We deal with patient families every day, and when it comes to the family members of patients who are dying or who are dead, we rarely know exactly what to say and do. Family members may be angry, they may show little or no emotion or they may react with disbelief.  Some are ready for the inevitable, and some are shocked by the surprise of a sudden death.

We are EMS, and we are often charged with the difficult task of saving a life, or bringing one back from the brink of death.  We do what we were training to do, we do it quickly and often robotically. CPR is initiated, advanced airways are placed, the monitor goes on, the IV is started, medications are pushed, we do all this quickly and often without regard to our surroundings.  I recall a core that we worked for 20 minutes before I realized that the young man who had called 911 for his neighbor was still in the room, backed into a corner with a look of horror on his face.Families are often on scene when we arrive, and I think we should do everything we can to give them the respect and courtesy of updating them on what we are doing, the progress and the possible outcomes.  Families might have different reactions to what we tell them, but in the end they will appreciate and remember that voice, guiding them and informing them of our actions as we work on their loved ones.

As emergency personnel, we deal with death and dying every day, we often use humor and experience to suppress emotion while we do our job. Each of us deal with death in our own way, and training EMS personnel to deal with the emotion and stress of death is difficult. We don’t deal with the subject very well.  There are always avenues for seeking help if the stress and emotion become overwhelming. There are counselors, chaplains, supervisors and friends, but asking for help is often just as challenging and difficult as the experiences that cause us to feel the need to seek help.   I imagine that at some point during everyone’s careers they will experience something that no person should experience, something that wasn’t in the job description, a shock to our systems.

Whatever your role in EMS is, you should always be cognizant of the people around you, your peers. Don’t wait for the “warning signs” before offering a helping hand or a shoulder. Ask questions, press for information, and expect that a difficult call WILL affect everyone, even the experienced, hardened veteran. Offer what you can, guide them and hope they do the same for you.

“And I looked, and behold, a pale horse! And its rider’s name was Death” Rev 6:8

The general public expects us to show up quickly, act professionally, take care of their problem, and transport them safely. So what are the problems we have in pre-hospital (from the view of the public).

It costs too much, we took too long to get here (perception of time during an emergency) and the care wasn’t adequate for the call.

So what are most services doing? Some type of tiered system… fire/first responders are dispatched, size up and decide if they need an ambulance. Services are using BLS ambulances who then call for an ALS ambulance or an ALS fly car. 

What’s the future of EMS and how can we increase public awareness and education to make our systems better? A new and exciting topic is the emergence of the community paramedic. A field based provider that can provide both preventative and emergent pre-hospital care. I believe this WILL be the future of our specialty. Treat the patient on scene and prevent unwarranted ER visits, which will in turn decrease the overall cost of healthcare. I also believe that we will see more single paramedic flight cars that will INITIALLY respond to calls that are triaged as ALS. A better educated, higher level provider who gets there faster (patient/family perception), triages, stabilizes, and begins treatment of the patient on scene, and an ambulance used for transport.

Each area of the country is different, with vast differences in level of care, response levels, fire response, etc. but a model that utilizes fewer (higher educated) advanced skill providers, that can DO more good for the overall outcome of patients is, in my opinion, the best thing we could do for healthcare and patient advocacy.

Break the norm! (Years of tradition unimpeded by progress)

Maintaining control of an emergency scene involves a skill set that, in the end, results in a smooth transition from an emergency to treatment and recovery. Making a specific list of attributes needed is difficult because each call we receive is dynamically different in so many ways.  Dealing with a violent, intoxicated individual at any fine downtown drinking establishment varies greatly when compared to dealing with a ninety year old diabetic patient at home.  Each case we encounter challenges providers to find a way to provide care, maintain control and treat and/or transport patients in a timely manner.

During my experience as an EMT basic and EMT intermediate I have observed many different styles and techniques of paramedics as they tend to patients and maintain control of the scene.  I have seen paramedics who showed textbook attributes of a provider who has mastered multi-tasking, those who need a strong partner to succeed, those who tend to do everything and others who maintained control by overseeing other providers on scene.  I have also seen paramedics who have obviously lost control of the scene or those who never had it to begin with.

Being a team leader is easy for some and harder for others. There are also other factors that come into play that may never cross our minds while on scene but might be observed by patients, family members and bystanders. Ethics, those little things that everyone says we should ignore but that are in fact always there. Race, color and religion are the ones that stand out, make the news and can get you fired from a job, but there are other factors that we come across during emergency calls that can cause a team leader to fail or falter in their duties. Some of the issues that come to mind are obesity, poverty, lifestyle, cleanliness, intoxication, drug use… the list can go on forever. Putting our opinion out of the equation is hard and sometimes near impossible, but it is important to, at the very least subdue thoughts, actions and emotions while we perform our duties as emergency providers.

I learned very early in my career that maintaining control of a scene is important, whether it be a simple medical call, a chaotic trauma or a mass casualty incident. I don’t take for granted that the next call I go on will be just like any other I’ve experienced and I’ve learned the importance of situational awareness. Keeping your head on a swivel, knowing what’s happened on scene, what’s happening now and what might happen is just as important as patient care, especially when my safety and the safety of other providers on scene is at risk.

