Ho Boy! I'm in trouble...!

Responding to a call of a "head injury" today, I was driving the ambulance to the scene and proceeding blinkies and woowoos down a narrow side street intersecting Broadway. The time is about 11:45 AM. Traveling about 10 miles per hour, there was a backhoe off the right hand side of the street. Just as we're passing the construction crew: Pop! and a jolt. I glance in the mirror and don't notice anything out of the ordinary so we continue on our way to the scene, just the next block over.

My partner is teching the call, so I take a quick look at my rear axle. Verdict? Slashed tire. Still drivable, but definitely not pretty. I pop into the lobby of the building, where the patient is sitting on a bench. A small cut to his forehead, and he's not complaining of any other ailments. We RMA and now the fun can begin. I need to place a call to the Director (Lucy McGillicuddy), and the Operations officer. They ain't happy. Not one small bit.

I call us out of service, and the cogs start turning to get the vehicle serviced. It's too far for us to drive to the truck shop, so they have to come to us. I usually meet another Crew Chief at 3:00 and she covers me for a couple hours as I attend to some business about this time every Wednesday. I'm informed by her that she would be keeping the keys and radio until shift change today.

"Huh?" I think. Another crew chief (we're just having a big ole party today!) walks up.

"Nice job on the rig, polarbear," she quips.

"Yeah, great. That backhoe just walked into me, I swear! There was nothing I could do!"

Next thing I know the Director walks up to the three of us.

"So, I guess you suspended me for the rest of the day, huh?"

"What? No. Where'd you get that idea?" he says.

"Well, you took me off call. That's a pretty good indicator."

"You're off call. You just got into an accident, common sense would say that you can't be on call for the remainder of this shift. There's just too many liability issues. There'll also be an Accident Review Board soon."

"You realize I'm scheduled for two shifts this weekend," I remind him.

"Oh, yes. I know."


Ooops. How bad did I screw up!?

My first code...

It's finally time for me to tell this story.

My first code happened when I was home from school for break about nine months ago, though it seems like longer than that. At first, as I was trying to remember the exact details, so that I could write them here, I had difficulty recalling the time of year, and the order of events. However, as I dwell on them, I now surprise myself by just how much I do remember. I know it was the summer since it was a warm sunny day, it must have been between 3 and 5PM. Those were the hours that I would consistently hang out at my volunteer fire department after my internship at the chemical plant. The call came out as an elderly person having fallen. I remember because I was chatting with the Asst. Chief, Jose we'll call him, and the tones dropped, and we both took the ten steps into the bays and got into our truck. He drove even though he's the ranking officer, so I sat in the officer seat. Our truck for routine medical calls is an older E-One box mounted on a newer 1997 Chevy 2500 frame, with a duramax diesel. The cab seats five, and the box holds all manner of small rescue tools, including a jump bag, heavy-duty first aid kit, suction, AED, etc, etc. It's got a nifty (and broken) stem light, cribbing, high-angle rescue gear, fire police equipment, and more. R-410. We took off with just the two of us.

Our system works such that the local volunteer FD (us) provides first response BLS service to about half my town. The other half is serviced by the paid fire district. We contract out to a commercial ambulance company who does our transports and ALS. The nice thing about this arrangement is that we always have ALS coming to us. The downside, of course, is that we don't transport, though that can sometimes be a nice thing. Depending on how busy the service is, they can run a little slow. Today was a mediocre day. They certainly didn't beat us to the scene, which when that rare event happens they rub in our faces, but they weren't the 30 minutes they've been known to pull (extraordinary for a mostly suburban part of the state).

As we're driving down the highway, it wasn't especially congested, about forty-five seconds after our departure from our house -- maybe two minutes after the call came out, our Fire Police Lieutenant gets on the horn (as I would find out later, he lived next door to the patient) and informs us "410-C to Fire Control, be advised that this is a full arrest. Full arrest! Put an expedite on [Generic Ambulance Service]!"

Fire Control: "7-5. Full Arrest acknowledged."

410 (us): "410 redirects." Suddenly I find myself propelled against the rear of my seat as I watch my Chief floor the gas pedal. I look up from the PCR I was starting and stare out the window.

Jose asks me, "Polarbear, did you hear that?"

"Yeah," I reply meekly.

Out of nowhere a police car approaching from the opposite direction turns across the highway in front of us. Blinkies and woowoos. We follow with a right hand turn ourselves. I now realize that that was a very nice coordinated and skillful piece of driving by the officer and my Chief for neither of our vehicles to slow down as we took that turn. Of course, Chief cut the turn short several feet so that we sliced out a nice portion of lawn.

We followed PD all the way to the scene, the Chief barely able to manhandle our larger truck and maintain sight of the far more agile police cruiser. We end up parking on the lawn of the neighbor across the street from the patient's house. I open the door just as I spot the police officer starting to race into the house, AED in hand. The medical equipment is on the passenger side compartments of our truck, so I yank open the cabinet's metal doors and grab the suction, AED, and jump and airway bags. Chief rounds the corner of the truck and we both run up the slight hill into the patients house. Elapsed time is probably no more than five minutes from the time of the initial call. At this point, I seem to be moving without thought. Acting but not comprehending.

The patient has fallen in the kitchen and I am greeted by the sight of our Fire Police Lieutenant, who is also the only advanced provider in the department (EMT-I, New York 'I', not NREMT, so like NREMT-I/85 or whatever they're called). His name will be Red. Red and PD (whose name I actually don't know) have just finished cutting the patient's shirt and applying PD's AED pads. PD hits analyze. Beep beep beep. Analyzing rhythm. Beep beep beep. Analyzing rhythm. Don't touch patient. Stand-by. Beep beep beep..... Enough already! Just let me hit the shock button. Beep beep beep. No shock advised. @%#$!!

We start to resume CPR. The BVM and O2 are broken out. My Chief points out that we need to take PD's pads off the patient since they're incompatible with Generic Ambulance Service's Lifepak 12. I rip off the pads, and apply new Medtronic pads, and power up our trusty old Lifepak 500 (Which I neither know whether it is trusty or old). We run through the routine again. I know, I know. Should have done a couple minutes of CPR, but hey, what's the harm. I hit analyze. waiting waiting waiting. "No shock advised. Start CPR." @%#$!! Again!

