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Ambulance: PTSD

Written by RSS Poster Medic Scribe

I attended a critical incident stress debriefing (CISD) a few years ago. I thought I had been invited to an informal get-together of folks from another service who I had been on a upsetting call with the day before. Had I known it was a formal CSID debrief, I wouldn’t have gone, as I had always avoided them in the past. Not that CSIDs don’t help some people, they are just not for me.

I have been in EMS for thirty years now, and I have been on traumatic calls. This one ranked up there, but since I wasn’t the first medic in, I didn’t catch the brunt of it. For me the worst calls are not always those that make the news.  I take it hardest when my patient dies in my care, when I have to witness a sudden deterioration and  feel helpless to stop it or feel like maybe had I done things differently I could have possibly affected the outcome for the better. Other calls where the patient’s fate has already been settled before I arrive are less taxing to me than they used to be.  This was such a call.

Each of us processes trauma and stress differently. When I...

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Ambulance: Beautiful Boy: The Movie

Written by RSS Poster Medic Scribe

Beautiful Boy, a father’s story of his son’s drug addiction, is now streaming on Amazon Prime. The movie, based on the real life stories of David and Nic Sheff, a father who witnesses his son’s addiction to methamphetamine and heroin, is forced to make artistic plot choices.

I wondered how the movie director was going to handle the son’s seemingly endless relapses chronicled in the book. A typical Hollywood story has the hero slay the monster and then when everyone thinks the monster is dead, the monster comes back to life and the hero must slay it again after coming perilously close to death yet again. The problem with the real life plot of addiction is that one relapse is rare. In the book, the young man had more than I could easily count. He had so many, I felt like flipping the pages to get to the end and some resolution. Enough already! I get it!

In the movie, the director makes the artistic choice of stopping the movie after the second relapse. The father’s love for his son is apparent. The son’s helplessness in the grips...

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Ambulance: Calm

Written by RSS Poster Medic Scribe

When I first became an EMT, a friend asked me why I liked the job so much. When I come through the door, people look at me like I am an angel, I said. What is it like driving lights and sirens? Another friend asked. Awesome — I feel all powerful. I hit wail and the cars part for me like the red sea parting for Moses.

If you asked me then if there was anything wrong with what I described, I would have been seriously puzzled by the question. I didn’t quite understand the true nature of the work.

When I became a paramedic I quickly learned to be a circus ringmaster, barking orders to partners, other first responders and even bystanders. All eyes were on me as I orchestrated getting vitals signs, med lists, moving furniture, putting on oxygen, getting an IV, delivering medicine, extricating the patients, even determining who could ride with us to the hospital. Eventually I brought that same leader of the band approach to running cardiac arrest (compressions, shocks, IV access, drugs, intubation, post-ROSC 12-lead, dopamine to support blood pressure, all...

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Ambulance: Tidying Up

Written by RSS Poster Medic Scribe

Twenty years ago when I was looking to buy my first house, my realtor didn’t understand why I did not like the home she was showing me that seemed to meet all my specifications: price, location, size. She did not understand that just two months before I had worked a cardiac arrest there. I could still see and smell the man and all his bodily fluids in the cluttered living room where he collapsed. If I bought that house I would have to live with his ghost. Not for me.

Home hunting is hard when you are in EMS. You walk in thinking as I always think when I enter a home, how am I going to get the patient out of here? A stretcher will never fit in that bedroom. Spiral staircase, forget it. Even if you didn’t do a cardiac arrest in particular houses, you did arrests or memorable calls in houses with the same design. You remember the mother screaming in the bedroom. You see patients wedged between the toilet and the sink. Blood drips down the stairs.  You see all the crap that was in your way that you had to move to get the patient out to the ambulance.

I...

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Ambulance: Muscle Rigidity in Opioid Overdose

Written by RSS Poster Medic Scribe

I wrote a number of months ago about fentanyl induced chest wall rigidity in opioid overdoses.

Chest Wall Rigidity

Fentanyl induced chest wall rigidity is rare in the hospital setting, but it should not be surprising to find it is a factor in overdose outside the hospital given that the amounts of fentanyl being injected are exponentially larger than in the hospital.

A typical $4 bag of properly mixed fentanyl sold on the streets of Hartford can be the equivalent of 1000 mcgs of fentanyl or 10 100 mcg fentanyl vials.  A bag with a hotspot of fentanyl would obviously have considerably more.

Since I wrote that post I had no further instances of possible fentanyl induced rigidity despite doing many ods.  That is until several weeks ago.

The call came in as a seizure in a restaurant that was closely associated with narcotic activity. We found the patient sitting awkwardly at a table at a table, looking almost like he was having a dystonic reaction. He was very stiff. His head was turned slightly to the left. One of the fire department...

