Reader BG Miller left the following comment on my post about how a seemingly NBD (No Bog Deal) chart could be the most important one we write:

Okay, question from one of the non-EMS readers…
One of the injuries being listed for Zimmerman is having his head bounced off the concrete one or more times.  So you have a patient with a possible head injury who is experiencing great emotional stress and possibly shock, (unless he is a complete psycho, but that’s another argument) is he capable of signing a refusal?

Of course he is.

“Having his head bounced off the concrete” is not an injury, but a…wait for it…mechanism of injury, meaning he experienced an event that could have led to an injury.  Similar to saying “He got stabbed.”  Well, where, how deep, with what?  All those questions have to be asked to establish the extent of a possible injury.  So if I was told that at the scene we would transition, in my opinion based on little else, that this would shift from a refusal to an AMA consult with online medical control.  He’d also get a full work up in my office, not in the squad car.  Depending on the discoloration, shape, sound and feel of his injury (yes, I said sound) refusal may be out of the question.  Certain injuries can indicate that a significant amount of force caused it and remembering that the brain inside the skull can be injured just as badly, if not worse in some cases, can lead us to determine appropriateness for transport.

In my system, if a person exhibits trauma above the clavicles, they are candidates for full C-spine precautions.

Being capable of signing the refusal is an easy determination to make, it is when he should be evaluated and refuses is when it gets sticky.  This kind of scenario is when the lie of kidnapping gets added and we all panic and say we won’t kidnap the person who needs further assessment and just walk away.

Under ordinary circumstances getting his head smacked might leave him a bit dizzy but aware enough to decide on his own treatment.  Under ordinary circumstances a fight/shooting might put him under emotional stress but able to understand the medics treating him.  But what about when those two are combined?  Does that change your interaction with him as a patient?

As I mentioned above, if you as a witness tell me those things happened I need to better assess for an injury.  That is when we move to the ambulance, doors closed, lights turned up, so we can see everything the cops and their flashlights missed.  Funny thing  about cops, they are trained to look for weapons, drugs, offensive motions etc, but few of them have any clue how to assess for an injury. “He ain’t bleedin’ ” tells my nothing Serpico.  Bleeding is the least of my concerns.  From the cot inside the rig we can assess and if indicated initiate transport after convincing the patient it is warranted. “Look, you’re already in here, we could be there in 10 minutes and it’s done.” “You don’t need it? Well, you might be right, but let’s make sure, wadda ya say?”  If he needs to go, we can convince him it was his idea in the first place if we do it right.

Emotional stress accounts for most of my calls.  I often joke that we spot you 20 points on your blood pressure because of all the sirens.  If I had just shot someone I would be…well…I don’t know.  I would have to assume I’m jittery from the adrenaline of nearly being killed, killing someone, and now being assessed for an injury.  However, the down from that high could also be intense.  we all handle stress differently and can’t draw any conclusions from a person’s demeanor or level of calmness at the scene.

Also, having read a few cop’s take on self-defense shootings, it seems common that the problem the police face isn’t getting the shooter to talk to them but getting the shooter to shut up long enough to be mirandized.  Like someone that’s been through anything traumatic they tend to babble a bit.  So as a medic do you note what they are saying in your report?  “Came out of nowhere,” being mumbled will have a different spin in court than, “I shot him.”

I too have seen a tendency of purposeful shooters to not stop talking, mostly of the walk by and drive by variety, boasting of their accuracy or the severity of the wounds of their target.  When it comes to documenting their responses or comments, I stick to what is medically pertinent.  In this case, since the patient was involved in a violent action I will have PD in the ambulance with me and searched prior to being placed in the ambulance.  If he mumbles something it is the officer that needs that information, not me.  I could not care less why he did what he did, I care about his injuries.  If he mentions “Dude had a baseball bat and then everything went dark…” I note the bat because it directly impacts my impression of the injury.  Other details we’re better off pretending we didn’t hear and let the police handle it.

