Power tool safety

An unfortunate mishap that a coworker had reminded me of a call I did about 2 or 3 years ago.

It was a bright summer day when we were dispatched to a amputation. Arriving on scene, we were met in the patient's driveway by the patient and the fire department. There was blood dripping down the man's hand and his right hand was wrapped in a bloody towel.

He has been using a table saw and the piece of wood he was using got stuck and he tried to get it unstuck without turning it off. The wood kicked back and he ended up amputating his thumb at the first knuckle and split his forefinger length-wise up to his hand.

The poor guy was so pale. The firefighters had searched through all the saw dust and found the tip of his thumb, so we were able to preserve it in hopes of a successful reattachment. We loaded him up and I called medical control for guidance. Shee, I know that he needed to go to the trauma center when they had micro surgery available to try to reattach his thumb but he was severely hypotensive--from shock, I think more than blood loss. He was also in an extreme amount of pain, but our protocols prohibited giving him anything because his BP was too low.

So I consulted with our local ED doc and he said to take him to the trauma center and to bolus him with fluids and titrate Morphine administration to his BP and pain control. We started 2 large bore IVs and gave him 2 mgs of morphine at a time. I so wish we could have given him more, but I didn't want to keep his pressure bottomed out.

It took 2 liters of fluid to get his pressure to 90 systolic. I think we ended up giving him 6 or 8 mgs of Morphine total. He was a lot more comfortable when we dropped him off at the trauma center.

I don't know if they were ever able to reattach his thumb or not but I know that we go him to the best place to take care of him, regardless.

Please remember---TURN OFF the power equipment BEFORE grabbing things when they are stuck. All your parts are precious and deserve to stay where they are--you will miss them when they are gone, I promise!!!

Because everything that you see on TV is NOT real!

I was watching Law and Order the other night. I love this show although it does get old sometimes. Well the other night, Detective Benson was driving Detective Stabler's wife to the doctor's offcie when they were hit by another vehicle, striking the passenger's front door and rendering Kathy (the wife) unconscious and pinned. Well once EMS arrived and they realized that she couldn't be removed immediately, Olivia begged until they let her re enter the vehicle without it being stabilized and without any personal protection gear. Furthermore, the medic on scene allowed Olivia to start an IV on her.

Number one, I am assuming that she doesn't have a license to do any medical procedures, nor does she have any training. Now many of our procedures are not that difficult, they just take a little practice. So I was totally blown away when the medic handed Olivia an IV catheter and told her he would walk her through it--AND then proceeds to tell her how to start an IV upside down.

Ok--this is where my problem is....I like to think that I am fairly skilled at IVs. Yes, I have my share that I miss as all providers do. But it took a number of year before I could successfully stick a line upside down. And I'll only do it if the patient's condition warrants it because the miss rate is higher. No WAY would I have done it on my first attempt AND have success.
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Now onto ER---

They are frequently doing things that would never happen in the real world.

WE DO NOT SHOCK ASYSTOLE.....Period!!! Asystole (flat line) is a non shockable rhythm according to the AHA. And you don't just give drugs until the patient is successfully resuscitated. Codes follow a prescribed set of algorithms until there is nothing else that you can do or the patient is resuscitated.

We don't have time to just "hang out" with the nurses and doctors chatting and cutting up--and most of them don't want to even bother with us anyways.

Patients do not always have a blood pressure of 120/80 and a heart rate of 80. Yes, I know that is "normal" but very rarely in my career have I had a patient that has "perfect" vital signs.

I just get so sick of people thinking that these medical and legal drama shows are how things work in the real world....It make our job much much harder than it has to be.

Are those really cockroaches?

Thanks to Jen for inspiring today's blog...

I head heard about them...The family that was so nasty the firefighters didn't even want to go inside. The house that you could smell from around the corner. The people that no one wanted to even touch.

I gave into the false sense of security..."They don't live in my zone, so I won't ever have to pick them up,"

Until I had to travel to another station to cover someone out sick....

I got the quick run down from the firefighters and my partner.

*Hold your breath
*Don't touch anything
*Scoop the patient and run
*Don't take anything in with you
*Don't let them touch you


So by the time they were done reading me the litany of dont's, I was thoroughly grossed out and VERY glad that I had brought an extra change of clothes with me.

