Poor Impulse Control?

Watch it, folks, these things tend to repeat:

From the Chicago Sun-Times, http://www.suntimes.com/news/24-7/2787746,ambulance-taken-100910.article

“October 10, 2010

BY ROSEMARY SOBOL Staff Reporter/rsobol@suntimes.com

A man who “thought he could get to the hospital quicker” jumped behind the wheel of an ambulance and took off Saturday while his ailing family member and two paramedics were inside, authorities said.

Jimmy McCoy, 27, of the 4800 block of West Superior, “probably thought he was helping” when he took the wheel as a relative was being treated for a diabetic episode, Fire Department spokesman Larry Langford said.

Jimmy McCoy
McCoy was arrested and charged with felony unlawful possession of a stolen motor vehicle.

Ambulance No. 23 was stopped in the 4300 block of West Wilcox at 11:30 a.m. while paramedics were treating the relative in the back, Langford said.

The male and female paramedics immediately radioed in, saying: “This is ambulance 23. Our ambulance has been stolen, and we are in the back with a patient,” according to Langford.

The paramedics were “somewhat agitated” but handled the situation professionally, he said.

McCoy allegedly began driving northbound on Kostner.

Fire Truck No. 26, which had gone on the medical run with ambulance No. 23, stopped the ambulance about three blocks away, Langford said.

Truck No. 26 “made a U-turn and made it to the intersection of Madison and Kostner, where it blocked the ambulance,” Langford said.

Police surrounded the ambulance and arrested McCoy.

Police said McCoy, who has been arrested 32 times before, allegedly told officers he “thought he could get to the hospital quicker” than the paramedics.

The patient was taken by another ambulance to the hospital, fire officials said.

No one was injured, officials said.”

The Numbers Game

Is anybody using anything other than the GCS for field assessment of head injuries?

Way, way back in 2003 DTs pointed out in a paper that there were only two GCS scores that were reliable:  GCS 3 and GCS 15.  And a 3 can be obtained by the CPR dummy, a chair, a rock…

The main problem is the number of ways a patient can score a GCS.  Different values for Eye, Verbal, and Motor can change and still give an overall GCS that remains the same.

A pre-hospital provider reports to medical control that his patient has a GCS  score of 9.  There are eighteen combinations of the three sub-scores which will result in a GCS of 9:

E4V4M1, E4V3M2, E4V2M3,  E4V1M4,  E3V5M1, E3V4M2, E3V3M3, E3V2M4, E3V1M5, E2V5M2, E2V4M3, E2V3M4, E2V2M5, E2V1M6, E1V5M3, E1V4M4, E1V3M5, and E1V2M6.  Each of these combinations is attainable; that is, it is not impossible for a patient to be E4V4M1.

Overall

Glasgow Coma Score

3 4 5 6 7 8 9 10 11 12 13 14 15
Number of Sub-score Combinations

To Total This Score

1 3 6 10 14 17 18 17 14 10 6 3 1

Patient’s Sub-scores

Inferred Accuracy

100% 33% 17% 10% 7% 6% 6% 6% 7% 10% 17% 33% 100%
Bell curve

Glasgow Coma Score Distributions

As the apex of the Bell curve is approached, the individual sub-scores comprising the GCS total score become less predictable.  There are, for example, seventeen (17) possible combinations each to account for a GCS total of eight (8) or ten (10); if one were to guess the individual sub-scores, one would have a 3 in 50 chance of pinning down the appropriate values.

The inherent problem with this scoring method is easily illustrated.  A patient who at the scene scores an E3V4M3 on initial examination receives a GCS of 10.  En route to the hospital, after interventions have been applied (e.g. O2, bleeding control, etc.) another GCS of 10 is derived – this time, however, from sub-scores E2V3M5.  The patient’s overall condition, according to the GCS scale, has neither degraded nor improved, as both are GCS 10.  However, the individual scores have changed significantly either because of or in spite of prehospital interventions. In this case, the Best Eye response has degraded from “Opens on command” to “Opens on pain”; the Best Verbal response has degraded from “Disoriented speech” to “Inappropriate words”, while the Best Motor response has changed from “Flexion withdrawal” to “Localizes pain.”

