me, you weren’t. If you think you were the patient, you weren’t. If you think you know when this call took place, you don’t. So now that the disclaimer is out of the way…

A while back my unit was dispatched to a local assisted living facility for an ‘abdominal pain’, downgraded to an ‘alpha’ response (1A1) just after dispatch. Now, typically, when that comes over the MDT and the announcement comes from dispatch, you can sometimes hear the groans in the ambulance. Just sayin’.

So the patient presents as an elderly person complaining of lower abdominal pain. The patient is walking the halls of the facility because ‘it hurts to sit down’. The pain has been going on since early afternoon (it is now early evening, five hours after onset. A quick assessment showed a conscious and alert patient, oriented to person, place, time, and event. Vital signs were unremarkable (BP 132/84, HR 74, RR16, SPO2 99% room air, FSBG 126, ECG sinus rhythm). Skin was warm and dry with good color. There was a little lower abdominal distension and tenderness, and no history of nausea, vomiting, and diarrhea.

We determined hospital destination, placed the patient on the stretcher, gathered our paperwork, and began our 15-20 minute transport. During the transport, my preceptee (I’ll call him Jeffro) initiated an IV and got an ECG and 12-lead.

Now, I know a lot of paramedics that right about now would have sat down in the ‘captain seat’ and started on their report. Jeffro couldn’t because I was sitting there. Besides, I push my preceptees to maintain a rapport with the patient and since this one was C&A&O, it was easy to do.

Part of the way during transport Jeffro noticed that the patient’s speech started slurring. He went ahead and performed a stroke screen and sure enough determined right sided weakness, right facial droop, and the already noted slurring. We notified the ED of the original complaint and our latest findings, along with out less than five minute ETA. After a quick exam backed up our en-route findings, a ‘Code Stroke’ was called.

So how did it turn out? Turns out the patient had a prior history of CVA (the facility’s paperwork conveniently neglected to tell us that, as did the staff) and was subject to transient episodes of the slurred speech and right sided weakness two or three times a day. This was confirmed by the family and the patient’s primary care physician (of course, the facility did not tell us about that, either).

Anyway, my point is that this patient’s condition changed in a way unrelated to the original complaint. And until the information was obtained a while later, there was no way we could have known that this was not in fact a stroke.

So what would have happened had my preceptee/partner taken the route of least resistance and plopped his a** in the captain chair and typed away? I know of at least one instance in my system where this happened, except the patient had ARRESTED and the medic did not know it. That is, not until they got to the ED and saw that sort of ‘dead look’ on the patient’s face.

I know, it is the path of least resistance. And I know the supervisors are always wanting us to clear the hospital in a hurry (some services and systems around these parts have a stopwatch running as soon as they get to the ED). And sometimes it is hard to carry on a conversation with someone in their 70s or 80s when you are in your 20s. But that is one of those things that is a part of your job. And I bet they did not tell you that in EMT school, did they?

Pay attention to little details. Just because the call started out as an abdominal pain doesn’t mean it is going to stay that way. Just like it is important to get more than one 12-lead, complete more than one stroke screen, and keep reassessing vital signs.

Because things change.

And if you don’t want to be the subject of blog fodder (merciless they are sometimes) or even the six o’clock news, you need to be on top of those changes.

Taking Care of People…

Over on The Happy Medic, San Francisco Fire Department Paramedic Justin Schorr writes about his family’s recent experience with a child’s medical emergency. And of course, Justin zeroes in on some EMS related issues. Be sure and go over to read his blog. Good stuff, it is.

But anyways, it kind of got me to thinking. How well do we really take care of people?

It depends upon what you think it involves. Of course, we have protocols to follow, skills to do, and on and on and on. But there are other things that we need to do that are just as important. And they have nothing to do with starting an IV, reading a 12-lead, or any of that other stuff you learned (hopefully) in paramedic (or EMT) school. It’s all about how you take care of people.

Justin mentioned something in his blog about warming a stethoscope. So just how many times do you take the time to warm up a stethoscope before you place it on a patient? Especially in the winter time when it has been hanging in the back of an ambulance, probably on that catch-all-netting at the head of the bench. Even when it is wrapped around your neck it gets cold. Little kids and elderly patients are kind of sensitive to that cold stethoscope. And guess who makes up a large number of our patients? Yep, you got it. So take a few seconds, tuck the bell under your arm. Probably would be a good thing to do when you are introducing yourself to your patient. You do introduce yourself to your patient, don’t you?

Over on 9-ECHO-1, I mentioned that the entrance to Walmart is smoother than the entrance to most of this area’s Emergency Departments. So, do you take it easy over those entrances, or just bump on across? Based upon what I have seen, most of us just bump on across. Probably feels really good with that broken hip, bone cancer, or any one of many maladies that hurt when you move. 

