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.

Who Goes There?

Returning from a shopping trip with my two strapping sons, they pointed out an engine racing into a nearby townhouse development. Moments later, an ambulance shrilled in behind the engine.

“Look, Dad!” said Good Guy #1, “There’s a fire!”

“No, son, it’s not a fire,” replied DTs.

“Maybe someone got shot!” said Good Guy #2 (Ah, television.)

“No, nobody got shot. Probably someone having chest pain.”

“Well,” they asked, “How do you know?”

Fair question, for DTs did not that night carry either radio or pager – and this was, besides, a different county from that in which he runs rescue, so no such information would have been forthcoming on this incident.

But I gots my eyes.

Now, the Parental thing to do would have been to slide unobtrusively onto the scene and ask a lounging firefighter, “Chest pain. Second floor?” and watch the Worshipful Eyes of My Youngun’s bulge when he replied, “Naw, third floor.” Second, third – close enough. I still would have garnered Wow! points.

DTs is however professional enough to have kept his unneeded arse out of the way of Working Folk. Instead, I reveal to you the false bottom in the top hat so that you yourself may perform this feat of legerdemain for your own progeny – with the understanding that it is better to Assert Parental Knowledge rather than going and bothering the rescue guys. Also, please don’t park (either in-car or with-butt) anywhere in their way to observe the goings-on, as this annoys them greatly. That said, let’s begin.

Notice first the Where. If all your emergency pieces and activity are on a road, it is reasonable (and seems obvious) to assume that the incident involves a motor vehicle – an accident involving car vs. tree, car vs. car, or car vs. pedestrian. You may of course slide “motorcycle”, “moped”, “bicycle”, etc. into any one of those roles, but not two – a “pedestrian vs. pedestrian” is unlikely to generate such excitement unless it is the rare and humorous “Death by Public Mosh on a Major Thoroughfare.” Certainly, EMS activity can signal “Heart Attack While Driving” – but you’ll be able to spot that once we’re done here.

Uncommonly you will find it to be a Car vs. Itself, in which case you’ll either note flame shooting from the engine compartment, smoke from the engine compartment, or (if you’re late to the scene) steam from the engine compartment as the fire guys put the thing out. If you see an ambulance at this type of scene, be prepared to say, “Watch now, the ambulance will leave,” as it is rare indeed that people driving burning cars won’t step out and thus avoid injury – no ambulance needed.

“Wheres” include anywhere there are People or Their Things, and so to exhaust all the possibilities – fields, parkland, rivers, lakes, etc – is quite a task. We’ll stick here with the likeliest of Wheres, the next likeliest being housing developments, hotels, schools – in other words, structures. It is within the Structures class of Where that we may Delight and Entertain The Young, by correctly guessing the problem.

Now, (dealing strictly with Structures here,) the second step in determining what exactly is going on is to notice Who is There?

The Police Rule: If there are no police evident, you may rule out Assaults (gunshot, baseball bat, or otherwise), Domestic Disturbances, or any other scenario involving Mayhem – including Harm to Self. EMS, and Fire Guys especially, like to think they’re tough, but we don’t look annoyed and say “Quit it, I’m busy” if someone is shooting at us while we work. Conversely, we don’t ask PD to come on every call “just in case”. Therefore, No Police Cars = No Violence. Police Cars = Violence of Some Sort.

It is in the details, by the way, that one may ruin a perfectly good trick – “Voila, a Dove!” elicits laughter, not “Oohs” of astonishment when, it turns out, you’ve prestidigitated a rabbit. If you see Police, cover your bases with your kids – say in a deep, melodramatic voice, “Looks like trouble…” and leave it at that.

Okay, with PD accounted for, scenes for the most part have Fire Apparatus and Ambulances. Sure, there are other types of vehicles pulling into some scenes, but it’s up to you to explain the Ice Cream Truck, the Bus load of Nuns, and the Horse Trailer, ‘cuz I can’t. Be creative.

If you see a single fire engine, your most likely bet is Smell of Smoke (someone smells dinner burning), Investigation (smoke alarm on the fritz), Outside Gas Leak (tree planting gone horribly wrong), Hazard (burst pipe causing water to run out the electric sockets) or other Potential Danger to Property.

If you see a single ambulance, you may safely wager Abdominal Pain, Obstetrics emergency (baby a-borning), “general illness” or a simple injury of some sort.

You understand now why Cybil was so vague… And remember, an ambulance (or engine) may be en route to the scene, so don’t guess too quickly.

It is in combination, both Engine(s) and Ambulance(s), that we truly may dazzle the uninitiated. And here I use “engine” to mean any fire piece. Just because it has a big ladder on it doesn’t mean they needed a big ladder on the call, that may just be the piece they were in when the call came.

A single engine, single ambulance may be many things, but note – if the ambulance pulls up and stops anywhere near the engine, it is probably not a fire. Fire guys get just as annoyed at Bambulance Folk as anyone else if we’re in their way. So, ambulance near the fire truck = the truck is probably there for manpower. Good guesses include chest pain and difficulty breathing. Less likely: the caller told dispatch the person with “leg pain” weighs 400+ pounds. Again, fire guys for manpower.

If you live in a jurisdiction that runs both Basic ambulances and Medic ambulances, you may see one of each. Thus, 1 Engine + 1 or 2 ambulances = medical emergency.

Two or more engines, you can dredge up your “Looks like trouble…” voice again. The ambulances (there will be one, at least, “just in case” for the fire guys) will park far away – perhaps even a block away – from the engine activity. This is either a working fire or the possibility of Something Bad. Say, an inside gas leak.

That’s basically it. There you have it. Mix and match.

Three things to remember, though: In your quest to look Knowledgeable, do not rely just on the number and type of apparatus on scene. Neglecting to point out actual fire and smoke, if your kids see it, can make you look silly.

