CHAPTER 18
REALLY MAKING A DIFFERENCE IN THIS COMMUNITY
On one February afternoon, Rural EMS was paged to a residence down the road that I live on. We were paged to a 69 year old male patient complaining of chest pain. I responded directly from my house to the address down the street. When I arrived, I got a quick history of the current illness. The patient had been sick recently with flu, cough, and congestion. His shortness of breath had started earlier today and had progressively gotten worse. He did not want his wife to call for help. He had refused to have her call when this started much earlier in the day. He had chest pain in the center of his chest that was radiating to his left shoulder and jaw. He had no history of any previous cardiac problems. I attempted to get a radial pulse, the one at his wrist, and was unable to feel a pulse there.
I reached up to palpate the carotid pulse in his neck, and could find that his heart was beating at 100 beats per minute and slightly irregular, but even this pulse was weak. His skin was pale, cool, and moist, but he was alert and oriented. He had respirations of 40 breaths per minute. We had one very sick man here.
The ambulance arrived very quickly while I was getting the history, and a pulse oximeter reading was taken revealing a 77 % reading which may or may not have been accurate considering the poor circulation to his arms and legs. His body was shunting the circulation away from his arms and legs, to maintain the best circulation possible for the heart, lungs kidneys, liver, and brain.
This patient was having a serious cardiac event.
This was the father of one of my friends. His father was very seriously, gravely ill. I wanted to help in any way that was possible. We put the man on the ambulance cot in his position of comfort which appeared to be in the semi-sitting position. We had 100% oxygen on the patient. He had a blue coloring around his lips, and his capillary refill in his nailbeds was very much delayed, possibly non-existent.
We attempted to start an IV, but the circulation deficits made locating a vein very difficult. We moved the patient quickly to the ambulance after making arrangements to fly with the local airlines. We moved him on the cot carefully down some very tricky steps on the deck-like porch and down into the ambulance. We looked very carefully--one of us on each hand and arm trying to find a location for an IV. We tried once to start the IV, but did not have any luck. We were feeling very inadequate and quite terrible at our lack of ability to help this patient. When all that you are allowed to do in the advanced life support area is to start an IV, it can be very frustrating when you are unable to locate an IV site. You also know very well that this friend's father needs a IV route for medication once he arrives at the hospital.
We arrived at the local airport, loaded the patient into the airplane, and flew with him to City Airport . We loaded him into the City EMS ambulance, but we refused to turn him over. We were going all the way to the hospital with him. When we arrived in the ER at City Hospital , there was a whole crew of people in the ER to help take care of our patient. We gave verbal report, and then they swarmed over him doing all kinds of things that needed to get done. They got the IV in the bright lights of the ER, hooked him up to the automatic blood pressure machine, and set up the electrocardiogram.
Beth and I kind of stepped back watching all the activity, but we could not be silent when the ER nurse reported that the patient had a blood pressure of 148/86.
We both, almost in stereo, stated, “That is completely impossible. He does not have a blood pressure that is palpable. He has no radial pulse. The only pulse we could locate was a carotid pulse.” The ER doctor looked our way and reached out to feel for a radial pulse.
He stated loudly enough so that everyone in the room could hear, “They are absolutely correct. There is no radial pulse in either arm. That makes the blood pressure below 80. We need to set up a dopamine drip STAT.”
That validation by the physician meant so much to us, the rural EMTs. We were from the rural area, and very seldom accompanied the patient to the City Hospital ER. The nurses there, although very nice people, had not had much contact with us, and had certainly not developed any confidence in our abilities to assess and treat a patient. After all, we were the “load and transport” rural EMS squad, very efficient at getting our patient to the hospital, but, in the eyes of the ER staff, we were not “tried and true” nor tested in our skills. This validation helped us toward that confidence that is seriously needed by all rural EMS people.
Unfortunately for this patient and my friend, the heart attack was serious. It had probably happened much earlier in the day. Time is muscle. His heart muscle had been seriously injured. A lot of heart muscle had been unable to survive the long period of time without oxygen. It was time for the family to gather at his bedside. The calls went out to all his children.
