Questions From a Reader, Part Two

Here's the next set of questions from our intrepid reader:

1. What are the indications of "Medic 1" "Medic 2", etc.? Seem to be a unit
of a vehicle with one or more people of varying qualifications.

Well, that's exactly it. Some jurisdictions have what is called a "tiered" system where some ambulances go out as Basic Life Support (BLS) that can do interventions and care to a certain point and others go out as Advanced Life Support (ALS) which are usually staffed by at least one EMT-Paramedic. The term "Medic" is usually a shortened version of "Paramedic" which indicates an ALS unit.

To get even more confusing, some areas will staff all their ambulances as a BLS unit, staffed with EMT-Bs and have paramedics in a "Chase Car" or a vehicle that is not capable of transporting a patient. Typically, the BLS ambulance will arrive along with the Medic in the chase car. If ALS is needed or indicated (indicated is a fancy medical term for "needed"), then the 'medic will ride in the back of the ambulance with his (or her) specialized equipment to provide advanced care. The MacMedic works this way, I think, and you can find much more information about it from him.

My jurisdiction has BLS ambulances, which are called "Ambulance" on the radio and ALS ambulances, which are called "Medic" units. They're basically the same except for staffing and some equipment. Further discussion of this answers the next question:

2. What kind of vehicles are these, though? At first, I thought they are
what we know as ambulances. But, then you often refer in descriptions to
"ambulance arrived". (See how much is assumed!?) It seems you sometimes
leave the vehicle you came in to ride in "the ambulance" or "the unit".

My "unit" is an ambulance (dispatchers in my area use the local accent which drops the "u" from the word and it frequently is spoken as "Ambuhlance"). In this jurisdiction being and "ambulance" means it is staffed with EMT-Basics, has equipment for Basic Life Support (BLS) only and is capable of transporting a patient (up to 3 in extreme circumstances). We do not have "chase cars" or anything like that. Every medically oriented vehicle that is dispatched, with the exception of EMS (Emergency Medical Services) supervisors are capable of patient transport.

The only other medical "unit" that is dispatched in my jurisdiction is a "Medic" unit. As my ambulance is called by it's number ("Ambulance 123," for example), medic units are the same ("Medic 45"), As mentioned above, a "Medic" unit is staffed by personnel trained and certified to provide ALS and the vehicle is equipped with the gear and drugs to enable them to do their jobs.

The term "Medic" can refer to both the "unit" (a specially equipped ambulance) and the people that staff it (paramedics). So, yes, these "units" are exactly what you know as "ambulances." The differences between a "Medic" unit and an "Ambulance" are not outwardly obvious. In fact, we use the same vehicle make and model for most of them. In my writing, unless I say otherwise, one can safely assume I mean a regular BLS ambulance when I refer to my "unit" or "ambulance" since I'm only licensed to work as an EMT-B in my area. This may change in the future as I become more personally qualified.

Now, know this: as many jurisdictions exist in the United States, there exist variations on these themes. As our federal government has assigned the regulation and operation of medical services to the states and these states to the local level, each state and local jurisdiction has determined how they want business done. The discussion on how each state has evolved their EMS system and what forces have affected their outcome is a discussion too long for this entry. Suffice it to say that one can encounter many different systems, configurations and organizational models for EMS throughout the country.

I hope my explanation hasn't been too confusing. To the reader who is not in the EMS industry my advice is this: allow your understanding and definitions of terms to be flexible but allow that an EMT is generally a short term for EMT-B and a 'medic is a short term for Paramedic. An ambulance is an ambulance is an ambulance. They mostly look the same but the difference between a BLS unit and an ALS "medic" unit has to do with the level of care and interventions each unit can provide.

Ah, maddog, you always take the easy questions, eh?

Hit the comments link or email me with more questions if you need clarification or with clarification if you think I'm way off track. The comments link will allow others to chime in with their 2 cents.

--maddog

Maddog Barks!

