…is my email inbox at work.  Or my voicemail…whichever…

I knew our CQI position handled citizen complaints, but I had no idea how many there were.

“It’s a thankless job” they told me when I took it.  Like being a Paramedic in the City was a thankful job?

Almost like clock work most mornings I get a call from a person I’ll call “Bob.”

Bob doesn’t like the Fire Department, or my mother, or my race, or the fact that I am his employee since he pays taxes.  Bob was taken to an ER for a complaint and was shocked and appalled we were directed to place him in the triage waiting area after a nurse assessed him.  In other words Bob is 99% of our business.

Bob and I have a 30-45 second conversation about his most recent abduction by the Paramedics and how they assaulted him, robbed him and left him to die…at the hospital.  When I pull up Bob’s run history the computer returns “Seriously?”

Some may say Bob’s calls are a hindrance or a distraction, but Bob keeps me on my toes.  Bob is my window into the mind of someone who does not know our lingo, our policies or our commitment to his overall health and safety.  Others may say I should report Bob, but that’s what he wants, a reaction, and all I do is listen, explain and then he hangs up.  then I get a coffee.  It’s a routine we have.

Other  complaints vary from legitimate clinical concerns from local hospitals, to regulators who question charting, to folks who simply want to vent.

But my favorite calls of all are the ones I can tell in an instant are without merit.  Bob helps he spot them easier.  How do I know?  They don’t know our lingo.

For example, if you tell me the ambulance people told you they would “throw you out of the truck” you’re lying.  How do I know?  Because a “truck” to us is a giant 5 man device with a 100 foot ladder on the back and is big and red.  We do not call it a truck…only you people do.  And by you people I mean the ungrateful masses who demand our services in 4 minutes or less only to complain that we took you to the wrong ER, since they “kicked me out” earlier today.

Kicked you out did they?  How do I know you’re lying?  Because they don’t kick people out.

When people get bored waiting 4 hours for a refill of Plavix (which they were never going to do in the first place, we told you that) they leave or are told to go to the pharmacy, but they are not kicked out.

We stole your wallet you say?  (Keep in mind folks, I am required to investigate these complaints no matter what they are)

Doubtful since I recognize your name from my days on the ambulance and we keep track of these things.  2 years ago you claimed we stole $500 from your wallet, then 8 months ago another $700 and today the total is up to $900 and we somehow walked off with your brother’s bass guitar.  I’ll investigate this but I should warn you, the No Merit letter is on my desktop I use it so often. (The Further Investigation by Investigative Services Bureau Recommended is there too FYI).

But just for once think about what you are about to say to me in your complaint.  If the crew kicked you out of the truck how again did you get to the hospital for the nurse to sign our form that they accepted you?

If we stole your grandmother’s $2000 necklace, why can you not describe it to me?

I’ll take your call, I’ll treat it as true until I complete my queries, but put some effort into it first folks.  If you’re unhappy and make something up you’re just wasting my time and yours.  If you have a legitimate concern I want to know about it.

Think twice about questioning the professionalism of the folks who took care of you when you didn’t need it, only wanted it, and how they did everything you needed up to and including taking you to an ER you did not need for a reason you could have handled yourself.

But if they weren’t professional, if they didn’t do what you needed, I’ll be the first one to tell you so.

Talk to you again on Monday Bob.

Josh Kennedy Photography

“Oh Happy! How could you use such foul language on your blog?”

How could you use such foul language in your run report?

Two of the most misunderstood yet widely used abbreviations in EMS today are WNL and SOB.

They drove me nuts as a basic, troubled me as an intermediate, frustrated me as a medic and now that I’m in charge of reading all these charts, I’m simply disappointed.  And it’s not just my guys and gals either.

How many of you out there are noting ‘WNL” for a vital sign or in a narrative describing a patient’s range of motion, bruising, etc?  Yes you have, don’t deny it.

WNL – What does it mean?  It has multiple entries in the medical lexicon, including We Need Lawyer, We Never Looked and, down at the bottom, Within Normal Limits.  But even then WNL needs a qualifier to be accepted.  For example “WNL 79″ for a blood glucose level.  WNLX is an accepted medical abbreviation but only when the value (X) being measured is mentioned.  Simply writing WNL in the abdominal section does not count.

What gives me the most frustration, however, is that many folks apply THEIR OWN normal limits in this assessment, not those of the patient.  If the blood pressure is 210/100 and they state that is their normal, can we mention “WNL 210/100 per patient”?  Absolutely!  Please do, because that will guide me as to why you didn’t treat for acute hypertension.  A simple WNL for BP is shoddy documentation and makes me wonder if you even assessed the value and applied it to the entire patient presentation.

So, WNL can be used, but only if qualified.  Got it?  Good.

