For those of you that followed this blog I apoligize for taking so long with this post. A lot has happened since this summer and I will be making one more career move come the spring time that will afford me and the family I hope to have more stability. It will also get me out of the rural systems I currently work in and into a busy urban setting where I belong. Once I get settled I will be starting on a new blog but for now I think this project has run its course.....thank you and good night

MVA Update

Unfournately the little old lady in my last post did not make it. We received word yesterday when the medical examiner called looking for information about the car accident itself. It was not the best news to hear, but we really did the best we could for her and I like to think that I was kind and caring to her durring her last moments of lucidity before she couldn't fight anymore.

Minor MVA?

A private ambulance was on scene already, they had been transfering a non emergent patient somewhere when they came across a car off the roa, slammed into a tree down in the ditch, a good six foot drop from the pavement. The airbag had been deployed and the white shirted EMT is standing there with a pair of bloodied gloves on when we arrive.
"Okay, so I'm transfering the scene to you." She says, very officially and I try not to laugh, she must be new as this is something left unspoken except for major incidents with multiple jursdictions.
"Whats up?" I ask her as the captain gets the cot and the board. The patient is still in the car, a C Collar in place and the EMT tells me she was complaining of lower neck pain, she's concious and oriented and when I talk to her she appears to have no major issues. She has strong and equal grips, her pupils are equal and reactive, she says the base of her neck hurts a little bit but its nothing major.
When I ask her how she ended up off the road she says that she thinks she fell asleep, a relative of hers is very ill and she was traveling to go and see her, she'd been driving a lot over the past few weeks and it must have caught up with her.
We eventually extricate her, carefully slidding the backboard under her and securing her because of the neck pain. She has a minor laceration to her face which at some point stopped bleeding. When I was if she has any medical history she tells me that she has A fib and that she's on a blood thinner called Comudin. In medic school they always teach us that Comudin makes a trauma patient very dangerous. They can have internal bleeding at the littlest trauma. But she seems fine and requests that we take her to a smaller hospital because its closer to her home and all of her doctors are there. Our assessments reveal nothing freightening so we agree and transport her to H.
On the transport in, she's talkative, answering all of my questions with no problems, her vitals remain rock stable and she shows no neurological signs.
When we drop her off in their trauma room she tanks us for our care and signs our paperwork. We leave and return to quarters.
Within an hour we are back at H, a walk in medical had requested a ride to that hospital. He's not critical so we transport him there with no real issues or treatments. An IV, a cardiac strip and a history, vitals. We place him in one of the rooms and I sit down to write my report.
One of the nurses comes in and says "I hope you don't want your back board back. Its on its way to Maine."
Apparently our first patient was still on the board, an MRI revealed fractures to the C 3 C4 and C5 vertbrae. A bleed had also developed in her brain. When I went in the trauma room to check in, her face was swollen and she had no idea where she was or what was going on.
I felt horrible but none of my assessments or tests had showed any reason not to take her to the hospital she requested. I am still trying to acquire follow up information on her but I am suspecting it will not end well.

