In all the discussion, bickering and complaining about what EMS providers should be called (EMT, Paramedic, Ambulance Attendant, Steward etc etc) I got to thinking about the first part of my current title:

Firefighter.

Walk into a room in most places on the planet, say you are a firefighter and I think it safe to say everyone knows what you do.  It has something to do with a big red truck and water and red stuff.  The specifics aren’t important and where you work isn’t important.  Or is it?

If I walk into that room as my 18 year old self I am a Firefighter following a 40 hour volunteer firefighter academy.  40 measly hours, yet I carry the same title as my counterparts in San Francisco, New York, Seattle, Los Angeles, Boston who have spent upwards of 18 weeks on the material.  They have more hands on training, more book time and a greater ability to do the job, but our titles are the same.  2 completely different skill sets and levels of education, same title.  No one who calls the Fire Department wonders how many IFSTA Certified, NFA FireFighter Level II’s are coming.  They care about how many firefighters are coming because what they need are people who can do the job.

At a car accident, no one has ever turned to a friend and said “Quick, call the EMT-99s this person is injured!”  No one holding a cyanotic child screams “Help! I need 2 Nationally Registered EMT-Basics trained to the new curriculum!”

They shout one of 2 things:

“Call the ambulance”

“Call the Paramedics”

The Paramedics

I say we run with it.

I am in favor of calling pre-hospital care providers Paramedics even though there is a large gap in the training, experience and capabilities of the many levels from sea to shining sea.  They don’t see the shiny patch on your shoulder is different than your EMT partner, nor do they notice you only inserted an OPA as an EMT instead of an ET.

They need help. We are it.  They call us what we are.

The  Paramedics.

Heck even most of us in the job are unsure exactly what a Paramedic should be, so what a great time to come together as one for once.

To those who will immediately back off and claim, falsely, that they earned a different title than the EMT when they completed their 2 year Paramedic program, come back when you’ve completed your Bachelor’s in EMS and tell me if you feel the same way.

My name is Justin Schorr and I am a Paramedic.  I have been a Paramedic in my patients’ eyes for almost 20 years, even though my little slip of paper says only 10.

We added a new CE source awhile back and they recently earned a permanent spot in the CE group.

Take a big sip of milk and click on this link to the most recent post at Ugly Things for Sale entitled, “There is nothing about this post I don’t like”

I haven’t laughed like that since they tried to convince me the King tube is better than the combitube.

This is good for 48 CEs for the author of that blog.

LATE EDIT -

Speaking of CEs, I’ve added Rogue Medic to the Mutual Aid Board, but will also give CEs for his insightful posts and unyielding desire to CITE HIS SOURCES when making an argument. I find people who make claims they can back up fun to read and great to learn from.

By the way, your CEs are only good for your Happy Medic refresher, so no more emails asking for the certificate provider number for your National Registry. Even though I’m sure they were a joke, I just wanted to set some ground rules for you new folks. Both of you.

I’m adding a unique blog to the Continuing Education Board here at Happy Medic Head Quarters.

The Engine 17 Project chimed in on a recent post and I’m intrigued. The author is finding the original Engine from his childhood neighborhood and restoring it to it’s prior glory.

The updates are coming slowly, but that is understandable with such a project. Click over and catch up, won’t take more than 20 minutes and counts as a full hour of CE’s for your refresher.

Plus she’s an ALF 900 series. Happy is in the market for this Engine’s cousin, the ALF 100′ tractor tiller.

A special welcome to a newcomer on the Mutual Aid Board, a new site I caught on day 1 following along on Twitter. Firecritic.com has some great stuff so far, with just enough angst between the lines to have your old pal Happy grinning and giggling.

Giggling aside, attached to a good piece about the Mexico daycare fire is this great video about residential sprinklers. This should be required viewing for every municipality considering requiring the installation of the little life savers.

