by Joseph A. Moore, EMT-P
This story is completely fictional. None of the characters or providers has any connection to any location, specifically not Beaver Island . Any assumed connection to the local residents, visitors to, or providers of Beaver Island will be completely wrong.
It is a crazy summer tourist season with twenty times the number of people in this rural area on this summer day than there is here during a February week. The holiday for the summer that used to start the summer season was 4 th of July, but now the Memorial Weekend seems to begin the onslaught. Who do you count as a tourist anyway? I always wanted to know the answer to this question. It seems to me that if someone lives somewhere for six months of the year and one day, they should be considered a year round resident for the community, but someone, somewhere has decided that you need to be living in the cold northern climate all twelve months of the year in order to be considered a year round resident. What do you think?
This really has nothing to do with the emergencies that we had today, but it certainly would help me answer the questions in my own mind about who we had for our emergencies. I get thinking about this issue, probably more than I should, but when people that I know and care about ask me, they usually say, “Was it a visitor or a year-round resident?” Of course, I can't tell them anything about it, but, if I could, how would I answer that question? Would I classify the person as a part-timer if they lived here for 9 months, 8 months, 7 months, or less? I'm guessing that if I could answer any questions about the emergencies for today, I would simply say that the three people who lived here had a bad day.
The first person was a teenager swimming at the public beach. There was a floating raft out near the edge of the deep-shallow dividing line, and he was swimming with lots of his friends. He decided to run across the short raft, nor more than eight feet by eight feet, and somehow stubbed his toe on something, tripped and fell, and managed to break his arm when he twisted. He was really lucky that he didn't fall head first on the shallow side of the raft because that could have been a disaster. His arm was completely bent at an un-natural angle with his thumb much too close to the bend of his elbow. It looked as if both bones of his lower arm were fractured with a severe deformity to the lower arm. If any part of this accident was positive, it was that the broken ends of the bone had not broken through the skin so this fracture was closed to outside bacteria. No open fracture usually means no infected bone, so this part, although quite small in comparison, was the positive part.
Upon arrival in the echo unit, I was first on the scene since it is usually parked in my front yard, I immediately got my uniform pants and shoes soaked by walking out into the water to help splint the broken arm using my two good arms. Once on shore, I asked him to sit down on a blanket provided by a bystander, so that I could do a complete head-to-toe assessment. “I know you have a very painful injury to your arm, but I need to make certain that your arm is your only serious injury. Did you fall into the water at all?”
“No, I didn't make it to the water,” my patient groaned.
“Did you hit your head at all?” I queried.
“No, I kept from hitting my face or my head with my outstretched arm. You can see what good that did me.”
“Well, young man, you actually may have prevented yourself from more serious injury with that broken arm. You did a really good job protecting your head, neck, and face, and you kept yourself from going head first into the water on the shallow side of the raft, according to your friends here. I'd say you did a great job, and that you were very lucky, because you could have quite literally broken your neck,” I stated as I examined his head, neck, and face. “Let me know if anything I do causes you any pain at all, but most important, you keep that broken arm from moving while I check you out.” I palpated (pushed and prodded) every nook and cranny except the genital area on his wet body. There was no pain, deformity, or further evidence of any other injury except a scrape injury to his right leg. “It looks like you dragged your right leg on the top of the raft. You have scraped some skin off of it, but it currently appears as if your most serious injury is to your arm. If you can walk, it might be more private if we finish out assessment and treatment in the back of the ambulance that has just arrived. Do you think you can walk up the narrow beach and climb in?”
“Yah, I didn't break a leg, so I can walk, and my friends are starting to make fun of me, so let's get out of here,” he said with a whiny tone of voice.
“Some friends they are if they are teasing you about this kind of injury,” I said more loudly than necessary for my patient to hear, mainly, wanting his friend to hear quite clearly. “It's a pretty serious fracture, which may require surgery by an orthopedic surgeon, so you guys won't have your friend here to pick on for a while.”
