Wednesday, December 12, 2007

Playing Catch-Up

Catch-up indeed. I haven't written in a while, mostly because there hasn't been much to write about. The same sorts of things have been going round-and-round, work is still about responding to emergencies and dealing with them, and my family and I are all starting to ramp up over Christmas and New Year's. It doesn't help me personally that I have to work on both Christmas and New Year's nights, but at least I'll have the day as well as Christmas Eve to be able to celebrate with my family. I can't complain about that.

As I said, there hasn't been a lot to write about. It's been an awful cycle of work, sleep, work, sleep, work, work, work, sleep, etc. I haven't really had a lot of time to do much, in terms of activity outside of work. And as of late, work has been quite busy, especially in the city. Since Manchester Fire went to system status management for dispatching apparatus, it seems as though our call load has increased. Or maybe it's because with the new system, trucks aren't sent out on rotation. Rather, they are sent if they are closest to a call location or longest in service in quarters. More often than not, we get caught at the hospital when we're trying to get run reports done or re-stocking our truck. Our supervisors have told us that as soon as we can after transferring care to the hospital we have to get back into service. I understand that - after all, we are there to do calls - but it's a problem if a truck is in need of supplies or equipment and the crew doesn't have time to get what they need. The biggest headache of all, though, is when you get stuck in that rut of doing 4 or 5 calls in a row because of where the calls are located and, especially, where the truck in question is. It's especially bad if it's a cardiac or respiratory call and the portable oxygen tanks are depleted and there's been no time to change them out. That's happened to me 3 times already.

I guess I'm venting about this because it really does seem as though the workload has increased. I'm not complaining, but it is tough sometimes. The good news is that I still wake up in the morning ready and willing to go to work. That, I don't expect, will change, as the motivation is there. Every day is different, and every patient I see has different problems or issues that need to be addressed. And as far as I'm concerned, I can put up with a lot of stuff just as long as I have to as long as the fundamental reason I do my job - the people I help - doesn't change.

On that note, some people who will read this, I suspect, will say "he's a whacker", or make some sort of judgment that I'm a naive, over-eager go-getter. Nothing could be further from the truth; I've been in this line of work for nearly 13 years in one form or another. I started as an EMT-Basic, spent 8 years as an EMT-Intermediate, and became a Paramedic only when I was certain that it was where I was to go, and more importantly, what I was to do with myself. As with many EMS providers, I've seen things that no human being should ever have to see, and I've been party to a lot that is good. I've saved lives, and on the other side of it, I have no doubt that I've inadvertently been responsible for some loss of life as well. Unfortunately, that comes with the territory; no matter how hard we try to make a difference, sometimes we can't and the result in the end is a dying or dead patient. That is hard for anyone who does this job for a living to come to terms with, but there it is. You pick up and go forward. That's all you can do.

I worked in Goffstown last night for my regular Tuesday shift. At 4:15 this morning we got sent to a local nursing home for a 95 year-old female having difficulty breathing. When the dispatcher put out the call, she said that the patient was changing color, never a good thing to hear at that time of day. So we got on the road, and when we arrived there, we found our patient in bed with a simple oxygen mask on her face, connected to a concentrator set at 4 L/minute. She was in obvious distress as she was grunting when she took a breath, and she was flailing around and using her accessory chest muscles. Her bed was at about 30 degrees, and that in itself is a problem as she had no way to rest those accessory muscles. My partner, Greg, and I immediately moved her over onto our stretcher and put her on our oxygen tank - we changed out the simple mask for a non-rebreather at 15 L/minute. Did I mention that her SpO2 on the simple mask was only 78%? I guess I didn't. Anyway, it was not good. She was pale, cool, her lung sounds were nearly non-existent, and her mental status was not good in that she was agitated (as evidenced by the flailing) and confused. She had a history of congestive heart failure as well as hypertension, plus she had been diagnosed with dementia which made it that much more difficult to treat her, mostly due to the agitation.

We got her out to the ambulance and loaded her on board, got a set of vitals, started a line, put her on the cardiac monitor and obtained a 12-lead ECG, and gave her a total of 80 mg of Lasix and one Nitro tab under her tongue. During transport we kept the Oxygen on at the high-flow rate and I re-assessed her for changes to her condition. My partner drove like the wind getting us the 5 miles to CMC from where we were, which I was quite happy with, under the circumstances. Her mental status improved slightly during the trip to the hospital, but her breathing and her lung sounds were still the same. The only good thing I noticed was that the pitting edema I noticed (initially +2 to +3) decreased during the ride. Usually you don't see that happen too quickly; in fact, this is the first time I noticed that happen so fast.

When we got to the hospital we brought her to Cardiac-1, one of the big rooms in the ED. I gave the nurse who was to take over from me report while we moved the patient onto their stretcher. I'd called in on the way, so at least he knew what to expect, and by the time we arrived, Respiratory Therapy was in the room waiting for us. Pretty quickly she was put on BiPAP, and within probably 10-15 minutes she was calmer, breathing easier, and looking much better.

Goffstown doesn't have CPAP machines in the trucks yet; the chief of the department purchased two units that he's going to get in-serviced to the crews after the first of the year. I use CPAP regularly when I work in the city, and it would have been nice to be able to use it on this patient in the truck. Also, I had a discussion with the attending physician about why I didn't start nebulizer therapy on her en route. He wasn't being judgmental or critical of the care I provided - I respect this particular doc a great deal, by the way - but he did point out that giving her a Duo-Neb of Albuterol and Ipratroprium would have done her no harm. I'd always been taught that starting nebulizer therapy on a patient in congestive heart failure was potentially harmful because it's possible, at least in theory, to push the patient into a situation where they go into flash pulmonary edema and ultimately drown on their own secretions. He responded to that by telling me about a study of pre-hospital medications given to patients in respiratory distress, and that the Duo-Neb therapy is probably less harmful that giving Nitro or Lasix to someone in CHF. He also offered to find a copy of the study for me, which I will gratefully read. In addition, I'm going to do some looking myself; it is certainly something to consider, and as long as it doesn't conflict with current NH EMS protocols, it will give me or any provider another tool to use when dealing with a patient whose respiratory effort is compromised.

Nice to learn something from a real call once in a while.

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