As I was watching it and marveling at the effort someone went through to build the prop only to light it off, the nozzle team comes in and makes me pause the video and rewind.
Are they still teaching this “cool down the ceiling with fog” stuff in fire college? Watch the video:

I posted a comment over at Fire Critic and wanted to expand on it here. I was taught more than a few years ago about cooling the ceiling with fog, then I had a chance to try it in a residential fire. When the darn thing kept burning I chose to aim the wet at the red and, wouldn’t you know it, the air stopped burning too.

Perhaps fire works differently where you are, maybe I’m in a vortex, but watching the amount of steam that escapes this prop when hey “cool” the air takes me back to how hot that hallway got when I tried it for the last time 10 plus years ago.

Yes, yes, I know, the fire went out. My point being, has anyone else noticed that a smooth bore from a distance works better and removes this need to “fog above?”

I am curious to especially hear from Nottrainedbutwetryhard, Lt Morse and the Road Dr on this one, mainly because I think they show a nice cross section of both readers and departments. (I only know one of them, that’ll do.)

To fog or not to fog, that is my question.

By all means, call 911 if you have been shot, or if you believe you have been shot.

Disclaimer aside, I think I had been watching too many movies over the last few years and reading into things.

A couple years ago I responded to a unique shooting. A man states there was a knock at the door, he opened it and a man he had never seen before shot him in the genitals.

I didn’t buy the “I don’t know who it was” excuse, but he had indeed been shot in the genitals. Treatment went smoothly and after transferring him to the ER staff, I started to wonder why someone would shoot someone else in the genitals.
“A message” was the decision I came to. Maybe too many mob movies or shows about the “Honor among thieves.”
Perhaps there had been an affair and the shooting party wanted to send the message that the affair was over. It made perfect sense at the time and we moved on.

Fast forward to a few weeks ago when I encountered the same kind of call. Different fellow this time, but the story was the same. Knock at the door, open, bang, ouch in the sensitive place.

I commented to one of the officers at the scene that I had seen this before and he laughed. He explained to me that the injury is likely self inflicted. It seems folks who shove guns into their waste bands rarely understand basic safety measures to take with a firearm. Then the friend who was nearby takes the likely illegal weapon away before we arrive. (Rarely do folks who have legal weapons remove them before police arrive.)

It seems folks are shooting themselves in the personal place while trying to carry a gun without a holster.

Go figure.

I was wandering through the sea of subscribers that is the FireFighter Nation awhile ago when I came across the avatar of Donald Noss. It is an image of a man standing in what looks like a burnt out kitchen, not in fire gear.
I sent a quick message, curious as to the image and got quite the interesting response.

Donald was standing in the remains of his kitchen at the Heritage House Condominiums in Rocky River, Ohio in 2006.

A late night fire raced through the building trapping many residents, including Donald and his wife, with no warning.

What followed could only be described as a perfect storm of difficulties and errors.
Donald wrote a book about his experience in the fire as well as the questions he had after the fire. Questions many firefighters never consider either when pre-planning or during a firefight.

The most amazing part of this book is that it is written from the viewpoint of someone in the panic of being trapped by fire, unsure of what to do or where to go, not some Fire Officer with 20/20 hindsight and an understanding of fire behavior.

On the third floor, they are awoken by a voice calling from the courtyard below. A police officer saw the faint glow of their TV on and is trying to help. Looking out the window they see flames climbing over 50 feet into the night sky. They hear no alarms. They hear no sirens. The officer calls on his radio for a ladder. No one is answering. They are on their own.

I ran back to the kitchen again and stared at the entrance door for a few seconds trying to figure out if we had to make a run to the south end of the building no matter what I remembered Drew telling me a few years earlier.. The hallways were quiet, but I knew they had to be deadly. .Why were they so quiet? .For a second, I thought maybe everyone was already dead.. I was scared and didn’t want to run into the smoke, but the fire was huge and heading for us. .And I didn’t know if there were any flames near our front door leading down the building’s long third floor hallway.. I knew they could be there but even if not, a tiny gulp of seven or eight hundred-degree smoke would be too much. .We had a long distance to run toward any exit.

