Where has maddog been?

My dog needed a vacation so I took her to the beach.



She's feeling much better.

--maddog

Better Living Through Chemistry.

I arrived at the station to find "Tuffy" is there. Tuffy is a volunteer at the station who also works in a nearby city as a firefighter. He and I get along very well as we have similar ideas about EMS and he's going to paramedic school as well. He goes to school at a different university than I but we both are keen on the subject. We are equally delighted to find we'll be running calls together tonight.

As we leave the Mexican fast food place from picking up dinner the radio calls us to action: "Personal injury after assault, domestic, police on scene."

Yippee! We arrive at the same time the backup police unit does. In the apartment is a mom, 3 kids and nobody hurt. The police are talking to mom when I realize that it's her that was "injured."

"Ma'am, are you hurt?"

"My daughter attacked me and tried to hit me on the arm."

"Did she hit you?"

"No."

"Do you hurt anywhere?"

"No, but I want you to take my daughter to the hospital to be evalliated. She got ADHD, ADD, OCC and ODC."

(I'm NOT making this up!!)

One police officer is with a surly looking 12 year old girl and mom's looking worried. I look at the other officer.

"No patient." He says.

We're gone! As we're leaving, I hear one of the police officers, "If I have to come back here again tonight..."

In the ambulance, Tuffy says, "That kid was on more medications than I've ever seen!"

"Hm, Pharmaceutical parenting?"

"You got that right!"

*sigh*

--maddog

Questions from a reader, Part Four

Good day, all! This next question from our reader is one that just begs to be put out there. We all love to tell war stories and I think this question will invite the best from the EMS providers who read this blog.

"Have you ever answered a call and found someone had begun first-aid that
was helpful (or not)?"

Hoo boy! That's just begging for some war stories from the street, no? Ok, Here's my challenge to my readers. Email me your story or post it in your blog and I'll either post the email content here or link to your blog entry. I think the comments section would be overwhelmed by this but you can leave one there too.

This should be great!

As to me, I'm covering at the Firehouse tonight and Friday night. I'll also be providing bicycle-based EMS for an ultra-marathon this Saturday. If you don't see some good postings from me soon, I've been living a life TOO ordinary.

--maddog

Veteran's day.

To all my brothers and sisters who have served and serve still, I salute you all.

I hope those who decide to send them into harm's way remember the irreplaceable loss of life that comes with each decision to use our military might. Don't spend that currency freely for it is very dear.

Today is a day for veterans and for armistices.

--maddog

Questions From a Reader Part Three.

This one comes via the comments on a previous entry:

"Is the decision to send ALS or BLS always made at the scene, or sometimes according to the information received from the call? Also, seems as if sheer availability might be the factor."

Once again our intrepid reader had provided an excellent question for us!

Decision made by the Government:
The decision on whether to send ALS or BLS are made on several levels. Some jurisdictions have all ALS response so, that decision is made on the governmental level or whoever had decided how their Pre-hospital EMS system is structured. (some areas have quasi-governmental "ambulance trusts")

Other jurisdictions have what is called a "tiered" system where BLS units, ALS units or both are sent to a call based on criteria. These criteria, if you remember from the last entry, are detailed in the medical protocols and set forth by the medical director of that jurisdiction.

Ok, as I keep repeating, each jurisdiction is different. I'll describe my understanding of how my jurisdiction works.

First off, let's get in our heads the concept of the process of an EMS event: First, someone gets sick or injured. They, a bystander or a family member calls 911. This is the first point where someone makes contact with the emergency medical system. This person speaks with an Emergency Medical Dispatcher (EMD), a person who is specially trained in telephone triage or interrogation techniques.

Decision made by the EMD:
Based on the questions they ask and what the patient or reporting person tells them, they make a decision to dispatch a BLS unit, an ALS unit or both. Of course, they have algorithms to help them make these decisions, just as EMT-Bs and paramedics do to help with theirs. Some calls have a requirement to dispatch ALS. Chest pain, trouble breathing and falls of greater than 25 feet are a few examples of calls that would get a Medic unit along with the ambulance.

Now, the Emergency Medical Dispatcher has made a decision as to whether the patient receives the services of ALS or BLS. Let's assume they send only BLS. That means somebody like me goes to this call.