Thanks for a great question.  What about you fellow EMSers?

Or he…I dunno.

What I do know is that the Trayvon Martin George Zimmerman situation has got us right back at each other’s throats just in time for the weather to turn nice (sorry Kansas, I didn’t mean it that way).  With the release of some video of the suspect in the police station soon after the incident surfacing, suddenly everyone is a medical expert.  Trouble is, there is only one document that can solve this problem of “was his nose broken and head bleeding?”

The PCR.

According to reports the suspect sustained injuries and was given “first aid” in the back of the police car by paramedics.

Now, because it’s the “media machine’ we have to assume everything specific is actually vague, right?  So it may have been a BLS unit, a police officer/EMT or a full fledged ALS response unit.

Despite your preconceptions about the case, because you DO have one regardless of the facts, imagine yourself on this response: (I designed it this way, this isn’t how it happened)

PD requesting ALS unit code 3 for GSW victim.  On scene they advise the victim is DOA but another person, in the back of the police car in handcuffs, needs medical attention.  Your partner confirms the DOA while you attend to the person in the police car.

After assessing his injuries, what does your chart include?  That he is in the police car?  handcuffed?  Is he in custody?  Under arrest?  What about your physical assessment?  Is it any less complete because he’s sitting in the back of a police car at night?  Do you move him to the ambulance?  Do you bandage wounds?  Do you clean wounds?  Do you clean clothes?

After deciding a refusal of care or no indication for transport, how is this documented?  Refusal? AMA? It depends on the injuries, sure, but if the patient is handcuffed in the back of the police car, does your system have a cut and dry policy for who can sign for them?

All these questions of what happened when and to what severity are hinging on what could possibly be a poor chart.  A chart that will not only be seen in court, but the way things are going, will be plastered all over FOX News and MSNBC for years.

Writing your chart for CYA takes on a whole new meaning these days.  Do it right. Every time.  You never know when a seemingly straight forward case hangs a hard right turn and crashes into a wall.

I’ll leave comments open if they focus on the importance of documentation in an EMS reference.  If I start to see a “debate” of the race-baiting, racist, self defense, stand your ground law, gun nut, 2nd amendment hater BS this has turned into I’m closing comments.  Let’s talk EMS here folks, sheesh.

At last year’s How to Become a Firefighter Workshop here in Northern (some will argue Central, long story) California, I presented on technology in the job hunt, focusing specifically on the pitfalls of social media.  It is a fantastic all day seminar held at the Las Positas Fire College and includes lunch cooked by the students.  The cost of the seminar? $12. Including lunch and a chance to speak to the people hiring you one on one, let them preview your resume etc.  Where was this when I was getting hired?

The seminar attracts Battalion Chiefs, Division Chiefs, Officers from a number of large metropolitan departments and someone you know who writes a blog.  Our pals Judon Cherry, Chris Eldridge, Sam Bradley and Thaddeus Setla helped film the video for the program and this year Judon and the Dridge were there again.  Oh, and I have nothing to do with the kick ass indexed screen shot BTW.  have a look:

The attendees had some great questions about facebook, twitter, email a whole host of issues, but one comment from the audience stood out and has caught traction recently.

In my presentation I mention that some employers are asking that you friend their HR director on facebook prior to the interview.  When I mentioned that the Chiefs you’re speaking with may want to friend you as well, one of them spoke up from the audience,

“I don’t want to be your friend, I want your password.”

The audience was silent.

If you were one of the final applicants being considered for this job, would you give a prospective employer, or anyone for that matter, your facebook password?

It could be considered an invasion of privacy, but I can’t think of a better way to see what someone does when they think no one is watching.  And with the way that an employee can ruin a department’s reputation with the simple click of “share” I think it is reasonable to ask for it.

So this year, when I gave the presentation, we discussed the privacy settings pages and how to eliminate tags in photos perhaps you wish others had not uploaded, comments on posts that maybe you made late at night after drinking studying, or perhaps something rather inflamatory, deragatory, racist, sexist, heterophobic…you get the idea.