Once in the back of the ambulance, I had four extra pairs of hands if I needed them. I had one person hold onto the patient from behind the cot. Since the patient was strapped to the cot, with the cot in the upright position, the first responder that needed to hold the patient's chest and shoulders had to get into a really uncomfortable position to do the job. I had him wait a bit while a prepared the patient. I had another person whose job it was to hold onto the upper arm when it became necessary to straighten the patient's arm. You see, there was no palpable pulse in the fractured arm. (We could not feel any circulation and the arm was turning blue.)
I spoke right to the patient right at the patient's eye level and said, “This is not going to be pleasant. As a matter of fact, this is really going to hurt, but we don't have any choice. We have to straighten your arm, but there are two good things about this. First, we are going to start and IV and give you some medication. Then we are going to straighten and splint your fractured arm, before we transport you to the hospital. You are probably going to swear at me when I do this, but that won't hurt my feelings. Do you understand why we need to do this?”
“I can see my arm is turning bluish, and my arm hurts like hell, so you go ahead and do whatever you need to do,” he stated bravely, but he was obviously frightened.
“You go ahead and get the IV going, George, so I can contact medical control, and we can get permission for something similar to a conscious sedation. I'll use the cell phone instead of the radio. That way I get to talk directly to our medical control physician and provide the needed report. What are our current vital signs?” I asked our fourth provider in the back of the ambulance—the one recording all the information.
“We are holding steady with a pulse of 96, respirations of 24, and a blood pressure of 126/86. As you know, you did it, the breath sounds are clear bilaterally and the only apparent injuries are an abrasion to the right leg and a severely deformed right arm,” she stated clearly.
“Hello, Doctor, this medic Joe. Yes, that's right, the one that works in the most rural of rural areas. We have an eighteen year old male patient here with a severely angulated fracture to the lower right arm. There is no pulse below the fracture site that we can find, and the arm is cyanotic. Our patient's vital signs are all within normal limits. Our patient states his pain is 10 on a scale of 0 to 10, with 0 being no pain and ten being the worst pain he has ever felt. He weighs about 100 kilograms. I am requesting permission to give morphine for pain and Versed for the sedation prior to pulling traction on the arm in an attempt to restore circulation to it. What do you say? Will you give us permission to do this?”
“How long before you can get him in the door of an ER with an orthopedic surgeon on staff like the one in Traverse City ?” the doctor asked.
“Our shortest possible transport time is one-and-one-half hours from this location, but most likely will be closer to three hours depending upon availability and weather,” I answered truthfully.
“I'd say go ahead with the conscious sedation plan, giving 5-10 mg of morphine after 5-10 mg Versed titrated to his respiratory rate. I'm assuming you have an IV started, the patient is on the monitor, and you have him on 100% oxygen. Keep an eye on his breathing, and be ready to assist ventilations, if necessary. Make sure you pull traction on the arm before and during the straightening. Splint the arm in the position that gives you pulses. Call me back and let me know if you do or don't get return of pulse to the arm. I'll stay here in the office in case you need my advice,” the doctor promised.
“Thanks for your vote of confidence, sir,” I responded. “We'll do our best to help resolve this. I'll call you back as soon as the procedure is completed.”
“Okay, we have the order from our medical director to move forward with this procedure. Is the IV patent and ready to go? (Nod recognized.) Oxygen is at 15 liters per minute by non-rebreather mask? (Nod recognized.) Okay, run a strip on the monitor while I draw up the medication. Then lay out the intubation equipment just in case, and have the suction ready to go.”
Can I remind you that we are in the back of an ambulance parked in the parking lot of a public beach and doing a conscious sedation on a patient with a severely angulated fracture of his forearm? Where in the urban EMS arena would this happen?
