Hauling Humans / A Paramedic's Perspective in a Fire Based EMS System

Oh the Humanity...Hauling the Homeless

2013-03-02T15:08:00.000-05:00

Each patient, whether you work in a 911 system and encounter repeat callers or you work in a non-emergency transport system where you routinely ferry patients to and from nursing homes, requires your utmost attention. Be ever diligent. Anyone can be a good paramedic on the good days. You need to be a great paramedic every time you begin a new patient encounter, regardless of the number of patients you have already seen in the shift, regardless of the number of meals you have skipped, regardless of the time of day or your fatigue level. Never forget the person in front of you is much more than just a patient. They are someones mother, father, sister, or brother. There is someone in the world who loves them very dearly, with all of their heart, and you should imagine that person is looking over your shoulder demanding your best at every turn. Treat every patient as if they were one of your own family members. Remember the little things. Sometimes a smile or simply being treated like a human being is the greatest and most important treatment the patient can receive. This is the philosophy I use to stay focused and try to give everyone I encounter everything I have to offer. Sometimes it's not easy, but you have been called to a vocation that is best developed with humanity, intelligence, compassion, and respect for our fellow man. With this in mind I would like to describe a patient population in the City of Fairfax I encounter on a regular basis which is a good example, the homeless.

The City of Fairfax and Fairfax County, Virginia collectively have the second highest homeless population in the National Capital Region second only to the District of Columbia. A large number of the Fairfax County homeless population are arrested at one time or another and charged with some sort of misdemeanor alcohol related offense. They are taken to the Fairfax County Jail by their arresting officer. After spending a warm night in jail they find themselves walking out to a bright and sunny morning smack dab in the middle of the City of Fairfax. They discover two major issues at that particular time in their lives. They are hungry and they are shockingly sober. In their minds these two situations require immediate attention. So what to do? Hit up one of the many 7-11 convenience stores for problem number one. But what to do about food? If they pay for food then they won't have enough money later for another trip to 7-11. Either by experience or by talking to one of their peers they learn of an establishment that feeds the homeless during the day. This establishment is actually providing an amazing service to the community. They are a church based group that has daytime hours. They offer food, showers, christian counseling, and help to get a man, down on his luck, back on the right path. They discourage drunkenness and offer a helping hand to any in need. God Bless them. A byproduct of this service, however, is after the doors shut and the sun goes down where does a guy get his next meal? Best bet is to just wait until morning for breakfast when the doors open up again. This behavior has created transient pockets of homeless tent communities throughout the city. Not everyone who frequents this establishment meets the description above, but I wanted to give a good descriptive example of one possibility as to why a small city in the suburbs of Washington D.C. could have such a high homeless population.

Inevitably the fire department becomes involved in the lives of the homeless when they become too inebriated to walk or go to jail. They may trip over a curb, discovered sleeping in the park in a near comatose state, or worse, involved in a traumatic accident. When this occurs in rush the firemen and paramedics who encounter a great number of different homeless personalities on a regular basis. Sometimes the same personality two or three times a day every day for several weeks or months. As a paramedic you often get to meet people on the worst day of their lives. The homeless population seem to have these days on a regular basis.

Regardless of their present physical condition, the fact they are alcoholics or mentally ill, homeless people are patients too, but above all else they are human beings and should be treated as such. They have all the same medical issues any other human being may have except all the signs and symptoms are clouded by alcohol and poor hygiene. Their lifestyle places them in a much higher risk category for all the major illnesses. What I hate to see is a paramedic becoming complacent with the local drunk and overlooking a major medical emergency. Paramedics dealing with a homeless population need to be ever diligent all the time. Regardless of the number of times you may have transported Otis to the hospital he requires, no he demands, your full attention because without another full patient assessment you have no idea what is transpiring with his current medical condition.

The astute homeless immediately complain of chest pain when aroused by local police. Many times this pain is non-existent or actually upper abdominal pain from an overworked liver or pancreas, but it is not our place to assume this is the case. I have discovered more than one case of V-Tach and more than one acute MI from just such a situation. If I had just assumed Otis was drunk again and trying to avoid arrest I would have missed a serious emergency and provided a horrible service to the public.

It's easy to be a good paramedic on a bright sunny spring day when all of your patients are pleasant and personable. The best paramedics are great all the time regardless. The next time you feel the pangs of burnout as you dread the next call or a certain type of patient remember what I have said and be a great paramedic, one that your mother would be proud of.

The Paramedic's Most Important Job

2013-02-24T11:15:00.002-05:00

The single most important role a paramedic can play in any patient's healthcare experience is to properly set the stage. Yes, we must all be proficient in the recognition and treatment of immediate life threatening conditions, but that is just the beginning. Unfortunately this is the area most paramedics mistakenly concentrate all of their efforts. Have you ever heard a paramedic say something like this with a confident tone, "Nothing to that one! Show me something like V-Tach or SVT and you will get my attention." This attitude couldn't sicken me more. Every patient should have all of your attention for the entire incident. The most underutilized skills I see in prehospital medicine are compassion and a good thorough patient assessment. The topic of compassion is for another blog. Today I want to talk about setting the stage and patient assessment. Setting the stage is done by performing a good patient assessment and interview, observing the surroundings and living conditions of the patient, and passing along the information, as well as, your opinion of the underlying cause to the receiving physician. Paramedics were intended to be the eyes and ears of the emergency physician and I think we have strayed from that mindset.

The future of EMS is bringing the emergency room the the patient's living room. With overcrowded hospitals and wait times growing we need to train the nations paramedics to think and act like physicians. When an EMS provider examines a patient in their home they need to have a high index of suspicion for any condition that warrants further evaluation in the hospital setting. When paramedics transport a patient to the emergency room they need to observe the initial actions and evaluations of the receiving physicians. If the paramedic's assessment did not agree with the physician's assessment then I can guarantee you one thing. One of them has something to learn. If the physician performs any treatments or interventions in the first five minutes after paramedics transfer the patient then ask yourself, "Should I have done that? Is that something we can incorporate into future EMS protocols?" The profession is it's own worst enemy. I have heard too many paramedics say, "Why do I need to know that? It won't effect my treatment of the patient." A more detailed medical education may not effect what treatments we allow paramedics to perform in someones living room, but it will give paramedics the knowledge to assure no patient is left at home with a potentially life threatening condition.

I just read this blog on Facebook from EMS12Lead.com

http://ems12lead.com/2010/06/81-year-old-male-cc-cold-and-shaky/

Its an interesting EKG but all I see is that paramedics let a STEMI walk out their door. Why did that happen? Was their index of suspician high enough for this situation? Should they have performed a more detailed patient assessment? Should they have asked different questions or performed more diagnostic tests? I think in hind sight we can all answer these questions. Don't let it happen to you. Be curious! Be inquisitive! Ask more questions more often! Don't rest until you understand!

Just encountered another BLS abdominal pain...NOT

2012-09-01T16:40:00.001-04:00

Elderly female 24 hours status post lap cholecystectomy having abdominal pain from the surgery. Not so much! Don't let the elusive MI slip by you.

RSI Part 1...Rapid Dosing for RSI...S,M,L,XL

2012-09-01T15:57:00.000-04:00

I have been performing RSI in the field for ten years now. I have developed systems for each phase of the incident to make this low-frequency high-risk call go smoothly with positive outcomes for both the patients, as well as, the providers.

I will be covering each aspect of this process over several blog posts. Today, I am going to explain my system for dosing adult patients in need of rapid sequence intubation. This procedure can be stressful for prehospital providers. Anything we can do to keep it simple so the provider can focus on the big picture is helpful.

Weight based dosing in the prehospital arena is guesswork at best. Unless you were a carnival worker in a previous life your weight estimates will be anything but accurate. With this in mind I have observed many a paramedic give their absolute best effort in estimating a patient's weight. We are mostly type-A perfectionists. Of course we will do everything we possibly can to determine the patient's weight and drug dosing so it will be absolutely accurate. I've watched providers look at a patient and say 150lbs or 175lbs, and then they begin the calculations to kilograms, consulting complex dosing charts that are in five pound increments. Using this method wastes valuable time and effort. If you are currently doing this type of calculation I submit you are simply wasting brain cells. Brain cells that could be used to figure out more important things such as the underlying cause of the patient's condition. Use those brain cells not to miss the potentially hyperkalemic patient (new onset kidney failure, rhabdomyolysis in an elderly patient laying on the floor of their house for two days, etc.) It is these types of patients that your succinylcholine will most certainly be the kiss of death.

When I am faced with an adult patient needing RSI the first thing I do is classify them as either a small adult (60 kg), a medium adult (80 kg), a large adult (100 kg), or an extra-large adult (120 kg). If you are off by 10 or so kilograms; if they are a little smaller or even a bit larger, trust me, it won't matter. They will still drop like a rock and you will still be able to control their airway without issue of drug effectiveness. The drugs used to induce anesthesia in patients for RSI have a wide margin of error in dosing. Use this to your advantage and estimate their weight in a simple even number of kilograms so your calculations will be easy to perform and easy to confirm.

