First Snowmageddon of the Year

Dear inventors of sandbags, 4 wheel drive, all terrain tires, and snow windshield wipers - my pickup truck and I would like to take a moment to thank you for getting us home last night in that blizzard. Also, thanks to all those folks with the flashing yellow lights and big ol' plows who like to slow us down on the highway. (I really do appreciate you guys... It's just a lingering jealousy that I don't have a plow and am stuck shoveling myself out...)

Seriously, though. If I'd been trapped at work, they would've had me on the road all night.

For all you crazy kids out there in this mess, be careful. Our big box truck stood the test today because nearly all of the roads we needed were plowed. Traction control can only do so much, if you even have it. The amount of ice that built up in our windshield wipers, and on our windshield as a result, made both my partner and I get completely turned around on two separate calls. And the wind... don't get me started on the wind.

I know you want to speed to that cardiac arrest. We did, too. Even after that sedan fishtailed partway into our lane while trying to pull to the right and scared the shit out of us.

But you know what? We got there in one piece, and the patient got to the hospital in one piece. No police officers, firefighters, medics, EMTs, family members or innocent bystanders were injured in the process.

Remember: Slow acceleration, slow deceleration, 3x the space you'd normally leave between yourself and the car in front of you. Drive like everyone else on the road is about to do something incredibly stupid. If you're responding to an MVA, chances are you'll be driving over the slippery sections that your patient lost control on. When you're out on scene, expect other cars on the road to be losing control on those same spots and stage appropriately. (This includes other first responders! That firetruck may not actually be able to stop. Get word to them via dispatch if possible.) Block the entire road if necessary until DOT trucks get there to clean things up. Level Zero is also known as: don't be stupid, because you of all people know that there is no one to save your sorry butt.

Snow can be very fun when you're off-duty:




BUT THIS IS WHAT IT LOOKS LIKE AT WORK:




Be safe. And bring your own shovel if your truck doesn't have one. <3

Texts From Last Night

It's almost finals. I'm sitting on a few real posts, but here's what I've mostly been doing with my (not) free time. For those of you who don't know, this website is an epically distracting collection of drunk text messages. And proof that we will always have job security. :)

As it pertains to us:

EMT / Paramedic /Ambulance

Hospital / Nurse / Doctor

Firefighter / Firetruck / Fire

Police / Cop


*Note: May not be suitable for work.

So You Thought Your Job Was Dangerous...

We all have some type of cellphone tower within our areas. This video was shot in the USA, and yes, he is free climbing for most of this, against OSHA regulations (ignore what the video says). And it's called a Guyed Tower, not a "Gided Tower".

But how would you respond if he had a medical emergency while properly secured at 1,768 feet? Or got hit by lightning at 1,768 feet? Or had a partial fall from 1,768 feet while secured, which resulted in a spinal injury? What if he hit his partner on the way down and you now have 2 patients?

Tower workers go through training for how to rescue one another at those heights. That guy holding the red tool bag is going to be your point man if anything were to happen to his partner. From what you can see, they travel light, so they won't have much medical equipment readily available. Does anyone do interdepartmental training with their local tower workers? Do your departments have protocols for how to handle these scenarios?

Personally, that's when I call the boys with the big red trucks. They have ladders bigger than the Empire State Building, right?




There's a good discussion about the technicalities of these towers HERE.

Paramedic-Assist

I am now licensed to stab you.

In the name of medicine, of course.


[Credits]

In New York State, EMT-Bs are allowed to play with glucometers if their agency has approval and provides training. Unfortunately, New York City has their own protocols, which don't allow glucometers to be used by BLS providers.

Up here in Massachusetts, glucometers are included in a separate Paramedic-Assist Certification. Which my job made me get. :) So I not only get to stab you to check your glucose levels, I also get to stick on EKG electrodes, secure ET tubes and do basic IV prep (spiking the bag, taping down the catheter). It also covers albuterol nebulizers, which are a regular EMT-B skill in New York.

The upside? More challenging calls. The downside? More cleanup.


For more reading:

How to Use a Glucometer - About.com

New York State Glucometer Protocol

Massachusetts Protocols

E4

My brand new Specialist is alive and well, and still has all her limbs attached in their proper places. She's flying back to the 'Stan tonight for another few months. We've got a last date to send care packages and everything. Cross your fingers that the brass actually sticks to their word this time.

While I was off having epic adventures, I was also contemplating the fact that I now work in a large town in a smallish state, where every department knows every other department's business. So when I go to statcounter and find that local folks have been visiting my blog, I can't really go gushing about how freaking awesome my new training is. (It's pretty awesome.)

Yes, ladies and gentlemen, I am stalking you, too.

And I have one question...


(Click to supah-size)

...Kuwait? Really?


PS: Props to Medic 999 for the linkage. :)

Getting Me Some Of This

...for 2 whole weeks of R&R. In New York City until further notice. <3

Esophageal Varices

Hey, remember this guy? That was my first real emergency, the first time I called in a note to the ER, and the first time I left a hospital knowing my patient's chances for survival were next to nil.

Well, I just learned all about what was wrong with him.

Upper GI Bleed is the vague overarching chief complaint for our paperwork. Or, as I put it at the time, Severe Bleeding from Nose and Mouth. Upper gastrointestinal bleeds usually present as coffee-ground emesis and a seriously unforgettable stench. To me, it smells like heavy metals. Like iron and something worse are so thick in the air that you can taste them.

The gentleman in question had a profuse amount of bright red blood gushing from his mouth and nose. He was so far gone in his dementia that he refused to unclench his teeth. We suctioned what we could, but anything more would've involved breaking his jaw. We couldn't drop an NPA with the amount of blood coming out of his face. For all we knew, he could've been hemorrhaging from his sinuses. We transported him left lateral recumbent with a layer of extra towels to catch the blood flow, and I held the NRB a centimeter away from his face enroute, to give me room to suction and him room to spit. The sheer terror in his eyes scared me more than anything, because he had no way of comprehending what was happening, why he couldn't talk, or where we were taking him. Trying to hold someone's hand, an NRB and a suction catheter all at the same time is not an easy accomplishment.

But back to the actual physiology, and not just Rookie Birdie peeing her pants.

Chronic liver disease (often cirrhosis caused by alcohol abuse), can obstruct normal blood flow through the liver. This makes the blood flow in your body backup, distending your finer blood vessels. In my patient's case, the ones in his esophagus. The technical name for these is Esophageal Varices. Being distended vessels, they're prone to rupture.

Ta-da! Upper GI Bleed.


For more reading:

Esophageal Varices - Mayo Clinic

Bleeding Esophageal Varices - National Institutes of Health

Bleeding Esophageal Varices - New England Journal of Medicine
*Note: REALLY COOL ENDOSCOPY VIDEO

Employment Win

Guess who has a job? Meeeeeeeeeeeeeeeeeeeee.

And I get one of these:


[Credits]

And one of these:


[Credits]

And some of these:


[Credits]

Thank you, Commonwealth of Massachusetts. That 3-week withdrawal from emergency medicine was BRUTAL.

Please Don't Text And Drive

To the idiot in the Jeep in front of me on the highway this afternoon:

1. We were in the middle of a monsoon.

2. We were doing more than 40 mph.

3. One of your headlights was out.

4. You were texting and driving. I could see your phone.

5. You were swerving into the other north bound lane AND the oncoming south bound lane.

6. I was playing this really fun game called preemptive triage via possible mechanism of injury.

7. I realized I only have one oxygen tank in my truck. Somebody (or -bodies) would've been SOL.

8. The game got even more fun when I started keeping my foot over my brake and looking at ideal places for you to crash based on room for staging areas.