Beth and I flew home very dejected. We know that we did everything we could for this patient and his family. We had provided the best care we could in this situation. We will never know what the outcome could have been had the phone call for help been made at the first sign of chest pain in the morning. We couldn't make that happen. It hadn't happened that way. There was nothing more that we could do. We still questioned our abilities. Was there something more that we could have done to improve this patient's outcome?
It was a very sad day when Beth and I attended that funeral. We both felt like we had lost the fight for our friend and our neighbor. This sense of loss is even more difficult for our rural EMS workers when they have relationships with the patient or the patient's family. We all try to talk out the emergency. We know we did the best job we could do. We still felt guilty and sad. Our best could not save him.
It's a good thing that we have some situations that turn out positive. It can be a pretty negative field to work in when you are in pre-hospital care. There are never any calls for anything really good. People are calling you when they are in serious need of help. Thank goodness that there are days when the outcome is good, and that the outcome is good because of what EMS has done to provide services to the patient. The April morning to be described next is just such a day.
“Rural EMS , respond to ….. for a 5 month old who is choking,” the dispatcher repeats the page three times. We have people responding from all directions. One of our medical first responders arrives first. I am convinced that Bryan, our first responder, deserves credit in saving the life of this five month old girl. He arrived quickly, carefully rolled the child over on his arm, and gave five back blows.
Then he rolled her over and gave five chest thrusts. The second set of five back blows allowed the child to started breathing. The ambulance arrived along with several other EMTs and MFRs.
When we arrived, Bryan went out the back door. He had done his job, and he left the rest of the work for us. The infant of five months of age kept going back and forth from able to breathe to unable to breathe. The child vomited twice. We suctioned, and then the baby would stop breathing again. There was yellow mucus with a red tinge every time we suctioned.
We considered the possibility of epiglottitis, a swollen or enflamed projection of the internal airway just above the opening to the trachea or windpipe. The FNP arrived and listened to lung sounds. When the child was breathing, the lung sounds were clear. We provided oxygen by mask that we held near the baby's face, a process called “blow-by oxygen.” We loaded the baby in her mom's arms into the back of the ambulance and began to transport to the local airport.
“Oh, my God,” the mom screamed, “she's doing it again.”
The baby started choking again.
“Hand her to me,” the rural EMT commanded. This time, we did the choking baby protocol again. The back blows again opened the airway, and the child started breathing again. At the airport, the child began to calm. The baby, mom, and two EMTs boarded the aircraft to fly to the city.
Before take off, I was sent back to the ambulance to get the suction unit. There on the floor of the ambulance was a 1 inch by ¼ inch spring covered by mucus. I picked it up, wrapped it up, and handed it into the airplane with the portable suction machine.
“I found this on the floor of the rig,“ I reported to the EMTs who would be flying with the patient.
“It could have fallen out of the baby's blanket,” was the response from mom.
I have my belief. I believe that the choking baby protocol followed in the back of the ambulance dislodged the spring completely from the baby's throat, which allowed her to calm down. I also believe that the spring had been loosened by Bryan to begin with. It explains why the baby went through the choking episodes several times.
It explains why there way no episode of choking on the airplane. It explains why the ER could find nothing more to worry about when the mom, baby, and EMTs arrived in the ER.
We have had the information about this baby's ambulance run subpoenaed three times over the last eight years. Different lawsuits and different legal entities wanted copies of the Rural EMS run report on this child.
We are thankful that Bryan saved this little girl's life. We are thankful that we found the cause of the problem, and we got the child out of danger, but to the closest hospital. We are also thankful that we have never had to testify in a court case related to this or any other EMS run. We felt much better after this run than after the run in February. We had found that our EMS system worked, and it worked well. We had found that our EMS system could actually save a child's life when it was in danger. Most of us went home very thankful for the knowledge that we gained on this day. We were all proud of what we had accomplished.
Today is Thanksgiving Day, and I could think of no more appropriate cases to be writing about on this day. Our community gets together for an ecumenical church service. We meet at the Catholic Church. All church members and non-members of any church are welcomed to this Thanksgiving Service. Each of the three main churches in our service area is represented in giving of the readings. There is a reader from the Episcopal Church, the Non-denominational Christian Church, and the Catholic Church. The service incorporates the community choir with members from all three churches as well. The prayers are spoken by all in attendance. The hymns are sung by all in attendance. The sermon is reflected upon by whichever preacher is available and wants to participate. This is a community celebration where the entire community comes together to sing and pray together to give thanks for the good things in life.