I have had… well, too many partners to count, and I cannot point out one as being “the best” when it comes to any aspect of advanced life support provider. Each one has been different, with strong and weak points. I can say that I have learned from them all, good or bad, and will attempt to carry what I’ve learned and experienced on with me as my career advances.

So… I start Paramedic school in just under a month. I’ve been an National Registry EMT Intermediate for something like 6 years and was a EMT Basic for a year before that. I’ve seen a lot, learned a TON, and have slipped in every kind of body fluid you can think of. So what’s next? I’ll advance my ability to do a few more advanced procedures in the field (like chricothyrodimy), push a few more drugs, rapid sequence intubation and hopefully gain the knowledge to continue NOT killing patients! School will take another two years or so, a lot of tests, being stuck in the back of the ambulance (trunk monkey), studying and reading big books with even bigger words. After successful completion of this daunting task, I’ll also get a significant pay raise which will raise my pay rate from nill to naught, but the most valuable thing I will gain is the ability to advance my career. The Intermediate level is just that, intermediate… somewhere in the middle. There is usually no pay increase from the basic level (not where I work anyway) and most jobs in the industry want the highest level provider. I’ll be able to work my way up the proverbial career ladder, of which I’ve been stuck (on a rung somewhere in the middle). I look forward to the challenge and the opportunity that going back to school will give me. So, to all you first responders, basics, and intermediates, never stop learning, continue to the top rung …unless you’re happy in the middle. To Paramedic school… I’m ready! BRING IT ON!

Every day paramedics, EMTs, firefighters and police officers go on hundreds of calls. They use light and sirens to get to emergency situations in a timely fashion. This is one of the most dangerous parts of the job! We train and educate to master emergency driving skills but there is always an inherent risk of driving faster than the speed limit and going through intersections without the protection of a green light.

The deadliest part of emergency driving is a distracted/inattentive driver. We all learn what to do when we see lights and hear sirens… pretty sure that’s still on the driving test, PULL TO THE RIGHT and SLOW or STOP. We see drivers do a lot of wrong things that increase the risk of emergency apparatus becoming the accident instead of responding to one. I’ve seen drivers slam on their brakes and stop in the middle of the road, speed up, pull to the center, one driver slammed on his brakes so hard he spun out of control and skidded through the center median into oncoming traffic!

So, in an attempt to reiterate and remind, here are some simple reminders and pointers for drivers when you see lights and hear sirens.

-CALMLY pull to the right and slow down!

-Stop if you can.

-Don’t go through a RED light to make room, if you can’t pull over far enough to let equipment through, we understand. Wait for the light!

-If you’re on a road that is PHYSICALLY separated by a median,  barrier, etc. there is no need to pull to the right.

-If you’re at a light and the car in front/behind pulls to one side, GO THE SAME DIRECTION.

-Do NOT slam on your brakes! We cannot stop a 35,000 lb firetruck carrying 9000 lbs of water on a dime!!

-If someone pulls over in front of you, there’s probably a reason! Check your mirrors.

-When in doubt PULL to the RIGHT and SLOW/STOP!

-Be SAFE!

Carbon Monoxide Poisoning and the LifePak 15

David P. Woods, NREMT-I

Carbon monoxide (CO) is a colorless, odorless and tasteless gas given off by the incomplete combustion of carbon containing fuels. CO is released from many sources including fires, heaters, car and boat exhaust, cigarettes and gas-powered generators. So why do we care about CO? CO binds to hemoglobin, the oxygen carrying molecule in the blood, with an affinity of approximately 250 times that of oxygen. This affinity prevents oxygen from binding to hemoglobin and the patient will quickly become hypoxic. CO poisoning is the number one cause of poisoning deaths in industrialized countries and often called the “silent killer.”

 In the past, detection of CO poisoning has been primarily limited to blood tests. The LIFEPAK15 is equipped to monitor CO levels and will alert the rescuer if the SpCO levels reach greater than 10%.

Signs/Symptoms:  Headache (sometimes described as a halo), confusion, shortness of breath, weakness, fatigue, unstable gait, nausea/vomiting, unconsciousness, tachycardia and chest pain. S/S may be more pronounced in patients that are young and old, and patients who are pregnant should receive priority care.

How to Use LP15:  To utilize the CO monitor, the pulse oximeter must be changed to the CO capable oximeter (marked with SpCO). Scroll to the SpO2 box, click and select SpCO. The monitor will momentarily show a reading but will automatically switch back to reading oxygen saturation if CO is less than 10%.

Treatment:  To treat patients with CO poisoning is high flow oxygen, monitor level of consciousness, transport. The hospital will continue monitoring CO levels, oxygen therapy and in some cases may transport the PT to a facility with hyperbaric chamber capabilities (in Colorado… Memorial, St. Luke’s, Poudre Valley).