To the receiving ER physician or Medical Control the changes in these individual performance criteria may provide significant insights to the patient’s condition or underlying problem, but reporting only the GCS total, which remains constant (10 in the example) will impart none of this information.

A workaround might be to report “Eye, Verbal, and Motor” scores separately rather than their sum.  Care would be needed in reporting over the radio, as “E” can sound the same as “V” if one is reporting “E 2 V 3 M 5″ for instance.  Or I suppose we could just say “Eye”, “Verbal”, and “Motor”, but this seems unwieldy.

But somehow I think we can come up with something just as quick but more useful.  We in EMS are used to scrapping stuff all the time when something better comes along – MAST, paper bags for hyperventilation, tourniquets, then bring back the tourniquets – we’re flexible.  The GCS itself is a replacement for a previous system.

Of course, we’d need to overhaul the Trauma Score (which uses GCS as one of its inputs), but, hey.

Anyone?

The Slows

Slow to post – glacier slow, as I have been otherwise engaged, in part by running with Arlington County Fire and EMS.

These folks are different.

On my first day there, I happened to hear a story being told about a crew who were recently called to an injury from a fall. An elderly lady had fallen and broken her hip – while exiting a car at the funeral for her husband of 60 or so years. The ALS crew extensively screened the widow and verified there were no immediate life-threats, stabilized the fracture and loaded her onto their cot, then trundled her to the gravesite. I’m not sure if a line was started, but the storyteller insisted that no pain meds were given – the patient declined them as she wanted to be “all there” during the funeral. The crew stayed with her during the entire service, and only when she was ready did they take her to the hospital.

Hearing this story, several thoughts popped into my head, a sort of “which of these reasons would I be called to the carpet for” game, conditioning from the time spent running in Woodbridge: “unit out of service for over an hour!”; “on-scene time way, way above normal!”; “withholding pain medication!”; “withholding definitive medical treatment!” – why, any one of these is reason to be sued, Sued, SUED! Certain of my Lieutenants would have “killed me, eaten my flesh, worn the rest, and if I was very, very lucky, in that order.”

“Man!” exclaimed one listener, in all sincerity, “I hope somebody put them in for a commendation!”

Hunhr?

“Yeah, well I’m going to check with the Captain. If nobody else has beat us to it, maybe we could be the ones to put them up for a commendation!”

“Well, somebody has got to, that was righteous!”

These folks are fantastic.

And What, you may be wondering, was that scalawag DTs doing in this fine and gallant company?

As detailed elsewhere in this bloggy-thing, all clinical and classroom work has been long, long completed for Paramedic. Excepting my lead-seat rides, of which I had only enough (30) to test for Intermediate, rather than the (50) required to test for NREMT-P. This shortcoming was being corrected. My initial thought, “Oh, I’ll get NREMT-I, then everything I do every day will automatically count towards my NREMT-P requirements” was woefully naive.

And truthfully, it was very nice to be back in a 911 system, even if only as a ridealong. DTs has been off the volunteer clock for some time now (various and sundry reasons) and the only EMS getting done is on the transport side.

A Different Beast, more “MS” than “EMS”. A Typical Transport:

Receive a page from dispatch: Pickup time is 45 minutes from now, at X facility going to Y facility, Joe Patient, c/c chest pain, weight 200#. Yawn – it takes 15 minutes to get to X facility, giving one 30 minutes to…

Arrive at facility, get detailed history and report from a nurse, who also by the way hands over a thick package with blood analyses, urinalysis results, toxicology reports, CT, MRI, X-Rays, several comparative 12-leads, retinal scans, three full sets of vital signs and the script for the upcoming episode of House. The patient has two or more patent IVs already started, fluids running (if indicated) and at least two rounds of stabilizing medications on board.

Compare and contrast to the usual 911 call of “situation unknown” and a “likely” address. Arrive, assess, treat and go!

Man, did DTs have a bad case of “the slows” on his first few calls! Shaming, it was, and a fine indicator that once the P test is done, it’s back into the 911 system for me.

I wonder if I can get my armor shiny enough to join the… wishful thinking!