As Chief starts pounding and Red handles the ventilations, I find myself without a job. I will soon learn that Jose likes chest pounding, and as this story will play out, he was probably the one pounding away all the way until the MD called time of death at the hospital 30 minutes from now. Oh yes, this story doesn't have a happy ending. I remember a few days later after Jose has downloaded the AED traces into the computer, the nice steady rhythm he was producing all on his own. Anyway, I was without a job for a moment and just as I was thinking that someone should have thought of three-man CPR, I notice a nice steady distention of the abdomen. I look a little closer and see Red pumping the BVM at a rate close to 40 breathes per minute, full bag, and over the course of about a quarter of a second. Sweet! I'll play airway coach.

"Nice and easy" I say to red.

Immediately you can see the anxiety and tension come off his face (remember, he was on scene by himself for several minutes doing one-man CPR) as his training kicks in again. He immediately slows down the breathing. We all take a second to expel the air out of pt's abdomen, and resume once again. I think, what can I do to stop this form happening again. We reposition the head, I slide in an OPA, and Red vents. At this point, a couple more members of the FD have arrived, some in their personal vehicles and a couple in the department flycar. One member picks up the PCR I have long abandoned. I apply cricoid pressure. Someone asks, "Anything I can do." Jose pounds away. Where the @&!$% is ALS?!?

Turns out ALS is another 3-5 minutes. Must not have gotten the message that this was a true MEDICAL EMERGENCY! The first man from the Generic Ambulance Service rig is a kid, a EMT-B, definitely younger than me, and the look on his face was priceless. I can still remember it today: Stunned silence. He literally stopped moving. Someone had to grab the drug box and tube kit he was carrying and out of his hands and place them on the table. He basically stood off to the side for the rest of the call. ALS provided from GAS was slightly better, walking in to the room and starting patient care, but certainly not taking control. Someone suggests hooking up that nifty Lifepak that she bothered bringing into the room. Good idea! All this time we haven't have a shockable rhythm. The Lifepak-12 goes into AED mode (I really know nothing about these things. I didn't even know that was a choice). No shock advised. @$%%@&! What's the point of these bricks if they're not going to deliver 300 Joules of life-saving electricity when you expect (and want) them to? CPR is resumed. The medic, an AEMT-CCT (that's NREMT-I/99, I think), begins attempts to start a line. This provides me with ten minutes of amusement.

About 4-5 minutes into this attempt one of our kindly volunteers inquires as to whether he could be of assistance in tubing the patient. Medic, surprised, nods and points to the tube kit. Our heroic volunteer, whose day job is work as the head respiratory therapist at a local hospital (and an expired paramedic, that's right, full NREMT-P), works his stylet and plastic tube magic, and a tube is in place. Ventilating begins. Jose still pounds away. Tube guy begins ventilations. I once again am obsolete. Red and I run out and grab the stretcher and backboard. The cot won't go up the front steps into the house. The board is brought in. Resp. guy suggests some meds down the tube. Medic lady, still trying to start a line nods and atropine is produced. Jose pounds away. Lifepak, neglected for so long (probably only four analysis provided since we've been on scene, nearing, if not over twenty minutes now) suggests a shock. Wonderful! ZAP! Shocks no longer advised. CPR resumes. Patient is transferred to the board and carried outside and set on the cot. I lift one end of the stretcher along with Jose who has the other end. Medic grabs her stuff. Where is that Generic Ambulance Service kid? The bed is wheeled down to the bus and Jose immediately hops in back and begins to pound away... again.

Off they go. Blinkies and woos. I inhale. I look up. I'm outside.

My head turns a couple times. There are now three police cars. The fire truck I rode in on. A FD flycar, and the FD pickup, and two personal vehicles. Lights blinking. I exhale. I look at the front of the house. Bystanders are around now. Neighbors are milling around. People have heard what's going on. Red comes out of the house, along with the other members of the department. I need to call Fire Control and let them know the situation. Technically, I'm now in charge of the scene, since I rode Officer on the first responding apparatus and there are no real line officers around (Jose off to the hospital, and Red doesn't really count). I realize I don't have a portable and actually turn in my place a few times as if one will magically appear. I see a blue uniform and some stripes, the PD sergeant. I call to her to ask her to radio dispatch and update them (Fire Control and PD dispatch is all one person on different frequencies). Red yells to me and tells me that he still has his portable. He calls in the conditions report. Equipment is put away. I'm the one who has to drive the truck back to the station. I get in an argument with the neighbor whose lawn I'm parked on. I want to back up while he wants me to pull forward. Whatever. I make sure everyone has a ride and call us back in service. Drive. Stop. Reverse into the bay. Close the door. I sit around a little and drink a couple sodas. Jose calls from the hospital and says he has a ride back and we're all dismissed. Good. I get in my car and go home.

Life's Ambitions

I need a place to put this list. Somewhere where it won't be lost, so I can refer back to it, change it, and add to it. Don't mind that it is not strictly (or at all!) EMS related. We'll file it under 'personal' for now.

Things to accomplish in life

-Get my Rescue Diver
-Become a SCUBA Instructor
-Get my Class A CDL
-Get my Private Pilot license
-Graduate medical school
-Take Firefighter I


Things that have been on above list and ACCOMPLISHED!



Things that used to be on the above list that I've resolved will never happen

House MD

I'm not a griper, but I was watching an episode of House, MD, my all-time favorite show on the "Idiot Box" and found the opportunity to bring up an issue.

The main character is quoted in one episode as saying:

"Dr. Gregory House: [to EMT guy who has just tried to give directions] If you wanted to be a doctor, maybe you should have buckled down a little more in high school."

this quote coming as EMS is wheeling a patient into the ED and saying something to the order of "he lost three units of blood en route, he needs a transfusion stat." Not that I would never say something as canned as that, but the response is still slightly off, don't you think?

Another episode has an EMT announcing to a crowded restaurant,"someone call for a wagon to Princeton-Plainsboro [Hospital]?" (Anyone ever arrive on scene and ask if someone requested a [meat]wagon, or even use our EMS slang: bus, truck, rig...?) The actor saying that last line is listed in the credits as the ever-dreaded: "Ambulance Driver."

This line of thought brings about the age-old topics of debate: (1) How do we rid ourselves of the title "Ambulance Driver" and (2) How do we cope with our profession (applicable to the professionals*) and care (applicable to the volunteers, professionals, and everyone else) being portrayed in such a manner, in such public view. We are all highly trained, and albeit paramedics much more so than us simple EMTs, but we all take great pride in our work, and I think we all take just a little offense when we see ourselves placed in a lesser role in life, given less respect than we deserve.