SOB- Commonly referred to in EMS circles as Shortness of Breath, but that’s about it.  outside of EMS, most notably in legal circles, it can mean something else entirely.  Officially SOB refers to See Order Blank unless, wait for it, it is given a qualifier.  For example, SOBOE is official for Shortness of Breath on Exertion, but a simple SOB is not enough to describe the patient’s condition.  When looking at the Chief Complaint drop down you may find a fancy word dyspnea.  Dyspnea is defined as the perception of respiratory discomfort, so someone can’t technically be complaining of a perception of difficulty breathing, can they?  Sure we could apply this term to a number of our asthma related complaints that have no idea what true breathing difficulty looks like and seem to have no trouble lighting up a cigarette during our assessment, but does it apply to our large population of unknown respiratory difficulty patients?

How do we describe shortness of breath without using SOB? Describe the signs and symptoms of course.

“Pt c/c SOB” tells me nothing. “Pt c/c difficulty breathing on inspiration” now there we go, and it didn’t take all that much longer to type.

It is also a good idea every now and again to define your abbreviations long hand in the chart. “Patient presents SOBOE (Short of Breath on Exertion)…” to allow for review and as a defense in case your abbreviations are ever called into question.  Your QI or a lawyer will pull your charts and see you are consistent in your use of the terms and abbreviations.

Now I hope your O2 sat reading doesn’t say WNL…

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?

I recently had the opportunity to attend a great seminar at the local trauma center.  Monthly, the trauma docs get all the trauma residents together to talk through a case from the previous month.  It sounds pretty dry until you realize how they present the case.

It starts with the Doctor playing the initial radio report recording.  Then he looks to his residents and asks “So, what positions are you assigning, who do you page, what are your chief concerns?”

I always knew the thousands of people in the trauma room when we arrive are important, but I never thought through that there was one person in charge of that room that asked them all to be there based on my report.  It makes perfect sense in retrospect.

In this particular case our medic made a near textbook MVIT truama radio report and had an ETA of 8-10 minutes.  A lot can happen in 8-10 minutes.

The Doctors discussed different concerns for maybe 5 minutes, then they went to the video.

In the corner of all the trauma rooms are cameras.  I always thought they were security cameras, but how great to be able to critique in real time referring to video!  The room is packed with gowns and masks, all awaiting the patient and the Doc stopped the video again.  “Who is missing?” He asked and the residents began to identify all the persons and departments in the room.  No one was missing.  Trick question, but I was impressed that everyone knew everyone else by sight.  a good sign of a team that works well together.

The video started back up and here comes the moment of truth for me, the CQI guy sitting on the side of the room:  The medics have arrived.

His tone was clear and even and he began his report with “Hello everyone this is Erma…”  My favorite way to start a report.  Put the team at ease and calmly describe your findings.  He went on to multi-task, describing the patient’s mechanism, vitals, his interventions and treatments, as well as his reassessment after the interventions.  As the patient was transferred and the swarm of gowns came in, the video stopped again and I was beaming with pride.  I know because the person next to me asked “How come all the reports aren’t like that?”

The Doc went on the quiz the residents about what their first assessments should be and he finished that discussion with “What else do you want to know before EMS leaves the room?”  his laser pointer now shows my guy standing in the doorway out of the way and removing his gloves.  They had nothing more to ask, he had covered it all. 22 seconds.  22 seconds was the length of his in person trauma report.  As the video picked back up he states over the heads of the crowd “you have access left AC 16g TKO on transfer and we put her back on the NRB at 15, I’ll be outside.”

I wanted to do the slow clap until I realized that this should be happening each and every time and, judging by the reaction of the room, it doesn’t.

The seminar continued to show the entire time this patient was in the trauma room, including the chest X-ray (then we all looked at it on the big screen), the abdominal and chest ultrasounds (interpreted by the residents) and even to the results of the CT.

Near the end of the discussion the presenter asked why no one was so quick to intervene on what they were finding.  Their answer?

“EMS is calm, we can take our time and see things through.  When the patients are bad these guys start to sweat.  This guy is calm.”

Awesome.

I’ve been sitting on this post for months and recent discussions on the facebook and around the interwebs are leading me to revisit it.

In an old You Make the Call we discussed when to take people to a  certain medical facility versus another and, sure enough, the topic of kidnapping came up.

It was reinforced in a (not so) recent story out of Florida about a man who claims to have been transported against his will.

Much in the same way Country kids sell the legend of cow tipping to City kids, I believe kidnapping of patients is an urban legend perpetuated by EMS managers and Chiefs alike to keep us from making waves and doing the right thing.  They need transport dollars to survive and taking people to their hospital of choice is an easier bill than not.