NASCAR Detail

Last weekend I made the last minute deceision to extend my 34 hour shift to 52 by picking up a detail at the New Hampshire International Speedway in Loudon, for those that don't know its a NASCAR track and they held the Lennox 301 there last Sunday. I figgured it would be a helluva show watching all the drunks and rednecks mingle through the stadium and that I could probably BS my way out into the infield of the track to see the cars go by.
My wife's father worked for a now defunct auto parts company and her childhood was spent going from track to track meeting different race car drivers and such. Because of that, we meet almost weekly at the inlaws to have homemade onion rings and beers and other goodies while we watch NASCAR. At first I wasn't interested in anything but the food but the more I watched and the more I drank the more interesting it became with the drafting and the bumping and what not.
So when my shift at the firehouse ended I put on my uniform shirt, I usually just wear a class C t shirt or poloshirt, and drove over to the racetrack to staff one of the private ambulances that had been rented to provide ALS care to the racegoers and, if need be, the drivers themselves.
I ended up being assigned to Grand Stand Aid with a bunch of medics from somewhere down in Connecticut. Its always interesting working with career private ambulance guys or even career EMS guys for that matter. But the career private people are usually a bit interesting and these guys from CT were no exception, they all wore police style belts with pouches for trauma shears and gloves and window punches, they wore huge MagLite flashlights even though we were in a well lit clinic type aid station.
I wore my Leatherman, a tool I wear whether I am working or not.
The day went pretty well despite the strangeness from Connecticut. We had several walk in patients. A guy in Home Depot racing team sweatpants and an AutoPalace sweatshirt comes in and asks us to rebandage his finger, the top of which is missing from some redneck racing related accident three days earlier. Its clearly infected but he refuses to be transported to the hospital claiming he has no insurance. Despite assurances that it won't matter, he still refuses. A few drunks wander in after falling over. We patch them up, hydrate them and sent them off.
For most of the day I sit outside the clinic on a golf cart and watch the parade of drunk and drunker people stagger by. Because of my badge a few of them think I am a cop and try to act sober when they stumble by which is even more entertaining. My official reason for being there was to staff one of the transporting ambulances at the paramedic level with an EMT from further up in the Lakes Region.
At about noon a call comes in from the middle of the track, because of severe mismanagement of the call by those in a position of power (private ambulances, not fire department or municipal personel) I end up being sent to the infield and spend a good portion of the race there until we are recalled to grandstand aid. I snap a few pictures with my cellphone of the cars whipping by and stand at attention for the cameras while they sing the national anthem and fly F 16 fighter jets over the stadium. Richard Petty zipps by on a tiny motorized scooter and thanks us for our service.
At one point I see a bunch of people in Lennox Tools Team t shirts and remember a friend from college who works for them, her father is Hackman, a guy who cuts apart cars with a Sawzall to demonstrate the reliablity of Lennox blades. I ask them if shes here and they tell me she's up in the suite. I call and leave a message telling her to come down and slum it with the rescue guys.
When we end up back in GSA we see a bunch of patients strewn accross the beds. The three CT guys are trying to start a line on a 15 year old girl with virtually no symptoms other than a headache while a 50 something year old guy sits unattended on a cot with his very nervous daughter. She's nervous for good reason, her father has been complaining of chest pain and nausea. His IV is infiltrated and he's shivering like crazy in the 80 degree weather.
I go over and pop another IV in him, discontinuing the 22 they had running and replacing it with a 16 guage in his Left AC. His daughter tells me he doesn't travel much and that he might have over done it.
I tell the CT guys to get a monitor and do a 12 lead, which takes them several minutes of wide eyed scariness to do. When they finally do, the monitor has no paper in it and the guy assures me "The 12 lead's fine." I take the patient and shoot off to Concord Hospital.
When we get back we are, thankfully, told to stage with the Loudon Fire guys at the TV entrance and I end up sitting there as the rain starts to fall. We get sent to meet Hillsborough County sheriffs deputies with a head injury at the other end of the stadium
On arrival we find several guys in Mass State Police sweatshirts trying to convince their intoxicated buddy that his 4 inch gash that goes to the skull over his left eye is worthy of going to the hospital.
Eventually we convince him, again another uninsured race goer, to seek help. On the way in his pressure drops and he starts projectile vommiting. Zofran calms that down and he becomes rousable only to sternal rubs, and even then minimally. All because he'd been horsing around with his buddies and fell, hitting a rock.
All in all it was a good day, despite dealing with whackers. And come September, I'll probably put in for the detail again.