It’s actually a good idea for everyone to visit those pages every few months just to check and see what you look like from the inside of social media.  We make comments to one circle of friends the other circles may find offensive, but is any of that going to be considered immature, dishonest or a misrepresentation of who we really are?  It matters greatly if the three key traits an emploer is looking for are maturity, honesty and trust.

What do you think?

If you got called up for your dream job in the fire service and they asked for your password, what would you do?

CISD – Critical Incident Stress Debriefing

OK GO – A band

Well, here we are, all healed, healthy and past whatever it was that was stressing us out.  We went through the steps of recovery, from anger to denial to acceptance, but now we have only one more lesson to learn from the guys of OK GO.

Conveniently enough it is their first video that went viral oh so long ago.

In this funny treadmill video we learn the most important step of healing:

That this will all happen again.  And you should have known it would.

Just when you think that you’re in control,
just when you think that you’ve got a hold,
just when you get on a roll,
here it goes, here it goes, here it goes again.
Oh, here it goes again.
I should have known,
should have known,
should have known again,
but here it goes again.
Oh, here it goes again.

It starts out easy, something simple, something sleazy, something inching past the edge of the reserve.
Now through lines of the cheap venetian blinds your car is pulling off of the curb.

And this concludes CISD with OK GO.  If you are having trouble sleeping, eating, feel your moods are shifting, or are experiencing any of the symptoms I mentioned in this series, please consider reaching out to a professional.  It’s easier than it sounds and the future you will thank you for it.

CISD – Critical Incident Stress Debriefing

OK GO – A band

If you’ve made it this far you have had trouble sleeping, drinking, eating, sleeping, talking, walking, holding conversations, holding your temper…you’ve run through just about every human emotion trying to come to terms with the event that has caused you so much trouble.  Keep in mind this could be a minor injury like mine, a serious injury like some friends of mine, a tough call at work, even a rough patch at home.  Anything can trigger a stressful reaction and much like a severe allergic reaction, there is no closing the feedback loop and we simply get worse and worse and worse.

As we’ve covered previously, reaching out for help can seem daunting at first, but it needs to be done.  No amount of internalizing will help you get through a stressful event.  Regardless of  what the thrice divorced EMS Anchor tells you about sucking it up, we need to address our emotions and understand them to recover.  It sounds all new age and touchy feely, and in a way it kind of is.  You are unable to handle somethings emotionally.  Only by understanding what and why can you later learn from it.

And when you accept help I mentioned a brief silencing of the chaos in your head.  Soon after that silence disappears something you do will begin to help you heal the emotional wounds that were opened.  You will wake up one morning without being upset.  You’ll still be a might disagreeable, but like having the flu, you don’t wake up healthy, each day just sucks a little bit less.  Then a little bit less, then a little bit less.  Then one day you remember being upset and smile, realizing that this too shall pass.

And then you see it in a different way, each part of your recovery laid out in front of you, but all the parts need to work together or else it stalls and you have to start again.

You can’t keep letting it get you down.

I got an email a bit ago asking if I would review a first aid kit.  My first response was “no.”  What do I need a first aid kit for?  I’m a Paramedic and carry a second, third and fourth aid kit when I work.

It was later that week when I was at a local shop that I began to wonder what kind of first aid gear they had on hand.  I decided to ask the odd question of the kid behind the counter, “Where’s your first aid kit?”

“Um, I don’t think we have one,” was his reply.  I got out my phone in the parking lot and asked to review the kit.

The Magid First Aid Kit is the most basic of first aid kits but packs a lot of useful gear into a tiny package.

The kit is contained in a sealed rigid plastic box with a mounting handle and clear lettering gives away its function.  Inside is a variety of early intervention gear in case of a job related injury.  Now, let’s be honest from the get go.  This kit is not suitable for the crane operator at the new Trump Tower.  This is geared towards the mom and pop restaurant, car rental center or other business that doesn’t expect an injury, but may want to act quickly to address some common ailments.