Take the dosages and drugs you use for RSI and write out a chart for all the sizes given above. You will notice a pattern that forms, as each size increment is exactly 20 kilograms. Once you commit this to memory you will be able to remove this stressor from the incident and be able to concentrate on other aspects of the call such as: safety, airway size-up, delegation of responsibilities, overall scene management, assuring each team member is able to perform their respective functions, and backing-up each team member to assure success!

Once you become accustomed to this type of dosing you will be able to quickly and easily draw up medications for the majority of the population without a second thought. You will be able to determine dosages in your sleep, which may be helpful for that 3:00 AM call of your life.

Another tip for drawing up medications for RSI is to use different size syringes for different types of drugs. I always use a 20 cc syringe for Etomidate, a 10 cc syringe for the paralytic (either Succinylcholine or Norcuron), a 5 cc syringe for Versed, and a 3cc syringe for Fentanyl. An addded bonus for where I work is the order of administration is largest syringe to smallest syringe. This way when the drugs are laid out beside each other they are clearly visible as to their function, order of administration, and should not be confused. I have watched paramedics use several syringes of the same size and place labels on each syringe. This is asking for confusion and just another waste of time.

Just a few thoughts on how to make this type of call go more smoothly for you. Hope it was helpful! Be safe out there!

When to Put on Your Fireman Suit

2012-08-26T19:10:00.003-04:00

Over the years I have noticed that persons assigned to an EMS unit have a habit of wandering around dangerous environments in half of their PPE or even worse no PPE. When we are assigned to a suppression piece and the tones drop everyone is very clear as to when we dress and when we don't. So why is there such a wide variance of PPE from EMS personnel? Regardless of the reasoning I am going to attempt to remove some of the fog from this issue.

There are three distinct incidents that I feel personnel assigned to the EMS unit need to arrive in PPE and ready to perform.

1) First Due Building Fire
When you are the first arriving medic unit to a building on fire you need to be fully dressed in your fireman suit and ready to work. Your primary responsibility is not to make the nozzle, ladder the roof, or run around and try to prove what a great fireman you are. You can do this when you are assigned to the engine, truck, or rescue. Your number one responsibility is to locate, triage, and treat any civilian injuries. In order to do this properly you need to be fully dressed so that you can safely approach and work in and around the scene. Large crowds are often found all around a fire scene. In these crowds you will find witnesses, homeowners, civilian rescuers, green linemen, and many of them may be walking wounded. It is your job to figure out what happened, how many are injured, and relay to command all of this information along with any additional resources you will need to begin to develop the EMS branch of the incident. Look for soot running out of nostrils or on clothing, torn or ripped clothing, citizens without shoes, cuts and scratches, or obvious burns. Adrenaline will be running high with victims and they will be ignoring any and all pain or discomfort. As you are doing this by no means should you neglect the kink in a hose line, but do not expect to be fighting fire. It is not a glorious job but a very important one. Everyone on the incident has a specific job to do and the EMS unit is no exception. If there are no civilian casualties your number two responsibility is to function as the initial RIT medic unit for any firefighter injuries or deaths that may suddenly occur. It has been said that the word "MAYDAY" is the most frightening thing that can be heard over a fire ground radio. It is your job to be prepared for and expect this event on every fire. Be familiar with the egress points and make a plan to evacuate any civilian or firefighter casualties from each exit point. Some tricks of the trade I have learned over the years are:

Place your cot in the down position in an area easily accessed by all egress points
Only bring essential EMS equipment away from the unit to perform the initial key functions in a cardiac arrest (airway, IV, defibrillation), everything else can be treated in the unit after the victim is evacuated from the scene.
Use a reeves stretcher or a large soft stretcher such as a Shamu to evacuate victims. They work much better over hose lines and around common obstructions found on a fire scene than trying to roll the cot everywhere.
Be diligent, be prepared, and expect the worst. Everything else will be no problem

2) Vehicle Fire
It is very important for the EMS crew to be dressed and ready to work on a vehicle fire. Not so they can smoke the engine with a dry chem, but to perform and/or assist in any victim rescue from the vehicle. It is a rare occasion, but the reason an EMS unit is dispatched on a vehicle fire is for just this reason. When you do roll up on an incident with a screaming victim hanging halfway out the drivers window with black smoke billowing all around them you better be ready. If you are not already dressed and able to easily and quickly don your SCBA you will be way behind the eight ball. Some tricks of the trade I have learned over the years are:

Be ready to break glass and cut seat-belts.
If you have an extra SCBA place it on the roof and give the victim air. We carry three on our units in case we have an intern.
Bring a dry chem to the car (to help extinguish the interior fire around the trapped victim). They will appreciate this even more if you have a mask on them so they don't suffocate from the dry chem as well as the smoke
Be mentally prepared for "whatever it takes!" If you have ever run an incident like this you know that it can be one of the most trying and stressful incidents you will ever run. There is nothing quite like being face to face with another human being while they claw and scream at you because they are burning alive. This image alone should be reminder enough for you to get dressed before you leave the house.
You may need to enter the vehicle while it is on fire from the opposite side to remove the victim. This is an impossibility without full PPE and SCBA.

3) MVA with Extrication
On an extrication it is the rescue's job to either remove the victim from the vehicle or remove the vehicle from the victim. It is the job of the EMS crew to access and treat the victim during the rescue. This cannot be done unless the EMS crew is in full PPE. There should be no one in the action area around the vehicle without the proper PPE, but too many times you see a member of the EMS crew popping in and out wearing a station uniform and a traffic vest. This is unacceptable and should never happen. Some tricks of the trade I have learned over the years are:

Be ready to break glass and cut seatbelts
Absolutely do not try to enter a vehicle that has not been stabilized
Coordinate with the rescue officer
Wear a low profile rescue helmet rather than a suppression helmet. It allows you to move around the interior of the vehicle more easily.
Carry a small amount of essential EMS supplies with you when you are the interior EMS. Be prepared to control an airway, start IVs, control bleeding, place tourniquets, etc.

These three types of incidents are when EMS personnel need to arrive absolutely without question in full PPE and ready to perform.

Prehospital Abdominal Assessment Part 4..MI?

2012-08-25T19:19:00.001-04:00

For the upper right quadrant we are not going to concentrate on bleeding ulcers, any stomach disorders, or the spleen. As I have said before paramedics are experts on what is going to kill you in the next 20 minutes, and the most devastating disorder we can encounter in the upper right, or any quadrant does not even originate from the abdominal cavity, it is a myocardial infarction.

You must scrutinize any and all abdominal pain for the presence of an MI, regardless of what the patient is telling you, regardless of the quadrant, regardless of your gut instinct as to the origin of the pain or discomfort. Not long ago a woman walked into a hospital complaining of gallstones. She had a history of gallstones. She told the triage nurse the pain was more to the upper left quadrant and she was sure it was her gallstones. The patient stated she should of had her gall bladder removed years ago but did not and now she is paying for it. The nurse and the patient had a very thorough conversation regarding the patient's history, all signs and symptoms pointed to the gallbladder. After the patient was escorted to a room the doctor ordered a routine EKG and found the following:

This was no gall stone! The only reason we perform 12 lead EKGs in prehospital medicine is to quickly identify the presence of an acute MI. We cannot successfully do this unless we get in the habit of rapidly (within 5 minutes of patient contact) performing a 12 Lead EKG on all patients at risk of having an MI. That means all chest pain, chest discomfort, dizziness, syncope, shortness of breath, nausea, and yes abdominal pain to name a few. There are few medical patients that you can absolutely rule out the risk of an MI. If you are going to perform a 12 lead EKG on a patient it should be done quickly and efficiently. Train your partner and crew to make this part of their initial physical assessment and acquisition of vital signs. A well trained paramedic should never say, "do you want to get a 12 lead now or wait till we get to the unit?" My response to that question is, "exactly how long would you like to wait to determine the patient is having an MI? Would 10 more minutes suffice?"

Don't let an MI slip through your fingers just because the patient describes abdominal pain. You do not want to be THAT medic!

Prehospital Abdominal Assessment Part 3

2012-07-07T11:35:00.000-04:00

In Prehospital Abdominal Assessment Part 3 we are going to take a good look at the lower left quadrant. The two conditions we are going to look at in the lower left quadrant are worlds apart from each other, kidney stones and an abdominal aortic aneurysm.