The term 'ambulance driver' probably, and you old timers would know better than I would, came from the point in history when the people who worked on ambulances were just that, 'ambulance drivers.' That casting can easily be seen when one watches such classic TV shows as 'Emergency!'. Those proud L.A. paramedics Johnny and Roy (who, Lord only knows how and why, can perform a trench rescue in nothing but their station blues and not get the slightest speck of dirt on them) would hop into the back of the ambulance just as it was about to be driven off by the... driver. Need I remind anyone that this was 1972. When was the EMT program established? Answer: 1973 with the federal EMS Systems Act. By the way, who was given authority for the development of the EMS curricula and development: why of course, the Department of Health and Human Services! Wait, but then why does it say Department of Transportation on the third page of your EMT-Basic text? Oh, now I remember.

According the Wikipedia, the first organized police department occured in 1667, the first organized fire department happened in Rome (that's Italy! not New York!) in the Year AD 6! EMS, the third branch of the emergency services could not even begin to be considered until the advent of CPR in the 1950's and 1960's. Being more than three hundred years older than the other 'uniformed' services, has its disadvantages: No NFPA, no PBA. I attended a lecture this past weekend about the safety of ambulances by Nadine Levick at the National Collegiate EMS Foundation's Annual Conference (I'll post about the conference itself.... later). Did you know that ambulances are only one of two types of vehicles on the road today that are exempt from federal safety standards. This ain't a good thing. If you dig around her website there are some spectacular images of what happens when an ambulance gets into an accident.

Essentially, no one is looking out for us prehospital care professionals, us EMTs, paramedics, etc. We have no strong unions (my friend works for a commercial outfit: their union, the teamsters. Another transportation related group). No lobbyists. The NFPA exists solely for the protection of firefighters. When they come out with a new regulation regarding building construction, it almost automatically becomes part of a municipality's local codes. How about a similar organization for EMS? Nope. Nonexistant. If you work here in New York City for FDNY as an EMT or paramedic, you are allowed to take the test and then accept a promotion to become a firefighter (No more EMS work). That's right, the career ladder clearly shows that firefighter is above EMS. Frustrating huh?

So all of this brings us around to our initial question. (1) How do we rid ourselves of the 'ambulance driver' stigma? and (2) how do we appear more professional than we are often portrayed?

The answer to both questions, I believe, are simple and obvious. We work hard. We provide excellent patient care, and we act as the professionals that we are. Through this, we as an industry, and as individuals working as EMTs and paramedics can open the eyes of the public as we touch them through our care every day and earn the respect that we deserve.

Griping fine. (My entire Italian lexicon put to good use)




*Professionals - Do ye volunteers consider yourselves as professionals or merely as workers? Or is professional applicable only to the career guys? Another side issue that could turn into a post, but probably never will.

Leadership

I've got this friend who's goal in life is to become a neurosurgeon. Let's call him Lucy McGillicuddy. Thing is, he could actually do it. He's one of those EMS protégés, you know, the best EMT on the corps. The guy who knows every protocol and every nuance. The guy who could recite 10 NYCRR 800.20:08-ii from memory [interim testing requirements and pass/fail criteria], if only you could somehow trick him to do so -- as you can guess his ego is pretty big (our fault). Not that that's a bad thing, he's absolutely friendly, and he really is an awesome EMT. Smart, funny, clever, etc. He has earned respect and he's dished it out where it's warranted. In a nutshell: you can get engaged in a conversation with him, but often there's a certain point when he says something, and you just have to go, "I no longer have the intelligence to participate constructively in this discussion." He's that good.

Trouble is, he's 19, and he was just elected to be the Director (Chief, for you non-PC folk out there) of our corps. His two-year reign begins.

Being *ahem!* years older than him, I've been trying to, subtlety, show him the administrative shortcuts I've discovered over the years (and get things I want done, done through him!). That is, the back doors that exist to procure the difficult to obtain, and the efficient ways to avoid red tape. He's learning: he's delegating, and he's dealing swiftly with the administration, he's making friends with those who can give. He's also making some good, if small, changes in the way our organization is run.

However, as I'm just beginning to realize, his overall leadership skills are not yet fully developed. He's not a bad leader, just someone who still has rough edges. Small things: like he'll crack jokes when he supposed to be serious, and not conduct meetings efficiently, etc. People have been commenting to me about him, which has triggered this line of thought. Reflecting on my friend's situation has sparked a debate in my head: what makes a good leader? Is it the ability to 'lead the troops'? The ability to recruit and retain? The man who's a friend to all? The one who gets the job done? The one you confide in when you have a problem? The regular guy who has the best skill set? The guy who makes good speeches? Runs good meetings? Doesn't hold meetings at all?

I view myself as a good leader, but I definitely have my flaws. I also realize that it took me at least a year in my first serious leadership post to develop the skills I needed to handle that job. I don't know if the skills I have would allow me to be competent in a different position, or a leader in a different situation.

I feel like the quintessential leader is thought of as the strong-willed person who have gained those he leads' trust. But that's not even close to being complete, is it? I know Lucy will, with time, become a good leader himself, but in this train of thought, I know that no matter who you are, you can also improve your leadership skills (by the by, this sentence you're reading has six (!) commas -- I've got to learn to be more concise!). I've resolved to reflect on the people who I believe to be good leaders, and think about which qualities in particular make those people the leaders they are. In identifying those traits, I hope I can absorb some of them and become someone better than I am.

Icy Day in the City

I had my first ever burn-out, apathetic feeling today. It just crept up on me, and as it was happening, not only did I not try to shake it off, I just didn't care. I let my partner run the call, and when we got to the ER, I basically stood in one corner all through triage, signing the pt off, and completing the documentation.

It was our fourth call of the day on this very icy, very treacherous day in New York. While Upstate got the fluffy white stuff (and feet of it, according to the first-hand report from my mother), down here we got gray, wet, heavy sleet and ice. The tones drop around 6:30 PM for "severe headache" and we arrive on scene to find a 42 y/o female c/o falling 11 hours prior (on her "butt," quoting my partner's PCR), with some dull achy pain in her head and sinuses, no recent hx of illness. Pt is prescribed two type of antidepressants, and denies SOB, LOC, neck/back pn, nausea, vomiting, dizziness, or cx pn. Pt is ambulatory and answering questions without difficulty, A&Ox3.