The main benefit of this kit is, unfortunately, the biggest drawback.

We in EMS have all seen that beat up metal box that some businesses use for first aid before we arrive on scene.  You know the one, dented box, yellow tape, antibiotic cream that expired in 1988.  This kit is designed to keep unused gear sealed up and safe from being thrown to the ground in a panic.

To test this kit, I placed it on my workbench and went inside the house.  Then, in true Paramedic fashion, I pretended the wife had just slumped over unconscious.  I ran into the garage, grabbed the kit and opened it.  Everything fell to the ground.  Easily read was the first thing I needed labeled CPR mask.  It took 17 seconds of panicked tearing at the packaging to get it open.  However, in my panic, none of the other items were on the floor getting stained, opened or discarded.

Each item, except for the nitrile exam gloves (2 pairs) are wrapped in plastic to protect them from the nervous rifling hands of someone dealing with an emergency.

The next test, I envisioned myself with a deep laceration to the hand which allowed me only one hand to open the kit and the packages necessary to treat my wound.  Again I was met with the difficulty of tearing the packaging open with my teeth.

I thought for a good while about whether this was a benefit or a drawback and I’m leaning more benefit.  This kit is designed to be placed in a place of business and there’s a good chance someone will be there to help get the packaging open if need be.

The kit contains a good variety of first action interventions including:

Burn Dressing, 4″ x 4″

FAGUIDE  First Aid Guide

Triple Antibiotic Ointment 6

Alcohol Pad 10

Antiseptic Towelettes 10

Woven Adhesive Bandages

2” Gauze Roll

3” Gauze Pads 4

Triangular Bandage with 2 Pins

Absorbent Compress 5” x 9”

Nitrile Gloves 2 PR

CPR Shield

First Aid Scissors

Tweezers

Ice Pack

Burn Cream 6

Hydrocortisone Cream 6

Adhesive Tape 2

Insect Sting Pad 10

Eye Pad with Adhesive 2

4” Bandage Compress

Eye Wash 4oz

The scissors in the kit are tiny and strong, not the usual giant EMS shears common in some other kits.  The tweezers are small and tough as well and won’t rust when someone inevitably spills the eye wash on them.

The boxes of items are color coded blue, green and orange.  The gloves and the CPR shield are orange,  the others are roughly sorted into bleeding and non bleeding emergencies.

Enclosed is a small, and I mean small, first aid guide that gives instructions on how to use each item in a given situation.  I would like to see it larger, but for the purposes intended I think it will work nicely.

In conclusion I recommend this first aid kit for small businesses, offices and other locations that don’t have a medium to moderate hazard level.  This kit really is the basic of the basic but can more than handle the everyday injury and have kit to spare.  And at less than $30, it’s a nice peace of mind knowing that the kid at the front desk can apply pressure to a customer’s wound, bandage it and put ice on it before help arrives.

Get yours HERE from MagidGlove.

CISD – Critical Incident Stress Debriefing

OK GO – A band

We’ve been discussing how the different emotions experienced after a traumatic event can be explained through the music of OK GO.  So far we’ve covered the initial responses to the incident, anger, in which everyone was asking us how we felt, are we OK? Leave me alone we said, Don’t ask me how I’ve been.  Then we stepped into the next stage of our faux recovery, denial, when we feel invincible.

Today we’ll look at the moment when you find yourself alone, likely in the middle of the night, unable to sleep, wondering “WTF is happening?”

Conveniently OK GO describes the same situation in their song WTF.

The opening lyric perfectly sums up how I felt just before my actual recovery began:

“I’ve been tryin’ to wrap my head around, what the fuck is happening.” (the official lyric says “oh well” instead of “around” but I don’t hear it)

That’s exactly what is going on in your head a few weeks into the recovery process.  Following the initial anger and quick invincibility phase is complete self doubt.  Confusion sets in and, like the video for this song, so much is going on in your head you just want it all to stop.  Colors, shapes, sounds, thoughts, so much races through your head leaving small traces of what just was only to be replaced by something else confusing and distracting.  Thoughts piled on thoughts piled on doubt.