“Hook up the pulse oximeter and the CO2 monitor. I want to know immediately if his O2 saturation changes and if his CO2 goes above 45. Does everyone know what their assignment is? (Nods all around) I'm going to give the medication. We'll monitor vital signs, and when he is completely out, I'll straighten the arm. Make sure that his body doesn't move. Make sure that his upper arm does not move. As soon as it's straight, we'll put the padded board splint in place, check for a pulse, and wrap everything up, making sure that we have a place to continue to check pulses. Everybody ready?”
You can be assured that the positive mood that I presented on the outside was not what was really going on---on the inside. I was scared to death and scared of death. “All right, you are going to get really sleepy, but when you wake up, your arm will be in a much better position, and it should be looking a lot better,” I told the patient. To everyone on my EMS team, I said, “In goes the Versed over about two minutes.” While they all held their breath, the team leader held his breath also as we watched our patient slowly, but surely close his eyes. “That takes care of the sedation. Now we will take care of the pain, before I pull on the arm,” I spoke out loud for all to hear including myself. “Is everything still okay with vitals?”
“There was a slight drop in the pulse rate, but the respiratory rate is still okay at 16 breaths per minute. O2 saturation is 96%, and the CO2 is 38,” my paramedic partner George told me.
“In goes the morphine over two minutes. Make sure the suction is ready, in case our patient vomits,” I repeat things when I get nervous.
“All is still okay with the patient's vital signs. Not much change in anything. I think we are ready to go,” my medic partner states.
As I began to reach for the arm, I was saying a little prayer asking God to make sure that everything that we did was correct. None of us wanted to cause this young man any permanent problems or issues. “I'm pulling traction, NOW, and straightening the arm, NOW.”
“Jesus……….. (with a few more expletives),” our patient said as I moved the arm back into its position of function.
“Splints in place now,” I ordered, “And wrap them in position. Do we have a pulse? Someone, check a pulse,” I commanded more like a sergeant than probably necessary. I really didn't need an answer to that question because I could already see the arm begin to pink up from the restored circulation. “Keep an eye on all of the vital signs and all the equipment,” I said a little more relieve as I wiped the sweat from all over my face on a couple of four-by-fours that I pulled from a storage cabinet inside the ambulance. “Let's get moving to the airport. I'm guessing the plane will be here and ready fairly soon, so we can turn our patient over to Lifeflight.” (Liveflight is an advanced life support air transport operation out of Traverse City and will return our patient to Traverse City to be seen in the emergency room by an orthopedic surgeon.) “Let's take it really easy on the way to the airport---REAL EASY. Our patient will probably be out for a while, but there is no sense in bouncing the patient around on these bumpy gravel roads. Keep monitoring the vitals every five minutes.”
At the airport, we turned our patient over to Lifeflight RN and paramedic after giving report. The flight nurse said, “You did a conscious sedation in the back of the rig at the public beach parking lot? And the patient is still unconscious, but doing okay? We'd never see this happen anywhere else.”
I did remember to call the doctor back on the cell phone, just as the aircraft took off on its way to the city hospital.
Rural EMS IS Different. This is just another example of how and why.
“ EMS , respond to two miles south of your location, for a diabetic emergency. We have a woman who is unresponsive at the wheel of a vehicle with the engine running. Can you continue from your location or should I page another ambulance and crew?” our dispatch asked us.
“Dispatch, we have a complete set of equipment in the echo car that we can use. It will not be necessary to page for another ambulance or crew,” I responded on the radio. So, off we went echo car and ambulance headed south from the airport. “Let's make up the ambulance cot after a quick wipe down with the antiseptic wipes,” I radioed the ambulance from the echo car.
“10-4,” was the ambulance response.
We all arrived to find a very concerned husband pacing outside of the pickup truck. “She's having a diabetic insulin reaction because she hasn't eaten any lunch. I tried to get her to eat before she made this trip down to the rental cabin, but she wouldn't hear of it. Her blood sugar is very low. I can tell by the language and the tone in her voice. I've already tried to get her to eat something, but she just spits it out. We left the glucose gel back at the house.”