9. During that really awesome drift/swerve where you were almost entirely in the south bound lane, I concluded that I didn't want to get out of my truck in the rain.

10. Thank you very much for getting back in your lane and putting away your phone after I leaned on my horn and flashed my brights.

By the way, I really liked the 'oh shit' expression on your face when you realized you were on the wrong side of the road. And the followup expression when you looked in your rearview and saw that I was wearing a blue uniform jacket and aviators.

Because if you hadn't put away your phone, your license plate number and vehicle description were 2 seconds away from being broadcast over 9-1-1 dispatch.


PS: I hope you got home and hugged your family.

Emesis

I missed college. I missed classes. I missed my friends. I missed college parties.

I missed volunteering to be vomited on at least once a week with our campus EMS squad. I missed my friends calling my cellphone instead of the Public Safety department and our official dispatchers, in a drunkenly sensible attempt to avoid being "reported" for drinking. Particularly if the soon-to-be patient is underage.

If I'm on duty, I have to radio my partner for backup because we're usually on opposite sides of the campus, and our radio system involves everyone on our frequency hearing everything. Nevermind that I have to call Public Safety anyways to let them know where and what I'm doing.

We are not the FBI. This is not going on your permanent record. You are not going to get expelled. No one is calling your parents. And hopefully no one is using the video recorder on their iPhone.

If you are sick enough to require more medical attention than we can provide, the fire station across the street will be glad to take you to the local ER. It's only 5 minutes away, and we can go with you if you want someone familiar holding back your hair enroute. The firefighters even stock these, just for us college kids. And they order extras right before our big annual parties.



Now that is what I call a good mutual aid relationship. :)

...Just don't puke on the new ambulance.

The Love of My Life

This is an ode to my baby, the love of my life, and the reason I haven't been around. Between the check engine light, stalling when I turn the wheel too sharply, the crack in the windshield, and putting on the spare tire last week cause I had a leak, she needs some serious tender loving care. Positive thoughts appreciated for my job interviews this week, cause this lovely lady will be getting dropped off for some rest and relaxation time as soon as I've signed papers that promise a paycheck within the next month. I don't want to clean out my emergency fund unless I know I've got more on the way. Nevermind that I need her to get to interviews, and hopefully a place of employment after that.



Ain't she purdy? And yes, it's that back passenger wheel that I switched out after this photo. You can see the chunk missing from the rim at the bottom, which had a sharp pointy edge that got bent in and wore through the tire. Switching to the spare means I won't be doing more than 50mph or using my 4x4 until I get new tires. (FYI: the previous owner cracked the rim, not me.)

But you know what?

That's my baby.

9/11 and The 'Stan

Everyone's got a 9/11 post. I was twelve years old and living in New York City.

End of story.

So here's to my best friend from childhood, currently deployed to the middle of nowhere, Afghanistan. You'd better kick some military ass and get your E4. Your monthly care package is a little belated but definitely enroute. I'm so proud of you for doing your EMT training while you're over there. You're going to be an awesome tech. I wish I was there to watch your back. I'll be waiting to completely embarrass you at the gate when you come home for leave next month.

I love you. Stay safe.



Photo compliments of NATO's AfghanistanMatters.

The Great Commonwealth

Finally mostly settled in up here and already doing shifts with the campus volunteer squad. If it's not a scheduled party night, you can almost safely plan on having six hours of study time while dragging around a jump kit and listening to Public Safety chatter on the radio. No, we do not have an ambulance. I looked in to getting one, but we don't even have $10,000 for a used one, let alone stocking and maintenance. Fortunately, the local fire station is across the street.

And they like to have barbecues. :)

Last Call

This time yesterday, I'd just finished my last call at my private ambulance company in New York City, a normal hospital to nursing home discharge. This time yesterday, I was sitting in the courtyard of the nursing home, playing dominoes with two elderly Latino men and my very Jamaican partner. This time yesterday, I was plotting with the one old man who spoke no English so we could defeat the other two at the table.

And not long after this yesterday, I sat in my car across the street from our ambulance base, crying.

I miss you guys.

Rookies and Flag Downs

Towards the end of shift. Sitting on a half-empty street with another one of our units, passing time as we keep the engines running for the mediocre air conditioning and music in 100+ degree heat. Taking bets as to whether we'll have another call before we get off.

The van pulls up to the curb in front of us. The driver hops out, frantically waving to us.

You don't just jump out of your bus for a crazy person in a van. It's late at night in New York City, and the general public thinks all ambulances carry narcotics.

"Our friend is having a seizure!"

My rookie partner is at the patient's side in the time it takes me to flag down the other unit for backup. Rookie partner looks like a deer in headlights.

The teenage patient is actively seizing, sprawled on a bench seat in the van.

Two more passengers have joined the driver on the sidewalk. They know a name and age, and that this is the patient's third migraine induced seizure in two weeks. The patient said they felt sick and began vomiting prior to seizing.

The stretcher lines up with the bench seat, we slide the patient on, and the tech from the other unit catches my eye and gives a nod towards my rookie partner reaching to put the stretcher in Trendelenburg rather than positioning for aspiration precautions. I intervene, and look towards the tech. This is technically rookie partner's patient, and so far they're looking as though they should be the one on the stretcher. I can't drive Code 1 and babysit from the driver's seat.

The tech winks and grabs their BP cuff from their bus, hopping into my bus with rookie partner.

In the 2 minutes I take to go 1.7 miles, I find the time to call a notification.

But we have no paperwork on arrival despite two techs in the back.

"It's rookie partner's call," the other tech informs me with an evil grin, before stepping outside for a cigarette.

First order of business: Get rookie partner a coffee. Second order of business: Walk through how Patient Care Reports are essentially the same for a flagdown. Third order of business: Show rookie partner that our patient in the trauma room is now sitting up and talking coherently.

The relief on rookie partner's face? Priceless.

Mucho Dolor?

The nurse at the doctor's office gave us his history, but we still had to ask.

Yo hablo un poco español. Un poco poco.

He smiled and nodded, explaining as simply as he could that he had pain in his lower back and down his left leg, and he couldn't feel his left foot.

O.K.? got him comfortably situated on the stretcher, and O.K.? made sure he was still comfortable after we loaded him into the ambulance.

He replied that he was fine, just the pain in his back.

Two minutes later, at the triage line at the ER, I asked for the two things missing from the doctor's transfer sheet.

ID? Driver's License? accompanied by a finger outline of their size.

He passed me his Medicaid card and learner's permit. I jotted the insurance and his address onto my paperwork and grinned as I handed them back.

Only a learner's permit? I teased, tapping the big words at the top of his shiny new ID.

He laughed and grinned back in understanding, then pulled a picture from his wallet.

His great-grandson.

Medication Caution: Revatio

I'm being lazy. Here's the text from the REMAC website:

Revatio® (Generic Name: sildenafil citrate)

Revatio (re-vah-tee-o) is a fairly new drug on the market used to treat pulmonary hypertension. Pulmonary hypertension causes increased blood pressure in the blood vessels of the lungs. Because of this, patients are not able to tolerate physical activity and exercise as they used to. You may find patients with COPD that also have pulmonary hypertension. It is very important for all EMS providers to be aware of Revatio because it is made of the same drug as Viagra. The generic name for Viagra and Revatio is sildenafil (sill-dena-fill). Patients on Revatio are contraindicated from receiving Nitroglycerin the same as those on Viagra, Levitra or Cialis. Administration of nitroglycerin to a patient on Revatio could cause a sudden and severe drop in blood pressure. This is an important thing to remember because oftentimes the patient is on a generic form of a drug rather than the brand name. Look for patients with a history of chronic breathing problems—especially when brought on by exertion, to be on Revatio. If you encounter a patient taking Revatio that has indications for nitroglycerin (chest pain), document that the patient is on Revatio and therefore, is unable to receive nitroglycerin. As a reminder, the State and Regional protocol for withholding nitroglycerin has been increased to 72 hours in the presence of Viagra, Levitra, and Cialis (erectile dysfunction drugs). You can find additional information at: http://www.drugs.com/pro/revatio.html

Current and Updated Protocols can be accessed at the Regional EMS Council website: www.nycremsco.org.