Figuring out what is happening inside your head will take time and professional help.  You don’t need 3 sessions a week for a year, or even the indepth psycho analysis we often see TV cops going through, but someone who can sit you down, discover what step of recovery you are in and give you suggestions to work through it.  You will be amazed when one of those suggestions suddenly hits the pause button on all the confusion and noise in your head.  It is in that brief moment, and it is brief, that you can glimpse a life without the hurt of what you are feeling.  Of course the play button gets pressed again soon after leaving the office of the person who is helping you when you realize you are the only one who can put in the effort to get things started.

But when you do finally work up the courage to start that suggestion and give it time to work, the results will astonish you.  You’ll wonder how on earth you let yourself get so worked up over what happened.  You’ll realize that this too shall pass, our next step in recovery.

CISD – Critical Incident Stress Debriefing

OK GO – A band

After a stressful incident in fire and EMS we tend to use dark humor to work through our issues.  It is a natural reaction to try to laugh instead of cry.  It seldom works though and we feel a bit uneasy about making light of something so serious.  This doesn’t have to be a minor injury like mine, or a major one like some of my co-workers have been through, but stress comes from any kind of event that causes us to lose control a little bit.  Its that “WTF am I doing this for?” moment that begins the subtle flame of impending burnout.

As a defense mechanism most of us get tougher, try to grow a thicker skin and let it roll off our backs like it’s nothing.  No matter how tough your co-workers pretend to be they are suffering just as much as you are, they may just not realize it yet.  The longer you keep these emotions locked inside, the more that little flame grows until it spreads into other parts of your life.  Ever wonder why the divorce rate is so high in emergency services?  Some will claim it’s the schedule, but it’s the inability to control stress that leads to self destruction.  I was on the doorstep of said destruction, not because I got hurt, but because I was having trouble externalizing the fear of what would happen to my family if the next ceiling that falls kills me.  That thought lit the flame of my impending burnout.

My first response when that idea popped into my head was “Bring it.  What ever doesn’t kill me makes me stronger.” I had no idea at the time that in retrospect long after the event (like me here right now) we can see how we learned from the experience is what makes us stronger.  For a few weeks my fear of death was replaced by a hint of invincibility.  If that ceiling falling that far only rung my bell, how bad could I really get hurt?  I mean really?  I always took full safety precautions, I didn’t have a death wish, but the little voice that often told me to be careful crawling down hallways, or to duck when the truck was breaking windows was drowned out by loud music in my mind to energize me to keep going without fear.

I felt invincible.

But we are not.  Of course we know we are not invincible, but why are we acting this way instead of grieving properly?  At this point it is a good idea to talk to someone who has experience dealing with stress.  If unchecked, that growing flame inside you will soon be too big to put out without leaving some intense damage.

Next we’ll discuss which OK GO song reminds me of when I suddenly realized I had no idea what was going on and asked myself “WTF is happening?”

CISD – Critical Incident Stress Debriefing

OK GO – A band

When we get in stressful situations in fire and EMS we have a tendency to assume that being macho and “sucking it up” is the right thing to do.  Nothing could be further from the truth.  I speak from experience on this folks.

Fancy programs exist in some Departments for you to talk about what’s bothering you, but some don’t have much of a support group.  In my experience some of these programs are a bit intimidating, swooping in and asking us how we feel.

I don’t want to tell you how I feel. I want to just forget what happened and move on.  We don’t understand just how damaged we really are yet.  I know these folks have a lot of training in talking to folks suffering from a traumatic incident, but when I first reached out I felt almost smothered.

