All ALS all the time?

There are those who believe that the idea of "all ALS all the time" is the best policy for providing EMS to the masses, and believe it or not, I'm not here to debate that fact even though I am a BLS provider myself. There are also those ALS providers out there who believe that BLS providers should not be able to make a determination about whether a patient needs ALS care. Surprisingly, I'm not here to talk about that either. Rather, let me tell you a story:

We're called for a 27 y/o female having an asthma attack. Our crew is fast today, and everyone is assembled and we're off in the ambulance in record time: 4 minutes after the initial call marks our arrival on scene. Walking into the lobby of the building, I find the patient sitting in a chair, barely moving any air; she states (barely) that she has a previously diagnosed case of childhood asthma, but doesn't have an albuterol inhaler. A quick listen to the lungs, and she has wheezes on the exhale; also a tinge of cyanosis to her lips. This is not a healthy person. My partner starts a more detailed workup, and I get on the phone to medical control for a request to administer nebulized albuterol, which we carry on board. The request is approved and we begin administration of the medication and start prepping her for transport.

My next call is for ALS backup. Stair chairing and getting her out the door has already run us through a couple minutes and the 1st dose of albuterol is almost already run dry to no relief to the patient. I'm back on the phone to Med Control and get an order for "continuous albuterol administration -- no dosage maximum," which is technically not in protocol, but I'll worry about my two unit dose maximum when I get there. Move onto the stretcher and loading into the back of the ambulance, I see a FDNY rig quickly approaching from down the street, "Good," I think, my ALS has arrived. The two guys from the FDNY rig get out and walk up. Judging from the confused look on their faces, I know the question to ask them.

"You guys ALS?"

"No.... what's up?"

"Asthma.... bad. You guys know if they have ALS en route?"

"I don't think so."

I hesitate a second, thinking, and my thoughts reach the same conclusion as the FDNY EMT's who urges: "you guys just go, don't wait."

My thoughts exactly. Already a third of the way through the second dose of albuterol, and no change in the patient's status. She's still struggling valiantly for breath. 'This is probably my second worst asthma case I've ever done,' I think. The worst one ended with the patient intubated... luckily for the patient, I suppose, she won't, and can't be subjected to that today... at least not in the field.

I'm driving so I hop into the cab of the bus. I take a second to bring up the hospital notification number on the phone, hit the SEND button, hit the sirens, put the truck into DRIVE and we're off. I tell the ER what we're bringing them. Conveniently, we're only three minutes out. Arrival in the ER brings our rush into the trauma room and the "Green team" descends on our patient. Finally, quickly, she gets some advanced treatment and interventions. A happy ending to a frantic twenty-minute procedure of getting the struggling patient to the hospital, quickly and alive.

By the way, at the end of it, when my crew of three were bringing in another patient a little while later, a now freely-breathing young women in hospital gown gave us all hugs and thanks. Guess BLS isn't so bad after all. But the conclusion of the story is, this is the second time in a month when I thought I needed ALS and didn't get it. All ALS all the time is well and good, but how about all ALS when you need it, all the time? In a city like New York, you'd think that ALS would be available when needed. The facts of the matter are that FDNY*EMS does not use EMD dispatch, and does not work with the voluntary and volunteer organizations operating in the City limits. How many lives have been lost because advanced care was not sent where it was needed? How many patients received ALS for whom an accurate determination of need was not established by the dispatcher? How does the public allow shabby, poorly-run systems to continue to exist?

In the Navy

When I first started working as an EMT, I had just got certified and was working for my local volly fire department during a summer home from college. We got called to the "Better Spaces" home, an 'assisted living' community for people suffering with Alzheimer's. I think most of you remember your time in this position, you didn't really know what you were doing: you had your training to guide your actions, but no experience.

I'm running lead on this call for a 86 y/o male with a fever. I've got the Chief, who is decidedly hands-off for this one, and another college-aged firefighter, not trained in EMS, except that he picked up the art of taking vitals somewhere along the line. We do first-response, and the Hudson ambulance service reports a delay in the time of arrival of their rig. In fact, when I start talking with the guy, he's appears fairly healthy and we find him in the dining room (how the staff found out he had a fever in the middle of dinner, I will never know) sitting calmly at a table.