If you don't know much about EMS people, it's that we are a superstitious group. We don't polish our boots much because as soon as you do, you go on a nasty call in the mud or get a really bloody trauma call. We don't wash the truck until the END of our shift because as soon as you do, you'll be off roading in it to reach a patient.

So, if there is a patient or a household that we do NOT want to go to, we talk around it...We never mention the address or the people by name because somehow, they know that you are talking about them and they call...

And of course, that is exactly what happened. The tones dropped for 1234 ABC avenue. If looks could have killed, I would be 6 feet under by now.

I let my student ride up front and as we went around the corner, I could smell the odor coming out of the house before we even pulled up in front of it. The fire captain handed me a little bottle of peppermint oil and told me to dab it on the end of my nose. Then they pulled out the boot covers and the trauma sleeves--and I'm thinking "Oh hell, what have I gotten myself into?"

As soon as we hit the front door, I was overcome with the nastiness of the house. The smell was overpowering. I felt like I was standing in the middle of a landfill. The carpet squished when you walked on it, there was so much crap piled up in the house that we couldn't even fit the cot in the doorway. The walls were supposed to be white, I think, but there were smeared handprints and dirt on them. You could see the lines in the walls where the drywall had obviously gotten wet. There were baby cockroaches crawling up the wall.....

So I finally pick my way through the house to the room where the patient is. I poke my head in the door and everything looked under control, so I made a beeline outside to the fresh air. On my way out, I made the mistake of peeking into the bathroom. No wonder the floor was squishy...the shower had boxes piled in it, I never did see the toilet, and there was no way to wash your hands. There were literally paths through the house but it wasn't just "stuff" hoarding. It was literally piles of human waste and other things I shall not mention here.

In the unit, I prepped for the patient. Vent fan on, windows open, fan on. Change gloves and then double glove. Towels on the floor to stand on.

The patient was clearly not well taken care of. She had dried food on her face and clothes and obviously hadn't been bathed because her belly button was crusted shut. The foulest odor came off of her as we tried to unwrap the sheets to perform at least a cursory assessment. Before re-wraping her, we noticed something moving under her gown. I didn't want to look, truly I didn't...

It was a cockroach. A teeny tiny cockroach. I think I screamed.

I used an entire bottle of disinfectant to clean the back of the truck, spray the passenger seat, and wet my uniforms so that I could not gross myself out on the way back to the station where I promptly chucked my uniform in a biohazard bag and showered for nearly 20 minutes.

Gross. I have never been so horrified in my life.

I've been on vacation...

For those who actually care---I've been on vacation since last week and have not posted anything. I am on my way home today, traveling most of the day. I did get some great ideas for new blogs (thanks to Jen!!), so look for a few new ones in the days to come.

Hope all my readers are being safe out there!!!!

Strange searches...

I am curious about how people find my blog and am almost anal about checking few places to find out where my readers have come from.

Here's one google search that pointed a recent reader to my blog:

poem my husband is a coke addict


Hmmmm....Is that coke addict (as in the beverage)? Or is that coke addict (as in illegal drugs)?

Either way....You made it to my blog so welcome!!!!

"I would never do THAT..."

The EMT I worked with on Sunday is in Paramedic school so I took the opportunity to refresh some of my knowledge by quizzing him on his cardiac rhythms, ACLS algorithms, and other EMS related things. One of the questions that I asked him was, "Which drugs can you administer via an ETT?"

Of course the answer is LEAN (lidocaine, epi, atropine, and narcan), although NAVEL (the previous 4 plus valium) is also acceptable. ETT drug administration is falling out of favor as we realize that the drug absorption rate and dose widely varies and we don't really want to be putting fluids into the lungs of our patients unless it's truly necessary.

So the discussion included other options for drug routes if ETT and IV access weren't available. Those include IO (into the bone marrow space), IN (intranasal), and PR (per rectum--ie, in the bootie). He very seriously told me, "I will NEVER give medications rectally." So I told him this story:

It was late afternoon and the county had been steady but not busy. A few units were out but otherwise most of us were getting ready for dinner. The tones dropped and we were sent out of our zone to respond to an infant having seizures. Well, most of the time patients having seizures are done by the time EMS arrives and don't need further care, just a ride to the hospital and monitoring.