Us, us, us and Them, them, them

EMS providers are a strange breed. Generally, they’re not just good folk, but nice folk as well. This isn’t too surprising to those who may have run with volunteer companies. The people who volunteer are contributing far more than just the personal time they spend running calls. There’s additional training, sometimes as much as a weekend or two a month, both mandatory and elective. There are those nights one is scheduled to run, and those nights where one fills in for a crew member who needs coverage. There are pub-ed functions and special events, county fairs and whatnot, where an ambulance or fire piece is on stand-by, staffed by folks who volunteer additional time to man the units “in place”, just in case.

“Ah, what a fine bunch, truly a selfless breed,” I hear you say. And you’re right. Most fire/EMS companies like to think of themselves as “families”; with all that time spent together, one truly comes to believe one may count on his “EMS Bruthuz” both in the field and in personal situations.

However, All Is Not Sunshine, because at the bottom of it all EMS folk are people.

Take for example one fire station, the denizens of which we shall label the “Hatfields”. The Hatfields are hardworking, hard-playing, fun-loving folk who live to serve, and can count on other Hatfields to shore up an unstable vehicle at an auto wreck, cover their backs at a fire, or lend them five bucks ’til Friday. They enjoy being at the station and providing community service.

Contrast them to another fire station, a mile or so down the road, perhaps even in the same county, but “separate” – we shall call them “McCoy”. The McCoys are hardworking, hard-playing, fun-loving folk who live to serve, and can count on other McCoys to shore up an unstable vehicle at an auto wreck, cover their backs at a fire, or lend them five bucks ’til Friday. They enjoy being at the station and providing community service.

And yet, one may have come to the conclusion (based on the carefully selected names) that perhaps the “Hatfields” and the “McCoys” just don’t seem to get along too well. If the McCoys get a good fire, one can just bet that the Hatfields are all over the details – which units responded, where they parked, how they set up their hose lines, how the fire was knocked down – and looking for mistakes. “Know what those dumb McCoys did?” a Hatfield will ask, and proceed to tell about it, for it is always true that if one looks hard enough, a mistake can be found.

This “one-upsmanship” is universal. It is prevalent in every state, county, city, and local EMS system. Heck, it’s not even confined to EMS at all. Army troupers in “Easy” company will complain about “Dog” company. According to Heinlein it is a matter of faith in the Marines that Navy ratings don’t wash below the collar-line. “Us” is good, but let me tell you about “Them”…

Perhaps DTs is just a little bit naive when it comes to understanding how unit pride works, for he feels that “I did well” works fine by itself without having to add, “… unlike that other ambulance on the scene. Boy! Lemme tell ya what they did.”

When an event throws Hatfields and McCoys onto the same scene, they will work together quite well: Your patients will be removed from the auto wreck; the fire will be put out. And there will be stories told at the Hatfield station and stories told at the McCoy station, about what “They”, those others, did wrong, stupidly, or inefficiently.

It’s just a people thing, I’m sure. Even a “good” people thing.

Of Hats

It is a difficult thing, being released as a medic on the transport gig, but Basic Life Support (BLS) on the rescue side.

Those not in the EMS field might think, “Hey – a medic is a medic is a medic. Why can’t you do medic stuff running 911 calls?” The short answer to all that is that each jurisdiction has its own medical director – a doc – and it is under the doc’s license that advanced life support (ALS, or medic stuff) is practiced. Naturally, the doc is placing his license on the line with each medic operating under him. Docs therefore like very much to know the medic’s capabilities before releasing said medic to the World.

On the rescue side, there is no one available to DTs to precept him as an ALS provider – so that’s not a Happenin’ Thing. One must continually glance upwards at the Hat currently in use. Is it the heroic white Stetson of ALS? IVs and ECGs all around! Raise your hand if you’re having chest pain, the attendent will be handing out nitro and morphine shortly.

Ah, but do we see the brim of the diminutive brown fedora of BLS? Yes? Uh, have some O2.

Indeed. One of DTs’ partners in the past was a fully-certified ER nurse, “slumming” on the ambulance, who had not yet gathered in an EMT-Basic certification. So saith the Seinfeld EMS Nazi: “No patient contact for you!”