Kidney stones can obviously occur on either the right or the left side as we have two kidneys, but we are going to discuss them here because we spent our time in the lower right quadrant focusing on appendicitis. Kidney stones are not life threatening but have been described as the most painful medical experience, including childbirth, one will ever encounter. One minute you are fine and the next minute it feels like you are being stabbed in the back or the groin. Most kidney stones pass on their own but the ones that don't may require some sort of urological intervention that can range from supplemental medications to surgery. Kidney stones do not cause symptoms until they try to pass through the urinary system. Symptoms are extreme pain in the back or side that will not go away, nausea and vomiting, blood in the urine, and fever/chills. The best prehosptital indicator that the pain your patient is experiencing is a kidney stone is a good history. A history that predisposes a patient to kidney stones are, male gender, previous stones, family history of stones, diet heavy in animal protein and eggs. There is no magic physical assessment tool here that will point towards a kidney stone in the field. The pain can be anywhere from the back to the groin, depending on where the stone has decided to get hung up, or radiating down to the groin. The best prehospital treatment for a kidney stone is good pain management. Pain medications are classically under dosed in the prehospital setting. Give an initial dose of medication and continue to give additional doses as long as their pain is greater than a 5/10. Your goal should be 0/10 pain management, but that is rarely possible with a kidney stone. Left untreated a kidney stone can lead to infection and sepsis.

The next emergency you should rule out is a big one and can definitely kill your patient faster then you can transport them to the nearest operating room. An abdominal aortic aneurysm is a permanent localized dilation of the abdominal aorta greater than 3 cm and is one condition every near syncope and every syncope patient needs to be scrutinized for. Symptoms can range from back pain to lower abdominal pain. it has been described as tearing, stabbing, or ripping pain. A pulsitile mass can be an ominous sign and if you feel one then you need to be very gentle with the patient and very carefully transport to the nearest hospital with an operating room staffed and ready to go.

Attached is a good YouTube video explaining the anatomy and the process of the surgical repair.

Prehospital Abdominal Assessment Part 2

2012-04-12T21:02:00.000-04:00

Continuing the prehospital obdominal assessment we will look at the right lower quadrant. In this area we are going to talk about the obvious acute appendicitis. In order to help us differentiate an appendicitis in the presence of RLQ abdominal pain I would like to add two more assessment tools to your repertoire: tenderness over McBurney's point and obturator sign. Positive results from these tests point toward appendicial irritation and possibly an acute appendicitis. McBurney's point is a site of extreme sensitivity in acute appendicitis, situated in the normal area of the appendix one third the distance between the umbilicus and the anterior iliac spine in the right lower quadrant of the abdomen. Finger pressure over McBurney's point in the presence of an acute appendicitis brings immediate and intense pain. Tenderness over McBurney's point is one indicator of an irritated appendix.

The next test you can do is called obturator sign. The internal obturator muscle lies close to the appendix and flexation of this muscle in the presence of an acute appendicitis will cause an increase in pain in the lower right quadrant. A picture is worth a thousand words so this test is best explained by watching the following video:

http://youtu.be/jV80jcnhNtA

This brings us to the topic of rebound tenderness. We have all learned that the presence of rebound tenderness in the LRQ could mean an appendicitis. Rebound tenderness is not an isolated test for an appendicitis. Anytime the peritoneum is inflamed you will find rebound tenderness. An inflamed and infected appendix will irritate the peritoneum thereby causing rebound tenderness in the area of the appendix. Rebound tenderness can also be an early sign of abdominal bleeding even before rigidity as blood in the abdomen will cause peritoneal irritation as well. So rebound tenderness in itself is not conclusive of an inflamed appendix. Using the assessment tools I have described above is much more specific and useful. When confronted with a patient with LRQ abdominal pain it is very important to determine the likelihood of an acute appendicitis as it is an emergent surgical case and a ruptured appendix can cause profound septicemia.

The most common signs and symptoms of an appendicitis are abdominal pain, loss of appetite, nausea, vomiting, and fever. When you have this presentation along with tenderness over McBurney's point and a positive oburator sign...think acute appendicitis

Coo Coo Bird? A Practical Prehospital Psychiatric Assessment

2012-03-23T21:44:00.001-04:00

Psychiatric emergencies can be one of the most dangerous and challenging emergencies that prehospital providers can encounter. Our training in these situations is scant at best and these patients present a myriad of challenges. If you are presented with a patient in the midst of psychiatric emergency emotions will be at an all-time high for the patient, as well as, you and your crew. If you follow these four simple guidelines you will increase your confidence and improve the patient's outcome in these very challenging emergencies.

1) They are having a medical emergency until proven otherwise.

This is extremely important as there are several medical conditions that can affect a patient's behavior: hypoglycemia, thyroid disorders, toxins, and stroke to just name a few. In the prehospital setting we can rarely rule out all the causes of behavioral changes so never pigeon hole a patient as a coo coo bird. This is a classic mistake and will only lead to poor treatment decisions and a horrible experience for the patient and their family who has summoned you to save them from a seemingly impossible situation.

2) Safety first: The safety of the patient and the emergency responders is paramount. One of the first determinations you need to make is whether the patient is dangerous to themselves or others. Always include law enforcement and never allow the patient to be alone at any time once you have made contact. Truly suicidal patients who are being cornered will make any excuse to get away from you and finish the task. It is not unusual for a patient to simply ask to go to the bathroom and then jump off of their balcony. Remember, once you make contact don't let them out of your sight and make sure you always have enough help to fully restrain and immobilize them in case the situation warrants immediate control.

3) Simple assessment questions: Ascertain the patient’s suicide scale and homicide scale. On a scale of 0-10 where zero is no thoughts whatsoever and 10 means they want to commit suicide right now; what number would they give themselves? If they give you any number above zero for the suicide scale the next question you want to ask is do they have a plan? A truly suicidal patient spends 24/7 thinking about and planning on how they are going to get the job done. If they give you a plan then add a few points to the scale because they are serious. If they give you any number above zero for the homicide scale the next question you should ask is to whom their aggression is directed. If they are having feelings of anger and aggression you need to know who the target is. Is it one person or a group of people? Is the person in the room? Are you the person? These are all very important pieces of information that will assist you in diffusing the situation. Ask the patient if they hear voices. If they say yes then you want to know what they are saying. If the voices are telling them to kill the paramedic then that is a very important piece of information. Ask if they are seeing things and what they are. If you ask every suspected psychiatric patient these few questions it will give you a very good snapshot of their mental stability. So remember to ask these questions:

Suicide Scale
Homicide Scale
Voices
Hallucinations

4) Diffuse the situation: The next step in mitigating these types of emergencies is to diffuse the situation and transport the patient to the nearest hospital with psychiatric facilities. If their suicide scale is anything above a zero then they warrant an emergency custody order and immediate transport regardless of their feelings about the situation. Consult your state laws regarding ECPs and TDOs. Never humor their delusions or lie to them about anything that is happening or going to happen. The best road to successfully diffusing the situation is honesty and professionalism. Remain tactical and aware of scene safety. Psychiatric scenes are very dynamic and can change rapidly from a pleasant conversation to a life threatening MAYDAY in a matter of seconds.

Prehospital Abdominal Assessment Part 1

2012-03-19T16:24:00.000-04:00

Prehospital education has classically fallen very short when it comes to an abdominal assessment. Check all four quadrants for tenderness or rigidity and that’s about it. We learn where the underlying organs are and then there's something about rebound tenderness for appendicitis, but if you ask any given prehospital provider about how to do a medical abdominal assessment that is about all you will get.

What I would like to cover in this four part series is how to do a good abdominal assessment that will help you recognize the conditions requiring immediate surgical intervention, or lead to a very poor outcome for the patient if left unattended. As I have said before I believe paramedics are experts in what will kill someone in the next 20 minutes. So let's expand upon that and talk about what serious abdominal emergencies need surgical intervention or may lead to death in the next 24 hours if not recognized and subsequently treated appropriately. Keep in mind this assessment and discussion is outside of trauma or obstetrical emergencies. Those two areas are completely different and I believe prehospital education does a pretty good job in recognition of those types of emergencies. It's the nebulous abdominal pain we are going to discuss. By the way, abdominal pain where I work is considered a BLS emergency and may be first assessed by an EMT with no ALS training. The conditions and assessment tools I'm going to teach you in these articles are not rocket science and do not require advanced knowledge of EKGs, IVs, or pharmacology. These are standard assessment skills every prehospital provider should commit to memory.

I plan on writing about each quadrant and also wrapping up with some general guidelines. Let's start this in the right upper quadrant. The medical emergencies I want to talk about in this area are cholecystitis, ascending cholangitis, and perforated duodenal ulcer. Cholecystitis is inflammation of the gall bladder. Ascending cholangitis is an infection of the bile duct and both cholecystitis and cholangitis can be caused by the presence of gall stones. A perforated duodenal ulcer can be life threatening and is a hole, most often on the anterior surface of the duodenum, that is formed which allows gastric contents to enter the abdomen. A duodenal ulcer requires immediate surgical intervention and can lead to sepsis, profound, shock, and death if left unattended. An inflamed gall bladder may need surgical intervention and acute cholangitis can also lead to multiple organ failure, sepsis, profound shock, and death. This makes these conditions true medical emergencies and something every prehospital provider should be aware of.