My partner and I checked en route. We talked about what to do when we got there and how we wanted everything to go. Dispatch radioed that the FD was already on scene and advising that the child was still actively seizing and had been for nearly 15 minutes now. They were administering o2 and would meet us on the sidewalk with the patient.

**Oh Hell in a Handbasket** Now we not only have a still seizing patient, but it is a child to boot.

I unclipped the narc keys and handed them to my partner. She got out the protocol book and we reviewed the pedi doses on Valium (IV and rectally). I told her that when we got to the scene, I was going to grab the pt and come back to the truck if she would get everything set up for us. About this time, dispatch advised that the FR was calling for Air Medical and did I want to go ahead and launch the helicopter?

Hmmmm....a seizing baby in what sounded like status epilepticus and no local pedi hospital...Well HECK YEAH.....gimme a fast ride to the level 1 pedi hospital.

So we arrived on the scene to find the FR standing on the sidewalk with the patient in his arms, still actively seizing. My partner dove through the pass through (space between the cab and patient compartment) and I went around and got a quick report. Mom was helped into the front seat and as soon as the pt was secured to the cot, I told my partner that I was ready to go. The FR asked if I wanted him to go with us. "No, I'm ok. I just want to go."

"But I am a National Registry Paramedic"

and so what if you are...so am I. DUH....Just get the hell out of the back of my truck and quit holding us up..... <--That's what I was thinking anyways. I would never be so rude as to say something like that to a FR on a scene.

So he went with us. The patient was hooked to a cardiac monitor (mostly artifact), o2 was continued, and my attentions were turned to gaining IV access. The FR made one attempt and it blew....so by my calculations the child had now been seizing for nearly 35 minutes. My priority, after securing the ABCs, was to stop the seizing. Without an IV, that meant rectal valium.

The child weighed 11 kgs as reported by the mother. So I broke the seal on the narc box and drew up the proper amount in a 3cc syringe. After discarding the needle tip, I took an 18 gauge catheter out and disposed of the needle, leaving me with the catheter tip. This I screwed onto the end of the syringe, and voila!! A way to administer the valium rectally.

Have you ever administered rectal valium to an actively seizing child? It's akin to giving a cat a bath. They wiggle all over and it's hard to keep the syringe in place after the drug is administered---necessary to keep the drug from running back out before it is absorbed.

It was the longest 8 minutes of my life. Watching to see if the drug would work, reassessing the pt status, determining my next course of action. As the seizing slowly stopped, I threaded a flexible catheter into the pt mouth and was able to suction his airway clear. A few minutes from the hospital, the patient began having irregular and agonal respirations. As the jaw was clenched, our only other option was to perform RSI to secure the airway, especially with the patient being such a high aspiration risk. I chose to assist the ventilations with a BVM as I could already hear the rotor blades from the helicopter. My thoughts were that the flight crew had much more experience with RSI for a patient that size and my efforts were better spent on good ventilations. They could figure out the proper doses of RSI meds MUCH faster than I could. I had the FR set up all the intubation equipment, we already had the length based resuscitation tape on the cot next to the patient.

When the flight crew boarded, I gave them a quick but detailed report and they agreed with my suggestion of RSI.

For my non medical readers:

RSI (Rapid sequence intubation) is a procedure that consists of administering a cocktail of meds that sedate and paralyze the patient in order to facilitate intubation. It is most frequently used for patients with traumatic head injuries, respiratory failure with impending respiratory arrest, and acute CVA (stroke). It can also be successfully used with patients who have overdosed on an unknown substance or with patients who are unable to maintain their own airways. It is not a procedure to be taken lightly, you must be sure of your intubation skills as a provider and feel comfortable that you can "sink" a tube on each patient. In my system, we used a combination of Etomidate, Succinylcholine, and Norcuron. We also premedicate with Atropine for the kiddos and Lidocaine for any with potential head injuries.