More on pulmonary hypertension later...

Recertification

So it's that magical time of year where I realize my EMT license expires next spring, and I ought to get a preemptive start on doing my refresher.

Obviously, this involves an epic choice between recertifying in Massachusetts vs. recertifying in New York. :)

New York EMT licenses last for 3 years. Refreshing in New York City involves Challenge Exams (similar to the normal state practical), and then 3-4 months of classes. You're required to attend the ones regarding the sections that you did badly on during the Challenge. Then you get a final exam.

Massachusetts EMT licenses last for 2 years. Refreshing requires 28 CMEs and a 24 hour refresher class. You can do all of the CMEs and 18 of those 24 hours online.

The 3 year thing is really tempting. When I got my original Massachusetts license reciprocated by New York, they went according to the date on my Massachusetts license. So both of my licenses expire in the spring of 2011, 2 years after I got certified.

But I'm moving back to Massachusetts in 28 days, so a refresher class in New York isn't exactly practical.

And, little known fact:

I LOVE ONLINE CMES. Even if I didn't need them to recertify, I'd still be doing them.

EMCert.com, my personal favorite and the place where I have a 1 year subscription :)

MedicEd.com

EMInet.com

WebCME.com

Going Home

A month ago, he was fine.

He was finishing rehabilitation after a total hip replacement, getting ready to go home.

Then the dyspnea began, and they found the clots in his lungs.

Medications solved that.

But during the follow-up exam, the doctor found rigidity in his abdomen.

A week later he was in the ER with severe jaundice and lethargy.

Cholangiocarcinoma. Cancer in the bile ducts.

Inoperable. They did one dose of radiation before the family made their decision.

He was going home. No one knew if he had a few days or a few weeks. I had a copy of the DNR in my paperwork.

And so we traveled across two states, with his wife of fifty-two years holding his hand and his grown children following in the station wagon behind us.

We gave them most of our extra linens.

No one was ready. They'd only had a month.

Acute Invincibility Syndrome

Overheard in the Triage Line

RN: So he's on Coumadin?

EMT Trainee: No, but he's on Warfarin.

I think I peed my pants a little trying not to laugh.

Dignity

Dignity in healthcare can mean a lot of things. But right now, to me, it means respecting your patients as human beings with the same amount of worth as you (or even more in some cases).

They are not unpleasant tasks to complete.

They are not lumps on stretchers to be shunted between hospital departments like a life size game of pong.

They are not there for you to resent when you get off from work late.

Most importantly, they have the right to bed educated on their condition and participate in their own care. They have this right regardless of what language they speak, or their psychiatric diagnosis (within reason, of course), or their ability to speak at all. A patient trapped in their own body after a stroke is just as capable of communicating their wants and needs and opinions if you take the time to ask.

If you find yourself unable to take the time to ask your patients if they're comfortable and doing okay (or as okay as you can be in a hospital), please, remove yourself from your current career path. That vitals machine above their bed doesn't tell you that they would feel...

...slightly more human if they had an extra pillow to support their bad back.

...slightly less terrified if you gave them a quick summary of what would be happening to them in the next few hours.

...slightly less embarrassed if you gave them a diaper instead of just leaving them on a chuck.

*

Dignity in health care should mean that when I walk in to an ER to bring a patient back to another facility, they should not be covered in their own blood while lying in a urine puddle that's expanded across half of the stretcher.

Dignity means that regardless of the facts that this patient only speaks Spanish and can barely move on their own after the stroke, they deserve the same respect and care that you would want to receive yourself.

When this patient proceeds to tell me that they're in severe pain, and I can see them still actively bleeding despite stitches, due to the fact that their extremely productive pneumonia related cough keeps tugging at the wound, you should not involve yourself in an hour long standoff with EMS over the transfer decision.

The correct bare minimum answer would be to properly clean up this patient, apologize, and apply gauze and an icepack.

When you haphazardly clean this patient, leaving them in their stained gown with clots still gurgling in their mouth and dried blood on their face and chest, and order me to transport them, that is an acute deprivation of dignity.

When you bounce into the hallway where you've left me attempting to mop up the ongoing flow of bloody sputum and announce that you've "won" because you called the receiving facility and they agreed to the transfer, I'm probably just going to stare at you.

Because I thought we were talking about patient care, and this patient's right to properly receive it.

I would've continued telling dispatch that I refused to transport due to the patient being unstable, but at that point I concluded that it was in the patient's interest to get as far away from you as physically possible. Even if that meant going via the receiving facility, where they refused to accept the patient once they realized that you had inaccurately described the patient's condition over the phone.

Because we transported the patient to another ER after that. And the first thing they did was far more effective than what I was able to do with a towel, saline and 4x4's in the back of my ambulance.

They asked how you were doing, did your interview in Spanish, and offered to get you a diaper.

When I saw how your face lit up with relief, I almost hugged the nurse.

Because dignity will always be a critical component of patient care.

MOLST (pt. 2)

This is a New York State MOLST form:



The original copies are always pink, but photocopies of the original can also be acceptable. The patient keeps a copy and the doctor who signed off on the form with them also keeps a copy. Patients are advised to keep a copy taped on their fridge or folded in their wallet. Nursing home patients should have their copy in their medical chart at the facility.

MOLST can be used for both pre-hospital and hospital care. I'm sure there's a little more legal discussion involved, but I know the basics in what I look for when I need to make decisions on scene.

The first part discusses CPR, and the patient can choose yes or no. Make sure this is signed by a doctor, the patient (or the patient's HCP), and 1 witness. It's no good without those pretty squiggly lines.

The next part (and this is where it improves on the traditional DNR form), gives the patient three basic choices for "Life Sustaining Treatment":

Comfort measures only: Comfort measures are medical care and treatment provided with the primary goal of relieving pain and other symptoms and reducing suffering. Reasonable measures will be made to offer food and fluids by mouth. Medication, turning in bed, wound care and other measures will be used to relieve pain and suffering. Oxygen, suctioning and manual treatment of airway obstruction will be used as needed for comfort.

Limited medical interventions: The patient will receive medication by mouth or through a vein, heart monitoring and all other necessary treatment, based on MOLST orders.

No limitations on medical interventions: The patient will receive all needed treatments.

The patient goes on to specify whether they want to be intubated or not, and for how long using which kind of machines. They can state whether or not they want to be transported to the hospital for further care. They can state if they want a feeding tube, a trial period with a feeding tube, or no tube at all. They can choose how aggressively antibiotics will be used in their treatment.

And then there's a little space at the end for the patient to write in whatever else they may or may not want to be used in their treatment, such as dialysis or blood transfusions.

Again, be careful with your squiggly lines at the bottom of this second part. You need the doctor, the patient (or HCP), and 2 witnesses.

There's a great online traning program for New York State EMS providers here.