The first assessment technique I want you to add to your arsenal is checking for Murphy's sign. Murphy's sign is a maneuver used to differentiate upper right abdominal pain. It is performed by asking the patient to breathe out and then exerting pressure to the upper right quadrant just below the costal margin which is just below the bottom of the lower rib cage. Then ask the patient to take a deep breath in while keeping pressure in this location. If the patient experiences an increase in pain this is a positive Murphy's sign and is indicative of an inflamed gall bladder.

http://youtu.be/9L7N89sOSuc

http://youtu.be/lk7c78G1zaE

Murphy's sign can be just as helpful if it is negative. It is usually negative in ascending cholangitis and perforated ulcers. It is a good assessment tool to give you more information about the origin of the patient’s upper right abdominal pain. If the test is positive you should then ask the patient if they have had their gall bladder removed as this is a very common surgery. An inflamed and infected gall bladder could be the source of their URQ abdominal pain. If the test is negative you can further differentiate the origin of the pain if the patient has a fever.

RUQ pain with fever and negative Murphy's sign

1) Ascending Cholangitis

2) Perforated Duodenal Ulcer

Ascending Cholangitis

You should begin to suspect ascending cholangitis when the patient is complaining of RUQ abdominal pain and Murphy's sign is negative. Then check for fever and jaundice. Jaundice is best seen in the eyes as it may be difficult to determine with some skin tones. The patient may also present with uncontrollable shaking and uneasiness. In later stages there will be shock and an altered mental status. If you have the above clinical presentation along with hypotension and confusion then think ascending cholangitis as this is a true medical emergency. Prehospital treatment is recognition, pain management, fluids to increase the blood pressure and transport to the nearest hospital with surgical services.

Perforated Duodenal Ulcer

You should begin to suspect a perforated duodenal ulcer when the patient is complaining of RUQ abdominal pain and Murphy's sign is negative. Then check for a fever. Unfortunately hypotension and high fever are late signs. The presentation is usually a sudden acute onset of epigastric pain that will quickly become generalized and may move to the RLQ. The patient may have a history of recent surgery or previous ulcers. The abdomen may present with board-like rigidity. Prehospital treatment is recognition, pain management, fluid in the case of hypotension, and transport to the nearest hospital with surgical services.

We are experts in emergencies and abdominal emergencies are no exception. Just recognition of these few conditions alone can save a life. So let's begin our journey into the world of acute abdominal assessment by committing to memory Murphy's sign, cholecystitis, ascending cholangitis, and perforated duodenal ulcers.

References

Silverman, P.M. and Zeman, R. K., editors. CT and MRI of the Liver and Biliary System,

Contemporary Issues in CT, Vol 12, 1990.

Ros, P.R. (guest editor). Hepatic Imaging, The Radiologic Clinics of North America,

March 1998, Vol. 36:2

Gamuts in Radiology

Nino-Murcia, M. and Jeffrey, R.B. Imaging the Patient with Right Upper Quadrant Pain.

Seminars in Roentgenology, Vol 36, No. 2 April 2001, pp 81-91

www.uptodate.com

Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed.

Cecil Textbook of Medicine 21st Edition

Saini, S. Imaging of the Hepatobiliary Tract. NEJM (1997) Volume 336:1889-1894

Hill AG. Management of perforated duodenal ulcer. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

DCHEATR Method of patient reporting.

2012-03-08T13:33:00.004-05:00

I developed this method of writing patient reporting years ago after I was tired of SOAPing and all the other mnemonic methods that didn't seem to have a good logical order to me. Feel free to use this as you see fit, change it, pass it on, help out our fellow providers. I also use this broad outline when giving verbal reports over the phone.

D: Demographics

Age, Gender

C: Chief Complaint

What are they complaining of? Not to be confused with what do you think is wrong with them.

H: Patient History

Pertinent past medical history, surgeries, medications, allergies

E: Events leading up to the 911 call

What happened just before they called for help that contributed to the emergency

A: Assessment

Your physical assessment findings
B/P, Pulse, Respirations, O2 SAT, Blood Glucose, EKG, 12-Lead, Lactate, and whatever other numbers are pertinent to the patients emergency.

T: Treatment

What did you do for the patient?

R: Response to treatment

How did the patient respond to your treatment plan?

If you could only give one piece of advice about being a good EMT or medic what would it be?

2012-03-08T12:44:00.003-05:00

I recently asked this question on Facebook and the responses I received are worthy of mentioning in this forum. Here are the comments without the names to protect the innocent. If you have anything to add to this list feel free to leave a comment here. The answers I received from this question were particularly moving to me as they came from some of the greatest EMTs and paramedics I have had the honor of knowing.

Asking for another opinion is never a sign of weakness. It shows a desire to be thorough.
It's not about "emergencies", it's about being good to people, being kind, holding the bucket when they vomit, picking them up off the floor at 2 in the morning and holding their hand when they are scared.
Nothing is above being a patient advocate. They called you for help and it's your job to do that to the fullest extent and to the best of your knowledge
Always carry a pen....
Learn and think on every call. Forever.
Never stop studying, you are either getting better or getting worse.
Compassion
Noone knows everything
Treating everyone like you would want yourself or a family member to be treated.
Remember it is not your emergency it's the patients. And if you think you know/ seen everything then you need to quit, because that's when you are going to hurt someone.
Learning the patients name and addressing him or her with it.. oh and a DOB wouldnt hurt either... :-)
make the less experienced part of decision making
know the basics
Show compassion even when it's not really warranted.
Keep your hands out of your pockets and show compassion.
Most important of all....don't forget to put the ladder truck in service for routine calls.......we need to get back to the firehouse as soon as possible to clean and cook for the Engine and Medic guys and gals, and the Deputy Chief and his Aide!!
People call us when they have lost control of something in their lives. It is very humbling. Sometimes they call us for something major, but, more often than not, it is something minor... but it is a situation where they need someone else to come in and take control.
Also worth remembering is that we have the publics trust. In very few other occupations can you go up to a person and they willingly hand you their child or give you unrestricted access to their life, home and property. Do not ever forget or betray that trust.
You have to put all your heart in to it and have the compasion to care for others. When we lose that things become boring. Thats when we tend to burn out.
Expect the unexpected, be aware of your surroundings at all times, use the buddy system,
The public call us when their lives are suddenly spiraling out of control. It is our job to restore order to their life, when possible, calmly with integrity, professionalism, and compassion.
Treat everyone equally and love what you do.
Do no harm.

As you can see there is a central theme in these comments which you can read in the title of this blog. The art of hauling humans is a vocation best developed with humanity, intelligence, compassion, and respect for our fellow man.

I want to thank everyone who responded to this Facebook post. It is all of you that has inspired me to create this blog and share the humanistic approach to fire and EMS with our brothers and sisters around the globe.

Thank-you

So you want to be a paramedic?

2012-03-07T18:42:00.001-05:00

The first step you need to take in order to be a good paramedic is to simply get in the game. I am a firm believer that a paramedic card does not make you a paramedic; it just gives you permission to learn how to be a paramedic. So just get the card and start your journey. I have worked with medics with graduate degrees and medics with GEDs. I have worked with medics who have graduated from a two year program that was touted as the best school in the area, as well as, the 6 week condensed course that jammed packed everything in so fast the students barely remembered a thing. Each and every one of these people was issued the same card. They each were given the same opportunity to begin their journey as a paramedic. I have seen medics from each extreme and all in between both succeed beyond my expectations and also fail miserably. So forget how you got the card. It doesn’t matter anymore. Don’t think you are the shit just because your schooling cost a fortune. On the other side of the coin don't be insecure because you received your training from the Fischer Price Paramedic School. It's all what you make of it. If you want to be a good paramedic start by being a good person first, then make a commitment to learn each and every day because if you aren't moving forward you and moving backward. Medicine is not a stagnant profession. It is always evolving and changing in practice. If you aren't learning something everyday then you are probably behind the times. Learn from each and every person you come in contact with. You can learn just as much from a bad paramedic as you can from a good one. You just learn what not to do rather than what to do. You can learn just as much from your patients, family members, and bystanders. Don't be afraid to ask questions. By all means don't be one of those paramedics that is silently ignorant. Just because you are a paramedic does not mean that you have suddenly become an all knowing savant. Just be honest, genuine, caring, and inquisitive and you will blossom into an excellent paramedic.

Bystanders...Get out of my way!