We're out on the road in the ambulance when we get called to a fire. Helga is driving and Tinkerbell is in the front seat. I'm precepting Tinkerbell so she gets to ride up front and do everything. I just observe and intervene when she goes awry. She's pretty competent and, during our post-incident critiques, shows that she's thinking more about the patients and medical stuff than most firefighers.

Tinkerbell is a firefighter who's transferred from another station. She's an EMT-B but our station is requiring all Firefighters to become qualified on the ambulance before being allowed to ride the fire engines. Good policy I say.

Helga is a real character. She's an EMT-B and a driver for the ambulance. She's overweight, has bad skin and is terminally socially awkward. She laughs nervously and snorts after every sentence and is extremely uncomfortable with silence. This means that she's always talking. She is very sweet, though and does not have a single malicious bone in her body. She's also infinitely selfless. I don't mind her quirks at all.

We get a call to report to a house fire as a back up BLS (Basic Life Support) unit. Since we're nearby when the call comes, we actually get there first. We pull in the street where the fire is to see a scene of apparent chaos: Fire trucks, hoses, personnel and equipment are scattered all over the area and flames are shooting out of the second story windows. Awesome! Helga pulls the ambulance into a position thats out of the way but enables us to depart quickly if we get a patient. I hop out, put on my gear and my helmet that identifies me as EMS-only. That way, nobody will expect me to grab a hose and they can find me quickly if needed.

As we're heading down towards the scene to report in with our stretcher and gear, a minivan pulls into the street and starts to pass us.

"Sir, you can't go down there." says Helga to the young driver. The minivan is full of teenagers. And it keeps going.

It starts from my belly and leaps from my mouth like a tiger:

"STOP!"

He does. The driver looks like he's been slapped. He's pointing down towards the fire and saying he needs to get to his house. It's obvious that nothing's getting through and obvious that there's a bit of something going on (DUH!)

"TURN AROUND!"

"..but I..."

"TURN THE CAR AROUND!"

"...I need to get..."

"TURN THE CAR AROUND NOW!"

At this point I'm barking at him. This is a verbal technique used by drill instructors and I used it a lot when I was in the service. Just beat them with your voice. Never waver, do not have a conversation. Beat them.

It was imperative that the van turn around. I was not going to endanger the driver, his passengers or any of the firefighters on scene by letting him drive right into the middle of a working fire. My face is a scowl comparable to a samurai war mask and I keep barking at him.

"TURN AROUND NOW! TURN THE CAR AROUND! TURN AROUND NOW!"

He leaves in a hurry.

"Sheesh, Maddog!" Says Tinkerbell.

"Good job!" Says Helga.

I give them my sweetest smile.

--maddog

Questions From a Reader, Part One:

This is from the reader in Japan who has a lot of very good questions. As promised, I'm endeavoring to answer one (or more) a day. Any and all of you readers are welcome to add your two cents via the comments log. I imagine we'll develop a treasure trove of information here.

"You use a lot of terminology about EMT-A, B, etc. Maybe a FAQ or background piece for civilians?

Right! Forgive me for my past entries since I seem to assume my readers know what my abbreviations mean. In the future, I'll try to be clearer or more explanatory when I use an industry-specific term. In the meantime, here's a short list.

EMT: Emergency Medical Technician. There are several levels of EMT and they differ from jurisdiction to jurisdiction. The national curriculum and testing standards for EMT are set by the National Registry of Emergency Medical Technicians (NREMT). They have assigned 3 levels of competency and skills known as EMT-Basic (EMT-B), EMT-Intermediate (EMT-I) and EMT-Paramedic (EMT-P). To be certified as a nationally registered EMT-Paramedic allows on to append their name with "NREMT-P." Pretty fancy, no?

Each level indicates a level of competency and to attain each one requires a certain number of training hours and a certain number of "patient encounters" or actual practice in the field. The differences can be significant. For example, as an EMT-B, I cannot start intravenous lines (IVs), perform advanced airway management (intubation or "sticking a tube down someone's throat") or administer narcotic drugs such as morphine. All of these things can be done by an EMT-P or Paramedic and these interventions may be necessary to save a life.

Most jurisdictions either follow the National registry guidelines or have their own versions that, for the most part, similar. Here is a good resource for people who want to learn more about EMTs.