And you can find more information here:

Medical Orders for Life Sustaining Treatment - NYS DOH

Dear lady in full niqab on the train,

I would have decked that racist bastard for you if the train doors hadn't closed. Taking the seat across from you and turning my favorite Nancy Ajram song all the way up was the best solution I could think of on short notice.

Anyways, the overdose on my eardrums was totally worth the expression on your face when you recognized it.

Or what I could see of your face, at least. :)

Apparently I'm a grownup, and all of my friends are having babies, or getting married, or engaged to be married, or just graduated and career hunting.

I missed the memo.

Seriously.

Things I Don't Like To Wear

Heroic EMT Slain In Brooklyn - NYPost.com

Mourning Bands are worn on your shield, usually from the time you hear about the death to the time the person is laid to rest. If you don't have a shield (most private ambulance companies in NYC don't require them), then you wear it on your left shoulder. You know, those buttoned down little flaps on the top of your shirt that you might attach your ID to?



Please be safe out there. Both on duty and off.


For reference, see:

Badge Mourning Bands - paradestore.com

Mourning Band Etiquette - forums.officer.com

Heat Waves (And Other Fun Things)

If the temperature outside is 103 degrees Fahrenheit, I do not want to stair chair you into your home. Stay in the hospital. They have better air conditioning.

Especially since I threw out my back last week on another stair chair job and am now wearing a ThermaCare heat wrap to deal with the pain. (Days off are for the weak. And for people with air-conditioned houses to relax in all day.)

I also do not want to go wandering around the worst (un-air-conditioned) housing projects in the city with a police escort looking for my patient. (Although I don't mind helping an old lady carry her new air conditioners to her apartment after we give up searching.)

I do, however, want to go to Brothers Police and Security Store. SO. MANY. UTILITY. POUCHES.

Sometimes...

...these things just happen. Ladies and gentlemen, your thoughts and prayers are much appreciated.

Ambulance Crashes Into Tree In Woodbury

MOLST (pt. 1)

Dear Healthcare Proxy (child over age 18),

When I'm transporting your parent for a dislodged PEG tube for the third time this month, I want you to know that this is not normal. I want you to sit down and discuss things with your parent. Deciding to set up a MOLST form (the NY State version of DNR/DNI) is not an easy conversation.

I am aware that your parent has expressive aphasia and hemiparesis from the stroke. But I want you to know that your parent is completely alert and oriented, and that we have very pleasant discussions (even if I do most of the talking and they make faces and squeeze my hand in reply).

I know you may not want to hear this. The MOLST form probably wasn't set up earlier because you had no reason to expect the stroke.

But I also know that transporting your parent to and from the hospital nearly every week is not a fun experience for anyone. Your parent is perfectly aware of their actions. Your parent is perfectly aware of their quality of life in a nursing home. And your parent has taken the situation into their own hands.

You can't change that reality by upping their dosage of anti-depressants.

Put on your grown-up pants and do your parent the biggest favor they'll ever ask from you.

Updates:

I made the blog a little purtier. Still loving the basic layout, it matches my EMT patch. :)

My house is full of strange couch surfers. Again.

I have an awesome sunburn. Note to self: apply sunscreen prior to ingesting alcohol. Also, still loving the Cyclone, but this new Luna Park has nothing on Astroland. And fun fact for you NYC EMS (and potential tourists): Bring your license to the Coney Island freak show and you get a discount.

More to come...

Lifting

Lifting is one of those basics we all learned in EMT class or at our first job in EMS. Squat, get a firm grip, and lift up with the legs.




We get lectured and lectured and lectured. Body mechanics, and injury prevention, and asking for lift assists when needed. You never ever bend your back to lift, and it's all because of the discs between the vertebrae in your spine. They cushion the weight across their full surface so long as your back is straight. When you bend your back, you're putting pressure on just a small portion or edge of the disc. Add a bunch of extra weight to a spine that isn't cushioning properly and your back isn't going to work the way you want it too.

These are discs. Be nice to them, because they can herniate, too. And no one likes hernias.



We all do stupid things. Particularly when it comes to putting our patients before our own safety. Because when you've got a bariatric patient in severe respiratory distress, sometimes you lift wrong to get the job done. As in, when your legs can't compensate for the additional weight and you have to throw your back and arms into it.

And then... you will be sore. You will be very, very sore, and you will have to take a sick day.

For those quiet times when you can consider things, like your sanity, here's some reading:

Lifting and Moving - hopperinsitute.com

Watch Your Back - emsresponder.com

Bariatric Lifting and Moving - emsresponder.com

Also, can I get one of these? As an early birthday present? Pretty please?

At some point in time I might separate my EMS related posts from my rest-of-my-life related posts. But as of right now, they're the sum of a whole. :)

And I should be less cranky now that school looks slightly realistic again.

And I can't drive for 3 weeks because I scratched the side of my ambulance pulling out of an ER bay.

Oops.

In the last 34 hrs I accomplished the following:

1 ten hour afternoon tour (that became eleven and a half hours)

followed by

1 eight hour overnight tour

followed by

getting home in time for a shower and change of clothes

before

getting back on the train to open the bookstore

followed by

working another eight hours

then finally getting back home

and doing a load of laundry so that I have something resembling clean uniforms...

...And discovering that my loan application for next year's full tuition at my chere college was approved.

So yes, the last 34 hrs without sleep were worth it. Completely and entirely worth it.

Dear EMS powers-that-be: STOP CHANGING MY EFFING SCHEDULED PARTNERS. I don't like working with a new person every single shift. I like coming in brain dead and half-done with my caffeinated beverage and having someone who already knows that I'm not fit for human interaction for at least three hours, and that I love to tech, and that I like bottom on stretcher, and that I take my second set of vitals in the bus before we leave the scene. I like predictable routine, ladies and gentlemen. Having a good relationship with your partner makes for better patient care. Building a new one every effing morning when I'm already grumpy and sarcastic as hell? Not ideal. I'm just saying.

In other news, I got promoted to manager at the bookstore. Yes, pay raise. Yes, staying part time.

Because standing in one place all day is starting to become a foreign concept...

Things I like:

Rubberbands shaped like sea animals.

Fruit bowls with just kiwi, strawberries and blueberries.

Movies about babies.

Ginger lemon white chocolate from Dylan's Candy Bar.

First firefly of the summer.

Also, my friends.

<3

Driving Code 3 (Or Code 1, for us Non-911 EMS)

This is why you alwaysalwaysalways STOP and LOOK before proceeding through intersections. Even if the light is green, there might be another emergency vehicle coming against the regular traffic rules. Props to these drivers. :)

Glucose Measuring Tattoo?

Can we just appreciate how awesome this is? Because this is AWESOME.

Nano Ink Tattoo Could Monitor Diabetes - DiscoveryNews

Who doesn't want a tattoo that changes colors depending on the glucose levels in their skin?

Wind Shear. Also Known As: Why I HATE Bridges

The New York Metro Area has 2,027 bridges and tunnels. Tunnels are easy. Make sure you've got enough clearance for your ambulance and don't change lanes.

Bridges are a whole other story. Single level suspension bridges have minor wind shear to begin with. Keep both hands steady on the wheel and stay in your lane.

Now, when you're in the ambulance that drives like a poor abused dog because it's been in too many accidents, this is a little more difficult. Every little bump and dip will send you drifting into your neighboring lane.

When you're in the aforementioned ambulance crossing a long suspension bridge in a spontaneous monsoon on an emergency call...

...you will be honked at. Repeatedly.