2012-03-07T16:13:00.001-05:00

I have observed and recently experienced the plight of the Good Samaritan. As emergency responders we arrive on a scene with what appears to be a strike team, an engine and a medic unit with a combined crew of six. We perform a rapid assault assessing the patient, mitigating any life threatening concerns, and then rapidly remove the victim from the surrounding area in an efficient and coordinated manner. It is poetry in motion. What I think we miss out on at times is paying attention to the bystanders and what occurred prior to our arrival. We tend to discount any persons input if they are not wearing a fire department uniform.

Recently I was off duty and witnessed someone have a syncopal episode. I was dressed in civilian clothing and had no indicators that I was trained in emergency medicine at all. I performed an initial assessment, garnered the patient’s history, and had what I considered a very good run down of what could have been the underlying cause and what treatment would be required. When the responders arrived they weren't really interested in anything I had to say. The first part of the strike team to arrive was an engine. I attempted to help them with their assessment and suggested acquiring a 12-Lead EKG. I was told that the medic unit would take care of that and was brushed aside. When the medic unit arrived the crew wasn't very interested in anything I had to say either. They repeated some of my assessment questions and never wrote down or appeared interested in anything I had done prior to their arrival. They then took the patient away to their unit. I later found out the medic unit obtained a patient refusal and the patient was never seen by a physician. WTF...I was beside myself. I saw the patient later in the day and he said that everything was checking out fine so he didn't go to the hospital.

Who were these people that came to check him out...WTF...of course it checked out fine...he was conscious now...anyone with any iota of medical training should know that a syncopal episode could be a medical time bomb waiting to explode...whatever caused them to go unconscious and then wake up just didn't last long enough to kill them...definitely a medical condition requiring further testing and follow-up. Not every syncopal episode denotes a dangerous life threatening underlying condition but it's possible and should be taken seriously.

I think it's very important to not only treat the patient as a human being but also all the other human beings in your immediate area at any given moment. Don't discount the value of the bystanders or allied healthcare worker on the scene of any emergency. They can be a valuable asset. The time you spend gaining information from them can possibly save you time later on. Not a sermon...just a sermon.

Fireman...or...Firefighter

2012-03-05T20:36:00.001-05:00

Are you a fireman or a firefighter? Since its conception the fire service has changed from a completely male dominated vocation to a gender diverse group. Since that time we have all been walking around on egg shells worried about what to call our fellow workers. I say cut the crap. Society in general has developed into a more diverse workforce. Women are no longer like June Clever living at home, and that's a wonderful thing. Now let's get down to whether we are firemen or firefighters. Let's break down each word and look at its meaning. Fireman is not a male gender specific term. There certainly aren't any firewomen. That word does not exist in the dictionary. Does that mean the dictionary is sexist? No, of course it doesn’t because the word fireman is not sexist either. The root form of the word man in the word fireman does not refer to the male gender. It refers to all of mankind. Mankind is composed of men and women, or women and men. Pick your favorite version. It doesn't matter. Firefighter broken down means we are fighters of fire. We battle the big red beast. We all do that, both men and women. We are all part of mankind, both men and women. So let's cut the crap and stop worrying about what we are called, or what we call each other. We are all in this together, risking our lives to save strangers. We all have each other’s back so stop walking on egg shells and just be firemen, or firefighters. Pick your favorite term but don't have any hang-ups either way. It all means the same thing. We are a special breed of mankind and we should stick together no matter what. Stop the madness...

STEMI...How Can we Improve??

2012-03-05T17:15:00.002-05:00

The reason we perform 12 Lead EKGs in the field is to find out if the patient is having an acute MI. EMS has made great strides in the recent past to make sure their ALS providers have been trained to perform and interpret 12 Lead EKGs. So what can we do now to make it better? I serve on the regional STEMI committee for my area representing prehospital providers within 30 minutes of a PCI center and I have put a lot of thought into this very topic. We all know that time is muscle so simply put we need to remove absolutely every obstruction that causes any delay from the time the coronary artery is first blocked to the time the cardiologist clears the obstruction and returns coronary perfusion to the cardiac tissues. Sounds like a good plan. The first step is to form a regional STEMI committee and bring representatives from each step of the patient’s journey to the same table so we can all get onto the same page. I could write an entire article on the importance of this aspect alone but today let's look at the improvements I see the prehospital system can contribute to the cause.

1) Patient Education: We need to educate the public as to the importance of arriving at a PCI center when their chest pain occurs. By dialing 911 and getting the prehospital system involved they will have decreased their onset to balloon time tremendously. In my area most of the extended times to a PCI center have come from inter facility transfers and not from prehospital initiation.

2) EMS vs. ER...The first 10 minutes should be the same: I am a firm believer that the patient's hospital stay should begin at the time the paramedics walk through the front door of the patient's residence. Door to balloon times are misleading as we need to start recording and improving first healthcare contact to balloon time. This is the 21st century and EMS around the nation needs to acknowledge they are not just a ride to the hospital; they are not just there to fix life threatening conditions and then hand the patient off to the ER. EMS should encompass all the initial actions just as if the patient walked into the front door of the ER. This should include patient registration, placing a gown on the patient, and any other initial actions or treatment taken by the ER in the first 10 minutes. If you want to know what actions and interventions EMS should be adding to its tool box all you need to do is watch what occurs in the first 5 minutes after you arrive with a critical patient. If you see any standard treatment or intervention occurring immediately then that is something EMS should be considering implementing into their protocols.

3) Prehospital 12 Leads: As I said previously we have made great strides in this area but what we have done is only scratching the surface. Most EMS systems have 12 leads on the ambulances staffed by paramedics. We need to extend that out at least another tier and make sure every fire truck and BLS provider can perform a 12 Lead EKG. Any patient suspected of having an acute coronary event should have a 12 lead as one of their initial vital signs. It is not an ALS intervention to place stickers and attach cables to a patient’s chest. Everyone should be doing it. Sure, paramedics are needed to interpret the squiggly lines, but certainly not to attach the cables and print out an EKG and have it waiting for the arriving paramedic to interpret. I have seen far too many paramedics perform an initial assessment and then move the patient to "their office" and then perform a 12 lead EKG. This is flawed thinking. Our goal should be a 12 Lead within 5 minutes of patient contact by any prehospital provider. How long should we wait to find out if they are having the big one? Any barrier in your EMS system that prohibits a 12 lead EKG from being acquired within 5 minutes should be removed. As we all know the first step of any 12 step improvement program is recognizing the problem. We can do nothing to improve the patient’s journey to a PCI center until we first recognize they are having a STEMI.

4) Transmitting EKGs: It is absolutely imperative you find some way of transmitting the 12 Lead EKG for the receiving ER physician to see. It is not that the hospital doubts our ability to interpret EKGs, although, in some parts of the country this may be true. It is simply a team sport. If the physician and the paramedic were standing beside each other when the 12 lead came out of the machine they would both look at it. It's just best practice to share this type of information. Just like all the prehospital providers hand the EKG off and show it to each other on the scene. This is just not the type of information you keep to yourself and the cost of falsely activating the cath team is extensive. You want as many people involved in this decision as possible. False activations occur in the ER. We do not need any bad press from false activations occurring from a prehospital EKG. If paramedics feel this is an insult to their intelligence...get over it. Anything that slows down onset to balloon time needs to be eliminated, and that includes your pride.

5) STEMI ??: So the squiggly lines look bad...what next? I propose a two tiered prehospital response to a possible STEMI:

a) Confirmed STEMI: This is a patient that both the prehospital providers and the ER physician agree is a STEMI. The EKG has been transmitted and everyone is on the same page so game on. The PCI team should be activated and every barrier that will slow down the time to the patients cath should be removed. The patient should be placed in a hospital gown and their groin should be shaved. No drips should be started and any interventions routinely performed by the ER physician should be moved to the prehospital arena such as heparin or integrelin boluses. If a chest x-ray is required prior to the patient going to the cath lab then a portable chest should be waiting in the ER and it should be performed on the EMS stretcher and then the patient should be immediately transferred to the cath lab. If your EMS system has extremely long transport times to an ER or PCI center and your STEMI patient would undergo TPA at the closest ER then this should be moved into the prehospital arena. IF the training or care level of the EMS system does not support this effort then a plan should be put into place to make it so. Whatever requirements your nearest PCI center will require prior to the cath being performed on a patient should be implemented in the prehospital setting. This is where it is crucial to have all the stakeholders at the same table with one goal in mind, decreasing the time from event to balloon.

b) Non-Confirmed STEMI: This is a patient that the ER physician has not seen the EKG but EMS suspects a STEMI. No drips, rapid transport, and all the interventions listed above outside of activating the cath lab, pre PCI treatments, or TPA should be implemented.