“Okay, sir, we plan to check her blood sugar, but we really appreciate the ‘heads-up.' We will need to transport her in the ambulance to the hospital even if we get the sugar level under control. Do you understand that? She will probably wake right up after our treatment, but we still need to get her monitored for a while, and the hospital is the best place to do that,” I said insistently.
“Do whatever you have to do, but she will not be very happy with you or me, if you take her to the hospital,” the husband intoned seriously.
“We can't wait to treat her, but we will have to transport her to make certain she doesn't have something else going as well as the sugar problem. When she wakes up, I try to make that completely clear to her,” I stated while climbing into the back of the ambulance. My EMT partners and my other paramedic has already move the patient from behind the steering wheel, loaded her onto the ambulance cot, and had her loaded into the back of ambulance while I had spoken with the husband. “Sir, you can follow us in to the hospital, if you want.”
“So, I see you have the IV kit out ready to start the IV,” I said as I moved into position on the side seat. “Do you want to push the D50?” I said to the basic EMT. “I'll get it connected, and you just push with both thumbs. It's pretty thick and will go in fairly slowly.”
“Sure, I've never done that before,” she said in an excited tone of voice.
I hooked up the needle-less adapter to the D50 syringe, which is about five inches in length and may two inches in diameter. “Just make sure that you hold onto the syringe. Don't let it drop, because it might pull the IV out from just its weight. This will take some thumb and finger strength to push this slowly, but surely through the IV line. I'll pinch the line above the connection so that it will go into the vein instead of back up into the bag,” I assured my EMT partner that everything would go correctly. In the glucose went, and, after about two or three minutes, it was almost completely in, and our patient began to slowly wake up.
“What the …… is going on?” our patient asked quite sarcastically. “Where am I? What the ….. am I doing in an ambulance? Oh, that's right. I was being stubborn and didn't stop to eat lunch. I suppose we're on the way to the hospital, …….it. Why do I have to be so stupid? Can we just stop the ambulance so I can get out and go back home?” she spoke more kindly now.
“No, I'm sorry. We can't do that. We need to make certain that you get to the hospital for them to do some blood tests to make sure that you are all right. This kind of situation is hard on your internal organs, and the hospital will want to make certain that you are okay before you can be released. I know you probably are embarrassed, but you really have nothing to be ashamed about. We will treat you with respect, and we will get you right into the emergency room quickly, so no one will know that it's you. They will run a few tests, and you should be out and back home, at the latest, by tomorrow morning,” I spoke very clearly and sincerely.
“That will teach me for being so stupid,” she said, and she was very quiet and subdued all the way in to the hospital. We rechecked her blood sugar several times, and about half-way into the hospital, we needed to give her a second dose of glucose, but this time only half.
At the hospital, we gave report, and left to restock our drug box. On the way by the exam room, we heard our patient becoming more and more belligerent with the ER nurse, which we knew meant she needed some more sugar. Stepping into the room, I whispered to the nurse, “A little sugar will cure that belligerence. She's a very nice person when she is herself. It took about a half tube of D50 to fix the problem earlier, but we had no complex carbohydrates to give her to eat. My guess is her sugar is back down to between 40 and 50, if not below.”
“Thanks, but I have to wait for the Doc,” the nurse stated.
“Okay, have a great day,” I said leaving the exam room, knowing full well that the patient's belligerence would lead to the patient's combativeness if the doctor didn't get in there pretty soon.
We were back at the garage, restocking the ambulance while two were doing the paperwork on the last two runs in a program called MerMAID. This program is required by our state and our local medical control to be able to document the assessments and the treatments for the patients in our county and state. The idea is that EMS in general throughout the United States is not very good at documenting in electronic form the patients that are seen in a format that can be accessed and presented to governmental agencies. The fire service has been good at this for years, and that explains why the fire service gets the funding that it wants and needs. EMS needs to be able to document its services in the same manner to be able to get the funding that it wants and needs. The replacement cot is cleaned and the bed sheets and blankets are in place when the pager goes off for the third time today. This means that no one here in this agency will be putting in a day's work for any employer because we have all been busy providing our volunteer EMS services for the entire day.