I introduce myself and start the routine I was taught in class.

"Hi, I'm a EMT with the fire department, how're you doin'?" I ask.

"Oh, I'm good! I'm feeling pretty well, and I'm just sitting here eating dinner.... what do you want?"

"Well, we were called here for you because you have a fever."

"Ah. I see," A puzzled look on his face, "I really feel fine. All of this is probably not necessary."

"Well, my partner here is going to check you blood pressure and pulse if you don't mind."

"..."

"You alright?" I ask as he seems to have momentarily blanked out. He blinks and I ask about the vitals again.

"What...... oh. Yeah, sure, whatever you need. Why're you guys here?"

I feel like I may have answered this question already, but.... seeing as we're in a home for Alzheimer's patients.... "Well, the staff called us because you have a fever, apparently. I'm going to take your temperature now, OK?"

"Sure," he replies, and I stick a probe in his ear: 100.2 F. Geez, I don't know what all the hubbub is about. Well, with baseline vitals unremarkable, EMT-Basic training states to begin OPQRST, and obtain a SAMPLE history.

"When did your fever start?"

"I have a fever?"

"Ummm, yeah." A staff member fills in the blank that they routinely take temperatures every evening before bed. I see. "And when did you take his temperature?" I ask the staff member. Blank stare answers that question. Right then, so proceeding right along...

"Does anything make it better or worse?"

"Make what better or worse?" asks my patient.

"Your fever."

"What fever?"

'Oh, Lord' I think. I look over at my Chief, who is happily engaged in conversation with a young blond nurse in a flowery frock. Firefighter partner has started wandering around looking at the artwork in the dining room.

"Have you felt sick recently?"

"Nope, I'm healthy as a horse!"

Skipping the rest of the history of the illness, I remember I need SAMPLE and AVPU.

"Do you know your name?"

"Sure, I'm Jim."

"Do you know where you are?"

"I'm at home."

"Do you know the day of the week?"

"Yeah, today is Sunday."

'Well, that's not right,' thinks I, seeing as it was Wednesday.

"What's the date?"

"Oh, It's October 14th, 1943. Speaking of dates, I had a cute, little one last night...." he smiles and winks, "yep, got me some shore leave for the weekend and had a little hook-up, if you know what I mean!"

I'm speechless for a moment... I start to open my mouth and I shut it. "What do you do?" I ask, stalling.... somehow I know asking for his allergies and past oral intake, etc., won't get me too far.

"I'm a hand on an ocean going tug," he replies, "we're in port for a week, so I thought I'd look up some gals that I know."

The grin on his face is contagious and tragic all at the same time. I can't even begin to relate to the patient. Here is a man who has lived his whole life, and now, nearing the end, the doors of his memories for the past 70 years are shut. The only memories accessible to him at this moment places him the morning after a one-night-stand he once had, with a person who now probably has grandchildren of her own, and yet, it seems like it was just yesterday. In a sense, the reality he's living at this moment is almost better than the reality that actually exists. The triumphant attitude of a virile young man facing the adventures of youth has to be far superior to that of a frail, elderly gentleman, stuck confined to four thin walls with locks to keep you inside - the smell of urine and sponge baths always prevalent. Is this the way the brain keeps us sane, in response to conditions that would surely drive us insane? Is this the way a body, barely able to respond to the demands of life, much less the enjoyment and full expectations of it, cope with the disappointment of a machine worn well beyond the limits of its construction? Alzheimer's is a terrible disease, I've been told, robbing its sufferers from their faculties. And yet, this smiling, talkative soul in front of me, older than my own grandparents, is enjoying life just as fondly as he ever could.

We chat a little more about things and wait for the ambulance to show up. When they arrive, the medic doesn't bother asking for a report from me. In and out. Jim is loaded onto the stretcher for another unnecessary ride to the hospital that Medicare or his insurance company will have to pay for. The assisted-living community I learn later has no medical resources, so for any ailment, no matter how small, 911 is dialed and EMS is summoned to transport its residents to the ER.