6) Transport: The patient should then arrive at the PCI center within 30 minutes. How this is accomplished depends on the local resources and the location of the PCI center. If air transport is the only way then EMS should be authorized to initiate this from the scene as transporting to the nearest ER and then transferring the patient will be an obvious delay.

7) No Bed Transfer: It takes time to move a patient from an EMS stretcher to a hospital bed. The patient should be moved directly from the stretcher to the cath table. If the patient needs to be seen in the ER for any reason they should stay on the EMS stretcher and be ready to roll to the awaiting helicopter or to the cath lab, whatever is the next step of the journey to a successful PCI.

8) STEMI Drills and QA/QI: We should be continually evaluating the system and looking for improvements. STEMI drills will make sure the machine stays well oiled and ready to perform when needed. Any improvements in time, procedures, and interventions that can be safely incorporated into the prehospital setting should be implemented as they become available.

I cannot stress enough that this is a team effort. All phases of the system from the patient, the dispatcher, to the intervening cardiologist need to communicate with each other and develop a cohesive plan with only one goal in mind, the well being of the STEMI patient!

Getting to the call...Think that's important?

2012-03-04T21:17:00.003-05:00

I want to take some time and talk about area familiarization. I know we are in a very high tech world these days but there is absolutely no substitute for knowing your area like the back of your hand. I feel it's becoming a lost art in the fire service. I have a challenge I give every new recruit we hire. I call it the Pepsi challenge. The concept is simple. Learn every street in our city in seven tours. That's about two months with our schedule. There are about three hundred streets to learn. I then give them a fifty question street test and they have to score a 100%. If they can do it I'll buy them a Pepsi or any beverage of their choice. It's not the free soda that they are working for. It's the knowledge, satisfaction, pride, and ownership of the job. Needless to say over the past 10 years not one person has passed the test. A year later I'd say 90% are still struggling during street drills. I find this very sad and pathetic.

Learning the streets is just the first step into a whole new world. What happens after we turn off the streets? We find ourselves in large apartment complexes, high rise subdivisions with commercial strip malls under townhouses, swimming pools hiding in the middle of complexes, as well as, innumerable hazards and pitfalls just waiting to be discovered during an emergency incident. Then what happens after you get to the buildings? Where are the hydrants and the connections? When you enter the building what floor are you on? Where are the elevators and stairwells? How do you access the attic or the roof? The questions are many and the time to determine the answers is not during the emergency incident.

The public expects us to know where they are when they call. When the sirens are getting louder they do not want to hear them fade away before they get louder again. This is extremely poor service and completely unacceptable. The best fireman or paramedic is useless unless they first arrive on the scene.

If you feel this is important I would suggest you get out a map book and start learning. Pick the neighborhood immediately around your station. If you can drive to the scene faster than you can look it up then you should know where it is. A good driver knows the streets, splits, and hydrants of the area immediately surrounding the station. If you think learning hydrant locations is extreme try finding one during a deep snow.

I challenge you to learn your area in 7 steps.

1) Streets

2) Numbering system, are the odd or evens on the right side of the road.

3) Splits: Do you have to drive a different way to get to certain addresses of the same street?

4) Hydrants

5) Connections

6) Subdivisions: What’s the layout? Are the buildings numbered and clearly labeled?

7) Get into the buildings and learn what’s inside. Where's the stairwell? Hallway splits: Apt 1-8 is to the right, and 9-14 is to the left. Finding the fire apartment will be easier and faster.

As you can see there is a lot to learn after number 1) Streets. It's not rocket science. Just learn something new everyday and berfore you know it you will be a wealth of knowledge.

MAYDAY...MAYDAY...MAYDAY

2012-03-04T15:29:00.001-05:00

What have you done today to prepare for YOUR mayday? I have a theory that every firefighter sometime in their career will be involved in at least one life or death mayday situation. I'm not talking about your air alarm going off, or misplacing a firefighter for a few minutes and having to say the word mayday over the radio. I'm talking about a hell yeah, life or death, whatever it takes extreme situation that may kill you or worse one of your crew. The question is every time you enter the firehouse are YOU thinking about this? You should be. We should be treating each and every day as if it will be the last day we will be on this earth. I'm not saying we should be acting recklessly with wonton abandon and disregard all common sense because tomorrow will never come. The mind set I'm trying to instill in everyone is to prepare for the moment, the moment that is inevitable if you spend long enough riding fire trucks and ambulances. So there are a few things I believe you should have in the forefront of your mind each and every day. If you have anything to add to this please leave a comment and let me know so we can all be better prepared for our mayday.

1) Physical Fitness: Make sure you are physically fit to survive whatever mayday situation is in store for you in the future, because one is waiting. You should work out on a regular basis as if your life depends on it, because it does. Extreme situations require extreme training. Be safe and don't hurt yourself but make sure your body is ready for the demands you will be placing upon it.

2) Mental Fitness: Probably more important than physical fitness is mental fitness. Make sure you are mentally prepared to survive the situation. I believe the first step in this process is developing a no retreat, no surrender attitude toward survival. Practice how you will need to perform.

3) Equipment Checks: Never take for granted your equipment is ready...check it out yourself, especially anything that will save your life.

4) What's in Your Pockets: Only carry things with you that will save your life. There is a tool box on the fire truck. You do not need to weigh yourself down with screwdrivers and pliers so you can be Johnny on the spot fireman who is ready for every routine situation. It is not an emergent situation to reset an alarm or change a smoke detector battery, but none the less, I see firemen carrying around entire tool boxes in the pockets of their gear.

5) Train When Tired: Practice self rescue techniques under extreme exhaustion. When you are fighting for your life you will be physically and mentally maxed beyond anything you have ever encountered in the gym. This will help your mental fitness as well. The body can do way more than the mind thinks it can.

6) No Air: Practice running out of air. We all train breathing air at times, but we make sure we have enough air for every scenario. Do you know how many minutes you personally have left while physically exerting yourself once your low air alarm starts to go off? Do you know how many breaths you have left once your vibra alert stops vibrating due to low pressure? You should, and you should train to extend those times. There are many techniques for air conservation. Pick your favorite one and try it while breathing air when you are nearly exausted. It's a little different when your body is screaming for oxygen.

7) Promote Readiness: A team is only as strong as its weakest link. Make sure the firemen around you in the cab are just as diligent toward the MAYDAY as you.

Keep in mind situational awareness and avoiding the mayday all together is your best option. Avoiding the mayday is a separate issue. This discussion is about being ready when all your preventative measures have failed, because one day they will. No matter how careful you are, no matter how aware you are of your surroundings, one day you will find yourself looking the grim reaper in the face and you need to be prepared to send him packing!