“ EMS , respond to the residence of ______ for a 44-year-old victim of a fall off the roof. He appeared to be unresponsive immediately after the fall, but is responsive now,” Central Dispatch stated.
“You have got to finish those reports and get them faxed to the hospital and medical control. We have enough people here to respond. So with two in the echo car and two in the ambulance, we headed out. Of course, we were not going to get there quickly since the address is about seven miles away, but we would be moving there at emergency response speeds with lights flashing and siren blaring. For us in rural EMS , three runs in a day is truly described as being pretty busy. You might think that is silly, but when each run takes more than three hours with the usual clean-up time in between, that makes it working over time in any other job. But ours is not a job, it is volunteering to help friends and neighbors of our community. We do it with loving, caring compassion for the needs of others.
I am in the back of the ambulance instead of the echo car for this run. It is the other paramedic's shift now, so she officially has the echo car for the rest of her 12-hour shift. Part of it was used up on the second run of the day, but who's counting? I spend the first three or four minutes checking to make certain that all the equipment we are likely going to use is present and easily accessible, literally ready to be removed from the ambulance. We have become pretty accustomed to having to make due with what we have to accomplish the goals for most of our patients, even if the service can't afford all the bells and whistles that might be found on an ambulance in affluent urban area. I have backboard, cervical collars, trauma bag, splints, padding, and backboard straps all ready to take out the back door of the ambulance. I have piled everything including the oxygen bag with O2, nasal canulas, non-rebreather masks, and oral and nasal airways onto the top of the backboard, so all we have to do is carry the backboard to the patient.
The echo car beat us to the scene, which happens almost every single time that we are paged, and radioed back to us that we would need the exact same equipment that was sitting on top of the backboard in the back of the ambulance. “10-4, good buddy,” was what went through my mind, but the response from the driver was, “Roger that.”
We arrived to find that this man had fallen off a roof while working on re-shingling it. He didn't really fall, based upon his description, but slid rather quickly down the side of the roof, hitting the ladder and knocking it out of the way and finally descending to the ground after bouncing off his woodpile. Since I was not the lead medic on this call, I had to stand back and wait to do whatever I was directed to do. She ran the assessment, backboarding and spinal motion restriction following textbook style procedures, which made her teacher, me, quite proud, but about halfway through the procedure, the patient yelled, “Owwwww!”
This pretty much derailed her calm demeanor, but I quietly and gently said, ”You are doing fine. Don't stop now, you are almost there.” She continued the procedure, and with amazing dexterity completed the task including the proper “chest, hips, head, legs” order to the strapping and immobilization procedure. I was so proud, since, did I tell you, she was one of my paramedic students. The patient was loaded up onto the ambulance cot and moved into the back of the ambulance.
Once in the back, she made sure that the vitals signs were taken. She started an IV smoothly and easily, attached the pulse oximetry probe, and the cardiac monitor. She did a complete neurological exam, and found out that our patient had movement, sensation, and pulses in all extremities, which was a really good thing. We were all quite thankful that our patient, who was also our friend and neighbor, was showing signs that would indicate no paralysis had occurred. A fairly quick trip to the hospital was accomplished with no further complications. Severe bruising and a possible fractured rib was all that came from this fall, but we needed to treat for the worst possible situation, and hope for the best possible outcome.
These were the three transports for this one busy day, but we happened to be paged three additional times for this busy EMS day to the rural health center to assist with patients that had come for help after the regular business hours of the clinic. Although not a record, six pages and three transports for this very rural service took up the entire day and half the night, quite a busy eighteen hour day for this rural EMS group. This is just another reason that Rural EMS IS Different.