While this hx is being obtained, I'm mindlessly walking around the room looking at the furniture, peering into the office adjacent, and generally not paying attention. We go through the motions, and before I know it, I'm reading over my partner's documentation and signing off, we get in the truck, and head home.

It took me a while to realize why that call was such a blur, and it shocked me even more to realize my state of mind during it. As a person, I always pride myself on the excellence of my patient care. I follow the protocols to a T, and never take shortcuts. I try to make the patient feel comfortable, and strive to be the best EMT on the corps (and in the city!). I am ashamed and disappointed by my behavior, and worse still, I don't know what brought it on. When I say this is the first time I've felt like this, it is the truth. I've been a volunteer EMT for nearly five years now ("nearly a fossil" jokes the triage nurse whenever we get to chatting about my youth), and I'd never expected to hit a point I hit today.

In analyzing myself, I think today was an especially hard day. The first three calls sapped a lot of my energy, and the continual maintenance of the bus during the storm today added to the burden on my shoulders. I think I just need to put this behind me, and refocus on why I love EMS in the first place. Not just because I'm an admitted adrenaline junkie, but always because I love caring for people, being able to help them through the worst times of their lives. It is also fun, and the challenge of constantly improving on myself in a goal truly worthy of achieving.

I hope I won't see the demon that poked his head out today for a long time, and I won't be remiss if he never shows up again. One can only hope.




To put it all in perspective, I found this cartoon online today. Drawn by Steve Berry, that omnipresent force in EMS humor (JEMS):

Template Change!

So blogger's new blogging system has a new template tool that I decided to give a whirl. While I was doing that, I lost a few of my customizations, so in restoring them, I kinda changed the look of the whole blog and added an important new feature: my email address!!

Let me know what you think of the new look, by commenting or via.... email!... and we'll see if this iteration stays. After all, it's now wicked easy to change templates. Thanks Google, I think.

Achilles

Call comes out as a "Male in the Fitness Center with a torn Achilles Tendon," which is an unusual dispatch for all the same reasons why you think it's an unusual dispatch, compounded by the fact that about 75% of our dispatches have us responding to an "Aided." (Yeah, someone needs to take an EMD class).

We arrive on scene to the University's basketball courts and find a 35 y/o male sitting on the floor by the sidelines, unrmk except that he's extraordinarily sweaty.

"What's up?" I ask.

"I tore my Achilles," the kindly athlete replies.

'Interesting diagnoses,' I think to myself. I also note that he did not say: "I hurt my foot/ankle/leg" or "I can't walk" or "I think I may have hurt my Achilles," but rather a affirmative statement about an injury that occurred less than five minutes ago.

Easy way to find out the truth about this. I palpate the back of his foot/leg/ankle. Well, let's just say, there certainly weren't no tendon where it's supposed to be. And there was instead a nice squishy hole where there ain't supposed to be one.

Pt --> Stretcher --> Ambulance --> ER.

I always find it amazing when the dispatches turn out to be correct.

Can one man really activate every EMS unit in the city?

It's a cool, sunny day in New York. The first snow flurries of the season (occurring in January!) had fallen the night before, leaving the streets wet, but just the fainted hint of white under the trees. The time is just past 1PM.


BEEP BEEP BEEP BEEP!!!!!

"Fair Lady, Fair Lady! Respond to the School of Social Work for a woman passed out!"

"Ummm, Medic 1 to Base, is the patient breathing?"

"Stand-by Medic 1!"

...two minutes later...

"Medic 1: Patient is breathing!"

"Ummm, thanks. 10-4. Fair Lady arriving."


By the way, in case you haven't yet figured it out, it is going to be one of those calls.

We arrive on scene to find our patient, a 63 y/o female, who was reported to us as passed out and in the lobby, already gotten up and traveled to the 7th Floor. Sooooo.... off we go! My crew and myself get off the elevator, through a couple glass doors to find the patient smiling and yelling:

"Oh you guys! No. No. No. Enough. I'm fine. Go away!"

Definitely one of those calls. My partner (and CCiT -- that is, Crew Chief in Training) approaches the patient. He quickly makes no headway. Intervening slightly, I steer the patient and my crew into a conveniently empty conference room. My partner directs the Probie (did I mention my crew comprises of FOUR people!) to start getting vitals. The patient puts up some fight, but quickly sees reason and lets us check her BP, etc. as my partner persuades her.

"Come on, I don't need this! You guys were here two years ago! I feel fine now," she says.

"Huh?" I think. "What happened two years ago?"

"Oh, I passed out, right over there," she points. "I went to the hospital and they told me I was having 'mini-strokes.' I'm also diabetic."

"Great."

My partner gets the rest of her history. Unfortunately, our patient has gotten even more vocal, and worse, when my partner suggests she takes a ride over to the hospital, she refuses, adamantly. I take the opportunity to pull my partner off to the side and remind him of the presenting problem's link to her Hx. Now, at this point in the game (Warning! Rant alert!) I would normally do a quick finger stick (and so would every other EMT on the planet) and check her blood sugar. After all, she did say she missed lunch today. Too bad. New York City BLS units aren't allowed to carry glucometers.

So instead I tell my partner to call Med Control and ask for a recommendation. Since the patient is under 65, Med Control physicians don't have authority to force the patient to be transported, but I figure what's the harm. I want to take her, but I don't want to get in a fight with the patient. I figure with a doctor's recommendation and the moral authority to pursuade the patient to spend a $50 co-pay, she'd be more willing to go. Little do I know. The Medical Control Doc orders us to transport the patient. Unwittingly, I have now entered a very, very, gray zone.

At this point, the Patrol Captain of the University's Public Safety Department strides in the room.

"Virginia," he begins (Name changed to protect Pt. con.) "you realize that you're on private property. If the Medics" (by the way, that's just the street name for Fair Lady personnel. We're all just EMT-Bs) "want you to go to the hospital, I can..."

I cut him off. I know where that statement is going, and the last thing I want is to force the patient to the hospital. I want her to want to go to the hospital. Besides, I can always call PD. I have a valid order saying I need to take her, I think. It also becomes increasing evident that my chances of convincing my patient to take a ride with us are becoming less than nil faster and faster.

"What do I do!" I think at myself... and in a moment of EMS competency I remember my protocols: "...care can only be transferred to a medical authority with a higher level of care."

