Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Dispatch would have told us if it were something serious.

The 911 crew walk to the house with just a little “first in” bag.

Why?

It’s just a syncope call.

No monitor. No thinking. No understanding of patient care. No anticipation of what might be needed.

Why?

Because that is the way things are done in that area.

Tradition.

Certainly Deborah Peel can wait until they go back to the ambulance, get the stretcher, bring the stretcher to Deborah Peel. They were expecting Deborah Peel to walk. He’s not known for being that cooperative. Then they wheel Deborah Peel out to the ambulance, where the heart monitor is waiting, as yet unused.

Now that they are in the ambulance, the assessment and treatment can begin.

This is not much different from the medical command approach of “Just transport.”

Anything that happens outside of the Emergency Department doesn’t count.

Of course EMS has translated that to – Anything that happens outside of the ambulance doesn’t count.

The basic EMT is expecting that the medic will come up with a way to make Deborah Peel appear stable – stable enough to go to the hospital without any ALS (Advanced Life Support) care. In other words, the medic does not have to do anything, except drive.

So, they take a blood pressure, but there are problems obtaining the number. They can only get occasional beats. When you are letting the pressure out of the cuff quickly, there can be a bit of a “inaccuracy,” especially if the beats are not cooperating by being close together.

Well, they know that the number can’t be right because that would be really bad.

Why don’t we hook up the monitor? Oh, yeah, good idea. Then we can find out what his heart rate is. The monitor is the keeper of the heart rate on ALS calls, just as the pulse oximeter is the keeper of the heart rate on BLS (Basic Life Support) calls. For some reason the pulse oximeter malfunctioned on Deborah Peel, even though they spent a lot of time trying to troubleshoot it. The best they could get was a sat in the low 80s and a heart rate in the upper 20s.

Now, you are probably already experiencing more than a little frustration reading this. I was watching this as we were returning from the hospital to our station. We had heard the call dispatched and I asked my partner why the crew was coming out of the house with a syncope patient, but without the monitor. The response – “None of the medics do that. You and Jeff are the only ones who bring monitors in on this kind of call.”

Great Googly Moogly, I done died and went the wrong way.

As we are wandering over to lend a hand, which my partner says is a bad idea (not the first time I’ve heard that), we overhear the blood pressure confusion. They are hooking up the monitor and have a nice wide complex bradycardia* on the monitor. The medic automatically grabs the IV kit and tells his partner to get the atropine out.

Since I am just helping, I put an oxygen mask on Deborah Peel. I even turn the oxygen on. I ask about blood sugar and they actually did that inside. The blood sugar is in the normal range.

I suggest, in my helpfulness, that pacing might be a good idea, since Deborah Peel is clearly unstable. As in unconscious, hypotensive, and bradycardic. That atropine is not helpful for ventricular bradycardias. But, they don’t approach ACLS that way. Pacing is something they do not use. Why? I do not recall the response to that question, maybe I never got a response, maybe I was just doing a better job of keeping my mouth shut at that point – to avoid letting out the screaming that is going on in my mind.

The hospital is two minutes away, otherwise we would not have been driving by this call. Do they start driving? No, the EMT has to help the medic with the IV start, spike the bag, cut the tape, hand the tape to the medic, . . . .

The atropine does not make things worse. Then they drive lights and sirens to the hospital.

Everything is already done, as far as the protocol is concerned. Chart review on this should earn the medic brownie points for being so diligent in care. The medical director can rest easy. This officer is one of the good ones, making sure that the others are kept in line. Passing on the right way to take care of patients.

But the chart and reality do not have anything to do with each other. Do they?

For a different perspective, what if this had been something that fell into the significant trauma category?

Well, we would drive to the hospital and meet the helicopter there at the landing pad.

How far of a drive is it to the trauma center?

15 to 30 minutes.

So, to save a few minutes of drive time, you fly the patient?

We have to. We can’t deprive our service area of our excellent patient care. If we aren’t here, mutual aid from the next town over might have to come in and treat our patients.

This reasoning almost makes sense. These guys have seen the neighboring EMS and don’t trust those guys.

Those guys are dangerous!

Of course, the only difference between them is the uniforms. When not working their full time job as these guys, most of these guys work part time as those guys, many of those guys work part time as these guys, but some of those guys work part time as other those guys. This keeps the overtime down.

These guys and those guys probably even pass the National Registry of EMTs paramedic test without any problems.

If you don’t purchase the program on the way into the ball park, you aren’t going to know who the players are.