The policeman on the ground tried to sound reassuring to us, but I could sense some panic building in his voice.. I didn’t know what he really knew and or was afraid to tell us. .He just kept saying, “they’re coming, they’re coming!” And then I wondered if anyone was even listening to his calls. .What was taking so long? We had to decide, right then! No second chances now. .Do we trust the policeman and the advice Drew gave me a few year’s earlier?. It was getting difficult to concentrate and breathe.. Do we Stay or Run? .I kept thinking about this over and over as I ran back and forth from the kitchen to the living room window. .I never asked Linda what she thought about trying to run out of the condominium.. Time was up.”

This book includes photos from both before, during and after the fire as well as dispatch transcripts all in an effort to learn why the fire spread so quickly, so quietly, killing the author’s friend and neighbor, Christine McSteen after she had been told to stay in place, a rescue was coming for her.

“…contact was made with Christine McSteen in unit #309 during fire suppression in unit #308 and she was told to go to her window to be rescued. Later she was found deceased.”

Through Donald’s eyes and words firefighters can learn what occupants are feeling, thinking and doing when you haven’t even been dispatched yet.

The most interesting part of the story, in my opinion, is that this happened 6 years prior and the problems were supposedly fixed. Firewalls in the attic, standpipes and a new alarm system. Did any of it help?

The Fire Chief says this fire was fought “by the book,” but won’t tell Donald what that means.

Link HERE for more details on the book. Read it and have a better appreciation for what your victims are going through while you’re “getting the glory” on the nozzle.

When trying to change a system, sometimes it’s important to start over in your mind and build an ultimate system, then try to meet in the middle. With that in mind, I find the following notes in the margins of my project notes. Not sure if they’re the ultimate side or the middle part. Thought I’d share.

Still hospital based! MD on staff but call ER for permissions? Why not operate under MD staff only?

Fire based FRU (fast response unit) home visits? Hour unit usage? Burnout?

Coughing considered contagious for decon? Decon air?

Redefine “patient” from medical side, not public side

I know what I can do for them not what they think they need, but they decide when to go.

Send ambulance implies transport needed, send motorcycle they get the idea.

Private ambulance for sick calls pre-scheduled

Permission to contact person’s MD at all hours could get them to actually see their patients and reduce call volume

Community clinics with special units who can transport for suturing to the clinic instead of ER

Dental unit? No.

That last one is near some sloppy notes, maybe I was partially asleep. I can hear it now, “Special needs dispatch for Dentist 3!”

I have met my nemesis, the Invacare TDX5 with tarsys. Those of you who don’t know what I’m talking about will soon learn where your medicare money is going and how I got a great workout yesterday.

First, the closest picture I can find of my new friend, the TDX5:

The TDX5 power chair is midwheel drive and uniquly designed to recline the rider by remote to seek comfort in various positions as a result of injury or illness. This requires the 4 stabilizing wheels shown front and back which angle outward when reclining. They’re designed for stabilization, not so much for pushing. The chair shown is from a blog of a woman who uses it.
The chair I encountered was custom built at a cost of $25,650.

That is not a typo. Her invoice from the supplier (name withheld) states medicare covered the entire amount of $25,650.

The TDX5 I met had full controls for the passenger and the “pusher.” this allowed anyone standing behind her to control movement and recline at the push of a button.
The foot rests were custom made to her exact dimensions as were the arm rests.

For those of you thinking I might be against chairs for those who need them, think again.
This looks like an excellent piece of technology to assist those who have pain I could never imagine.

Let’s move along to when I met my lovely TDX5.
Dinner was just being served at the firehouse when the call came out to “Assist a citizen.” Before we can get going the phone rings, it’s dispatch. They paint the picture of a little old woman stranded at the local grocery store in her wheelchair and unable to move. We tell them all we’re going to do is plug her in and maybe the store can help, but no answer.
This location is notorious for folks getting off the bus with dead wheelchair batteries. I’ve even pushed a man across the street to plug him in, as you’ll remember.