Wow! That's a lot just to cover "EMT!" I'm heading out to school in about 10 minutes. My next post will continue to expand on this with descriptions of BLS, ALS and will segue to my dear reader's questions about the terms "Medic" and "Ambulance."

Stay tuned....

--maddog

Questions From a Reader (Wow! People read this stuff!!)

I've received an extremely interesting email from an American living in Tokyo who stumbled upon my blog. I apologize for his suffering (for having read my blog, not for living in Tokyo). He has asked me a bunch of questions about EMS, my experiences and for clarification on a few terms and methods. He has agreed to let me answer them here in the blog.

As I am madly pressed for time in my day to day business, I'll endeavor to post a question a day from him, my answer and to invite the rest of my readers to give their feedback via the comments link. Some of his questions are beyond my scope of knowledge or practice so, I'll call upon some of you more experienced readers to contribute your wisdom. Some of the questions have answers that vary from jurisdiction to jurisdiction. Again, I'll call upon you readers spread far and wide to contribute your experiences as well.

As it is 10pm and I have 8 miles to run before my 9am class tomorrow, I shall now retire. I'll post the first question and my answer tomorrow.

Thanks for hanging in there.

--maddog

Maddog on the fritz...

Sorry, all, for being so absent. I've been inundated with schoolwork and have been trying to get caught up. You see, I've been neglecting my schoolwork in favor of devoting my time to Herself and the aftermath of her mother's death. Since I've done no schoolwork or review for the first couple weeks of class, i've been a bit behind the curve and the past two weeks have seen me scrambling to catch up.

Fortunately, i've been successful and am feeling much better about where I am scholastically. I'm dying to write and share with you all.

Don't worry! Good stuff on the way. Thanks for your patience.

--maddog

Google Search Fun

If you enter "shit etiology" into a Google search, my blog comes up on the first page of results!

I feel so special!

--maddog

The Final Chapter:

We're plowing our way through heavy traffic to get to the accident site. Plowing is about right. We have to get right up behind each car with blaring horn, siren and flashing lights before anyone notices us and then gets out of the way. People can be so stupid sometimes.

As we pass one car in particular, the driver pulls the cellphone from her head to holler an obscenity at us and give us the finger with the other hand that's holding a cigarette. No hands for driving and she's in heavy traffic. Yep, I'll see her again. In the back of my ambulance, I'm sure.

*Sigh!*

This particular road is a highway with only 2 lanes in each direction and a huge, impassible median. On the scene, there's a line of crunched cars, a closed lane around them and a line of people sitting on the grassy shoulder holding various parts of the bodies while wincing. I count four. I request another unit, make that two.

I get one. Oh well!

I hop out as we stop and go up to each person on the shoulder. I find out which car they were in and briefly ask them their complaints. All the while I'm assessing mental states, airway and range of movement. The police are already there interviewing everyone and their states of mind and physical conditions are not getting me too worried. Good, I have time to look at cars.

As I mentioned in the previous entry this is "...U-haul truck into Saturn Sedan, into Chrysler Sedan into Acura hatchback..." and none of the cars' passenger areas are displaying any deformity with the exception of the Chrysler. The drivers seat in that one has been knocked off it's track. That's the car with the patient who's complaining of back pain.

By the time I get back to the patients, the other unit has arrived and are with Mr. ChryslerBackPain. I give them a quick report on the state of his car. The driver of the Acura has wandered in to the scene complaining of neck pain and looking stiff. One of the EMTs from the other unit manually immobilizes her C-spine by holding her head & neck in a neutral position.

He and I, with some help from another firefighter, perform a textbook-perfect standing takedown and get her into my ambulance. A standing takedown is where we put a backboard behind a person who's standing and immobilize her to the board in such a way as to protect her spine while we tilt the board back and get the whole assembly on a cot. In school, the test for a good standing takedown is to pickup the boarded patient (another student) by the side and there should be only a minimal amount of shifting on the board. Of course, we did not try this with our patient but as we lowered the board to the horizontal position, I was pleased to see that she did not shift at all.