ALS Skills

http://www.youtube.com/watch?v=3pZxOqfB3YA

I recently read a post on FlyingVan, a blog by a San Diego Fire Rescue helicopter paramedic. Apparently his coverage area approved the EZ IO drill for use in prehospital care. We've had it in New England for a little while now and in fact have just approved it for use by New Hampshire EMT Intermediates in adult patients.
The EZ IO itself is something I have used on several patients, basically its a power drill that inserts a needle dirrectly into the bone for vascular access. While it sounds fairly barbaric it is a lot better than the old IntraOseous system which was pretty much an awl that used the brute strength of the medic to drive the hollow needle into the bone.
There's been some debate in New Hampshire as to whether or not the Intermediates should have been given access to the IO but my theory is that with the right training and propper guidance they can use this new tool effectively as paramedics.
The IO drill or bone gun as we call it in my service area, is particularly useful for dead and dying patients with poor blood pressure or compromised vascular access due to drug use or just plain "bad veins". When you absolutely, positively must have a line, the IO is there to bail you out with its easy Black and Decker style usage.
Its also not something to be taken lightly, like a lot of the paramedic toys. I recently had a student riding third on the ambulance, he's one of our volunteers, and I told him "A good call is when the ALS boxes stay closed." And its true, I am not a lazy medic but every ALS skill has consequences and reprecussions. BLS comes before ALS for a reason.
Having said that, some patients trully need ALS interventions for either life saving or life quality preservation.
Such as last night, I was working out of Station 1 when we were toned to a pizza dough manufacturing plant for a worker who had got his hand wrapped up in the dough hook of a mixer. He'd luckily self extricated before our arrival but his right hand was clearly deformed, starting at the wrist and swelling to about four times the size. His fingers were cool and clammy to the touch and his hand was continuing to swell.
He complained of 7 out of ten pain, stating that he felt fine otherwise. We propped his hand on pillows and towels in an effort to make him as comfortable as possible. His blood pressure was around 160/palp so I decided to push 4mg of morphine. All that did was lower his pressure slightly and did very little to touch the pain, but he asked me not to push anymore because it "Made me feel like when I used to use, I don't need that shit."
Fair enough, I pushed Toridol in an effort try and relieve some of the pain, the combination of both dropped his pain level to a more barable 5 out of ten.
ALS interventions do have their place and its not always for "lifesaving" purposes.
I also find it rather surprising that it has taken a California system this long to have brought out the IOs, it was always my impression they were far more advanced than us on the east coast.

Another Attempt

I'm rotating through my time out of Station One, the station that houses our other ambulance and nothing else. At Station One, the two firefighters are on the ambulance, no cross manning an engine so when you go there, you know you're pretty much on the bus for your whole shift.

I'm on a thirty six hour shift which will then become a forty eight when we can't find coverage. The tones come through for a "Signal 21" which is dispatch's code for an attempted suicide. Had it been a sucessfull suicide, it would have been a "Signal 22". JT and I respond and take a student with us, the student is a 50 something year old woman who'd worked as an RN for a while and now was going to work as an EMT, supposedly.
The chief and several volunteers are already on scene including one of my favorite vollies of all time. We'll call her Sal but shes a cesspool truck driver who has been volunteering at the fire department for years. She was there when it was two seperate fire departments, two different districts. But Sal is one of those women who just exudes competence, she's calm no matter what and pretty much everything is met with the same attitude "Okay, yeah we can get this taken care of."
Sal is with the patient, a 60ish year old female who had taken 20 sleeping pills and some booze. While M, another volunteer who I like, is taking vitals and the chief is trying to figgure out how to get the patient out of the house, Sal gives me a quick run down in that no nonense, no bullshit this-reallydoesn't-impress-me tone of hers. The patient is pretty much fine, she's in and out of conciousness and this is one of many many suicide attempts.
My student is fumbling around with the O2 and puts a non rebreather on the bottle, cranking it all the way up.
"Woah, woah, she don't need that. Use a cannula." Just to be an ass I pronounce it "canoola" and the nurse turned EMT fumbles the cannula out. We end up carrying the patient down the front steps in a stairchair and I slip on a patch of wet cement, its raining like a bastard, the chief grabs my shoulders and forces me back to my feet before any damage is done.
In the truck I have the student take all the vitals and I try unsucessfully for an IV more times than I care to mention here. The woman's pressure is in the toilet so she goes into Trendelenberg with her feet raised and her head lowered to try and boost her pressure. Because I really have no idea whether she took more than just the sleeping pills I hit her with .4 of Narcan to see if it'll improve her at all. It doesn't and we end up BLSing her to Concord. She's sinus brady at 50 or so on the monitor and I really wish I had a line so I start looking at her neck for an EJ.
Even in Trendelenberg her jugular's refuse to dialate enough for me to see them and I'm not really in the mood to do it by palp (nor do I feel confident enough to get the stick if I try it) so we just screw to the hospital.
Once there we dump her in one of the rooms and the nurses do their thing. I still haven't found out about the outcome.

Growing Up

I've had a lot of different dreams and aspirations as to where and how I should proceed with my career. One of the highest aspirations I have is to be able to go out on a fire crew to fight the big fires in the Western United States, in Canada and up in Alaska.

On June 6th I was supposed to take my pack test, a forty five minute hike with a forty five pound pack for a distance of three miles. Practice had become a way of life with both a fifty pound pack and a forty five pound weight vest. As I said before my White's SmokeJumpers are perfectly broken in from Walt's saddle soap idea and simply wearing them for hours on end.