Decision made by the EMT-B:
Now, let's assume the call is "Injured leg after a fall" and once I get there, I discover the 65 year old patient is having chest pain and shortness of breath consistent with heart attack as a result of all the excitement.

What do I do? Yep! You guessed it! I grab the radio:

"Ambulance XXX to Communications, Request ALS our scene or meet en-route"

Here are examples of how the decisions are made to send ALS. Sometimes the dispatcher makes decisions to send BLS only. Sometimes, BLS units will determine that the ALS, or Medic, unit are not needed and the call them off. I've seen other EMT-Bs do this when they get to a call and decide that the patient is not in need of a paramedic.

Me? Here's what I think (and do): If a Medic unit has been dispatched to my scene, I'm not going to call them off until they see the patient and make that decision themselves. I figure, if a patient has chest pain, they're MUCH more qualified to decide it's only muscle pain than I am. I figure, they're already on the road, it makes little or no difference if they turn around on the highway and I'd much rather they come to the scene and look at the patient.

Decision made by the Paramedic:
In a tiered system, the Paramedic has the opportunity to "downgrade" the patient to BLS. They can decide the patient doesn't need ALS care and leave it to clowns like me to transport to the hospital. In a tiered system, there are less ALS units per capital than one that is all ALS. This decision allows the Medic unit to be available for the next call. Of course, in an all-ALS system, everyone rides with a Medic.

Ok! I hope that answers the first part of your question. As to the second part, whether dispatch decisions are made based on availability. Well, I'm not privy to the decisions made by the EMS supervisors in my jurisdiction but I have experienced situations when dispatch tells me that "no medic available" or "ETA (estimated time of arrival) is 30 minutes" on a busy night. I've also heard from friends and associates that work in less populated areas that citizens are lucky to get a BLS unit let alone a paramedic.

Any of you other readers have opinions or stories? Hit the comments link below or send me an email.

I hope this answers your question. Thanks for reading!

--maddog

Dogs and happiness....

I've written before about my dog. Today, I was discussing bad stuff with a friend. She said, "Please call me if you're feeling depressed!"

"No depression can withstand the sight of my dog frolicking in the woods." said I.

"True, True!"

Ah dogs!

--maddog

Questions From a Reader, Part Three

Howdy, all. I'm sorry that I've been gone so long. Here's another great question from our querulous reader. This one in particular, I invite everyone to chime in.

"3. When you describe deciding to administer certain procedures or even
medications, it seems you are able to decide these on your own. Are there
some procedures which require "authorization" from an M.D. over the radio?"

What an excellent question! The answer is "Yes." If you remember back to my previous entry about the different "levels" that EMS providers achieve, there are associated levels of care that each one can provide. In short, all EMS providers in the pre-hospital environment operate under the license of a physician. We are extensions of his legal and medical authority. Each jurisdiction has a medical director who is responsible for all that is done in the pre-hospital setting and, ultimately, is the one responsible for the care provided by EMS personnel. We call this Medical Control.

There are two types of Medical Control. On-line medical control is when the EMS provider is speaking directly to the medical director or, more commonly, an authorized doctor at the hospital that will receive the patient or a specialty hospital depending on the needs of the patient. We do this consultation in order to get permission and guidance in the treatment of our patients. More on that in a bit...

Off-line medical control usually appears in the form of written standing orders or medical protocols. These protocols differ from state to state in the U.S. and even from jurisdiction to jurisdiction. These written instructions are how the medical director gives instruction to us EMS providers without having to talk to us all the time on the radio.

These instructions detail how and what we can do with patients as their conditions present. They also tell what interventions each level of EMS provider can give under our own judgment and what we need to consult with medical direction to do. For example: I can, as an EMT-Basic, administer an epinephrine auto-injector to someone who is in anaphylaxis, or severe allergic reaction. If I am presented with a patient who is having a severe asthma attack, using the Epinephrine injector may help them very much but I am required to consult with medical direction before administering it.

This is all written out in a book that is readily available. The protocols also direct me as to what drugs, their dosages I can administer and goes into what equipment to use with patients and when. The protocols contain a lot of algorithms that are basically patient care flow charts. There is no shame in consulting with one's pocket version of the protocols when treating a patient.