The driver of the Uhaul truck claims to be uninjured and (this sucks for him) is married to the driver of the Saturn Sedan. Hoo boy!

With Ms. Acura on the cot talking to the police, I do a quick assessment of Ms. Saturn. She's complaining of shoulder pain. She says she put her hand out when her husband rear-ended her car and her shoulder got jammed when her car hit the Chrysler. She denies neck and back pain and her range of motion is good with no pain reported. I decide not to collar her and she goes into the rear-facing captain's chair in the ambulance.

This position allows me to treat and assess both patients in turn as I sit on the side bench and I can still reach all my tools and materials in the ambulance. Being over 2 meters tall (6ft4in) I usually can reach anything in the ambulance from anywhere I sit.

So, Ms. Acura-on-the-backboard is complaining of a headache, 7 on a scale of 1-10, but an appreciable lessening in neck and back pain once we have her immobilized. I get her on 15Lpm of O2 via Non-rebreather Mask (NRB) and turn to Ms. Saturn. She's guarding her shoulder pretty well and complains of pain of a 7 on a scale of 1-10.

Junior pops his head in the side door at this point.

"How you doin'?"

"I'm good but let me get a good assessment and stabilize this shoulder before we roll."

"That's cool, Let me know when you're ready."

I assess the shoulder and find tenderness at the top and side of the shoulder but the clavicle (collarbone) is unremarkable and painless as is the scapula (shoulder blade) ribs and humerus (upper arm bone). I put her arm in a sling, stabilize it with a body-wrapped cravat and apply a cold pack on the painful part of her shoulder.

We roll.

Ms. Acura, as a result of the O2, is now rating her head pain as a 2 on a scale of 1-10 and Ms. Saturn's shoulder pain dropped to a 3 as soon as I slung and stabilized the shoulder. Yay! Both had unremarkable vital signs on scene that remained stable during transport.

We go to a hospital I haven't been to before as an EMT since traffic would make transport to the geographically nearest hospital a 2 hour endeavor. At the new place, everyone is organized, pleasant and professional. Nice! No waiting and the admitting nurse was very interested in my notes on the vehicles' deformities and the patients states during transport. That made me feel much better that I took the time to note it. Often times, on a busy night, our local hospitals don't even seem to care or listen to my prehospital notes. I suppose that's common enough.

When we get back to the station, we discover one of our members has come in with a real "hotrod." He's taken a bright yellow 80cc scooter and done it up with flame decals, a logo from Orange County Chopper. This thing's also equipped with a remote alarm and remote start.

We all take turns starting it up and zipping around the station trying to look like a badass while riding a tiny yellow scooter.

Hoo hoo!

I've got ANOTHER duty night tonight. I'm sure there's more on the way.

--maddog

Liver Lacerations??

This is continued from the previous entry.

We roll past the car on the shoulder and I see a woman in the driver seat (pregnant? Oh shit!) sitting with her legs out the open door, talking to a Firefighter and 3 kids in the back. (Shit, shit, and Shit!). The rear of the car is pretty deformed. It's basically been transformed from a sedan to a quasi-hatchback but the passenger shell (from the "C" pillar forward) looks good.

I grab the aide bag, portable O2 kit and the pediatric bag and head to the car. I see 3 kids who are not crying but are alert and orienting to the Firefighters that are collecting around the car. The woman in the front of the car seems pretty oriented but it's hard to tell as she'd on a cellphone, her husband is trying to reassure her and 2 Firefighters are talking to her. She looks pregnant to me and a quick eye shows me the kids in the back still wearing their seat belts and they're looking back & forth with free head and neck movement. The seating area shows no deformity and the seat back has not shifted. This is the car that got hit by the missing drunks in the pickup.

Time to get the woman out of there.

She's fine enough to walk to the ambulance. No complaint of neck pain, just a pain in her lower back, 3 on a scale of 1 to 10. (I'm still thinking she's pregnant and starting to get worried). She turns out to just be fat. Minor back pain, mostly anxious. This was much easier to determine and to give her a full trauma exam in the back of the ambulance.