Jesus in the Fire Service

2012-03-03T02:25:00.001-05:00

I just read a tweet from a friend of mine that said "Nothing feels better than knowing that you have Jesus in your heart." I couldn't agree more but I wasn't always that way. Today I think the fire service needs to get closer to God. In order to understand how I came to that conclusion let's take a step back in time and meet Craig Christ. A nickname that causes me to cringe now but used to bring a smile to my face every time it was uttered in my presence. You see, I spent the majority of my adult life as what I called a devout atheist. This was an oxymoron I found quite humorous as I sat around the firehouse kitchen table each Sunday morning and preached my special brand of devotion to nothing. I was dubbed Craig Christ by my peers as I always had a quick retort about the origins of Christianity or Jesus himself that would bring most Christians to their knees and cause others to go to church twice the following Sunday. I was raised to ask questions. Never rely on a single source. Seeing is believing. Skepticism was my calling. I used to follow black cats around, break mirrors, and walk under ladders just for the fun of it. Tempting fate and challenging God at every turn. All the time daring God to show himself. I would stand outside during a thunderstorm and dare God to strike me down. Open the kitchen door at the firehouse with horizontal rain beating into your face as you look up and ask to be struck down by lightning and see how quickly the room clears out. I had it all figured out. Mother Mary was a harlot who cheated on poor Joseph behind his back all the time claiming immaculate conception. If we had DNA testing 2000 years ago I would have bet the whole issue would of been cleared up in no time. Jesus was actually the son of the blacksmith up the road with zero morals and a silver tongue that seduced poor Mary into an impossible situation for the times. So what happens to a child that is raised from birth being told he's the son of God. He goes crazy of course. Schizophrenia manifested itself in Jesus' late teens and compounded itself into his early 20s. Hearing voices, having hallucinations of angels, and talking to himself as he spread the good word all the way up to his inevitable execution by the state. Sure enough if you have enough followers and are preaching a way of life that is against the grain of society eventually the government will kill you. Just ask Jesus Christ and more recently David Koresh. I had fashioned a most intricate version of the past to justify my lack of faith and devotion. It was an entertaining version of events, but not one bit of it was based on a shread of evidence. Then I met Marc Racette. Marc and I shared a kinship for EMS, as well as, fantasy and science fiction. We instantly bonded on every level except religion. Marc was a devout Christian and I was a devout Atheist. We would spend hours on the medic unit debating the meaning of life and the origin of man. We both swore that before we retired one of us would convert the other. I would leave atheist propaganda on the inside of his food locker and he would leave Christian writings for me to find throughout the firehouse. This went on for years and neither of us budged. One morning in 2007 I awoke at the firehouse to find a book on my nightstand entitled "I Don't Have Enough Faith to be an Aheist". An interesting bit of propaganda. I was impressed by the title but I hardly found it compelling enough to read. So it collected dust for years. Then following my divorce I met someone and we became very close friends. We could talk for hours about anything...anything except God. She didn't find my special interpretation of the events humorous at all. In fact they would bring tears to her eyes, and this broke my heart. One day she looked me in the eyes, took my hands, and asked me to take a serious look at God. She told me that I was a smart guy and stressed how important it was to her that I stop kidding around and seriously look into it. I was completely taken back. I was used to debating and arguing with whatever the antithesis of fire and brimstone was. I was used to having the last word and completely frustrating or causing even the most devout catholic to doubt their beliefs. No one had ever asked me to look at the other side with such sincereity and concern for my well being. I was accustomed to being either agreed with or simply dismissed. I was speechless. So I did the only thing I felt I could being faced with such kindness and concern. I told her I would. Thus began my journey to God. My co-workers will tell you I changed my mind overnight. How quickly time flies when you aren't the one thinking and studying during every waking hour. I had no idea where to start. I spent the next several weeks confused and wondering how my lack of faith could be so upsetting to her. Then one day as I was driving to work I remembered the book Marc had left on my nightstand. I had no idea where it was. When I got to work I looked up the title on iBooks and sure enough there it was. So I spent the best $9.99 of my life and began reading. Over the next several months the transformation was complete. Soon after that I was Baptised and I haven't looked back since. I felt like my eyes had been opened. In a profession where any day could be your last, a profession that has more than it's share of morally questionable people; just watch a couple of episodes of "Rescue Me", or listen to the old adage: "cops and firemen, trust them with your life but not your money or your wife," I couldn't agree more. Nothing feels better than knowing that you have Jesus in your heart. Don't misunderstand me. Some of the bravest and most honorable people I know are firemen. Both men and women, but like any profession we have to populate it's ranks with mankind and mankind is flawed. Unfortunately the type of personality that is willing to risk their life for a perfect stranger is also the same personality that tends to live for the moment. When you live for the moment you tend to make poor decisions. So, back to our original question: Jesus and the Fire Service? Amen to that!

My Paramedic Final Exam

2012-03-02T22:31:00.002-05:00

The final exam I took to become a paramedic, or more accurately to remain a paramedic, did not take place in a classroom. The day of my final exam was a cool, autumn day in October. I was on duty in Fauquier County as a paramedic driving a Ford Explorer as a response vehicle. My job was to respond with any of the five fire and rescue departments in the southern region of Fauquier County and fill-in the gaps. Mostly, this meant operating as a paramedic on medical emergencies, but my job also required me to be a firefighter, drive fire trucks, and generally help out the volunteer agencies as needed on each individual emergency incident. My exam took place at 4:09 PM on October sixth. The events of the day leading up to my exam are not clear in my mind, but every minute between 4:09 PM and 4:32 PM is permanently etched into my soul.

There were three of us; we were professional firefighter/paramedics employed by the county of Fauquier. Fauquier County has been described as the bridge between northern and rural Virginia. For emergency response purposes, the county was divided into three areas: north, central, and south. Each area encompassed approximately two-hundred twenty square miles of beautiful Virginia countryside. We worked from 6:00 AM until 4:00 PM, Monday through Friday. This was the time paramedics were most needed because the volunteer paramedics had normal nine to five jobs. Although our official day ended at 4:00 PM, I often procrastinated and marked off duty usually no earlier than 4:15. It just didn’t feel right leaving sharply at 4:00 PM when I knew there would be no volunteer paramedics around until at least 5:00 PM, or in the worst case scenario, until I marked on duty the following morning.

I was sitting in the ready room at Company Two, the Remington Volunteer Fire Department. I was passing time and contemplating the ten minute drive back to company thirteen. The Lois Volunteer Fire Department was where I marked off duty and left the title of ALS-2 behind each day and returned home. I had nothing planned for the evening, and paramedics were a scarce commodity that time of day. I had just listened to my two peers, ALS1 in the central area and ALS-3 up in the northern area mark off duty. I was now the only career personnel on duty and, therefore, would be dispatched on any call in the county.

I’ll wait until fifteen after, then drive back, fill out the logbook detailing my calls and actions for the day, and mark off duty at 4:30. That’s about all the time I can justify without actually being dispatched on a call.

As I completed this thought, the radio came to life with a piercing tone signifying a medical emergency, “Companies six and one, 4780 Red Spruce Lane, for a cardiac arrest.” Time immediately screeched to a halt. This was the address where I had spent the majority of my life, my parents’ home. Thoughts of my father were thrust to the forefront of my mind. He was sixty-seven years old and had several heart blockages he had been ignoring for years. He had been afraid to undergo the essential cardiac bypass surgery that would save his life. He still smoked cigarettes and had been doing so for the past fifty years.

Dispatch did not send me on this call because they know it is my parents’ house. They are supposed to dispatch me on any call in the county. No matter, I will certainly be responding to this emergency.

“Craig…Craig…are you okay?” asked Zoey, a young volunteer who had just completed her initial emergency medical training.

I had stopped talking mid-sentence, and all the color drained from my face when the address echoed throughout the room. I stood up, quickly walked to the phone, and dialed the phone number to my childhood home.

“Hello!” my father answered in an exasperated tone. His breathing was harsh and fast. He was panting, and his voice was clearly faltering as he struggled to utter a simple hello.

I was taken back. My father was the sick one. My mother had high blood pressure, and she smoked as well, but otherwise, she was healthy. What could be going on here? I had prepared myself for my father’s death, and now I was speaking to him on the phone!

“What’s wrong dad?” I asked in a determined voice.

“Your mother is dead! I came home from the store and she’s dead.”

My father was never one to mix words, but when he said this so abruptly, a switch flipped inside of me. I became very tactical and calculating. The world slowed even more around me. I would not let my mother die. I can fix this. I am a paramedic for God’s sake. I’ve done this before. I can do it again. This is my mother. I have to do this. I needed a few simple bits of information, and then I would be on my way. My vehicle was idling out front.

“Is she cold and dead, or warm and dead?”

“She’s not that cold,” he answered.

“I’ll be right there!”

Click…I dropped the phone back on the receiver. That was all the information I needed. I began quickly walking with a purpose out of the building to my awaiting vehicle. To run would

be to lose control. I was not going to lose control. I was going to be completely in control of this situation. This is what I did for a living. I took chaotic situations and brought them back to order. I did this several times a day for other peoples’ families. Now I was going to do the same for my own.

“Do you need any help?” I heard Zoey say in the background as I headed out the door.

“If you can keep up!” was my response, and I meant it! Nothing was going to stand in my way. Zoey scrambled across the room and out the front door, barely shutting the passenger door before we peeled away.

I grabbed the microphone, “ALS-2 responding.”

“ALS-2 responding 16:10,” answered the dispatcher.

I activated the lights and siren and began the 15 minute drive to my parents’ house. Not a word was spoken inside the vehicle during the trip, but my mind was racing. The air was ladened with tension. The monotonous siren was a distant white noise blending into the background as I mentally prepared myself to work a cardiac arrest on my mother.

I can do this. What good is all of this training if I can’t perform now when it really counts?

The drive was down country roads. Trees and signs flew by me in the blur of my peripheral vision. Suddenly, one particular sign instantly took shape. It formed out of the haze as we approached the first sharp turn: “Maximum Safe Speed: twenty-five miles per hour.”I glanced down at the speedometer. It read eighty-five miles per hour. I eased onto the brakes.

Slowing down too fast at these speeds could be detrimental. I don’t remember how fast I was going when I entered the turn, but I pushed the Ford Explorer to its limits. As we rounded the turn, I lifted my foot from the brake and slammed back on the accelerator powering out of the turn at maximum speed. I felt the centrifugal force pulling my body out the window as we steered through the turn. The seatbelt did its job holding me firmly in place, the vehicle struggling to keep all four wheels on the pavement. Zoey’s handprint probably still can be found on the passenger door handle, her knuckles turned white as she held on with everything she had. Having successfully navigated the first major obstacle, my thoughts trailed from driving and returned to my mother.

She’s probably going to vomit. I have to be able to put in the breathing tube before she vomits. I can’t let any vomit get into her lungs.

I grew up driving these roads. I knew every turn and every bump in the road. If I had only known I would need to make this trip in record time. If I had only known my mother’s life would depend on how fast I, the only available paramedic in Fauquier County, could get there, I would have practiced it more.