Friends and family would call me while lying on the couch wondering if my head was bleeding on the inside and ask how I felt, how I was doing.  How am I doing? A fracking ceiling fell on me and I’m on a host of meds and I can’t have caffeine or alcohol! I want to scream but am afraid the ringing in my ear will only get worse!  We get angry, upset, confused and begin to push away.  Every person I talked to wanted to ask me how I feel.

This is my response:

Just leave me alone.  Don’t ask me how I feel.  Quit acting so friendly…

The lyrics to this song fit so perfectly with how I felt soon after my injury that every time I hear this song I flash back to 2007 and wish I could make this the answering machine message.

Next we’ll cover what happens when we push everyone away and start to buy into the BS line that whatever doesn’t kill you makes you stronger.  Well, at least not right away.  We are not Invincible.

Stepping through the doorway into the run down house was like stepping into a light syrup.  The air was heavy and seemed to be nearly visible.  Rotting boxes, papers, food items and animal waste of many kinds was piled up against the walls as far as the Pup could see.  Two clear channels were dug into the waste showing carpet worn down through the pad to the wooden floors below,  like ancient Roman wagon roads permanently dug into rock.

Curiosity took over, thankfully distracting Pup from the odor of rot that was now permeating the crisply pressed uniform. How could someone live in this filth?  Pup got nervous when dishes were left in the sink to soak overnight at home.  The corner of Pup’s eye caught something running between the piles.  It looked to be the size of a small cat, but the chances were good that the creature was something else entirely.  Something that in other homes would be hard pressed to find food and a place to sleep away from predators.  In this environment, they thrive.

“Back here!” an officer calls, no urgency in their voice, but shouting as if the stench and heavy air will stifle regular conversation.  Following the ruts in the floor, Pup feels almost like a train, unable to turn off the path even if needed.  It was then Pup saw the doorknob.  Halfway down the entry hall was a door to a room.  Judging by the waste and trash piled in front of it, this door has not been opened in years.  A brief moment had Pup wondering what might be in there.  A memory too powerful to let out? The bedroom of a dead child?  Perhaps where this hoarding pattern began and the room is full of discarded items from decades ago?  If Geraldo Rivera was here, he’d want that door opened live on camera.

Carefully stepping over assorted animal and human waste in the hallway, Pup now stands in the doorway of the kitchen, near the far end of the hallway.  Here the officers have opened a window about 4 inches, “as far as it goes, the others have been painted shut forever,” the older officer notes.  There were 3 of them standing in the kitchen, as if late for a dinner party and wondering who gets the last of the guacamole.

Pup’s stomach did another back flip when thinking of the food and vomit was close by.  If this sensation was still present when encountering the body, it was going to make it out without a fight.  Pup began looking for the bathroom in case a mad dash would be needed but there was no dashing through this house.  Each doorway was covered in years of greasy, dirty hand prints where the occupant, or occupants, had tried to pull themselves over the piles of trash and into the next room.

After a cursory look around the hallway it suddenly occurred to Pup where the bathroom was.  The forgotten door in the hallway.

“Oh God, Oh God, Oh God” Pup’s inner child began to panic.

Led to a rear sun-room the odor is almost like a curtain.

There on the porch, lying face down, was an elderly man.

But something wasn’t quite right.  Pup was new, sure, but the amount of odor in this house could not be created by what appeared to be a recently deceased person.  At least not as deceased as the odor was giving away.

“Is this the only body in the house?” Pup asked, noticing the volume of the responses of “Why? He’s right there!”

Pup approached and noticed the discoloration of the parts of the man that touched the floor giving away that the blood inside him was pooling, not pumping.  The body is still slightly rigid, allowing Pup to avoid the awkward task of finding a clear level place to put down the cardiac monitor.

“He’s not the source of the smell, guys” Pup called out, voice also raised in an effort to be heard over the smell.

“Sure he is, he’s been dead for weeks, right?” An officer asked while coming to the doorway.

“No, he’s been gone only a few days, he hasn’t started decomposing yet.  Something else in this house is though.”