Safety suggestions, according to my partner:
1. Slow down
2. Open front windows of vehicle
3. Change to middle lane (the left lane is not your friend, that divider makes the situation worse)

Safety suggestions, according to the American Red Cross:
1. Keep both hands on the wheel and slow down.
2. Watch for objects blowing across the roadway and into your path.
3. Keep a safe distance from cars in adjacent lanes as strong gusts could push a car outside its lane of travel.
4. Take extra care in a high-profile vehicle such as a truck, van, SUV, or when towing a trailer, as these are more prone to be pushed or even flipped by high wind gusts.
5. If winds are severe enough to prevent safe driving, get onto the shoulder of the road and stop, making sure you are away from trees or other tall objects that could fall onto your vehicle. Stay in the car and turn on the hazard lights until the wind subsides.

So here's some information on wind shear and suspension bridges. (Don't read stuff about the Tacoma Bridge. It's not reassuring.)

Suspension Bridges - bukisa.com

Wind Shear - Wikipedia.com

High Wind Safety Tips - American Red Cross

Driving In High Winds - Midas

Sometimes you get patients who ask if you're studying to be a nurse or doctor.

No, actually, I'm a double major in International Relations and Geography.

They usually ask how you got in to this.

My friends made me do it. Peer pressure and all.


But sometimes you get patients who spend the next three hours discussing the economic sustainability of the European Union with you. :)

Nebulizers and Albuterol

NYC REMSCO BLS Protocols state that Albuterol via Nebulizer is indicated in patients over 1 year of age presenting with exacerbation of asthma/wheezing. Albuterol is the only medicine EMT-B's in NYC can give via Nebulizer. Refer to the 2010 protocols if you want more details.

This is how you do it, for those of you who didn't learn in tech school.

1. Gather the necessary equipment.
2. Assemble the nebulizer kit.
3. Instill the premixed drug (such as Albuterol or other approved drug) into the reservoir well ofthe nebulizer.
4. Connect the nebulizer device to oxygen at 4 - 6 liters per minute or adequate flow to produce asteady, visible mist.
5. Instruct the patient to inhale normally through the mouthpiece of the nebulizer. The patientneeds to have a good lip seal around the mouthpiece.
6. The treatment should last until the solution is depleted. Tapping the reservoir well near theend of the treatment will assist in utilizing all of the solution.
7. Monitor the patient for medication effects. This should include the patient’s assessment of his/her response to the treatment and reassessment of vital signs, ECG, and breath sounds.
8. Assess and document peak flows before and after nebulizer treatments.
9. Document the treatment, dose, and route on/with the patient care report (PCR).
(Randolph County, NC, EMS System Standards Procedure - Because really, I couldn't have said it better myself.)

Here are some video links if you're a visual learner like me. The narrator is using an actual Nebulizer machine rather than an O2 tank, but it's the same concept. It's a series if you want to see every last detail (and how to use Nebulizer masks), but these are the parts relevant to what I carry on my ambulance.

How to Get Nebulizer Ready for Use

How to Load Medicine in Nebulizer

How to Use Nebulizer Wand With a Child

Babysitting

I had a partner practically fresh out of tech school today, so we did the following:

NOT feeding the driver. >:(

1 highway flagdown a la 1 off-duty cop on motorcycle + 1 minivan driver about to miss their exit = 1 off-duty cop not on their motorcycle.

1 3-flight stairchair, with lift assist.

Attempting to feed the driver. Attempt FAIL.

Driver now caffeinated.

1 long distance interstate transport.

No food while driving 65 mph. :(

1 emergency call for respiratory distress.

15 mins waiting for NH elevator. >:(

Getting 1 hr of OT a la extended triage.

Driver so hungry they are no longer hungry.

DONE.

Apparently this was a hand-holding cheek-pinching sort of day.

No, really, I put antiseptic on my face after that one.

But old ladies are so cute, they can totally get away with it.

Also, the one who kept proposing to my partner in Italian may actually be my hero.

Security, I like you. I really do. But when I tell you that I can transfer a psych patient without an escort, it means that I can transfer a psych patient without an escort. It means, I've read the medical history. I've read the summary of events leading to the present hospitalization. And I'm telling you that this kid is going through a rough patch, but they're a kid. In fact, they're a downright sweet kid who got dealt a really tough family situation and a little bit of bad genetics.

So please, security, do not start telling me that I need an escort because kids like this might burst out. Do not tell me that all they know is violence.

Do not start telling me that in front of my patient.

Because you have never been on the other side of that. You have no idea how bad he's already hurting.

How do you think I got out of the hellhole I was born in?

There was a psych ER involved.

And do you really want to know what that kid told the doctors?

"I just want to help people."

Taught myself how to do a fingerstick today.

On myself.

It was 84. After eating cookie dough. :)

Then taught myself how to fingerstick a cat. It's all about the edges of their ears.

Will now be fingersticking the bookstore's diabetic cat for OT pay.

WIN.

Things you don't expect to see in the ER:

One of your old friends triaging themselves into CPEP.

:/

You needed that epic hug and kiss on the head, even if they did make you start crying again.

Love you love.

GPS...

...EMS style. :)



All 911 Ambulances in NYC have their own full-size computer-screen call-receiving GPS units installed (volunteers excluded). They've even got time-stamp programs. It's big. It's shiny. I mostly kind of want one.

We've got a pager, and a GPS installed in the truck so dispatch can track the truck.

Clearly, that doesn't help us much.

Hello, TomTom.

Why Paramedics Should Use GPS Navigation - Everday EMS Tips

GPS Technology Will Change EMS Response Times - EMS EXPO

GPS Computer Navigators To Shorten EMS Response And Transport Times - American Journal of Emergency Medicine

Things you don't expect to see on your day off:

Another private ambulance company dropping off a patient in your house.

As in: your landlady's mother.

So glad I came down to do laundry after they were done with the stairchair, since you can't just walk by without asking if they need a hand.

And when I got back from the laundromat her husband finally introduced us, since I've told him before that they can knock on my door anytime.

And then she gave me a mango juicebox.

WIN.

I would like if my partner told me they got their driving privileges revoked before I stay up super-late the night before trying to figure out student loans.

In related news, my right leg is tingly...

But that might just be the epic bruise on my iliac crest from the aforementioned nightstand.

Dear partner(s),

Yes, I will be incoherent for the first half hour of the shift. I don't care what time we're starting. I just rolled out of bed. Wait 'til I finish my donut and OJ.

Yes, we will be doing 5-6 jobs a day. You will be working for your paycheck.

Yes, I will sing along to every song I know on the radio. And maybe even the ones I don't. You had better like everything from Jay-Z and Ke$ha to Bruce Springsteen and Queen.

Yes, you had better be singing along, too.

Yes, I will buy a 1 lbs bag of ice the instant the temp or humidity goes up. And I will eat it, too.

Yes, you will automatically gain weight from being in my presence. Please see above regarding pints of ice cream. And boxes of 1 dozen donuts from Dunkin' Donuts. And entire Entemann's chocolate cakes.

Yes, I can lift. Yes, I will be taking bottom on both stair chair and stretcher.

Yes, I like to tech. I like hanging out with patients in the back.

Yes, we will be stopping at totally random delis. I'm involved in an epic search for the perfect roast beef and provolone hot on a hero.

Yes, I do love OT.

And most importantly:

Me + psych patients = happiness. Keep your mouth shut. I can sweet talk them into anything.

(No, seriously, I love psych calls. LOVE.)

Having days off to do stuff like laundry? Totally overrated. I don't need no frigging clean laundry. I'd rather have OT pay.

Besides, why waste the quarters when I can wash it in the bathroom sink?