Aha! This is what ALS was designed for. Sorta. Well, it'll do the trick regardless. While, I no longer have the authority to RMA, and ALS rig still does. So I get on the horn and call MARS and request an ALS bus to our location. I decide the patient is in the good hands of my partner. I go downstairs and await our backup. 10 minutes later, a BLS rig pulls up. @&%#! I approach. I speak. They speak. I call MARS again, reinstating my request for ALS. I am informed that since I already have a BLS bus on scene, they are the ones who need to request ALS. I remind the nice man on the other end of the phone that I am a BLS bus. The nice man tells me to pound salt. I look at 16-E and tell them what MARS told me. We both roll our eyes. 16-E decides he wants to make contact with my patient. We go upstairs. 16-E talks with the patient. He asks me, "Do you want me to call the Conditions Boss?" Me, never ever having heard of an entity known as the Conditions Supervisor says, "Huh." I seem to be doing that more than usual today.

The Conditions Boss, 16-E informs me, is an FDNY dude who solves situations just like ours. Awesome. I grant him permission to proceed.

"16-E to Central. Request Conditions Boss at this location."

"16-E! No Conditions available in the vicinity. Will you take an ALS unit instead?"

Mon dieu! 16-E looks at me. I nod.

"16-E. Go ahead. We'll take an ALS unit here."

"10-4. 24-U respond to....."

Let's go over the cast currently on stage:

-1 patient, hereknown as Virginia.
-1 concerned friend, female.
-2 crew members, BLS unit 16-E
-1 Public Safety Patrol Captain
-3 random extras, assorted genders, looking through the window into the conference room
-4 Fair Lady crew members

Basically, we're all looking at each other.

Final Act

"16-E! 16-E! Pick it up!"

"16-E."

"Conditions Boss is now available. I've sent him to your location."

Enter 24-U, the ALS unit. We fill them in. We also simultaneously hear the Conditions Supervisor pulling up to the front of the building. I take a quick peek out the window and see:

-Public Safety Patrol Car
-Fair Lady Ambulance (Type III)
-Conditions Car (Ford Excursion)
-16-E Ambulance (Type II)
-24-U Ambulance (Type I)

All blinkies going strong.

The Paramedic goes, "What's your blood sugar?" Patient sticks herself with a meter that I have now determined she has had on her person all along.

Patient: 132

Paramedic: Right. Good! Well, finish your lunch, sign here, and we'll all leave.

Patient: Great!

Handshakes all around.



We all pack up and take the elevator down. As we're leaving, I'm not quite convinced the paramedics did everything they should have, especially since on the way out the door I'm stopped by a coworker of Virginia's. He states that the present incident is actually the second in a row. An earlier episode having occurred an hour before we started this call. I'm concerned, but I shrug, and head back to the vehicle. I've already passed care to a higher level.

What are your thoughts? What would you have done?

Wow!

Hey! it works! My "new" website: clickthrough

Nifty Internet Stuff

So being an Internet "Have-Not," I envy the ease and finesse of the Internet "Have." Which is why I'm trying to add new features at this page, but seem to be failing miserably. Anywho, tried to register a new domain name for this: www.flashingbluelights.org and have it automatically forward (and step 2: mask) to my nice little Blogger address. So far, no pie.

We'll see what happens in a day or so.

Try it!

Vehicle (and Mental) Disfunction (or rather, Malfunction)

We had our ambulance malfunction today. I mean, the vehicle that shouldn't be malfunctioning was malfunctioning, as opposed to our other vehicle which is in a state of constant, perpetual malfunction. The latter will, sooner or later, end up in the scrap heap. This former will too, but hopefully not for many more years to come.

No, the problem was that we park our ambulance in a nice, convenient location on a usually pedestrian only street which is suited just as much for display purposes as accessibility. Free advertising you see. The other reason we park it there is that being in Manhattan, no one wanted to buy us a building with a garage. Unfortunately, when it gets cold out, our ambulance gets cold too. And while the fine first responders on our corps. can bundle up, our ambulance can't. So cold ambulance + diesel engine = vehicle that does not start.

This is all fine and well until one tries to respond in said ambulance, and instead of sailing away with blinkies and woowoos to the rescue. Said first responders, call the Fire Department for assistance, and hoof it on foot to the scene with trauma and O2 bags slung across our fine, broad shoulders. Luckily campus is not all that big, so we can walk to just about any scene in a few minutes. (Insert comment on how FDNY arrived on scene 15 whole minutes after we did, a sum total of 25 minutes after the call initially went out.)

But I stray...

How, you may ask, does this occur when modern block heaters and shore-powered space heaters, and magic heaters of thine heart, and all the rest are there to there to prevent such occurrence? Answer: I have no clue. All I can say is that hopefully, we'll get the rig checked out top to bottom, and maybe a problem will be caught. Something along the lines of, "oh, there is no engine block heater after all...!" (When this happens, I'll be the one going "Thwack!" followed by our Operations Officer going "Owwww!").

In the meantime, we were able to jump the engine (and the battery was cranking just fine, which is odd) and get her started after the call was completed. For the past day or so, at three hour intervals, I'm also going out and starting the bus and letting it run for 15-20 minutes. So far so good, but I'm just waiting for the moment at the next call when I realize she's not going run this time either.

All I can do, I suppose, is turn up the heat of mine heart, and hopefully, prayerfully, there'll be enough warmth to light a fire of fuel injected diesel and metered amounts of air in a cast iron block to keep the public safe and happy.










P.S. I realize there hasn't been a simple medical related post in a while (or ever?), so the next one will be. I promise, I swear. I's gots me some good idears. I's swears. I's promises.

Driver Training, part Deux

As a solution to the lack of an EVOC course, or even a large parking lot nearby where I can set up pylons, I've been taking willing guinea pigs to the famed Fairway supermarket near 125th St. on the Hudson River here in Manhattan. This is the only place within twenty miles that I know of that has a clear stretch of pavement that will hold more than five cars. In fact, in itself, it's like a pre-built obstacle course just waiting to be used by college aged EMTs learning to drive the rig for the first time.

Of course, a few weekends before the Christmas break, I was having my pro tempore preceptee doing the serpentine in reverse around the thick steel columns that held the West Side Highway fifty feet above our heads when a friendly RMP from the local 26th Precinct pulls up as I'm walking alongside the vehicle, spotting the driver.

"Good Lord, what the Hell are you guys doing now?!?" says over-caffeinated patrolman.

"Driver Training," replies Yours Truly.