We arrive to a familiar woman, often found shouting profanities from the floor near her bed after falling out, again. She is also known around town for the elaborate rigging of PVC pipe on her power chair which had netting, a tarp and, I’m not kidding, fog lamps for driving at night.

But she is not in her regular chair, she’s got a new TDX5.

“New chair?” I ask walking over to where the charger should be attached.
“I just got it today, but the battery died. I need a push home.”
“We don’t push,” says the officer looking to me to plug it in, but the charger is not hanging in the spot engineered for it to sit. It’s a seperate unit (Maybe 4 pounds) with the wall plug and a power inverter. Why they don’t just build it in, I’ll never know.
“Where’s your charger?” I ask looking over the amazingly outfitted chair.
“I didn’t need it, the battery said 50% when I left home.” It was then I noticed the large tags still attached in places.
CHARGE BATTERY FULLY PRIOR TO OPERATION

After a few minutes of trying to figure out how to charge it, the boss asked her where she lived. The other firefighters and I knew exactly where she needed to go, 3 1/2 blocks away.

The middle wheel drive TDX5 has 2 motors which allow it to turn like a tank, on a dime. We were able to release the motors so the chair could be pushed. And push we did.

Some specs on the TDX5:

Power wheelchair with mid wheel drive.
• Comes with TrueTrack technology
• SureStep Suspension
• MK5 electronics
• Center Wheel Drive and Stability Lock.
• Speed: 7.5 mph maximum
• Seat To Floor Height: Min. 16.5″ @ 0 degrees tilt; Max. 21″ @ 5 degrees tilt (18.5″ and 19″ with Tarsys respectively).
• Product Weight Capacity: User weight capacity – 400 lb. with ASBA, 350 lb. with Tarsys, 300 lb. with Tarsys and vent.
• Overall Height: 34″ with 16″ back height; 37″ with Tarsys and 22″ back height.
• Overall Width: Base: 25″. Seat width to outside of joystick (16″ width): 24.5″. Seat width to outside of joystick (20″ width): 28.5″.
• Turning Radius: 22-24″ depending on riggings. • Arm Height: ASBA/2GT: 9-13″-2GR/GTR: 10-16″.
• Incline Capability: 9 degrees.
• Overall Length: Base (caster to trailing caster): 35″.
• Product Weight: 314 lb. (with ASBA seat),388 lb. (with 2GTR Tarsys).

The chair alone weighs 400 pounds. Add in our 200 pound patient and we pushed 600 pounds 3 1/2 blocks to her apartment. All the way she told us about all the features of her new chair as we weaved through the tourists and curious onlookers. It swerves quite easily with 2 of us pushing so many minor adjustments had to be made.

When we finally arrived at her apartment we opened her door to the familiar smell of stale cigarettes and there it was, glaring like a wife might at a husband home later than expected. The old chair.
“Is it broken?” I ask, stretching my back.
“No it works fine, the salesman said I could get a new one free, so I did.” she said happily, as she moved first her limp legs, then her tired body from the new dead chair to the old working one.
“So why get a new one if the old one still works?” My fellow pusher asked noting the dozens of extension cords criss crossing the room.
“This one was built just for me!”

In the end we spent over 45 minutes pushing that chair from where she was to where she needed to be. It’s hard to imagine a fire engine being deployed to push a 600 pound chair with occupant home, but that’s more and more what our job description requires.

I took this as a chance to learn more about the technology available to those with mobility issues and thus have come to admire the TDX5. From a distance.

Firehouse Magazine contributor Daniel Byrne has a great article in the April issue that just came into HM HQ.

In it he tackles the issue of college educated recruits and how the mission of the Fire Service has changed to the point that advanced learning can actually be a plus instead of a hindrance.