I've seen enough of this home to know that most of those who live here aren't nearly as active as my patient today was. Many go through the day barely aware of their surroundings. I've taken calls here where the patient, after falling down in their room, with copious bleeding from certainly painful injury to their arm or to a leg, can barely comprehend the simplest questions, or even tell us if there's any pain at all.... the only indicator yelling or screaming when a site is touched or pressed upon, or maybe not. Yet.... what is happening in their minds? As the world progresses and time continues around them, what reality and what present are they interacting with? Is it possible that they're in a better place? As a patient is picked up, bandaged, and carried to the ambulance, are they vividly reliving their time on shore leave?...smiling, winking, laughing, and enjoying the art of living.

Cool! A nifty map!

With the help of a great site created by Phillip Holmstrand, I was able to plot and map the locations of every 911 receiving hospital in Manhattan, as well as specify the trauma centers (in orange). This is a screenshot of the map created and an interactive version can be found by clicking the image. Enjoy!

Ooooooh...pretty....

I just wanted to put this up. Good ole Fair Lady. Excuse the unskillful removal of license plate numbers and name. It is a nice truck though, isn't it?

The Maze Known as a College Campus

As a New Yorker, I'm fairly accustomed to finding my way around the city easily enough. And while I'll admit to the small difficulties every once in a while, like where exactly do I get off on the Canarsie line to transfer to the Crosstown Local (and by crosstown I mean Brooklyn/Queens); in Manhattan north of Houston is easy enough to find: The numbered streets go East/West, the numbered avenues go north/south.

I bring this up because a most amazing phenomena occurs every third or fourth day as I look out the 9th Floor window of my apartment onto Amsterdam Ave, and my college campus beyond it.

"So what is this strange occurrence?" You ask.

"Why, it's an FDNY ambulance traveling north on Amsterdam Ave., slowing as they approach the intersection and the gates to the main entrance to campus, then gradually stopping. In fact, they look....lost! You can see into their vehicle as their poor heads search the area, turning left, right, up, down. The the driver takes his foot off the break pedal and the FDNY rig pulls a U-Turn in the intersection, slowly, and starts heading back south."

Three minutes later they're back again. Same routine. They know that they're not in the right place, but probably close. They travel north this time, past the wrought iron gates, but once again, back they return, fruitlessly traveling north and south, pulling U-Turns while, I can only assume, their patient waits -- panic slowly setting in, until a campus Public Safety officer walks up to them, listens, gives directions, and off they zoom to save the day. This is where my ambulance service comes in. Our ability to excel in our service to our community of 50,000 students, faculty, visitors, and staff lies very much in the fact that we can respond directly to a location much faster than ye standard Citywide ambulance.

For example, this is a photo of a building on campus:

When yada-yada person calls into the 911 system and says, "Hi, I'm whoopie-wheepie, and I'm having a heart attack, and I'm in Shapiro Hall at The University." Citywide EMS dispatch will send all sorts of folks over, who will promptly not know where to go for several minutes at least. On the other hand, when same person calls x99 and contacts campus' Public Safety, we get the call, and we know exactly where Shapiro Hall is. In fact, we even know to ask for a clarification since there are actually TWO Shapiro Halls in existence. Thus, we hop in our truck, off and away, and establish patient contact in a much more efficient fashion than would otherwise be attainable through the municipal system.

Though this efficiency does not come easily. We require of our new Drivers that they memorize almost every location for each named building on campus, a list of about 100 places, each with it's own physical address, and some buildings with multiple addresses, as well as multiple buildings with a single address! What fun!

I've been working on a document for several months now, and tonight we are presenting it to the rest of the corps. It is essentially a standardized route listing for each possible location on campus. Here is an excerpt:

Schapiro Center
PRIMARY - Access through Peters Hall entrance on X St. Take your first left and walk past loading dock to the giant Freight Elevator. When returning to vehicle, remember that only the freight elevator reaches this level, and not the regular passenger elevators.

(2) – Access through entrance to Schapiro building on X St. requires changing elevators at Campus level. Beware, the first set of elevators are very slow.