And you know you like my drying skills. :)

A-Fib (On Coumadin)

A-Fib (Atrial Fibrillation) is the most common type of cardiac arrythmia. 1 in 4 Americans over 40 have a risk of developing A-Fib. You can recognize it from the moment when you go to take a radial pulse and it's nowhere near a predictable rhythm. 8% of adults over age 80 have A-Fib. Some people have spontaneous A-Fib spells, some suffer from A-Fib during exertion, and some have continuous (chronic) A-Fib. Approximately 30% of A-Fib patients don't know that they have A-Fib.

Simply, there's extra electrical impulses going on in your heart, and the atria are beating faster than the ventricles, creating arrythmia. It's not life-threatening on it's own, but it can cause palpitations, fainting, chest pain, CHF, and most importantly, strokes.

Patients with A-Fib are 7 times more likely to have strokes than the regular population. Blood can pool and clot due to inadequate contractions of the atria. A-Fib strokes are therefore typically ischemic.

35% of patients with A-Fib will suffer strokes if untreated.

15% of all stroke patients have A-Fib

25% of A-Fib stroke patients have no prior diagnosis of A-Fib

23% of A-Fib stroke patients die (compared to 8% of non-A-Fib stroke patients)

44% of A-Fib stroke patients suffer serious neurological damage

Now that I've overwhelmed you with numbers, enter Coumadin. Coumadin, or Warfarin, as we all know, is an anti-coagulant (blood-thinner). Anti-coagulants prevent clots. Therefore, your patient with a PMH of "A-Fib (On Coumadin)" most likely has chronic A-Fib and other risk factors for stroke.

Some A-Fib patients may use Aspirin, Heparin, or Dabigartan for the same effect. Aspirin is more common in younger A-Fib patients.

They may also be on medications to control their heart rate such as: Metoprolol, Atenolol, Bisoprolol, Diltiazem, Verapamil, or Digoxin. (I see the first and last regularly with my geriatric patients, even if they don't have a PMH of A-Fib. More on those some other post.)

See also:

Atrial Fibrillation - Wikipedia

Atrial Fibrillation - a-fib.com

Incident Reports? Not so much fun.

Getting home and finishing that sandwich you ordered 12hrs ago? Epic.

Children's Tylenol, Motrin, Zyrtec and Benadryl Recalled

Just so you're aware, ladies and gents.

Children's Tylenol and Other Drugs Recalled - NYT

The full recall list is here:

McNeill Product Recall

Don't panic. Nothing terrible has happened yet, just violations during a factory inspection leading to a voluntary recall. But if your peds patient is acting funny, and they took one of these, maybe mention it to the triage nurse? Or even better, grab the bottle, so that you or one of the ER nurses can check the product lot number. Even if it's just to tell their parent(s) that they should toss it.

Happy =

Sunshine

Mani-Pedi day behind the counter at the bookstore

1/2 tube of Nestle Tollhouse chocolate chip cookie dough

Kentucky Derby Barbecue Birthday Party in Williamsburg

Best scallion dumplings and pork buns ever at friend's noodle shop

Getting home at a normal hour mostly sober

Your daily PSAs.... :)

Four out of six patients agree, it's pneumonia season.

If I'm driving lights and sirens on the left-most lane of the highway, please merge with the lane to your right. Pulling left and stopping accomplishes nothing. I will not fit between you and the speeding traffic to my right.

If you have the bariatric stretcher in your bus, you will have at least one patient that weighs over half a ton.

Walking into the same ER four times in one day will make you wonder when you see that CHF patient you brought in at 11am in the exact same place at 6pm, and that migraine patient stops you to ask if they can get a ride home now.

If you're going into OT on a call, you will have to wait 45 mins on both ends for a lift assist.

Getting back to base 2hrs late with 700 L of O2, no NRBs and no nasal cannulas. Yes, it is most definitely pneumonia season.

Telling your partner, "Dude, you should auscultate my lungs. Now that's some freaky ronchi," will result in, "They probably caught it from you. You're seriously infecting everyone."

:)

In non-EMS news: Does anyone have 2 weeks worth of antibiotics that I could maybe permanently borrow? Pretty please?

About this whole being uninsured thing... :/

At least my partner doesn't mind that my lymph nodes have been super size tumor status for the last week and half. And that I'm sleeping every single spare second in between calls. And that I legit lost my voice today. Try giving a triage report when you can barely talk.

Between the 2400mg of ibuprofen per day, my daily otc pseudophedrine and my proventil inhaler, I should be fine.

Right?


Functioning immune systems are for losers anyways. :P

Abuelita

"Abuelita!" shakeshakeshake "Abuelita!" shakeshakeshake "Senora!" shakeshakeshake "Como estas?!" shakeshakeshake "Senora! Senora!"

"I'm gonna say that's a GCS of...eight. Paperwork says the fingerstick was 1213."

Could you call us before our diabetic patient's sepsis gets so bad that their glycemic level goes higher than a fingerstick can count and you have to estimate a number?

I don't like spending the entire noisy bumpy Code 1 ride to the hospital just trying to find their goshdarn carotid pulse because they're so damn thready with some crazy-bad JVD.

Maybe? Pretty please?

Because rolling into the ambulance triage and finding no nurse immediately available results in us switching our patient to the hospital stretcher and rolling right on in to the emergency department.

And the emergency department wasn't even mad at us.

...At least not after I gave a verbal report straight to the doctor and they took a good look at the EKG.

:)

Scleroderma and Implanted Infusion Pumps

Had a patient with scleroderma presenting with shortness of breath today despite their home oxygen therapy. Finding a radial pulse on super-thick skin is not the easiest thing ever. I had to go way higher up on their forearm, because the skin around all of the joints was super-bad. Also, every little thing we did was painful. Our patient took it like a champ, but they were all bones and thick skin and the beginnings of contractures. Totally alert and oriented and involved in their own care despite bed confinement.

They were just a pinch over forty years old.

There's no set explanation for causes of scleroderma, but the most common cause of death from the disorder is lung related issues.

Scleroderma - Google Health

Scleroderma - WebMD

Our scleroderma patient had an internal/implanted infusion pump for chronic pain management, so they could self-administer pain medicine as needed. It looked like a cellphone, and it had it's own little bag and everything:

(Compliments of medtronic.com)

But that circle bag is implanted under the skin, and it goes a little something like this:

(Compliments of kimberlygraves.tripod.com)

Your doctor fills up the bag as needed. There's a little portal hole type thing in the bag, so they can just do it with a regular needle through your skin and the portal. I didn't get the name of which painkiller he was on (I wrote it in my paperwork! Just not on my hand for future reference...) The pain medicine is delivered intrathecally, kinda like an epidural.

Most often seen on late-stage cancer patients and other serious chronic-pain-inducing conditions.

Infusion Pump- Wikipedia

Internal Infusion Pain Pump/Intrathecal Drug Delivery

Medtronic Fact Sheet

Apparently St. Vincent's EMS has officially started diverting. I ran into a couple of their medics in the Beth Israel ER.

WEIRD.

No longer holding my breath about my chere college. Now praying to find a bank willing to loan me $52,000.

It's so nice being told by an institution I adore more than anything that I'm not worth investing in.

:(

Stretcher = 2, Finger = 0



Yummy. Bloodblisters. So very tempting to pop.

CUTEST. PATIENT. EVER.

Because really, watching a seventeen-month-old sleep for an hour and a half is enough to make anyone happy.

Totally makes up for how sore I am from that three flight carry-down via spiral staircase this morning.