Secondly, if you see multiple Police, multiple Engines, and multiple Ambulances – calmly go someplace else, as that is probably not a healthy place to be just now.

Third, and most importantly – Stay Out Of Their Way. I mean it.

I wouldnt venture out there fellas. This snipers got talent – Pvt Jackson

Wednesday, September 07 2005

Sitting in the day room last week, I couldn’t help but wonder at the outrage and disbelief expressed by many of my co-workers when CNN announced that someone was sniping at EMS in New Orleans. If you missed it, it’s all in their article, Sniper fire halts hospital evacuation.

Outrage? Absolutely. Asshat snipers. But disbelief? Not if you’re over thirty.

Ah, this starry-eyed generation! Snipers were a big problem in the LA riots of April, ’92, after the Rodney King verdict. A favorite tactic being to set up on a rooftop across from your arson, then pick off the responding firemen. So, yeah, there were a bunch of people being total asshats.

Skip back a couple of years and riots, 1968, in Trenton and Washington DC, where the weapon du jour was bricks thrown at fire fighters. “Oh, bricks,” you say. Hey, a brick is damned heavy. They still stone people to death in some places. Again, a bunch of people being total asshats.

And forget about the August ’65 Watts riots. Everything was going on there.

Hells bells, the story is basically the same for every big riot, and not just in America. Civil disorder and chaos begins, and otherwise normal folk take the opportunity to loot and pillage like damned Visigoths. Lo and behold, anyone representing Order would – gasp! – mean an end to this, so let’s make ’em duck and cover.

Now, we get shot at (and shot) on plenty of occasions – it doesn’t have to be a riot. This article, for instance specifically discusses EMS and body armor, just because some folk take exception to us covering up the pretty gunshot holes they made in a gang banger. They see us saving their victim, so they plug the victim a few more times to finish him off and give us a couple to think about, too. It happens, too often, but then again once is too often.

It all boils down to scene safety. We’re not supposed to go in unless everything is safe. I wouldn’t be at all surprised, however, if there were some elements in EMS who float the idea of arming the medics – just in case the police are occupied elsewhere. Personally, I think that would be the wrong image, but armed responders do seem to work well elsewhere.

A well-written, two-part piece describing EMS in Israel points out that terrorist bad-guys have been gunning for first responders for decades. Snipers are common, as is the use of secondary devices – a second bomb timed to blow up while police, fire and EMS are on the scene of the first explosion. While the article states that no EMS personnel has ever used his side arm while on duty, there are plenty of stories where one came in handy. Of course, almost everyone in their system is IDF, and well trained.

Should EMS go armed? Well, being armed does not prevent police officers from being sniped, so in that respect, probably not. Amateur snipers probably have a heightened sense of invulnerability anyway. They can take their time to pick their spot and set up, and can usually vacate before they’re pinned down – they wouldn’t care about a glock.

How about for the gang-banger? In my opinion, anyone who is still on-scene after a shooting, wandering around with a gun, is crazier than a… well, would probably not be impressed.

Guess I’m content to continue letting the cops do their job while I do mine.

Laughing, I suppose

Saturday, July 02 2005

We are certainly some strange folk, in EMS.

We left a house where “great-uncle Fred” hadn’t been seen since retiring last night. Turns out, well, he’d had a few medical conditions he may have been ignoring, and died sometime in the night. Not knowing this, dispatched to a “stoppage of breathing” call, we rushed in with our paraphernalia, four of us on the bambulance and several from the wagon (dispatch will if they can send a wagon on such a call, in the event we need more hands for CPR, etc.)

Nothing to be done. The departed had been down for some time based on rigor and lividity. Call the police, and hang around until they show up on scene. All deaths not attended by a physician or occurring in a hospital are “crime scenes” until cleared by the PD. Sensible. Family sad but not surprised or inconsolable.

And what do we all do, hanging around thus? Well, neighbor Dad and his three- and five-year-old sons had waved at the pumper as it roared into the street. Go outside and make happy with the kids!

The youngest was much too shy to leave dad’s shoulders, but the older proudly wore an engine crew’s helmet as he sat in the cab and pushed the buttons he was shown (surprise! This one’s the air horn). I swear his grin was this big. Fortunately we carried in the bambulance some plastic toy fire helmets and stuffed animals. He and his brother seemed quite pleased to have them, when time came finally for them to dismount and we be on our way.

And it occurred to me, as we cleared the scene after PD arrived – you know, that was righteous. What better thing to do, but play with kids after leaving the scene of a not-entirely-unexpected family tragedy?

Now, it followed to ask me self, When exactly would such a thing seem strange? When first I ran EMS, I played imagination games: What if? If this then…? How would…? It always seemed, since we were all about life, that a death scenario was going to be the biggy, the deep dark heads-down heavy-step past the cameras to the unit “no comment” call. I dreaded such a call.

Harumph. DTs remains “death free” lo these many years – I’ve come to scene for dead folk, and I’ve run folk who are dead (but we worked ’em), and turned over to the ED folk who’ve later died. Never put a live patient into my unit and had ’em die on the way, though. Odd pride. Off topic. Nevertheless, death is just one of those things you get used to. For other folk, I mean.

We speak fondly of a particular suicide – “He unloaded the clip and just put one in the chamber to do himself,” we say, and the other EMS folk say, “Wow, what a nice guy!”. If the weapon were full-clip it would be more unsafe. Very considerate. And I think, “Wait a minute – this guy killed himself, and here I am complimenting him on technique.”

But that simply helps to illustrate the odd viewpoint of EMS, I guess.

A HUGE thank you to everyone who offered congrats, public and private, on me EMT-I. You’ve earned yourselves a free downgrade in needle size on your next IV… 🙂