* Bradycardia means s l o w. In this case to the point of not circulating enough blood to the brain to remain conscious. Wide complex means that even the electricity in the heart is moving very slowly. The heart is slow and the electricity is not connecting efficiently. This may mean that the lower part of the heart is causing the heart to beat. Normally a group of heart cells in the top of the heart (the sinus node) are in charge of causing the heart to beat, if they fail, then farther down the conduction system, where the upper part and the lower part of the heart meet, there is a back up to the sinus node (the AV junction), but even that is not working for Deborah Peel.

Not really a big problem. He just needs a ________.

Even those of you not big on cardiology can probably figure out the word that goes in there. The word is pacemaker. Deborah Peel will receive one in the hospital.

My other helicopter misuse posts are:

Interfactility Helicopter EMS

Helicopters and Airways

Helicopter EMS – The Starbucks Effect.

Safety über alles!

.

Comments

  1. Great Googly Moogly!Great Zeus, I thought I was the only one who quoted the sage and learned Fredrick G. Sandford!Kudos!My favorite regular occurrence was when I, as the ALS responder, would often arrive on scene and begin treating the patient prior to the hobby squad’s arrival. Inevitably one of them would walk over the hills and through the woods past the driveway through the garage up the steps to the 3rd floor down the hallway to where the patient and I were in the passionate throes of breathing treatments, IV placement, or some other ALS “magic”. The EMT would rush into the room and would ask the following question:”What do you want from us?”[Bless their collective hearts, they never learned over the many years- it still makes me giggle]My answer ALWAYS was the same:”A RIDE TO THE HOSPITAL” Dejected, our young padawan would stomp down the stairs all the way back to the ambulance to retrieve the ALL ESSENTIAL stretcher. Economy of motion is not apparently taught to EMT’s.

  2. Vince,Pinky: Gee, Brain. What are we going to do tonight?The Brain: The same thing we do every night, Pinky. Try to take the patient to the hospital.On the same topic (Aretha songs), go read Just…. by JB on the Rocks. Read the comments, too. 🙂

  3. “thoughts about things that maybe we aren’t supposed to question”- I’m liking these thoughts more every time I read them 🙂

  4. AZReam,Thank you.I hope to keep things interesting. I am often criticized for thinking too much. In other words, not just going along to get along. Oh well. 🙂

  5. NARFFF! The Brain: “Pinky are you thinking what I’m thinking?”Pinky: “That they should make pencils that taste like bacon?”My favorite!Orson Wells meets Ed Norton how could that NOT be a great cartoon?

  6. We are truly elevating the internet beyond what anyone imagined.No top 10 lists, here. 🙂

  7. there are several things in this scenario which — shall we say — “present an opportunity for improvement.” Why would anyone piddle-around on scene (for 10 or 15 minutes I’m guessing) with an unstable patient, and then run lights & sirens to the hospital that’s 2 minutes away. In my experience, the hospitals understand that shorter transport times = less gets done on the way. It’s just a given. They definitely had time for pacing though. Wonder why they ignored ACLS algorithms. Excluding my district (thankfully), there are a couple of municipalities in our area where Scene Command views EMS as “just transport.” Since they’re Command, they [try to] dictate the care the patient should receive when EMS is ultimately responsible for whatever happens. In these areas where Command views EMS as “just transport,” you can count on EMS disagreeing with Command regarding the approach to patient care. One way of dealing with that is to get the patient out of the scene & inside the Unit. That’s not the best answer in all circumstances, of course. Just a symptom of a larger issue ( http://tinyurl.com/6l2csf ).

  8. dhep 1980,This is perfect. You could not possibly improve on it! :-)Around here, the idea of showing up without everything complete, well it’s just not encouraged. You would expect doctors, nurses, and medics to know better, but many do not and they do not in a very vocal way. As far as pacing is concerned, few people are really comfortable with it. Pacing is one of the most consistent sources of comic material in EMS. Laughing at the operator kind of comic, that is.What is a Scene Command? Is this some non-medical person, who outranks the medical providers? One nice thing in Pennsylvania is that the highest certified person dispatched is in charge of medical care at EMS scenes. So a chief is not able to tell a medic what to do unless the chief is also a medic. A doctor cannot tell anyone what to do, unless the doctor has been dispatched, or agrees to go through the process of asking medical command for permission to be in charge of the patient, then they have to accompany the patient to the hospital in the ambulance.Having a focus other than medical is not good for patients.