Any procedure that is outside the scope of what I am authorized to do in the protocols requires me to consult with medical direction. As mentioned before, this consultation is usually in the form of me speaking with a doctor at the receiving hospital via radio. This is also done to notify the hospital of what we have and our expected arrival time so they can be ready for us. This helps to provide continuity of patient care and reduce the wait time at the hospital for the patient.

When an EMT does call for consultation, we give the consulting doctor a ton of information but in a well organized format. According to Essentials of Paramedic Care, Bledsoe, et. al., Pearson Education (2003), a good format for the consultation report is SOAPIE: Subjective information, Objective information, Assessment, Plan of treatment, Interventions taken, Effect of interventions.

Subjective information: This is what the patient tells the medic. "My chest hurts. it feels like an 800lb gorilla is sitting on my chest!" That sort of thing. Often what the patient is complaining of is not the actual problem. These are also called symptoms.

Objective information: This is what the paramedic observes about the patient, the vital signs, patient condition, evidence of trauma, etc.. These are also called signs.

Assessment: The paramedic puts the above all together and, by process of ruling out other possible causes of the patient's condition, comes up with a diagnosis.

Plan: Here the paramedic details what he plans on doing to treat the patient all the way to the hospital. If the paramedic is asking to perform a procedure or intervention that requires approval from the consulting doctor, here's where it is detailed.

Interventions: The paramedic tells the consulting doctor what he/she's done already to treat the patient's condition.

Effect: This is a description of how the patient responds to the treatments and interventions given.

All of this information helps to give the consulting doctor a clear picture of the patient's condition so he or she can give a good consultation to the paramedic and so that the receiving hospital can be ready for them. As with any communication system, there are breakdowns and miscommunications. I have heard tons of stories about bad consultation, poor communications and frustrating doctors.

Do any of you more experienced readers out there have any "war stories?" If they're too big for a comment, post it in your blog and I'll link to it.

I hope that answers your question, Dear Reader. I'll continue to answer more!

Thanks for reading

--maddog

Herself and Herself's Mom.

        
Tonight was the memorial service for Herself's mom. Herself asked me to speak. I did. I cried. I promised myself I wouldn't. I did anyway.

Here's what I said:

" My life is a good one and [Herself's Mom] had a lot to do with that. I am lucky to be in her family and I am proud to be her son-in-law.

Her kindness, consideration and obvious affection for her family are key elements of her personality. Her company was always a delight. I have always admired her perseverance, grace and poise.

She has provided me an excellent example of how to live well. She enjoyed the company of friends, the love of family and was always pleased by their presence. I know of no person who did not think highly of her.  All of these things come as no surprise to anyone who knew her.

As I wrote this, I imagined everyone nodding their heads in agreement. There is not enough ways to express how wonderful my mother-in-law is. I will treasure her memory, the example she has set and the lessons she has taught me. "

If you want to share the moment with me, proceed to cry like a baby right now. That's what I did.

...

I had walked to the podium crying.

"I promised myself I would be poised." I said.

"You are!" Said someone in the audience.

...

After the ceremony, we are inundated by well-wishers and I cry again and again to meet people for the first time who were touched by Herself's mom.

Later, we're at home. Multiple families and many generations are gathered as one. We all are hurting.

At one point, Herself is talking on about something to someone. My hand falls on her heel. We're on the couch, side by side. Her heel fits perfectly in the curve of my hand. I mean: Perfect!

At that moment, she's mine. I'm holding her heel. I don't think I've held anyone by their heel.

She knows I'm there. She smiles at me over her shoulder. She knows. She's mine. I'm hers. That's how it's supposed to work.

Good?

Good.

Somehow, together, we'll get through this.

--maddog

I have not abandoned you....

        
I apologize. My house is teeming with visiting relatives, school is sucking my time like a leech and sleep is just a memory.

I have more questions to answer and a few stories to tell. I'll do more soon, I promise!!

--maddog

Election day!

        
Boo!

--maddog

(That's the most political statement you'll get from me!)

Happy Halloween!

Boo!

--maddog

Happy Halloween!

Boo!

--maddog