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Ambulance: Manual Versus machine Blood Pressures

Written by RSS Poster Medic Scribe

How do you want to be known as a Paramedic/EMT?

A. Reliable
B. Frequently wrong

According to a recent article in JEMSDitch the Machine to Improve Accuracy in Blood Pressure Measurement and Diagnostics, “automated blood pressure readings are frequently inaccurate.”

Is this a surprise to anyone?

Yet, many of us continue to relay on automated BP cuffs to direct our clinical actions.

In a March 2016 article in the Journal of Clinical and Diagnostic Research, Which is More Accurate in Measuring the Blood Pressure? A Digital or an Aneroid Sphygmomanometer:, digital devices:

  1. should be used with caution, doubt and suspicion
  2. are not up to standard
  3. (can cause many people to be) wrongly or misdiagnosed
  4. may prove disastrous

Powerful words.

The JEMS article points out that even the manual for the Physio-Control Lifepack 15 contains this warning:  

“shock may result in a blood pressure waveform that has a low amplitude, making it difficult for the monitor to accurately determine the systolic and diastolic pressures.”

Got that.  Your...

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Ambulance: Balance

Written by RSS Poster Medic Scribe

December 8, 2018: This weekend, I am in Worcester, Massachusetts at the New England Short Course Meters Masters Swimming Championships as a member of the Connecticut (CONN) team. Last year, we shocked many of the other teams by taking first place. Points are awarded based on place finish in individual and relay events. Each swimmer is only allowed to swim a maximum of six events a day or 13 for the entire meet. Friday evening is distance day (800 Free), Saturday and Sunday are for the relays and the main swimming events. Last year I scored 119 points swimming 12 events despite having a pretty severe chest cold. I also swam in three of the four relays. I came in second in the men’s 55-59 200 Meter Butterfly and earned 15 points for it. I was second out of 2 swimmers. Last year I finished 25th in the nation in that event in my age group. 25 out of 25. Still I was proud as it is a difficult event, particularly for someone who did not know how to swim the stroke five years ago. I am swimming it again this year, and if all scheduled swimmers swim, I will likely...

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Ambulance: Not My Addiction

Written by RSS Poster Medic Scribe

This is great film, made by EMS for EMS, to help us understand addiction and the stories behind our patient’s lives.  The 37 minute film tells the story of four addicts in their own words, including one who was once in EMS.  Listening to these four tell their stories helps people understand how easy it is for a person to fall into the grip of opioids and how hard it is to get out.  As I mentioned in another blog post, I recenly heard a mother describe her daughter’s descent into opioids, which ended in her death, as “an innocent entry and an impossible exit.”

I met two new young people this week who were ex-addicts struggling to reclaim their lives.  One was a former army medic, who told me he became addicted in Afghanistan. His squad often found caches of heroin, hidden by villagers. It was hot there and they were always hydrating themselves with IVs.  One day they added a few grains of heroin to the IV.  Three days of this and he found himself coming down with a horrible flu.  It took awhile for him to realize he was in opioid withdrawal.  When he...

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Ambulance: Napping in EMS

Written by RSS Poster Medic Scribe

Do you nap on your EMS job?

While many EMS organizations prohibit sleeping on the job and others allow it only in designated areas, a safety panel empowered by the National Association of State EMS Officials recently issued recommendations that included encouraging napping as a way to mitigate the adverse effects of fatigue.

Recommendation 4: Recommend that EMS personnel have the opportunity to nap while on duty to mitigate fatigue.

The panel determined that current evidence supports the use of naps while on duty as an effective strategy to positively impact fatigue-related outcomes. Naps improve alertness, reduce sleepiness, and improve personnel performance (e.g., reaction time).

I recently posted about a picture put up on our employees only Facebook site where a crew was blasted for being photographed while sitting in their ambulance, the driver with eyes closed, and the passenger slouching in his seat.  I found some links to fatigue on the job, but did not get around to reading them in their entirety until later. I was surprised and pleased to...

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Ambulance: Down Time

Written by RSS Poster Medic Scribe

A few days ago on our employees only Facebook page, someone posted a picture another person had taken of one of our crews while they were parked by the side of a street. The driver leaned against the window, arms folded, eyes closed.  The passenger had his eyes open, but he was slouched down in his seat. They were clearly in rest mode, but it wasn’t like they needed Narcan.  The comment was if they wanted to sleep, they should find a more secluded spot than a downtown street. The concern was every crew represents all of EMS, and the poster thought this crew looked unprofessional.

A fair point, perhaps, but I admit I felt bad for the crew to be shamed by a few fellow employees (the comments mainly agreed with the poster).  There are few days I have worked when either myself or my partner have not been guilty of shutting our eyes at some point in the shift. I can’t say there hasn’t been snoring at times. (Most in EMS work either mega-overtime or multiple jobs in addition to trying to raise families and fatigue in EMS has been well-documented in the...

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