Also, prettiest location for a children's rehab ever. It looked like my summer camp. And while I have to wonder what they do in emergency medical situations, since they're out in the sticks, it's totally somewhere I would recommend for long-term care. And I like the nurses. As soon as we showed in the readmission office, the staff picked our patient up and wouldn't put them down. As if all of them knowing our patient by name wasn't impressive enough. :) That is most definitely patient care I can support.

See also: Panhypopituitarism and its relation to Traumatic Brain Injuries.

Accomplished the following today:

1. Eating an entire pint of Ben and Jerry's Peanut Butter Cup ice cream.

2. Seriously grossing out my partner.

3. Following it up with a large quantity of pizza.

4. Doing five calls with a stretcher that's 1.5 x my body weight.

5. And not calling for a lift assist on any of them.

6. Who loves bariatric stretchers?

7. ME.

8. :)




(Image compliments of blog.syracuse.com. They also have a neat article on Rural/Metro Ambulance Service in Syracuse and some of the Stryker gear they've outfitted their bariatric buses with.)

St. Vincent's

Now, ladies and gents, for something near and dear to my heart.

St. Vincent's Hospital Manhattan To Close - NYT

A little over twenty-one years ago, I was born in that hospital. I spent twenty seven hours torturing my parents by deciding I didn't particularly want to come out on their schedule, and the doctors finally concluded I was just too damn big and would have to be cut out. I spent the first three days of my life terrorizing the nurses, demonstrating my superior lung capabilities while the rest of the nursery was sleeping, and being so big and fuzzy that I was repeatedly mistaken for a boy.* My parents were actually asked on one occasion if they needed their son circumcised.

That's right, I was a nine pound twenty one inch monstrosity with a full head of hair. And I knew exactly what I wanted and when I wanted it. I suppose I was enjoying the only moment in my life during which I would tower over my peers. I would proceed to be the smallest person in my class for decades to come. Same temperament, though. And the lungs still work, though I have some crazy asthmatic issues from growing up in a filthy apartment above a pair of drug dealers who always were smoking something illegal.

But back to St. Vincent's.

They're shutting down a Level 1 trauma center in the middle of lower Manhattan. St. Vincent's even had their own totally awesome ambulance unit. Yes, NYU and Bellevue are both Level 1 trauma centers, and they're only a couple of minutes away. The world's not going to end. It's just going to be missing a hospital that's been around for one hundred and sixty something years. You know, one of the hospitals that treated Titanic survivors. More importantly, the place where I was born. (You think they'd want to keep it around, so they can make it a landmark when I become famous. Seriously, think ahead, people.)

I guess not even big donors could fix years of mismanagement and $700 million in debt. There's not much profit in charity work.

Dear healthcare system, you can has be fix now?

*Note: This has no relation to the fact that I secretly am a twelve year old boy. Particularly around super-gross stuff. :)

Traumatic Brain Injuries

The ABC's of TBI

Compliments of JEMS. :)

I know most of you have already read it, but between the trainee EMT and a head cold, I've been booked. I've got some good ones coming, I promise.

And if you need a laugh, picture this: The projects, a 300 lbs paralyzed dialysis patient on the stretcher, and five steps to go up to get in to the building. Stair chair is not an option (also, would be just as inconvenient). Me, 5'3" tall 105 lbs white girl, crouching down, sticking my butt out and using my entire body weight as leverage to weigh down the front end of the stretcher, and then wiggling backwards so my partner could lift up the back end and roll it forward.

My patient and her HHA were laughing all the way up to their apartment, because apparently I was the funniest one yet. And it got the job done. Double win.

Thirteen

If you were transporting your thirteen-year-old self, what would you say? If you went to take vitals on a wrist etched with scabs, and shifting to look at your watch, saw the layers of scar tissue lining the inside of your arm. If you could turn back time eight years, what would you want to hear?

If you could lay hands on your thirteen-year-old self's significantly older significant other, for leading them down a road lined with weed and cocaine, leading them to a place in life where they completely disappeared for months at a time, for disrespecting and selling their body, for leaving them in the pediatric emergency room with wounds that antibiotics won't cure...

...would you?

And when you're giving your report to the triage nurse, would you be internally raging when she gave your thirteen-year-old self the dirtiest look-over and then refused to sign your PCR?

Because if my thirteen-year-old self's aunt and my own trainee EMT hadn't been with me, I would have said much, much more than I did.

When really, I just want to take my thirteen-year-old self in my arms and hold tight until all the bad goes away.

Take care of yourself, love. No one's going to do it for you, and if you want this life to be good, you're going to have to fight for it every step of the way. No one can make that decision for you.

Do not tell aggressive psychiatric patients to calm down. It will not work. They may attempt to whack you upside the head, as my partner may or may not have discovered.

If they think they're perfectly fine, smile and nod and treat them like they're perfectly normal. Agree that they have every right to be perfectly upset about the situation. They want to bring a stack of bibles? That's fine, but advise them they might get lost in the ER. They want all six of their baseball caps? Sure. You'll even make sure they don't fall off. Let them rant. They think the doctors are out to get them? Reassure them you'll make sure the ER doctors are good.

This would also be how I got my patient to hand over his belt, shoes, and the aforementioned stack of bibles when we got him to the psychiatric holding room at the ER. For safekeeping, of course. Totally normal.

Because yes, paranoid schizophrenics do present a danger to the long term care facilities they reside in when they become agitated and aggressive.

But they have every right to not be reprimanded to control behavior that they literally can't control. At least for the ten minutes that they're in the back of my bus.

For all you know, on some deep level, they themselves might be terrified at what they've become. Imagine being trapped in a mind that you can't control.

They're still human. You just reason with them a little differently. And you may have to repeat yourself a few times, cause it won't sink in at first.

Totally normal.

80% Of Nitro Prescriptions...

See:
F.D.A. Says Millions Got Unapproved Nitroglycerin-NYT

Check what's on your bus. It's not being recalled, but that doesn't mean you shouldn't take initiative. If it doesn't say Nitrostat by Pfizer, there's no guaranteeing that it's going to be as effective as it should be in the field.

And what I didn't know? Nitroglycerin prevents heart attacks in 3-4% of patients with chest pain. So that other 96-97%? It decreases blood pressure and strain on the heart, of course. That's what happens when you take a vasodilator. But how exactly did they get that number?

And how many states allow BLS to use Nitroglycerin?

Massachusetts BLS crews are allowed to give up to three Nitroglycerin with five minute intervals between each dose, so long as the patient's systolic remains above 100. ALS is activated if needed.

New York City BLS? We don't even carry Nitroglycerin. We can assist the patient with one tablet or spray of their own prescription, if ALS is enroute to us either while we're on scene or while we're transporting AND if the patient's systolic is above 120.

The confusion of being licensed in two states. :P

PEG Tubes vs. Jejunostomy Tubes

For those of you who may have been curious. I had a patient with a sub-total gastrectomy recently, and that was not a PEG tube. Looks similar. Different placement.

PEG = Percutaneous Endoscopic Gastrostomy. It's for gastric tube feeding. see: PEG Tubes - Wikipedia

No stomach (or an unsuitable stomach) means no gastrostomy. Therefore, the Jejunostomy tube goes directly to the jejunum (the middle section of the small intestine). see: Jejunostomy - Wikipedia , Jejunum - Wikipedia

Yay lower risk of aspiration!

And then, just because it's in the picture, too, see: Nasogastric Intubation - Wikipedia

(Credits for the pic go to nutritioncare.org)

Definitely almost threw up in the middle of a hospital lobby with a patient on the stretcher ready for transport to rehab.