The comments today were perfect in the scripture reflection. The good list of things that we can fairly easily give thanks for is only one of the lists that we have. For this list we give thanksgiving. There is also a list of negatives that builds character and makes us into the disciple that we are meant to become. For this list we give “thanksliving”. We give thanks for the negatives that have shown us how precious the positives in the list really are. We give thanks that we are still living to be able to give thanks for the positives. We give thanks for the life that we have chosen to live. Happy Thanksgiving and Happy Thanksliving to all of you reading this. Rural EMS and I hope that all of your positives may outweigh your negatives, and, if not, you must truly be blessed.
In May we are called to the home of a 52 year old male patient who was having difficulties this morning at a little before seven in the morning.
Our patient said, “I have a prickling in the arms, a hot and then cold feeling when I rub my arms, and my tongue feels thick. When I got up to got to the bathroom, I passed out against the wall of the bedroom without urinating. I have tingling feeling in my legs also.”
He denied any pain of any kind. He did say that he went to the bar and had a “couple of beers” which he does not do very often. He wasn't sure that he needed to go to the hospital. We weren't sure that he needed to go to the hospital either, but we weren't going to make any judgments about his alcohol use. We were going to do a complete patient assessment.
His hand grasps and foot presses were all strong and equal. He had no history of heart problems and no previous history of any mini-strokes or stroke, but there was a family history of stroke. His skin was pale, but warm and dry. His pupils were equal and reactive to light. His vital signs were pulse= 70, respirations of 18, blood pressure of 120/70, and his oximeter reading was 92 on room air.
We called a report to the nurse in the City ER and got an order for an IV of normal saline to keep the vein open. We administered oxygen by nasal cannula at 4 liters per minute. The patient's history included that he was a runner who ran 2-3 miles, three times per week. We used the stair chair to carry the patient from his home down the steps after the patient demanded to be fully dressed before leaving. We assisted the patient from the stair chair to the ambulance cot, loaded the cot, and transported the patient to the local airport where he was flown to the City Airport with further transport to City Hospital by City EMS. We provided him safe and efficient transport to the hospital.
The interesting thing about this particular ambulance run relates to the fact that his insurance company would not pay the ambulance bill with a pickup point of his residence and a drop off point of the local airport. You see, the land ambulance part of Rural EMS service is licensed. The air transport portion by local airline is not licensed. The city ambulance part of the transport is licensed as well. The insurance company could not get past the unusual aspect of this kind of rural ambulance run. They would never pay for an ambulance that dropped the patient off at the local airport instead of taking him directly to the hospital.
I am not bad mouthing insurance companies, but they just don't take the time to look at the rural EMS issue, and figure out that it makes a lot of logical sense to allow rural EMS some leeway in the rules and regulations. The insurance company did, in fact, pay for the mainland ambulance because their destination had been the hospital. They paid them without any question, but they could not see the relationship between the beginning and the end of this patient's emergency.
It took them almost six years of patients and Rural EMS letters to explain the situation before we finally got this problem worked out for our patients. We also had a hard time convincing them that the reason for us using a non-licensed mode of transport was because we didn't have any choice. I don't know of any ground ambulances that can travel across thirty-two miles of water. I sent map after map, letter after letter, and finally we got them to realize the following: IF A LICENSED AIR TRANSPORT AIRCRAFT IS NOT AVAILABLE, the patient still needs to get to the hospital in an emergency; there is a need for a minimum of two ambulance services to be involved, one in our service area and one in the city; and Rural EMS will use whatever means of transport that we can devise to get the patient where (s)he needs to go, licensed or unlicensed. A further example may demonstrate this situation.
At this very moment, if an emergency were to occur on this Thanksgiving Day, we could contact Lifeflight's fixed wing aircraft and ask the dispatcher to send the aircraft during the daylight hours only . We have a letter sent by way of the rural health center that states that, due to the deer problem at the township airport, the Lifeflight aircraft would not be landing at this airport during the nighttime hours, in other words, when it is dark. This would remain the Lifeflight policy until such time as the Rural Township Airport has a fence completely around the perimeter that would prevent deer from crossing the airport property, but, more importantly, it would supposedly keep the deer from crossing the runway, and therefore prevent an aircraft deer collision.