Why did I get a job in this damn county? I shouldn’t be here. No one should have to do this, but I was the only one who could do this. I had to keep it together.

The Explorer was not going fast enough for me. My foot was to the floor, and it felt like we were crawling up this large hill. As we crested the hill, all four tires briefly left the road, my stomach leapt into my throat as we touched down. On the downside of the hill, my speed increased to a more satisfying level. I didn’t feel I was getting there fast enough unless I pushed the vehicle to its breaking point at every moment.

I need to make sure the IV gets placed quickly. Mom has good veins on her hands. It’s better if I can get an IV closer to her heart, but I will start in her hands just to make sure I have access. The sooner I can give her medications, the more likely she will come back.

The last long, straight stretch came up. I hated this part of the trip. The forty-five mile per hour speed limit was onerous on a normal day. I could feel the vehicle steadily gaining speed. I didn’t have the resolve to look down and see how fast I was going. I just concentrated on not making a mistake. Two more turns and I would be at the half mile gravel driveway to the house.

Get there fast, but don’t wreck on the way. That will help absolutely no one. But, I’ve got to get there first. I’m the only paramedic for miles around. If I can’t get to mom in time, she will never make it. How am I possibly going to get through this? Shut up, you freaking wimp. I’ll tell you how you’re going to get through this, one damn step at a time. And you are not going to make one mistake. Mom’s life depends on everything you do. Sometimes every single thing counts, and this is one of those times. Keep it together!

I made the last two turns and began driving up the long gravel driveway. The house was at the very end. Dust surrounded the vehicle as I went as fast as the gravel would allow. The rear end occasionally swerved right or left as my speed caused a loss of traction on the loose gravel. I pulled into the front yard and stopped ten feet from the front door, sliding through the grass and leaving brown ruts in the lawn as the Explorer came to a halt.

“ALS-2 on scene,” I barked into the radio as I swung open the door, leaving it open and bouncing against the hinges from the force of my exit.

“ALS-2 on scene 16:18,” replied the dispatcher. I had made the fifteen minute drive in eight minutes.

Eight minutes. Oh my God, that’s too long. Brain death occurs in four to six minutes. I can still do this. I have to do this. I’m the only one who can do this. God help me!

I grabbed the bags, the cardiac monitor, careened into the house and floated up the stairs. I could hear my father in the master bedroom, so I knew where to go. I rushed to my mother’s side. She was sitting up in her bed, pillows propping her up, with the remote control for the television in her hand. How many times had I seen her sitting in bed like this watching her favorite soap operas? She looked peaceful. The blanket was pulled up to her chest. I could tell dad had not disturbed her. I dropped the bags and placed the monitor by her side.

Rapid defibrillation is the key. I have to deliver shocks as fast as I can to save her life.

When I reached out and touched her for the first time to feel for a pulse, I was startled by how cold she felt…so incredibly cold. There was no pulse. Her jaw was frozen in place, as was her hand around the remote control. I couldn’t open her mouth at all. Her arms were stiff and ridged. Rigor mortis had set in. I grabbed the cardiac monitor and began placing the electrodes on her chest to read her cardiac rhythm. The room began populating with several people, but I remained fixated on my task. They were like flies buzzing around me. The ambulance had arrived. The police had arrived. My boss had arrived, and I was oblivious to them all.

To this day, I don’t know why I began to attach the cardiac monitor. There was no need to see what her heart rhythm was if rigor mortis had already set in. Such diffuse rigor mortis meant she had been gone at least three or four hours. It was a complete waste of time, but I wasn’t ready to let go. I didn’t get a chance to save her. I didn’t even get a chance to try!

A voice entered the din of my existence as the ambulance driver piped up, “You don’t need to do that, Craig.”

I glared in his direction. How dare him! I wanted to unleash a fury of anger on him for having the nerve to interrupt me. Before my anger was fully formed and able to lash out, I felt my resolve begin to lapse. When I was finally able to respond, I simply answered in a meek, cracking voice, “I know…but do you know who this is?”

Silence was my only answer. His silence disarmed me even more. A tear began to run down my face as I finished hooking up the cardiac monitor. All hope and determination was siphoned from my body, and numbness took its place. When I was done, I just starred at the flat line as it crawled across the screen. A flat line signified no electrical activity. There was nothing I could do. I was powerless. I was defeated. All of my training meant nothing. I collapsed onto my knees beside the bed and began crying uncontrollably. I don’t remember when I stopped.

The funeral was held several days later. The death certificate stated sudden cardiac arrest as the cause of death. The doctors said it was either a massive heart attack or stroke. My father had gone into town several hours earlier and returned home to find her. She must have died shortly after he left. No autopsy was performed. There was no need because there was no suspicion of foul play. She was elderly with several risk factors for both heart attack and stroke. As I sat in the funeral home listening to different people speak about my mother, I thought back to that horrifying day. I didn’t feel responsible or guilty about her death because she had been down for so long. There was nothing I could do. I felt guilty for risking my and Zoey’s life on that eight minute hell ride only to find my mother beyond all hope. I was angry that I was robbed of the chance to try and save her. If only my father had not gone to town. If only he had come home earlier. These were just a few of my thoughts as I tried to make sense of all this. Throughout those days, I came up with so many what-if situations, but not one of them helped bring my mother back. I did not blame my father. He was just following his routine and taking care of his daily chores. He had no way of knowing the love of his life would be taken from him that day.

When it became my turn to speak, I rose from my seat and approached the front of the room to deliver my mother’s elegy. I reached into my inside coat pocket and pulled out a poem I had written. I don’t think a single person in the room understood a word I read because I was sobbing throughout the entire reading, but this is what it said.

Regarding the Loss of My Mother

In times like these it seems that sorrow is the norm. No matter how much the sun is shining, I can feel the tears swelling up like the coming of a storm.

There are no words to express such a tremendous loss, loss of a mother, loss of a life, not to mention the loss of my father's wife. So I will spend no more times remembering the bad, only the good things that bring me to what I now have.

The memories of a mother that was unsurpassed. A woman who could make a house into a home, that could create a family and make it last. A woman who welcomed children into her home, they were just friends of the family, but she raised them like her own.

For 44 years she took on this task, never thinking of herself, for richer or for poorer, in sickness and in health, till death do they part. That's how it should be and that's how it was done.

If you can hear these words please remember your mother. If there is ever an undying love it exists in no other. If your mother is gone you can feel my pain. If you've forgotten to love her, never do it again.

Yes, in times like these it seems that sorrow is the norm. But we must remember the good things in life as we continue to morn. With each breath of a new baby's life another mother is born. This undying love now exists in another. But still, there are no words to describe the loss of my mother.

I returned to work two weeks later. When I marked on duty, I opened my log book and turned to the date October six. The date was neatly inscribed at the top of the page. A sea of white followed without a single blemish. It remains blank to this day. Somehow it didn’t seem right to record my actions of October six like it was just any other day. It was anything but a typical day. It was my final exam to remain a paramedic, and I passed. When I sat in class learning how to be a paramedic, I memorized human anatomy, cardiology, pharmacology, and treatment algorithms for various medical emergencies. I completed the course with flying colors. It all seemed so easy. I was so proud of the knowledge, skills, and abilities I had learned. I felt very comfortable managing medical emergencies, and I relished the challenges, but nothing I learned in any class or anytime throughout my life had prepared me for that day. It was difficult to return to work even two weeks later, but I did. If I had failed that exam, I wouldn’t have returned to work, and I wouldn’t be a paramedic today. It could have easily stripped away my identity.

Lesser trials have broken better men. That particular October six occurred fifteen years ago, and I still work as a paramedic today. Since my exam, I have been tasked with training many new paramedics. I have dedicated myself to helping prepare paramedics for their individual final exams. I often tell new students that all the initial training and certification does not make you a paramedic. Don’t worry about the test to become certified. That part is easy. Successfully passing the simple classroom trials only gives you permission to learn how to be a paramedic. The real test will happen one day when you are least prepared, and it will occur when you least expect it.

Firefighter's Pledge

2012-03-02T22:27:00.001-05:00

I promise concern for others.
A willingness to help all those in need.
I promise courage-
courage to face and conquer my fears.
Courage to share and endure
the ordeal of those who need me.
I promise strength-
strength of heart to bear whatever
burdens might be placed upon me.
Strength of body to deliver to safety
all those placed within my care.
I promise the wisdom to lead,
the compassion to comfort,
and the love to serve unselfishly
whenever I am called.

-Author Unknown

2012-03-02T20:39:00.001-05:00

Practice as you perform. 12 floor high-rise in full gear and SCBA. 30 minutes up and down for today's workout. Getting in PT on a busy medic unit isn't easy. You have to make it quick with the most impact.