All the while, Firefighters are giving me anxious glances. There's no fire and they want to leave. Too bad. Patient first.

Actually Patients first. Next is the 3 kids. One of the Firefighter/EMTs has checked out the kids and found them to be OK but one of them is complaining of abdominal pain.

"Can you point to where the pain is?" I ask her.

"Here." She points to the right side of her belly, just above the line of her navel and below her ribs. Where the seatbelt was resting.

At that precise moment, I recalled an entry by Doc Shazam where she specifically spoke about the insidious nature of liver lacerations in children who had abdominal trauma. I mean, this this jumped into my head almost word for word. Thanks, Doc Shazam! You're the best!

The 9 year old girl has her shoes off so, I carry her to my ambulance and I start checking her out. I don't have a CT scanner on my bus and I'm racking my brain to remember the etiology and symptoms of liver lacerations. All I can do is get a set of vitals (good and strong), determine her mental status (alert, oriented and laughing at my bad jokes), ask about pain (none) and check for tenderness in the entire abdomen (none). I even listened for normal gastric noises and heard some.

At this point, I'm torn. The kid seems fine to me. Do I recommend rolling or do I let 'em go? Am I even vaguely qualified to make that kind of decision? The woman and her husband (they're aunt and uncle from several states away) are already talking about getting back on the road. They are 1 hour away from the kids' house after about 9 hours of driving.

After examining the other two kids, I give both of the adults an honest assessment of what I found and explained to them that they can call 911 at any time after they leave us. I also tell them that i'd be more than glad to take the whole bunch to the hospital.

"But we won't all fit!" Says the little girl.

"I'll call every ambulance in the state if I have to." I say to the father. He can see that I mean it. So does a nearby firefighter and a brief look of panic crosses his eyes.

hee hee

Other than a crying 5 year old boy who's too tired for all this drama, everyone else is fine. I get a mountain of signatures and we roll on to the next bit of fun.

hee hee

The next bit of fun:

U-haul truck into Saturn Sedan, into Chrysler Sedan into Acura hatchback! Bang! + Bang! + Bang! = Maddog juggling patients in heavy traffic!!

(All in one night!!!)

Stay tuned...

--maddog

Motor vehicle accident on suchandsuch interstate at the intersection of somethingoranother parkway.

We had just been stood down to assist police at a nearby restaurant and we were at the exit for suchandsuch interstate. Junior's driving. (I call him Junior because his father volunteers at the station on the same night and was a former chief). Traffic is heavy and we blare and honk our way through.

We get on scene to find a tractor-trailer (articulating lorry for you readers in NZ and the UK) diagonally across 2 lanes blocking traffic. I fear the worst. Once we pass the rig we see a white pickup truck, perpendicular to the lanes of traffic, sitting empty. A few other cars on the shoulder. Great! I LOVE it when my patients are walking around complaining of back and neck pain! We cruise past the pickup and pull over down the way.

As I get out and head towards the pickup, I see that it's pretty deformed in the front. I'm immediately approached by about 4 people who are all babbling at once.

"Who was in the truck?" I ask.

"They split! They're gone. They ran off" say all the bystanders.

Dang! Well, I better look at the truck so I get an idea of what to do if they come back.

It's an early model Ford Ranger Pickup. It's got a half empty case of Corona beer in the back, the other half are empty bottles in the front. The seat and floor are littered with the bottles and a mess of really bad Mexican pop CDs. The kind you hear in the local burrito place when the kids are running the shop. There's also an obviously deformed steering wheel, a broken seatback and two perfect stars on the windshield at head height. I don't see any blood or tissue on the windshield but it looks pretty rough.

About then, a man approaches me and says, "My wife...my wife is down the road in our car. She's in shock, I think."

Uh oh! "Was your car hit?" I ask while looking the guy over.

"Yes." comes the reply, "My wife was driving."

I look about 1/4 mile down the highway and there's a car at the side of the road. I signal to Jr., Put the husband in the back of the ambulance and we roll on down to the next wreck.

Lacerated livers?

Stay tuned...

--maddog