And when entering the ambulance entrance to several of the area EDs, it seems that the worse part of the trip is when you are turning into the ED. And we know doubt know it since we do it enough. So how many of you just turn on in, bumping and swaying? And how many of you think about your patient (and partner) in the back of the specialty vehicle you are driving that is NOT known for its smooth ride? If you are the one that just drives on in without consideration for your passengers, I bet you are the one that does not slow down and ease across railroad tracks as well.

But what about other things along the lines of ‘taking care of people’?

Do you explain what you are going to do and why you are going to do it? As I get older I am exposed to the healthcare system just a little bit more. At my colonoscopy I saw a wide variety of ‘explaining’ and the lack thereof. The nurse that started my IV had a good technique (well, her tourniquet technique sucked) but she barked out orders like Gunnery Sergeant Hartman- “Put your arm down”, “Make a fist”, “Hold still”. And when she was done she just walked away. Oh yeah, and there was that introduction- “I’m gonna start your IV”.

Well, she did tell me what she was going to do. And what do to. In no uncertain terms. But ‘why’ would have been nice. So would a personality.

I always tell my patient (even if they are unconscious) what I am going to do, why I am doing it, if it’s going to hurt, etc. And you should too. It is part of the reassuring process. For a lot of people (I like to think most of them) the whole process of getting hurt or sick and calling 9-1-1 is a pretty stressful and frightening event. A big part of our job is reassuring them and alleviating their fears. And to do that you must tell them what you are doing, why you are doing it, and quite frankly, if something is going to hurt. Before we do it.

And how well do you ‘relate’ to your patient? You know, that rapport that you have to establish early on to gain their confidence. I have seen some people that are really good at it, while others…well, some people are really good at it. It’s all of the stuff above, and a little more. In my old system we used Panasonic TOUGHBOOK laptops to complete our call reports. And there was a natural tendency to type as you rode. And that is OK if you can pull it off. By 'pull it off' I mean that you have to maintain that rapport, that relationship, with the patient. And that means you have to talk to them. Pay attention to them. And, egads, reassess them.

Reassess means more than let the Zoll's blood pressure monitor recycle every few minutes and take a look at the pulse oximeter reading every few minutes or so. It means talking to them. It means asking them if they feel better, if the oxygen is helping them. Of if they’re feeling worse. And you CAN’T sit in the ‘captain seat’ and do that. And sitting in that captain seat, typing away, and asking your patient, from behind them, without making eye contact, if they are OK, to me, is worse.

Taking care of people is a total package. Sure, starting that IV and reading that 12-lead is important. But being nice (because nice matters) is just as important. Maybe more so. In the end, it is the total package that matters. It is the total ‘A’ game.

And you have to bring that total ‘A’ game to every call, every time.

Anything less is not doing your patients (or their families) any favors.

Stroke stuff...

Don't you just love it when the powers-that-be try to make everything fit into a simplified process? Kind of like everyone thinking that the Cincinatti Stroke Screen is the end-all and be-all to assessing a potential stroke patient.


"A good man's got to know his limitations" H Callahan.

Well, it IS useful. And pretty good to use MOST of the time. But it does have it's limitations. Seems that there are those other times, that, well, just tend to screw up plan A.

Over on Ambulance Driver's site, he recently entered this reminder that everybody does not fit into the 'normal' parameters and sometimes, well, you just gotta think about stuff.

Over on Paramedicine 101...

...there is a good post about professionalism. Mostly, it is about how we conduct ourselves in front of our patients. It is must reading for all of you.

WAIL-YELP-WAIL-YELP-WAIL-YELP-CHIRP-CHIRP-CHIRP-WAIL-YELP-WAIL-YELP

This afternoon me and my other half were out and about. At one point we were sitting at a stop light in the second biggest city in our county, in front of the great big mall. Now we were sitting on the front row at the stoplight when I saw RESCUE 2 coming down the road with red lights going. There was a moderate amount of traffic and on their approach they went to the outside lane (passing on the right). As they approached, out of curiosity, I turned down the radio.

After they passed, I asked the missus when she heard the siren. The same time that I did- after they were already in the intersection.
Later, we were in another one of the smaller towns, sitting at another stop light, when I heard a siren approaching from the rear. I looked in my rear view mirror and saw a deputy sheriff approach from behind. As he approached he came up on my left, stopped, then eased out into the intersection before proceeding.

I heard him coming from a distance of about one and a half football fields.
The difference? The fire unit had their siren on yelp. The deputy had his on wail.

And we had the radio in the Tahoe turned up so we could listen to the hockey game when the deputy approached.

I don’t know the science behind it. But at some point we were taught that this crap of changing tones and stuff made us more easily heard. That it would move traffic out of our way better. That it was safer.

Purely anecdotal evidence at this point, but it holds up time after time after time.

I know. I harp on this. A lot.

But it is amazing how many wrecks involving emergency vehicles I have heard of that the other driver “never heard them coming”. On yelp. Or phaser. Or that cutesy switching back and forth stuff.