(3) If responding to a call above the above the 7^th floor in Shapiro, try going through Mensche Hall Sky Bridge. Access is given by the 10^th floor of Mensche Hall. Use this is you like parking in the grove.

As you can see, there is a Primary route of access, and two alternatives. This may not make any sense to you, but by referencing other landmarks on the campus, this allows for a more streamlined approach to access to locations. The next steps will be distilling this down to something that anybody can use, especially for FDNY fire and EMS, NYPD, and anyone else who may be conducting emergency responses to our campus. Hopefully, in providing the municipal agencies with a listing of buildings with their corresponding physical addresses, and the best way to get into them, we can make this maze of a campus much safer (even if it means loss of business to my volunteer ambulance service)! Now, anyone know how to get FDNY to listen?

Why send an Engine company anyway?

Dispatched to a call for a "22 y/o female fell down the stairs with a head injury," I think first "Woohoo!" as the tones go off, then "Hmmm, this might be interesting," as the dispatch comes across. Little did I know how interesting.

The FDNY*EMS system is an entirely separate entity from the FDNY Fire system (and entirely separate from Fair Lady). They have different radio systems, different dispatch networks with different computer systems, different chains of command, and they don't even talk to each other. In fact, surprisingly, they also have different 10-Codes, which despite NIMS, both organizations are completely married to, and I would be surprised if "10-84" changes to "Arriving" anytime in the next 25 years (Nevermind that arriving is easier to say with one less syllable than 10-84).

Despite this, when the Citywide EMS system gets swamped, like it did last night, FDNY*EMS starts sending Engine companies to the serious medical calls. Since we're unaffiliated with FDNY completely, there is also the possibility of a dual dispatch if someone calls the University's Public Safety emergency line directly, and also calls 911, this also occurred last night. We arrived on scene to find the engine company, with their crew of CFRs, already tending to the patient. I dropped my partner and a Probie off at the front door, and went to stage the ambulance a little farther down the street. NYPD and Public Safety were also already on scene. After parking, I grab a stair chair and head into the building about 30 seconds after my partner entered. After I enter the foyer, I pass a firefighter who says, "You're going to need a backboard." I drop the stair chair, do the twirl, and head back to the the rig. Things progress nicely from there. My partner and the Probie do a nice job stabilizing C-Spine at the foot of the staircase, and we secure to a backboard.

I got the full story eventually from a friend who told me that the patient tripped at the landing on the top of the stairs and rolled all the way down to the bottom, head over heels. About 20 feet. Technically this is major trauma criteria, so even though the pt was negative for AMS, and PE revealed over some abrasions to her head and bruising to her arm, I called a notification to the trauma center, and we hustled to the hospital.

After we clear from the call, my crew sits together for a quick post mortem review. This is when my partner tells me that when she first arrived on scene, the FDNY firefighters had a 4x4 out and were pressing it against the pt's head. No manual stabilization of C-Spine, no collar out, no backboard. This suddenly struck me as odd since it was an FDNY firefighter that had originally told me that the pt would need backboarding to begin with. So, basically, the FDNY crew knew what needed to be done, but didn't bother doing it.

New Engine

As promised, I now go into the details of the new engine that I discussed in the last post. It's funny, I joined my local volunteer fire department so I could do EMS, but I found that I also began liking the fire services as well. Crazy world, who would have thunk it?

This engine is a brand-spanking-new, Pierce pumper with a 500 gallon tank outfitted with a Waterous fire 1250 GPM fire pump, and all the bells and whistles.... I mean that literally, the department actually ordered the truck with bells and whistles, which can be seen mounted on the front fender in the picture below. We tried out these bells and whistles, but you actually can hear them over the mechanical or electrical siren or the air horn. It's a full foot taller than our other, older Pierce Quantum, a 1999 model. This new truck replaces our trusty, well-used Pierce Dash, circa 1980, and is now designated E-411, and is also our FAST truck.


I spent an afternoon over break, helping get the new engine into service. Basically there were five guys there, the three college students, and the two chiefs. We transfered hundreds of feet of hose: hand lines, supply lines, and everything else from the 1980 Dash to the 1999 Quantum, and from the 1999 Quantum to the 2007 Quantum. Fun times, eh?

