Agreement

I was told that the Schiavo “incident” brought end-of-life issues into the national spotlight, but then again it’s easier to Monday-morning-quarterback somebody else’s end-of-life issues than to do anything about your own end-of-life issues. Kinda like what I’m doing now.

Terminal cancer patient in her 80s. Asystole. Hospital bed, diapered, gastric tube, even mortuary arrangements. But no DNR. Legwarmers and spandex have a better chance of coming back than she does.

Family at first says they don’t want anything done. They clearly expected her death and have come to terms with it. Then they say they don’t want her to be shocked, not that that was going to happen, but they want other things done. Then some want us to do what we can. Some don’t. No agreement. OK, we’ll be in the next room running the code while you guys make up your minds. In the meantime, someone please catch her dignity before it leaps out the window.

Resistance

A longtime medic told this story about resistance to change in the fire departments. In 1983 he was to teach the first EMT class at a fire department, then at the beginning of the process of training every firefighter to at least this basic level of care. At the time, firefighters were only trained, medically, to the first responder level, which is akin to first “don’t move the patient and wait for help” aid.

An EMT class is about 120 hours long. Nothing brutal. And they got paid to be there. Overtime. But firefighters resent medical responses, and even to this day old feelings die hard.

The medic introduced himself, and asked if anybody had any questions.

“Yeah, why the fuck do we gotta be here?”

The union got the class canceled 3 days later.

Plane crash

A patient is immobilized on a longboard on the gurney in the ambulance. I’m sitting quietly in the jumpseat by the patient’s head doing paperwork while a police officer is getting a statement from the patient about the accident she just caused while high on Valium.

My partner, standing at the back doors of the ambulance, has the yellow copy of the fire department’s field notes that they give us on every call. Needing that sheet for the patient’s info, and being too lazy to ask the patient for her info, I ask my partner is she knows how to fold a paper airplane.

“Not really.”

“How do you not know how to fold a paper airplane?” I ask, half-incredulously and half-mockingly. I turn to the officer, “Do you know how to fold a paper airplane?”

“Yeah.”

“How about you?” I ask the patient. She’s nodding off when her eyes aren’t rolling around in their sockets, high as she is. “Ma’am! Do you know how to fold a paper airplane?”

“Uh, oh, yeah…” Back to sleep she goes.

My partner starts to improvise her construction project with the fire sheet. It’s kinda pathetic. She finishes, and tries to fly it in my direction, but it breaks sharply to the right and hits the cop square on the cheek. Another officer was just reaching the back doors and starts laughing loudly.

“You should arrest her for assaulting a peace officer…”

Saved?

TNT has a new drama about paramedics called Saved. Kinda like Rescue Me, I guess.

It may very well turn out to be worth watching, but in a recent trailer I saw a character – a paramedic – running into a building with his equipment, presumably to a call. Totally inaccurate. We don’t run to calls. Ever.

Can’t swing a dead cat…

USA today had an article dated May 21, 2006 on paramedics, well, too many paramedics… A new study found that survival rates for out-of-hospital cardiac arrest were higher in cities with fewer paramedics per capita. This mirrors USA Today’s findings, first published in their special report, “Six Minutes to Live or Die,” in 2003, that called into question the national trend of putting firefighter-paramedics on fire companies.

The reason, at least the one stated publicly, that fire apparatus are carrying paramedics is to decrease the response time for paramedics in medical emergencies. Fire stations are everywhere, and it’s extremely impressive on paper to have ALS capabilities in less than 4 minutes on every medical call. In cardiac arrests, especially ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), it is absolutely essential to have a defibrillator on scene within 4-6 minutes for the patient to have any chance of meaningful survival with limited disability.

However, the majority of 911 calls for medical assistance are not cardiac arrests; instead they are for such minor medical problems as cut fingers, ‘flu-like symptoms, homeless alcoholics, baby spitting up, etc. This is not to discount such requests, but certainly an ALS engine response and an ALS ambulance response is a bit of a waste of resources, like arresting, without evidence, a teenager who wasn’t driving for a hit-and-run that no one saw. In tiered systems, calls deemed to be not life-threatening are handled by BLS units, simply because there is no need for ALS personnel who can be better used on more serious calls. In other words, save the paramedics for the good stuff. Paramedics would be thrilled to be able to avoid calls that any taxi can take care of.

Now, some have suggested that the use of paramedics on fire apparatus is motivated by self-interest. Fire departments have – along with powerful unions and excellent public relations machinery – big budgets. But years of public education, prevention and enforcement, coupled with modern construction techniques and strict building safety codes, have so dramatically reduced the number of fires that fire departments don’t have much to do these days. Simply put, in order to justify their budgets, they respond to medical calls to bump up their call volume, which, for the reasons stated above, isn’t necessarily a bad thing, especially in VF/VT arrests. Fully 70-80% of a typical fire department’s responses are for medical assistance, and the other 20-30% are not all for working fires.

The other problem with ALS fire apparatus is more subtle and wasn’t easily envisioned before it actually happened. In some regions, a paramedic license increases enormously one’s chance of getting through the ultra-competitive firefighter recruitment process, so some of these paramedics may not have the right motivation to begin with. Also, many  firefighters are firefighters because they want to respond to fires, not medicals. As a result, some firefighters view medicals as something they’re forced to do by their management, and we all know what happens when you have to do something you don’t want do. This is a source of tension between ambulance crews and ALS fire crews. (I personally don’t care as long as everyone’s nice to each other.) Add to this the longstanding fact that EMS is extremely trying on your patience most of the time anyway, and sometimes quality goes straight out the window.

Back to cardiac arrests and having so many paramedics that you can’t swing a dead cat without hitting one on medicals… The defibrillator needs to be available within 4-6 minutes of the onset of cardiac arrest, but it doesn’t have to come with a paramedic. So why not have BLS fire apparatus (and their very short response times) equipped with defibrillators respond to cardiac arrests, followed by an ALS ambulance? As it turns out, the EMS systems with the best survival rates do exactly this, and they have been doing it way before these specials and studies were produced.

Cut finger

Code 3 for bleeding.

It’s just a small 1/4-inch cut on the thumb because the knife slipped. Two friends are waiting to follow the patient and the ambulance to the hospital in their car. If you’re wondering: people really do call for cut fingers.

She was very nice though, and that’s really all that matters to me.

Let them go

This is a good first step. (Another link.)

People can’t rely on their families to ensure their wishes are followed. Many times families chicken out and let us go through an entire resuscitation attempt before producing the Do Not Resuscitate (DNR) form. “Well, why didn’t you say something?” Certainly a lot more paperwork and cleanup now that we ran the code. The fact is, most attempts are unsuccessful anyway.

Or they simply tell us to start the resuscitation, because, well, that’s what they want and who gives a crap what their dead relative wants. As we saw during the Schiavo saga – and without taking anyone’s side – human beings once again demonstrated that they are incredibly selfish. Besides, the dead patient can’t object.

Codes are not pretty. Ever. Nakedness for starters. Loss of bowels. Puke. Defibrillations. Intubation. IV starts, sometimes many attempts, maybe one in the neck. Rib-cracking chest compressions. The “bone gun” in the chest. Not much dignity left.