The urge to provide care in excess of my current Hat status can be strong. An elderly patient fainted when he stood up? Medic sense is tingling… could be a heart problem, but must… restrain… hand… from… monitor. Can’t… hook patient up… as a BLS provider.

We were called out to a Recreation Place recently for a fellow who felt chest pain on exertion. He was sitting in the manager’s office when we arrived, no pain, no tightness or shortness of breath, slightly diaphoretic (sweaty), alert and oriented, no history of cardiac problems, hypertension, etc.

The medic arrives and places the patient (as medics may do) on the heart monitor – 3 lead. Everything looks fine. Hmmm, says the medic. Let’s do a 12-lead (which gives a more detailed picture of the heart’s electrical function).

“Aha,” says DTs, pointing, “ST elevation in AVF. Inferior wall injury. Yay 12-lead.”

The medic is amused, outwardly, but inwardly… DTs’ psychic abilities detect a “why the heck did you guys make us drive all the way over here when you could have handled this?” Or perhaps it is not his Psychic Abilities, but his Overactive and Defensive Imagination.

Sometimes it feels like being Clark Kent, with nowhere to change clothes…

The amusing thing, thought DTs, is that this patient would probably end up with a coronary stent – a procedure not performed at the hospital to which the medic was taking him. It would be entirely possible that in his transport gig it would be DTs who took him to the cath lab.

“Say,” he imagines the patient saying. “Nice Stetson. Aren’t you that guy with the fedora?”

Ozymandias

Well, word has finally arrived concerning DTs’ efforts in the 911-job-hunting arena, Part Deux. Specifically, with the City of Alexandria.

All is Despair.

While the process is public knowledge, the Powers of Alexandria do not go out of their way to explain things to the prospective candidates; DTs is therefore breaching no confidentialities here.

To review the process with a baseball analogy:

At Bat: Everyone who registers is notified of and is invited to take the written test; one needs only show a photo ID at the gate. The test is known as the HOBET, or Health Occupations Basic Entrance Test. It takes three hours or so, and the questions are broken into categorical sections. Each test section is timed. The sections are Essential Math Skills (whole numbers, decimal operations, fraction operations, percentage operations, number system conversions, and algebraic equations); Reading Comprehension, Reading Rate, Critical Thinking, and Test taking Skills. Other categories include a Stress Level Profile, a Social Interaction Profile, and a Learning Style evaluation section.

First Base: The test results return. DTs scores a 98th percentile again, which is slightly disappointing as I studied up on the fractional math stuff, having done little with it since High School. Still, a pass is a pass.

Second Base: The actual numbers are murky, but of 139 (or so) taking the test, 60 (or so) actually passed. These are invited to participate in a practice physical (detailed in this blog elsewhere.) DTs passes the practice with ease, but vows to continue his beefcake regimen anyway.

The actual EPAT is administered in two steps: Step 1 in under 2:45 and the totality of the test (Steps 1 and 2) in under 5 minutes. His Beefiness accomplishes Step 1 in 2:24, a full 21 seconds ahead of schedule, but cautioned by Aesop’s tale of the Tortoise and the Hare DTs does not lounge – no! He completes the physical test with a 3:18 total time.

Third Base: The culls are dejected, but Our Hero is not among them. Thirty or so candidates remain. A Panel Interview is scheduled. The panel consists of three EMS supervisors who ask a total of six questions. Questions include, “How would others describe you as a person of integrity?”, “How would you deal with cultural differences in our patient population?”, and others whose wording I don’t recall, precisely.

To this point, one may note, nothing at all has been done of a real-life EMS nature. The HOBET does not ask any EMT questions; the physical is a composite of EMS skills, but in reality one would never have to perform them all in that certain time period. The questions are of the same nature, with the exception of this question, which has appeared before DTs twice: “You are toned out to a home where a patient has a knife and is threatening to harm himself – what do you do?” DTs is a firm believer that Folk with Knives can kill you, and that anyone who wants to do themselves in may very well Do You In to accomplish this. Exit, stage right, and call for PD is, I believe, the correct answer, and the one I gave.

Rounding for Home: DTs receives a letter in his recently-restored In box (an untimely computer crash has been repaired):

“Thank you applying for an ERT position with the Alexandria Fire Department. Unfortunately, the panel did not recommend you for interview with the Deputy Chief.”