After moving the hose, we moved the tools, radios, and everything else, and finally, we were good to go. as mentioned, I got to ride in it that very evening towards an MVA, on it's very first call. It's a nice piece of equipment, and hopefully, it will provide several decades of service. The pictures included here are from the Pierce plant in Wisconsin, just before the decal work was put on, (and saving me the trouble of re-anonymizing the images through Photoshop) right before it took its trip to its new home in Upstate New York.
(click to enlarge images)

Hometown Happenings

Well I've been back home this past week for Spring Break, and had the chance to run about again with my local Fire Department. First though, I should mention that I coulda/shoulda posted about an event that happened two weeks ago, but due to some of the implications legal and whatnot, I'll refrain from doing so for now. However, I'll give you a keyword: RUM RABBITS! When I mention this keyword again, refer back to this post to give yourself a timeframe when I do write about the events that occurred.

It's been a busy week here at home. My town of about 20,000 is essentially a suburb in Upstate New York. Not unexpectedly, the type of calls we get here are different from the calls down at school in Manhattan. For example: no substance abuse calls. However, this was a three wreck week with three MVAs (together with a structure fire last week, a car fire this week, and a variety of medical calls: including the ever-joyful recurring trip to the local home for persons suffering with Alzheimer's.)

The first MVA occurred on a clear, sunny, morning with dry roads. A 79 y/o female lost control of her car on a winding road by the river and drove across the lane of oncoming traffic (thankfully missing everyone) and into the grass, trees, and shrubbery on the opposite side of the street. Tones went out on the pagers and I responded from home. I live almost exactly a five-minute drive from the fire house, so after hopping out of bed, into my clothes, driving to the station, donning my turnout gear, I had missed the first-out rescue truck. Luckily (or unluckily, depending on your point of view) many of the department's members work during the day and therefore can't respond, so I was the second person into the first-due engine and got to play officer. We left the station on that piece with a crew of two. Arriving, I see a mostly unharmed vehicle, I'm asked by the Chief, as one of the few EMT members of the department to help with the medical aspect. I walk up and see that the crew of the rescue rig are already maintaining C-Spine, with a member in back of the sedan holding stabilization of the driver. There is only one patient. Another EMT is conducting the PE and so I start the paperwork. Overall, she's not badly injured, but due to the MOI (and the fact that he car's no longer drivable), we ship her out via the commercial Hudson Ambulance company (the fire department is strictly first response, name changed) to the local hospital. Since I had arrived on the engine, the rescue packed up and left, and I got to stay and now play Fire Police, directing traffic around PD and the tow as the vehicle was removed. 20-30 minutes on scene and we're done. Not a difficult call at all.