What does this mean for Rural EMS and the patients that we serve? It means that for almost two-thirds of our twenty-four hour day from the months of late September through late April or May, we are without a legal air transport agency that can transport our patient. Two-thirds of the year and two-thirds of the days in that two-thirds of a year, we have no legal way to transport patients from our service area.
So how do we function in the meantime? We violate, quite literally ignore, the law. We have no other choice. A heart attack patient does not have the time to await the next daylight period of time to get to the hospital—neither does a severe allergic reaction patient, a fractured femur patient, or a chainsaw accident patient. What do we do?
Our order of transport and our means of transport is based upon the patient's ability to have delayed transport, and even more importantly, it is based upon the weather, both here in our service area and at the patient's final destination hospital. We do what we have to do to get the job done. We have an unwritten policy that is really very simple. Get the patient where he needs to go as quickly and as safely as possible. There is no insurance company issue considered. There is no law that is considered. There is no easy solution for the Rural EMS EMTs to consider. Every transport situation is judged on the patient's condition and the weather.
There are very few urban ambulance company employees that have to face this type of situation. How would a city paramedic react if (s)he were paged to the serious medical emergency, and, quite literally, had not one hospital to transport his/her patient to. This hospital that exists could not be reached no matter what route that was considered. There was no way to divert to another hospital. You have an RN on your crew who is also an EMT. You have up to 48 hours to be responsible for this patient. You have telephone and radio contact with your medical control hospital. You have the supplies that are present in your rig and a few extra stashed at your station, you have plenty of runners, but you are it.
You are this patient's only healthcare providers. You do have a small emergency-like ER room to go to for waiting with a few bandaging supplies. The room is warm, and there are restroom facilities available along with water, hot and cold. The patient will be kept as comfortable as possible in this warm room. The patient will be moved over to this ER-type bed for comfort. Even when you are and advanced life support agency, you have your one set of drug boxes in the rig. You have another set of drug boxes in the echo car. There is no access to any other drugs. There is no access to any laboratory facility.
You are the patient's only hope of survival. By the way, you knew all of this BEFORE you were even paged. You lived with this possibility every day of your life, 24 hours per day, 365 days per year. You could be the only healthcare provider your patient could see for up to 48 hours. Even if you are an advanced life support agency, you have limited supplies, limited amounts of drugs that your patient needs, and never enough help. Boy, do you love this rural EMS !
It's what keeps you going every single day. It's a challenge. Tell me one EMS law in any state that covers this situation. Tell me one training session that you have attended in regular paramedic school to prepare you for this situation. Our average, AVERAGE, patient contact time is three and one-half hours from the run beginning and run completion including restocking and paperwork.
Our shortest was the run to the local airport where a lady had tripped and fallen and fractured her hip. Our response time was 5 minutes. Splinting, backboarding, and loading her on the cot and into the aircraft took fifteen minutes. The flight to the city took 20 minutes. The City EMS trip to the hospital, after unloading the patient from the aircraft, was about ten minutes. Our shortest ambulance run without the trip back to the service area and the stocking and the cleanup was 50 minutes. If you add the time in the hospital, the return trip to the service area, restocking, cleaning, and electronic reporting, you can at least double that amount of time and then add some. We would guess about two hours is the MINIMUM amount of time spent on each ambulance run.
In Grand Rapids , some ambulances run ten ambulance runs in one twelve hour shift. Beginning to end averaged out, this is definitely quicker than our minimum without any down time, coffee and donut time, or any networking time. As I have already stated, our longest ambulance run on record was 48 hours of responsibility for the patient. The cause of this situation was two days of solid fog in which no airplane or helicopter could fly, and there was no other mode of transportation at that time of year either.
On a day in May, Rural EMS is paged to the power distribution grid for an electrical worker who is down. The “man down” page is almost always one which will require every bit of skill that an EMS provider can put together and employ. This man had been working at this location on the electrical wiring at the substation on this corner. He had been electrocuted. On the arrival of the ambulance, two first responders were performing CPR. EMS took over the CPR and patient assessment continued. We noted multiple burns on his hands, chest and head. Some of his clothing was smoldering. The clothing was removed, and an automatic external defibrillator was attached.