Tagged out! Tanj dammit!

It is enough to call one’s self-esteem into question, but DTs is essentially a cheery fellow. I recall the wise words of Wallace Shawn, who played Vizzini in The Princess Bride:

Vizzini: “Ever hear of Plato? Aristotle? Socrates? Alexandria EMS?”

Westley: “Yes.”

Vizzini: “Morons!”

Harsh, perhaps too harsh. A kinder interpretation is a completely fictional behind-the-scenes conversation:

EMS Supervisor 1: “He’s perfect!”

EMS Supervisor 3: “His intellect is dazzling. He’s astute, manly, and handsome. A Catch!”

EMS Supervisor 2: “Yes. But perhaps he’s… too perfect.”

EMS Supervisor 3: “You mean…?”

EMS Supervisor 2: “He would have all of our jobs, and do them more splendidly than ever we three did, together, were he hired. This Must Not Happen!”

EMS Supervisor 1: “Our course then is clear…. [Stamp!] There!”

Ah well. Alexandria was given the First Crack at DTs because they, unlike many systems in the area, do not require their medics to be firemen as well – DTs has no interest in the fire fighting side of things (actually, DTs just hates rolling hose), but there are Other Systems into which some thought must now be given…

EPAT

In a perfect world, the dispatches for our calls would sound something like this:

“Medic 2, on Five Adam, for a difficulty breathing, 123 Fubar Street.”

“Medic 2, be advised, your patient weighs four hundred twenty pounds and is in the back bedroom on the fourth story of the townhouse. The hallway to the back bedroom is narrow, much furniture will be in the way. Your patient will be unable to stand or walk. There is no elevator. The stairs are narrow and unlit.”

In the real world, of course, the first sentence is about what we get. It is after all Dispatch, not the Psychic Friends Hot Line. But all the other stuff could be true, too. To the extent we can, therefore, we anticipate.

Since we don’t receive such detailed information (“Sven! Ahnold! Put down the fire truck and go with the ambulance for a lift assist!”) we the crew must be able, within reason, to handle the physical end of things

Fire guys have their physical tests, and so do EMS folk – the EPAT, or Emergency (rescue technician) Physical Abilities Test. Generally administered in the dawning time of a system’s hiring process (each locale – city, state, county – is called a “system”) the EPAT strives to find if, in general, a candidate is minimally qualified to do the kind of stuff EMS does all the time.

The particulars of such tests vary between locales, but one local system conducts the EPAT test thus:

The candidate will

  • go twice up and down a flight of steps (3 landings) with 25 lbs of equipment in each hand, no skipping steps;
  • perform CPR on a mannequin for one minute at a timed rate;
  • “rescue” a 165 lb mannequin in fire fighter gear by lifting it and dragging it backwards 30 feet;
  • hoist a 100 lb bag and carry it thirty feet, up a stairs, back down, and another thirty feet.

The candidate is given 165 seconds to complete the aforementioned, after which he must

  • lift one end of a Reeves stretcher, with a 165 lb patient, above his head and lock his elbows;
  • lower same in a controlled manner;
  • push a weighted (400 lb) cart sixty feet and pull it back (60 feet) in a controlled manner.

The total time allotted for ALL tasks is five minutes – but if one misses the 165 second mark on the first set, the test is over – “Thank you, come again.”

“DTs, my mind is calmed,” I hear you say, “To know that my girthy Aunt Bertha will be carried safely by no Caspar Milquetoasts. But why mention this test?”

I mention the test because, on Saturday, I have the wonderful opportunity to take it. Last week DTs took the “practice” – same test, same timing requirements – and passed. His feeble suggestion at the time that “this should, you know, count” was brushed aside, though, and so it is all to do again.

Truthfully, DTs took the test last year, and passed as well, so one would expect a breezy attitude. It is to laugh – Test Anxiety is ever the hobgoblin. And so he daily retreats to the dim and sweaty corner of his abode wherein resides the Gym Stuff, slurping noisily at chocolate Mus-L-B-Big shakes.

Away with him, then – back to the cables and pulleys to prepare.

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