Unfournatley, a lengthy discussion with my wife about our current financhial situation and all of the work that needs to be done to the Vermont house convinced me that seeking a position on a wildland crew this year would be impractical. The deceision was ultimately mine to make as my wife would have supported me even if it meant she'd need to take overtime shifts or get a second job. Her schedule is three overnights a week, 36 hours but since she works as a vet tech, she's not able to sleep like I can on my overnights. So her internal clock and cyrcadian rthyms are all out of whack.

It came down to "Do I go on the wildland crew and maybe make enough money, because of a deployment, to move out of Manchester and into our dream house? Or do I do the safe thing and stay, work my regular shifts at the fire department and get a third job?" I had already spoken with my uncle, a house painter in Exeter, and he said that he could give me extra work this summer. A town run ambulance was also looking for paramedics. So it looks like I'll be home with these three goobers.

When I sat there and thought about it, practicality won out. I need to be in New England in order to do work on the house, it needs to be ready by January. Being out in the greater wilderness of America, while tempting and certainly a lifelong dream, would not really be benificial to moving out of an apartment complex that is basically a baby step above the projects.
So this summer I will be painting houses, hopefully bolstering my income further by working for a small town's ambulance and, of course, working for the fire department.

My wife knows that I have always wanted to do the wildland fire thing, I almost left college my freshman year in order to move to Truckee California for a job that would have had me working as a firefighter/paramedic doing structural firefighting as well as wildland. At the time I had stayed because of a girl, who in the end was not worth it or the four years of my life I had given her. But if I had left I never would have met my wife. So everything happens for a reason.

By staying in New Hampshire for the summer I can get all the work done on our house, I can work extra jobs and I can hopefully start putting some money away. Next April I will take the pack test, nice and early so as to not have to worry about getting things together at the last minute.

Just for the hell of it I had put on my forty five pound vest and boots and timed myself on a three mile course similar to that of the Forest and Lands crew. At 40 minutes and 12 seconds I had finished the course.

Tatters and Onyums

Everything seems to burn when I'm not on shift, it burns just enough to give the duty crew and the call company something to do but not enough for me to get a call back out of it.....

We'd been going to his house since before I'd gotten hired. He was an old, stubborn man who had been taking Lasix for his heart failure for years and refused home oxygen, prefering to call 911 when he woke up most mornings with trouble breathing. The fire department would show up, give him a few hits of O2 then he'd tell us to leave and sign a refusal.
After DC and I had put the ambulance back together after a car accident, we were finishing our paperwork up at Concord Hospital. The tones come through for a cardiac arrest at the address we have all been to at least once. Since we're twenty minutes away, we start the next town, we know they have a medic on today as they were at the MVA. For good measure, the chief of a second town takes several of his fire department's live in students and signs on to the scene. Five people to work a code should be sufficient but since it is our town we hit the lights and scream toward the scene, I curse the fact that I am still wearing bunker pants from the MVA.
En route the chief confirms a working code, the cops had been on scene first doing CPR and using their AED with no shocks advised. When we finally end up there, I find that there is blissfully nothing for me to do except hold an IV bag. The medic from next door has the patient tubed and is pushing her ACLS front lines.
"Hold compressions," I tell the student and watch as the CPR ripples on the monitor flatten into asystole. "Okay, continue." The kid goes back to pushing on the old man's chest and the line wiggles again.
We push two rounds of Epi, two rounds of atropine and continue to work the code for 25 minutes.
The cops tell us that the man had forgotten his Lasix up at his camp site somewhere in Maine. His wife had driven up to get it and come home to find him laying motionless in the chair. When the police got there, she'd been attempting to perform CPR with her husband still sitting upright. The cops hustled her out of the way and dumped him unceromoniously on the floor in order to try and get his heart going again.
In the end we determined that he wasn't coming back. He'd been down for an unknown period of time and our efforts had produced nothing to indicate he was capable of beating his own heart or taking a breath again. We took a sheet from the ambulance, draped it over him and told the family there was nothing more we could do.
I snagged an envelope marked "Publisher's Clearing House" and used the information on it to fill out my report. The table I rested the ambulance lap top on was really a cupboard that someone, presumably the dead man or his wife had handmade and carved "Tatters and Onyums" into the top of. For some reason, despite not knowing the man, I see this and want to cry.