"Wow, you guys train a lot."

"Name of the game."

"You know, we were following you guys the other day, you were doing CPR in the back of your bus..." the Officer says.

'Uh-oh' I think, I know where this is going...

"Yeah, but we got a little confused when you guys drove past the hospital. Guess you guys were training, huh?" Officer says with a smirk.

"Yep, had to show the newbies what it felt like to be chest-pounding in the back of a moving vehicle," I respond.

'Great,' methinks, 'At least I know we getting talked about the the Precinct house, but you gotta make do with what you have.'

Louisiana?!

So I accepted a job drilling for oil in offshore in Louisiana (details not so relevant), which I may or may not report to come June, but anyway, I was browsing for apartments and the like in the towns around Lafayette. Interestingly around, this is my first major move in around four years, which is a little more than the total time I've been involved with EMS. So I was surprised when I discovered myself looking first for towns that had volunteer EMS squads and fire departments as the primary criteria of where I might want to go live. Oddly enough, I found out that many towns (in fact all of them) are serviced by a single commercial ambulance company. Investigating further, I discovered that much of the entire STATE of Louisiana's EMS system is this single outfit.

Now, there are many volley fire gigs, but most of the fire gigs don't do EMS, as evidenced by the online lists of members with only one or two members at most being certified as EMT-Bs. I'm a little disconcerted about this situation, and as much as I like working the fire service, EMS was always (and I hope forever will be) my primary emergency gig. This is quite a conundrum since I swore that I work never work commercial EMS. This quandary turns out to be the principle misgiving of moving from New York City to Louisiana. Anyway, two concerns: (1) I hope the single commercial ambulance outfit that runs everything down there has good QA/QI because they own the business, and no one has a choice to the EMS they get. (2) I wonder if they hire per diem Basics who spend 3 weeks a month offshore?

Bite Nails and say, "Driver Training!"

New found duties as Crew Chief: (1) Driver Training (2) Crew Chief Training (3) Probie Training... I'm sensing a theme here. Regardless, it is issue #1 that scares the bejeezes out of me. Now, to refresh your memory, recall that Our Fair Lady is a COLLEGE ambulance service in MANHATTAN! Driver Training just isn't so easy.

Our squad is jointly run by the college Health Service and the Department of Public Safety. The Health Service's job is to give us as little money as possible and reduce that amount every time we screw up. Public Safety's job is to let us do whatever we want and not ask questions.... until recently. Apparently their vehicle insurance rates are increasing, which means questions are coming down from the TOP. Specifically, questions phrased as commandments: i.e., STOP GETTING IN ACCIDENTS! Not an unreasonable request.

In Manhattan you're bound to get in minor fender benders here and there. But some drivers new to the art of Emergency Vehicle Operations don't seem to realize that one needs to be a more conservative driver when going blinkies and woowoos (sorry DTs -- such a great phrase), rather than blowing through every intersection without looking and twice on Sundays.

Don't get us wrong, we train our new vehicle operators. First we give them CEVO (the cheaper, textbook only version of EVOC), then they hook up with the wayyyyy overprotective CCs (of which, may I add, I have recently joined the club) and start driving.... slowly.... around the streets of Manhattan. Going Cold, aka, no blinkies. No woowoos. This phase (DiT 1 -- Driver in Training 1) lasts until the trainee gets used to driving an ambulance, that is, a vehicle with a big ole butt (We have Type IIIs) and no rear-view mirrors. This phase sometimes lasts months. However, when a DiT 1 has proved himself, they get promoted to DiT 2. Eligibility to drive HOT! (Fun Fun). Believe you me, if a DiT 1 EVER got in an accident while driving, they would NEVER make it to DiT 2. Oddly enought, not many DiT 1s get into accidents.

Now another note: We have a relatively small campus. It's only 3 blocks wide and 10 blocks long. Response times are not very long at all. So why is it, that after that certain moment when the Captain grants a certain person the privledge to drive HOT and forever after, that the drivers just can't stop banging into EVERYTHING!?!?!

While I was still a Driver, the rank directly below Crew Chief, responding to a call, my crew chief was driving. We were HOT -- full blinkies, full woowoos. We enter an intersection. We need to make a left hand turn. We stop behind a car waiting to make the same turn. The (I assume) nervous driver in front of us panics a bit. He pulls his car forward a few feet. My crew chief sees him starting to move and starts to move as well. Two seconds later: BAM! We've rear-ended the car in front of us.

Now both vehicles could not have been traveling faster than 0.5 mph. Yet somehow, we've just got in an accident. Luckily it was late at night, and there was no other traffic. We sustained a dented quarterpanel, the other driver was unscathed. No one was hurt.

These incidents happen all the time. The most common one is that a driver will, while reversing, back the ambulance directly up into one of the giant yellow concrete posts that sits on either side of the bays at the hospital. (Almost as bad as reversing directly into the side of the fire house -- but a story for another day.) How can we improve? We have a fairly rigorous and conservative training program. But unfortunately, the nature of our personnel is that they are all young, inexperienced drivers, who have never driven an emergency vehicle before coming to us.

We have even considered hiring out and getting an instructor to teach the Corps. the full EVOC class, practical and everything. Trouble is, our budget isn't very big, and it would require us to take our one main ambulance out of service, drive one hour (each way) to the Northern Bronx, just to find a parking lot big enough to set up an obstacle course. We also have a second ambulance, which we don't run since we don't have the required call volume to justify keeping two crews fully staffed 24/7. It is, fortunately older, and unfortunately, smaller, than our main 2003 Horton Type III. Upside: No one cares that we ding it, Downside: it is not a good training platform. It seems to be asking for trouble requiring our new drivers to learn on a smaller ambulance. I can just hear it now: "Well, he got into the accident because he didn't realize that his vehicle is actually 2 feet longer than he thought it was."

The conclusion that everyone seems to draw at the end is that we're just going to have to do the best with what we've got, and accept the fact that we won't ever cure our problem. We will always get into the minor accidents, and perhaps, even small dings and scratches to the paint job are OK, just so long as we never get into a major accident, no laws are broken, and we NEVER hurt someone because of poor driver training.

The End.

...Now where did I put my Probie Whipping Stick?

Crew Chief -- At Last!!!

As of tonight, Yours Truly has finally been promoted to Crew Chief! Ahhh, three long years...