“Stop CPR,” I yelled due to the tension of the incident.
The AED advised, “Shock Indicated”, all participants were clear of the patient, and one shock was given. The message from the AED, “No shock indicated. Check pulse.”
Upon checking for a carotid pulse, the pulse was not present. The patient was transported with CPR being performed enroute. CPR in the ambulance. CPR in the aircraft. CPR in the City EMS ambulance, and CPR in the door of the City Hospital . The patient had 100% oxygen, his respirations were being provided by an EMT using a bag-valve-mask. The patient arrived at the closest hospital as quickly as anyone could get him there. Unfortunately, this patient was pronounced dead in the ER. We had done everything we could for this patient. We had gotten him to the ER as safely and as quickly as humanly possible.
Rural EMS learned that, even doing everything right, all patients may not survive. We grieve for ourselves, for our community, and for this patient's family. Even though we did our best, we lost.
In June we were paged to the southernmost region of our service area, for a 77 year old male patient. He had been in the hospital for a knee replacement and was discharged and sent home five days ago. He had two episodes of rectal bleeding this morning with dark red blood noted. The patient had made arrangements to get to the city doctor's office this morning early, but when he had gotten up, he became lightheaded and was unable to continue the process of getting ready to leave. That was when we were paged to come down to help get him to the hospital.
Upon our EMS arrival, the patient was on the floor. His pulse oximeter reading on room air was 92%. His skin pale, cool, but dry. He was complaining of knee and back pain, the same knee that he had had the surgery on. He was alert and oriented. We placed a pillow under the knee with the pain, and that seemed to help with the pain.
His vital signs were somewhat normal, but we noted that he had atrial fibrillation with an irregular heart beat ranging from 96 to 128. Rural EMS was paged just a little before 8 a.m. The patient had been put on a blood thinner to prevent clotting due to the atrial fibrillation clot formation that is likely. The patient's blood pressure was presenting postural problems. When he sat up, his heart rate increased to the highest, and his blood pressure plummeted from normal to 90/60. The patient needed some additional fluids. Circulation was shunted away from his arms making location of a vein difficult.
The RN and the EMT-Specialist both attempted IV insertion and finally got a 20 gauge catheter in the right antecubital area on the opposite side of the arm as the elbow. Transport was delayed due to weather. The Rural EMS ambulance waited at the local airport for the weather to clear. We left the residence at 8:30 a.m., and were still waiting for the weather to clear at 9:45 a.m. Our medical control doctor was quite aware of the situation as we maintained radio contact throughout the wait.
The local airline were not able to fly until the weather had cleared, so contact had been made with the USCG Air Station, and a helicopter had been launched to our service area. We had not idea when or even if the helicopter would arrive. Our waiting period always seemed very, very long with each minute seeming much longer than a non-emergent minute.
One of the older pilots, seeing us waiting in the ambulance, came over to the driver's side of the ambulance and asked, “What are you waiting for?”
“We're waiting for the Coast Guard helicopter,” our driver answered.
“How long before they get here?” our experienced pilot asked.
“We're not sure,” the rural EMT responded from the back of the ambulance.
“If you don't mind flying with me, we leave right now,” was his response.
The decision was an easy one. Wait for a helicopter without an estimated time of arrival or leave now with a very ill patient. I think you know we chose to leave now.
The patient was flown by the local aircraft with EMTs aboard. While ten minutes into the flight, we heard communication from our ambulance to the helicopter.
“Rural EMS , this is helo 3445,” from the helicopter to the ambulance.
“Go ahead, helo 3445,” our ambulance responded.
“We are ten minutes out from your airport. Can you give us an update on patient condition?” the helicopter requested.
“Helo 3445, this is Rural EMS. We have tried to contact you for more than ten minutes. We have arranged alternate transportation for our patient. The patient is currently enroute to City Hospital via private aircraft. Thank you very much for your response. It is certainly appreciated,” our ambulance replied.
“Rural EMS , no problem. Glad to be of help. We will return to base. Out,” the helicopter radioed and began the return flight to the air station.
Our patient arrived at City Hospital without any further complications to his condition.
We were to learn that he was later transferred back up to a level two hospital where he had had his knee surgery and where he could receive treatment from his cardiologist.