I’ve heard many a time that “college boys” had no place in the firehouse and that they could never learn “with all that stupid crap in their heads.”
I never told them I was a college boy. When it sneaks out that Happy has a bachelor’s in EMS, they cock their heads and say things about how funny it would be if I was telling the truth.

But there it is on the wall here at home, framed next to the wife’s degree, Medical School tassel proudly hanging form the corner. Wow did those Pre-Med folks hate having us next to them at graduation. We weren’t real Medical Students while attending and then weren’t real firefighters when we got out.

Byrne’s article is available on the Firehouse.com website for registered members, which I am not, and I hesitate to reproduce it here for obvious reasons but I would like to add in one quote that made me smile.

“If you think your college-educated rookie, who has a proven ability to learn and comprehend difficult concepts, cannot grasp the basics of our job, then the problem may in fact be yours.”

Find a copy or subscribe, this article alone is worth it.

Just in case I invented this technique, I’m calling it the Happy Inverted Trendelenburg Leveling Airway Stabilization Technique or HIT LAST. Hence the late Dr Trendelenburg inverted here.

We are always taught to deal with supine patients, but how many of them present differently? Most often when we find them we manipulate them into our treatment position. But that isn’t always best.

We responded to a female who had not been seen for days and was found prone on the bedroom floor, emesis of varying type and time drying on the floor near her face, which was slightly turned to one side, likely saving her life.

She is unconscious, responding to loud verbal and pain only with mumbles clogged with emesis. The textbook says to roll her over and manage her airway. I figured since her body has been dealing with this for sometime, I’ll trust it has an idea how to solve it. As she’s breathing I can hear the stridor and the aspirated emesis is still pouring out slowly. Some may argue it was spilling from the esophogus, but I have to assume at this point it is coming out of the airway.
Her O2 sat is in the 80′s and her pressure is in the 60s, but I’m still hesitant to roll her over and create a natural blockage for all that junk to roll right back down into her lungs.

Then I got an idea.

All we had were a bunch of police officers at the scene who broke down the door for the well being check, so I put them to work. We ruled out trauma, so the unfamiliar movements we were about to perform could be handled by unfamiliar hands.

I fired up my suction with my airway kit open and ready. I instructed the legs to be lifted slightly first, just about a foot off the ground. When they were set, I had the next two officers, positioned at her waist, lift her mid section about 8 inches off the ground. When the wave came, I was ready. We gathered close to 200 cc of emesis from that movement and the stridor cleared. Since gravity was doing all the work, I was able to get fluid a supine patient would have choked on. She coughed a few times, understandable, then her sats started to climb after replacing the O2 we had on during set up.

Now supine and onto a board for removal and her lung sounds were far better. Not perfect, but better than the globs of fluid I heard earlier. Not even rhales, ronchi or bubbles, but sludge like. Like when your foot sinks deep into a mud puddle. Now I hear ronchi.

Code 3 to the ER she’s satting 99% on high flow, color is improving and she’s opening her eyes from time to time while taking 10 good solid breaths per minute.

At the ER, after RSI meds were administered,(gag intact pre-hospital) the Doc’s have that fancy slide scope, the one with the camera on the blade. They see all sorts of chunky goodness my mighty suction couldn’t clear that she was breathing around. Stuff so old it didn’t wiggle when she breathed. Her pressure was over 100 and a nice narrow complex rhythm was beating along as they intubated and “stabilized” her.

When I described my actions to the Docs, they smiled and said, “Yeah, that works alright.”

It’s not an A list intervention, but in this case I think allowing the junk a natural escape assisted with suction was the way to go. Many may argue that immediate full supine access and intubation would have been the way to go, but she still had a gag reflex in place and I have no access to alternate intubation methods. Yet.

So the HIT LAST is born. Keep it in mind the next time you hear that voice in your head say, “Oh crap, this airway sucks.”