I'd like to send my appreciation for today to dimenhydrinate, ibuprofen, and ice cubes.

Because sticking it out to the end of shift meant hearing a life story from an ex-heroin addict recently paralyzed patient who really needed to talk.

And who thanked me and my partner for our kindness and professionalism.

Because sometimes you just need someone else to hear your story, to orient yourself. And the more you tell it, the more you can put it in perspective. Sometimes you need to call for back-up, for someone to help you sort things out, when they get too complicated for you to sort out on your own.

Knowing yourself is seriously something to aspire to. Once you've got that down, you know where you want to go. And then you find a way to get there.

But sweetheart, you've made it this far. Keep going. Even if it's out of sheer orneriness, to show the universe that they can't hold you back for anything. You intend to live, and you intend to live well.

Go kick some ass. You'll make it through.

<3

1198, 1198, can I get a Code 1 to 9999 99th Ave., in Queens? 20-something female, severe abd. pain and uncontrollable vomiting, suspected food poisoning. That's a Code 1. Oh, and 1198? That's going to be a one-flight carry-down.

Ahaha, oh wait, that's me. And I'm uninsured. So don't worry guys, no stairchairs today.

I did however set a new personal record today. Vomiting 10 times in less than 8 hrs. Water, you are not my friend. But at least you're not too bad to see a second time.

Also, hypothermia via dehydration is not as attractive as it sounds.

However, 2 hrs in a hot bath and 2.5 trays of ice cubes later (because I can chew on ice but not drink water? wtf?), I'm feeling a little bit human.

But unless I make a spontaneous full recovery overnight, I'm going to have to call out again. And there goes half my paycheck for the week. Oh, 90-day probationary periods and the lack of sick-pay therewithin.

(Also, please note: Private companies use Code 1 for emergencies and Code 2 for non-emergencies. So our Code 1 is like the FD's EMS Code 3. It's all about the lights and sirens, baby.)

Got my tax refund a la e-filing.

Only $12,000 left to pay off on my student loans. :D

Also,

House Approves Health Overhaul, Sending Landmark Bill to Obama-NYT

Who has a happy? I has a happy.

...I can has insurance now please?

C-diff. Offically scarier than MRSA.

My last MRSA patient was firmly bandaged, blanketed and bundled before we even arrived. There were multiple decubitus ulcers involved, but only one that we had to be a little scared of, and that was in the sacrum/buttocks region. Definitely nowhere we needed to be involved with at the time.

I still wanted to fill a swimming pool with Purell, jump in, and stay there for a very long time.

My partner had to burst my dream, of course. Compliments of C-diff. His only advice? You'll know it when you smell it.

"...the rate of hospital-acquired C-diff infections was 25 percent higher than MRSA infections." -NYT 3/20/10

Alwaysalwaysalways use your PPE/BSI.

(Purell is still my best friend, though.)

If you're not scared of narsty spores transmitted through diarrhea, please, continue reading:

Infection Know as C-diff Seen as Growing Hospital Threat -NYT

C. difficile -Mayo Clinic

General Information about Clostridum difficile Infections -Center for Disease Control

Waiting 2.5 hours for a suicidal psych to actually be admitted to a hospital? When you knew they were coming?

Can you tell I was in a not happy mood for the rest of the day?

Patient not happy = me not happy.

I watched all that optimism they'd managed to muster about getting somewhere to finally get help crash and burn by the 45 minute mark.

Dear dispatch, if you send me there again, I will be admitting myself as well as the patient. I cannot deal with incompetent people. They make me want to throw things. But, being the professional that I mostly am, I have to sit and make small talk with a patient who's getting sadder and sadder as I watch. And I can't fix that.

Type II Diabetes, Heart Attacks, and Blood Pressure Medications.

Bits and clues to connect when treating. :)

The short and sweet of it is:

In Type 2 diabetes, the body is resistant to the hormone insulin, leading to abnormally high blood sugar levels that can cause eye, kidney and nerve disease. But heart disease is what kills most patients. A quarter to a third of heart attack patients have diabetes, even though diabetics constitute just 9 percent of the population. And 25 percent of heart attack patients are on the verge of diabetes, with abnormally high blood sugar levels. -NYT

What this means, girls and boys, is that roughly half of your heart attack patients may have diabetes or something close to it.

Now, why you should look at your patients' medicines:

Diabetes Heart Treatments May Cause Harm-NYT

Because all those medications that are supposed to be keeping their blood pressure down? Those may actually be increasing their cardiac risk factors due to severe side effects.

Now, what I really want to know is how Nitro would factor into this. Or does it only apply to long-term daily medications?

Private ambulance companies are preferred over fire department ambulances by skilled nursing facilities because:

a) They don't like the drama of the fire truck showing up and the entire station tromping around the place.

Or:

b) They don't want the city seeing all the health code and safety violations.

I like option a, because I think it's funny in a "well, at least we do something better than you" sort of way. :)

(Your buses are definitely prettier. Because you know, my dream car is a bright red Ford F350. And that's what you drive. With an ambulance on back. Jealousy? I think so.)

But someone very tired and very grouchy at the end of a shift pointed out option b the other day.

Now, I've got my opinions regarding the many, many places I visit every day (see previous post). I have opinions about where I would send the people I care about, and my expectations of the staff and facilities for them. But I've never had an issue with the essential structures and mechanics of a facility. Maybe I didn't like the architecture, or the paint scheme, or the fact that they lock the front door to keep residents in. But most of my impressions of facilities were made up by the nursing staff. Even the most untrained lowly health aide can go a long, long way in my respect by caring about their patients. The more you care, the more you study. The more you study, the more employable you become (and the more money you earn).

You and your patients can have a mutually beneficial relationship. Remember, you signed up for this. Make the best of it.

I don't think I'll be outraged about option b until I run into a facility that doesn't have an AED on the floor where it's needed, or is incapable of treating a complicated case that they in fact said they were capable of treating (ie: patient with wound vacs transferred there from hospital, when the facility doesn't have any wound vacs or trained staff).

All of my issues with facilities come down to human error. Apathetic humans are one of the few things I cannotcannotcannot stand. I would never verbalize my opinion of you in front of a patient. There may be a lot of history involved that I'm not aware of during the ten or fifteen minutes that I'm on scene.

However, I can't promise I'll be able to control the need to frown meaningfully in your general direction. I might even go so far as to raise an eyebrow.

Though mostly I'm concentrating on smiling at my patient. Because even the worst dementia case will brighten up and smile back. It's human instinct. And sometimes the simplest forms of communicating are the best.

(No small non-verbal children were harmed in the development of this theory. Other than wetting their diapers from giggling. But they probably had to go anyways.)

Didnotdidnotdidnot want to transfer that totally awesome retired superhero to that rehab facility. Nor was said retired superhero at peace with the situation. That was for real the hardest to watch. One of the original superheros from waywayway back in the beginning of EMS going to a place like that for post-op rehab.

But I cannotcannotcannot turn to said retired superhero and inform them that their doctor is an idiot and reccommend they transfer to one of what I consider to be the two best rehabs in the city.

Not when said retired superhero is worried enough that they may never be walking again. As in legit scared that said rehab is the end of the line.

Ladies and gentlemen, do not leave your parents alone in those situations. They need someone to hold their hand, and I'm not a very good liar. They need someone to advocate for their care in the long term. I have to leave them once I finish my paperwork. Even if that means leaving them alone, in a strange room, with a plastic bag of their belongings, being straight out ignored by the attending staff.

Because no lie, I left that place wanting to cry. Or punch several medical professionals.