MARS: "Mutual Aid Response System"

There once was a little pig called MARS. He was the system set up by the FDNY administrators to send jobs to and recieve requests from EMS agencies not affiliated with the Fire Department, or field requests from agencies for additional resources, including ALS, Fire, PD, HazMat, and more. Unfortunately this little pig is dead, and we're not talking about freshly killed. No, we're talking carcass hit by a bus years ago, and all that remains is a clean little skeleton that the flies have long since left.

You see, as one of two volunteer ambulance agencies headquartered in Manhattan, and the only one in service 24/7, we are relatively small. We have a group of eagar college students by day / EMT by night that staff our single ambulance. Mainly, we serve the campus: but since the university is the third largest landholder in the city, that area is relatively large. We crank a good 700 calls a year.

OK, enough shameless self-promotion -- The real problem is Big Red has a very long history of not paying attention to or establishing links with other agencies in the city. While many agencies outside of the Manhattan proper seem to have more success, within the city, there is not much support. Here are the problems with MARS:

1.) No Training -- Us college kids have never been trained in using MARS by the Fire Department. What we know is limited to what gets passed from the Seniors to the Freshmeat.

Solution: One FDNY rep could spend an hour talking about how to and when to inplement the radio system*

2.) VHF -- The Fire Department is on VHF. We're on UHF. MARS is essentially a radio based system. There is a work around where we use our cell phone to call the MARS number, but that's just ridiculous! Can you imagine calling a dispatcher on the phone only to tell them that you're 10-XX.

3.) 10-Codes. They're all different. 'Nuf Said.

4.) It's easier to call 911 -- Yes, that's right. Our current system for when a drunken 250lb. football player starts wailing on my crew. Step 1: Run! Step 2: Dial 911. Step 3: Dispatcher sends an RMP (Radio Motor Patrol -- The guys with guns!) AND another BLS unit.

5.) BLS arriveth -- #1 reason to call for help: Request ALS. #1 response from FDNY after requesting ALS for our patient through 911: BLS car.

6.) Computer Assisted Dispatch -- Yeah, we don't have it. Do you know what it costs to put one of those systems in your truck!?! Unlike the Voluntary units (for-profits), the Fire Department (the professionals), the volunteers don't make money (we don't do cost-recovery), hence we can't afford toys.

7.) CPMU has NYPD -- The other volunteer EMS unit in Manhattan is dispatched by NYPD. Their radio system works just fine: it the police system! (Might I mention how odd it seems for every other agency in the five boroughs to talk with Fire, but the Central Park Medical Unit talks with Police -- even if it is the Central Park Precinct.)

8.) Disaster Strikes! -- Please don't, hopefully it won't happen again, but the way things are going, it's bound to sooner or later. Then what?

Someone help!



*PS: Any fire folk out there: Could we borrow your training academy? We've looking for a place to do EVOC.

Back on Campus

As promised, here is the down low on EMS in a chemical plant. A little background info to start with:

I worked over the summer in a small-to-medium sized chemical plant in Upstate NY. Located in Rotterdam Junction there were two side to the plant, the "Chemical" division, and the Performance Resins Division (PRD). I worked mostly with PRD, but also spent some time on the ChemDiv side, and also at the Waste Water Treatment Plant (WWTP). The ChemDiv manufacturtures alkylphenols from phenol raw material. A decidedly boring process, but extremely dangerous. Phenol (and alkylphenol) will kill you in under a minute if you get exposed to a 3"x3" splash of it on your skin. PRD uses the alkylphenol produced in ChemDiv, reacts it with formaldehyde and produces resin. The resin is sold to company who use it in many different products, but the most prominent customer is Goodyear which puts loads of it in their tires.

I've been holding off on writing this entry for a while because I wanted to see some EMS in action. The plant has a First Response Team that could respond to any medical emergencies, and they also took care of fire, confined space rescue, and incident command.

The biggest hazard in the plant is response to phenol spills. As mentioned above, it's nasty stuff if it gets on you. Luckily, there is a treatment. Polyethylene Gylcol, or PEG, is effective in stopping the action of the phenol, and application to an area of exposure alternating the PEG with water is essential. PEG stations are located throughout the plant. Initial response is straightfoward and usually a person exposed is able to start treatment on his own, and with the assistance of a coworker, can do an effective job. The FRT will be contacted by radio, and an ambulance will be called as well.

Here is where things could get hairy, I believe. All the workers in the plant are trained to the precautions to take when handling and being around the material. The FRT members are EMTs who can provide more initial care. However, the personnel staffing the ambulance, assumedly from an outside municiple or commercial agency would not have the training necessary to avoid accidents or becoming contaminated themselves through contact with the patient. Many EMTs (and hospital staff, as well) are trained in use of PPE to avoid bloodborne pathogens, but I know of very few who are trained in chemical precautions. For example, many solvents will easily penetrate or even dissolve latex gloves. With nitrile gloves you're a lot safer, but they still won't protect you from fuming chemicals or agents.

The plant I worked for had a visitor's video that was shown to all guests, but in an emergency situation where transport to a hospital is critical, ambulance personnel may very well be quickly shoved into a situation where they were not trained and are not prepared for. Here are the lessons learned: (1) Scene Safety!!!! -- more important than ever in an industrial setting. (2) Proper PPE -- Most hazards can be mitigated by protecting yourself. (3) Advanced Preparation and Knowledge -- If you know that there is an industrial facility in your jurisdiction, ask them to bring someone to your agency to give a presentation on the risks, hazards, and precautions they should take when they respond. You can also simply try going up to the front gate and asking for a quick overview yourself.

Summer Transition

After an extended absence, during which I passed by practical (again), finished off the current semester at school, worked graduation, moved back home, and started my glamorous summer job working at a chemical plant.

With the transition from collegiate volunteer ambulance corps to town volunteer fire dept complete, I eagerly wait some interesting calls. My town is home to about 30,000 people, covering about 25 square miles, spanning three independent fire districts. Zoning is mostly residential, some commercial and just about no industrial. It's a mainly commuter town while much of the population traveling for work and play. We're located in the Capital Region of Upstate New York. The fire department is dispatched by the police department. PD sets off one-way radio pagers and whoever wants, responds to the station to pick up a truck (EMS, fire, or Rescue) and heads to the call. Volunteers are issued blue lights ("courtesy lights") and only lieutenants, captains, and chiefs are allowed to head directly to the scene. Only chiefs have red lights.