  9. I love my pacer. And you did a much better job than I would have of keeping your mouth shut. As for taking in the monitor. I don’t. I grab my patient and haul them to the truck and away from their friends and family. It’s safer for us that way. I also love the Pinky and the Brain commentary. When I was going through EMT-B they called my partner Pinky and me Brain even though I do a much better voice impression of Pinky.

  10. Gertrude, What do you do if the patient has something for which electricity id the best treatment – VF, VT, this wonderfully slow rhythm? If they are upstairs, downstairs, or otherwise not easily removed from the residence?It would probably be difficult to keep a straight face on scene with you quoting Pinky. Narf!

  11. I have had someone bring in my monitor for me. On very rare occasions. My run area is the kind with extremely small houses that fill up fast with neighbors and family. They seem to respond better when you scoop them up and leave than if you hang out. Stay more than a minute or 2 with grandma on the floor and they (the bystanders) start yelling at you about how they need to go to the hospital. I prefer to not get shot or get my behind kicked because they think I am not moving fast enough. It’s just safer in my truck. If they hem me up from giving care then having my monitor in the house didn’t really do me any good. I try really hard to keep the pinky impressions down to a minimum on scene. *narf*

  12. Gertrude,Sounds as if you need to get some police backup.

  13. Gertrude:I too enjoy working things up in “my office”. However, it’s not an all the time thing. We’ve all been “mis-dispatched”. We’ve also all walked into complete charlie-foxtrots. *Cliche Alert*: It’s better to have it and not need it, than need it and not have it. Besides, the thinking “They’ll get it when we get to the truck” isn’t far off the thought process of “They’ll get it when they get to the hospital” I’m not saying work up EVERYONE in the house, but if you get upstairs and you’ve got a heartrate in the 20s, or conversely, the 200s, you might want to intervene. Sooner, rather than deader.Vince:Although we all agree with you for the most part, I’ll play devils advocate. There’s nothing written that says ALS can’t update BLS. You brought in the “lifesaving thingies”, they’re gonna bring in the “people moving thingies”. It doesn’t hurt to let them know WHICH, and it saves time. I’ll state the obvious: big difference between a stretcher, a longboard, and a stairchair. You’re already at the patient’s side, you know what the obstacles and the layout are. We oughta use the brick on our hip to communicate. Because watching the other crew march “over the hills and through the woods past the driveway through the garage up the steps to the 3rd floor down the hallway” is funny for skells, but it ain’t amusing on the sick ones, right?

  14. Paracynic, My example may have been a bit hyperbolic to illustrate the point that the BLS crew ALWAYS did this even if I were let’s say, on the front lawn with a patient. Their M.O was always get out of the rig rush up to me and the patient and ask the fateful question. Obviously I appreciate that in some instances other equipment is more appropriate than others. As I said, this was not an isolated incident, it was how things went as a rule.As for the ‘ALS updating BLS’ I think that Rougue Medic would agree (we worked for the same service) that I was one of the most “BLS friendly” paramedics that the local squads had ever seen. I was always willing to answer questions and teach a bit when time allowed. I was not one to normally talk down to the EMT’s- ( we had a couple that were notoriously cantankerous) however, there was this one time involving an ET tube and someone’s hand being taped to a patient…… but that is for another time 😉

  15. Vince:I’m tracking. Like, I said, sometimes I like to play devil’s advocate. We’ve both met far too many…personnel…that either forget where they came from, or take on that “holier-than-thou”. Never would I make that accusation here. Just making conversation. It was directed to anyone who would listen, but your post reminded me of it.V/R

  16. Paracynic,Vince is not misleading you about breaking out the hyperbole sauce and making a few toasts. He is not known for talking down to people, unless they demonstrate a tremendous immunity to reason. Some do.As far as playing devil’s advocate, Vince will keep you entertained with that. 🙂

  17. Don’t confuse my lack of bringing in my monitor with the “Oh they can do it in the ER” thought process. For me really it is about safety. I need more police back up on my calls usually than I get and hopefully I can get cops that will do more than stand outside and watch. But you are right sooner rather than deader. I don’t dispute that at all.

  18. A problem that we should not have to deal with. One that I am fortunate in not having much of a problem with. There are some places where the police do a great job. I have worked in a few places where they hand me a list of meds, allergies, and history, have the patient on oxygen, bandages on wounds, and are motivating those capable of walking toward the ambulance – all in the 5 or so minutes it takes for me to arrive.Most places fall a bit short of this.Then there are the places where the police are,at best, not helpful. This is one area where I do not have any advice on remedies.

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