Number two didn't actually happen in our fire protection district -- The town is split into three such districts: District #1 (clever name), District #2, my territory (equally clever name), and Magical Heights (name changed, except the 'Heights' part). This one was a more interesting call. Initially, my pager announced the dispatch, which it shouldn't have since it was alerting District #1. I was just about to reset the pager, when I hear "...two car collision with multiple injuries, multiple calls coming in. Repeating for District #1..." "Uh oh," I think, "could be bad." As apparatus start to arrive on scene, it sounds even worse. I decide that the we're probably going to get called for mutual aid on this one and I change out of my PJs, and head to my car. As I'm leaving my home for the station, I hear: "OK. We've got four patients. Send out tones for addition manpower from District #1 to the scene, put Medflight in the air, tone out District #2 for assistance in extrication, call Hudson Ambulance and give me two additional ambulance on scene, ALS if they have them, but we'll take a BLS, and put Magical Heights on standby in their station to cover the town for fire and medical." I hear first the call go out for the additional District #1 manpower, then my tones drop, then the call goes out for Magical Heights. Aside: note that District #1 is a paid, professional department, while we're volunteer, and that their paramedics already had two district-owned ambulances on scene (and all their on-duty personnel). It's now about 9 PM, and I'm the second person in the station. I start the rescue rig and run to don my turnout gear. I'm riding in back, and we're out the door about 3-5 minutes later. It's a relatively long drive, ~8 minutes, since we have to go across town. We also sent one engine to establish a landing zone for the 'Bird' at this time, but my truck goes to the scene. By the time we arrive, some District #1 medics have already rapid extricated and sent an ambulance off to the hospital for a trauma-arrest. This patient is the first and only death of the evening. The scene is pretty bad: A full-size pickup had ignored a stopsign at an intersection and is T-boned by an oncoming small compact car. Due to the velocities of the vehicles and the circumstances, the compact acted as a wedge and slid under the pickup, causing the truck to roll and adding to its momentum. The truck, however, never completely rolled over since a three-foot wide metal utility pole impeded its rotation when it was at about a 45 degree angle, causing the cab to collapse in on itself and "squishing" the passenger's head between the truck body and the pole, ultimately causing her death. I couldn't believe the status of the pickup when I saw it: The entire bady and frame were actually visibly and uniformly bent in the middle, to the tune of a good 15-30 degrees, such that the floor of the truck was almost touching the surface of the road when it was set back straight, regardless of the height of the wheels and axles; this being a large truck whose strongest characteristic is supposed to be the frame itself. Unreal. The two passengers of the compact were relatively unharmed and that vehicle did not require extrication. Extracting the driver of the pickup was fairly easy since that side of the truck was largely intact. The door was popped off, and the patient was fairly OK, though in the end he was flown to the Regional Trauma Center, because of the MOI and because the chopper was already on scene. Once again, the crew of our rescue truck did some Fire Police: closing down the roads surrounding the scene while the site was cleaned up and PD conducted their investigations. We returned to quarters after about an hour after initial arrival.

MVA #3 happened last night during the blizzard that swept through Upstate, leaving behind about 18" of snow in my town. One of our department's members actually was driving behind the vehicle involved in this one and told us the complete story. Through my town, runs a fairly large state highway, two lanes of traffic in each direction and a center turn lane. People were traveling at reduced speed due to the snow, but apparently not slow enough. My comrade-in-arms stated that she was watching this car slowly lose track of the lane markings in the road, and watches as the driver gradually drifts over to the left. At the time of the accident, he was actually driving almost exactly in the middle of the turning lane. Cresting a small rise in the road, the car collides with an oncoming snow plow approaching in the opposing direction, one of the big mothers owned by the state. The blade of the plow hits the left side of the car, spinning it and destroying almost all of the front end. We're toned out and due to the snow and the distance of the station, I proceed slowly to the fire house, actually displaying my blue light, which I rarely do (irregardless of the title of this blog!). Ironically, I have to pass the scene of the accident on the way to the house, but such are the rules of the department. Expectedly, I miss the first out rescue, but again, I am the second person in the first due engine (a different one from MVA#1, and a brand new one that arrived in the past week, post on that to come). I again get to play truck officer. We make it off the apron, when the Chief radios us to remain in quarters. Not an easy thing to do: turning this new beast around, and not wanting to take a chance, we do the great circle routing of going three right turns through a development to get us back home. Second bit of irony for the night, we come within about 300 feet of the accident scene before we hit the street that will allow us to start heading the right direction. Nonetheless, we sit back for the ride and enjoy the comfort of this new piece of apparatus, basking in the knowledge that I got to take it out on its first call as a fully equipped piece of fire suppression goodness. The patient was able to RMA and this was a close call that could have easily been a whole lot worse.

Not a good week for E(me)rgency Services

The results came back from the Accident Review Board and I've been suspended from driving for a two-week period. The worst part was the 'serious talk' from Lucy McGillicuddy who, I remind you, is *rum-pum-pum!* years younger than myself. Could have been worse, could have been better. I guess the moral of the story is that everyone makes mistakes (yes, even me!) and there are consequences to those mistakes. At least my mistake caused no permanent damage to Fair Lady's vehicle and no one was hurt.

Can't say as much for FDNY's Engine 123. This happened yesterday. Again, good thing no one was hurt. We will all learn from our mistakes.

Read This!

http://www.neenaw.co.uk/index.php/ambulances/174/weeding-out-the-snifflers/