It's a pretty decent system, but no guarantee of a response, hence automatic mutual aid. However, I think it's been years since AMA had to be implemented for our district. Overall, I think we have some of the most dedicated volunteers I've ever worked with, who get up at all hours of the night to help strangers.

It's this reason why I love EMS so much, and it's not just my town. I plan on going to Medic school after I graduate college, but I never plan on working the system as a full-time job. True, I enjoy the medical applications and such of the job, but I enjoy the job more because of the great people I get to work with. They tend to be the most honest and selfless people in all of society.


Next time: EMS in a Chemical Plant

Patience with Patients

Fair Maiden is dispatched by the university's Public Safety department. Given this, you can understand that we don't always get the best or most reliable dispatches in the business. No times of transmissions, no detailed information, and no chance for updated reports., though PS is usually pretty good about sending an officer (read: security guard) to meet us at the job. We got toned out for a 'possible intoxication' at a student's dorm room around 3AM towards the tail end of the Friday night shift. Of course, this was the one time PS doesn't send an officer when we might actually need one.

We step off the elevator and walk into the suite... "EMS!" Note that PS wasn't able to obtain a specific room number, and so there we were: standing in the suite, everything quiet as a dormouse on Christmas Day. I was about to start knocking on random doors, when out pops a tall, slender, rather flamboyant looking kid, ~20 y/o...

"Oh hey guys! Heh heh, sorry about that. False alarm..." Note: this kid wasn't even close to needing an ambulance, so course that makes him only the supporting character, i.e., the friend trying to cover up for his pal who's currently in the room either puking or high. This is going to be pleasant, thought I...

"Well, can you tell me what's going on?"

"Oh, my friend had a little too much to drink, but she's alright, she's sleeping now. I just got off the phone with her mom, and she said to just let her be."

"Do you mind if I have a look?"

"Ummm, well, gee..." You could almost see the wheels turning in his head -- trying to figure out a way to prevent me from entering the room. Finally, "Alright, but she's sleeping."

I walk into the room to see exactly what he said, a female (wearing all her clothes), laying in bed, apparently sleeping. 'Great!' thinks I -- quick, easy RMA. Back to the friend, "What's her name?"

"Oh, Monique," says he. (Names changed, of course, to protect the guilty, and cover me from big bad HIPAA.)

Shaking the poor soul, "Hey Monique, how are you feeling? Monique... Monique..." Nothing. I can see she's breathing, and she feels warm and dry, and I'd be a monkey's uncle if she was actually asleep, but I'm not too concerned... "Monique, honey, what's wrong?" Suddenly...

"Will you just leave me alone! And stop calling me Monique! My name's Sandra!" Hmmm. The plot thickens. She's too drunk to realize her friend was trying to cover for her. Being drunk in a dry dorm won't get you in a lot of trouble, but it will earn you a call to your mother in the morning. I look back at the friend, giving him my best, "Monique...?" look.

"Oh, it's just a nickname...." Yeah, suuuurrrre.

As my partner tries to talk to the friend to get some real info and start the PCR, I try to talk to our patient, and ask her about the night's events.


Things quickly get out of hand.


I hear the friend shout, "I don't see why you need her phone number!" why the patient starts throwing a tantrum, flailing and screaming, "Leave me alone! Leave me alone! Leave me alone!"Now there were a lot of other people in the room, who started getting agitated as well.

Seeing as we run crews of three, a lead, a driver, a third, and this go we had a probie, for a grand total of four, there were just enough ruffians in the room so my crew could have just gotten away with a man-to-man defense. Seeing as that setup only seems to work for the Jets, I needed to turn the tables in our favor. "Medic to Base, can we get a PS officer up here?" "10-4, he's on his way."

As the arguing escalated, I tried to deal with the patient and the rest of my crew dealt with everyone else. My partner taps me, "Want me to ask for a 10-50?" He's from Jersey. "A what?" I say. "911." replies he. Let's give me another thirty seconds. It seemed like hours before it happened,

In walks, like the shining figure of authority the square badge on his chest might imply, the Public Safety officer. My trusty partner starts explaining the situation to him. Everyone looks expectantly... unfortunately, it seems the HE doesn't speak English, oddly enough. So what does he do...? Picks up the phone, dials, and says, "Yeah, it's XXXXX, can you give me a sgt? Alright, bye."

Oy!

At this point, I'm thinking, 'OK, if we just grab the patient and go, we may get away with it. AMS is great. Under the protocols, that's not kidnapping. If she slugs me, great. I'll slug her back. If the friends get involved, it's a felony...' Happily, I put my brain in before I got out of bed this morning.


---And here I end the story--- Quick finish: The sarge walks in with a complement of five more officers and clears the room (finally!). So all that was left in the room was my half my crew (I sent the other half outside to wait with some of the officers) the sarge, another officer, and the patient. First the sarge talks to her. Then my partner, then the sarge, then me. Finally after a FIFTY-FIVE MINUTE on scene time, the poor soul jumps from her bed to our stretcher and we make boogie faster than mice on ice. Good times.



The upside: No one got hurt, no one got arrested, and no one got sued.
The downside: Looong on scene time, and people could have gotten hurt. Oh, and no one got arrested.


Brings up the questions, when do you handle the situation by yourself, when do you call for backup, when do you call for PD, and when do you run?

The way it was, I could have called for Public Safety the moment I walked off the elevator and started getting sass from the pt's friend. I could have called for an RMP as soon as the sassing friend got out of control. I probably should have gotten my crew out of that room rather than waiting for Public Safety to show up. But where would that have left us? The patient would have been restrained and probably booked, possibly her friends as well. I wouldn't want to do that to someone if I didn't have to, though it would have meant I would have initiated transport a LOT sooner.

I suppose I liked the way I handled this situation the most, but then I'm biased. I know a lot of people who would have liked to get in & get out, and wouldn't have the patience to talk a patient into coming with us. And in the event that this had been a real emergency, and not just a drunk, I would have probably liked to do the same. I know when I was working under someone else, we had a person O/D on an unknown medication (a story for a later day), and I was starting to request RMPs and the cavalry to force this person to the hospital when my partner (and the lead) told them to cancel. Boy that pissed me off. We were on scene there for about thirty minutes, all the while, I'm waiting for this person to collapse, seize, or go crazy while my partner tries to talk her down.

I suppose it's just a judgement call, as like any other, but remember what they teach you: First the safety of your self, then the safety of your partner(s), then the safety of the patient, and finally the safety of others.