We prepared all the equipment and I successfully placed an ETT on my first attempt. Following intubation, the patient was ventilated well and packaged for transport. We got them all loaded into the helicopter and they flew to the Children's Hospital.

I called a few days later and was told that the patient was still on a vent and the EEG and brain scans had showed some kind of abnormality but because of the age of the patient, they weren't sure what it was or the treatment yet.

This patient was discharged about 2 weeks later and was home for 2 days before suffering another seizure. This patient has since become a regular for our service. They finally determined that there was some kind of lesion in this child's brain but determined it wasn't safe to do surgery because of the age. Unfortunately, the patient continued to have seizures despite aggressive treatment and today has significant mental, emotional, and developmental delays. We actually had a protocol written specifically for this child because it got to the point that all the Valium in the world wouldn't touch the seizures.

After relating this story to my partner, he said, "well, I guess I'll never say never again."

I told him that there was a big difference between saying that you would never do something vs. saying that you would prefer not to do something. I told him that the first time he laid eyes on a beautiful child with big blues eyes who had been seizing non stop for 30+ minutes, the thought of not giving a drug rectally wouldn't even enter his mind. I told him that I didn't want to perform a Cric (a different patient--for a different blog), but I did and because of it, the patient lived. But if I had always told myself that I'd never do one, the thought that a patient might need one would have never crossed my mind. And that patient would have died before he even reached a hospital.

Teaching moments...They are valuable when they come along and can be related to something that the student can easily identify with.

Until next time....

Ever had one of those days where you just don't get it?

So I was thinking the other day about some of my really "head scratching" calls. You know, the ones where you just never really understand what happened and decide that you probably never will?

It was maybe a year ago--I know it was freezing outside but I don't really remember when it was--that my partner and I were dispatched to a MVC with a "minor headache". It was also O'dark thirty outside and we had been asleep for a few hours.

So ok, we check en route and Mike (my partner) drives us the short distance to the scene. When we got there, I think that I dang near soiled my britches!

This was no minor accident--This was a full blown tractor trailer--18 wheeler--semi truck, half flipped over, and teetering off the side of the road. Regardless of the status of the patient, we needed more help to safely access this patient.

I radioed dispatch and told them what we had, requested FD for rescue and extrication assistance, and asked to have Air Medical put on standby. We could see skid marks at least a half mile up the road. As I surveyed the scene, I also saw a sign that read "WARNING--GAS PIPELINE UNDERNEATH. CALL BEFORE DIGGING" Oh crap.

Well, step one was to get everyone out of the danger zone, including the cops who were crawling all over the cab of the truck. I inquired about the status of the patient and was told that she was semi responsive and "talking out of her head". Hmmmm. Thankfully the FD was only a few blocks away and they arrived on scene in record time. As soon as they had the semi initially shored up, Mike climbed inside and started an initial assessment of the patient. Once he relayed his findings to me, we launched the helicopter. We were also waiting on a large flat bed wrecker that had the capabilities to rig up safety wires to keep the semi from fully rolling over.

I started hanging lines and getting the patient compartment ready. I turned the heat on, attached electrodes to the cardiac monitor. I had already taken Mike the portable O2 and a non rebreather mask as well as a ccollar, so we had the basics covered until we could fully extricate the patient.

We wound up having to remove her from the truck through the side window. The doors were jammed and we decided that trying to have the FD use the jaws of life to pop the doors and gain access that way was just too risky. We were afraid that the wiggling and moving might cause the semi to become unsteady. I just wanted all my guys away from any potential danger as quickly as possibly.

So out she comes onto a LSB and we secured her quickly and got her in the back of the truck. We did a full trauma assessment and began treatment. Continued o2, monitor, warmed her up, IVs, etc. Her BGL was in the 40s. So she also got an amp of d50 which helped to perk her up some as well, although she was still lethargic and not responding appropriately.

We were driven to the LZ and in short order had the pt packaged for the helicopter and report was given the the flight crew and they flew her to the closest level one trauma center.

We went back to the scene and stayed with the FD and the wrecker crews for several hours while they attempted to remove the semi truck from the ditch that it was half in.

I guess the moral of the story is if you hear hoofprints, look for the zebra.