Are you confused with the definition, both of the word and the action?

kidnapping n. the taking of a person against his/her will (or from the control of a parent or guardian) from one place to another under circumstances in which the person so taken does not have freedom of movement, will, or decision through violence, force, threat or intimidation. Although it is not necessary that the purpose be criminal (since all kidnapping is a criminal felony) the capture usually involves some related criminal act such as holding the person for ransom, sexual and/or sadistic abuse, or rape. It includes taking due to irresistible impulse and a parent taking and hiding a child in violation of court order. An included crime is false imprisonment. Any harm to the victim coupled with kidnapping can raise the degree of felony for the injury and can result in a capital (death penalty) offense in some states, even though the victim survives. Originally it meant the stealing of children, since “kid” is child in Scandinavian languages, but now applies to adults as well.

Gerald N. Hill and Kathleen T. Hill.

Hmmm…

Taking someone to a hospital where they will receive medical care is not kidnapping as far as I can tell.  I’ve been looking at many different definitions of kidnapping over the week and keep coming back to the same definitions at heart.

If you do it for the right reasons, how can it be the wrong thing to do?

If you are doing it to get back to dinner, get off duty on time, or because your manager tells you to, THEN we have an issue since your position of authority could be interpreted as intimidation, but taking someone having an MI to a proper facility instead of local band aid ER is not kidnapping as far as I can find.

This discussion started when we discussed a patient who did not want to be taken to the appropriate medical facility for his presentation.  The discussion that followed revolved around him being “alert and oriented” “not intoxicated” and “I’m not going to kidnap him.”

In that situation YOU AREN’T!

You may do some research and find a term called “simple kidnapping” which appears to cover a slew of false imprisonments, holding without permission, and similar crimes, but in no definition do I find an example of a kidnapping being taking someone to the hospital.

Keep in mind your jurisdiction may have their own definition and you need to be familiar with it, but let me extend this one hypothetical step further.  If a person claims they need a transport and take me against my will, since I don’t think they need to go, is THAT kidnapping?  I’m being forced to go somewhere by fraud and could suffer harm as a result.

That more closely fits the definition of kidnap than taking a person to an appropriate medical facility, conscious & alert or not.

We are told not to disobey the patient and do what they say, take them where they want, and 95% of the time that works out just fine.  Your stomach hurts?  Sure we can goto St Farthest.  Your leg itches again? Kaiser patient, not a problem.  Trauma patient wants to goto St Farthest?  Aren’t we supposed to be patient advocates and do everything we can for them?

Isn’t EMS supposed to be patient centric?  So why aren’t we teaching EMTs and Paramedics what the definition of kidnap really is?  Probably the same reason we avoid teaching them what liability really means.

There are a lot of problems that will come bubbling to the surface if we started acting in our patients’ best interests and none of them are ours OR theirs.

A common practice in my jurisdiction is the art of hospital shopping.  A person will identify as a member of a hospital they rarely attend because they believe the doctors there to be superior, or that the nurses are prettier, or the other place “kicked me out” but in actuality they are simply trying to get someplace new, or clean, or where lunch is served at 1 and it’s 12:45.

In the pilot episode of Beyond the Lights & Sirens, I had a conversation with a regular named Val.  She presented with chest pain, 10/10, radiating, with history, a mere 10 blocks from an appropriate facility.  Her requested facility, 2 hospitals and 25 minutes away was on saturation divert, or no longer accepting patients by ambulance.  I transported her, per chest pain protocol, to a hospital that was not her requested facility.  No kidnapping charges were filed.

Many of you would argue I kidnapped her.  I moved her from one place to another without her consent using intimidation (My position of authority).  But looking at the situation unfold, I did not kidnap her, but get her to the appropriate facility for her chief complaint, as defined by my Medical Director, County EMSA, State EMSA, Chiefs and Captains.

Don’t default to the stories the Anchors tell you about kidnapping charges being brought against a long lost co-worker for taking Erma to the wrong hospital.  That case likely had a different, more shady reason for leading to termination, not kidnapping.

Perhaps we should spend less time worrying about vague definitions that don’t apply and spend more time in the airway lab?

And I hate that I have to remind you of all this, but these words are my opinion and are not those of my employer, a lawyer, an expert, my daughter, the crossing guard or the guy at Sears who stocks the vacuum bags.  Before you act on these words, consult with your local system administrators for the rules and laws applicable in your area.

Awhile back, actually right before I stopped treating patients on a regular basis, I was asked to take a look at an airway app.  My initial thought was probably the same as yours, “I barely have time to bag, get the tube and see the cords and now there’s an app for that?”

Kind of, yes.

I’m not a big fan of field guides, cheat sheets, crutches or other devices that give you a false sense of security in not having to know everything you need to know.  We’ve discussed this before boys and girls.  If you refer to a guide on scene perhaps you need to spend more down time studying.

The Difficult Airway App was designed to be user friendly in the field to assist with difficult situations.  With the doses for many meds, especially RSI, dependent on a number of factors it could prove very helpful in a tight spot.  If you have the resources for someone to access this app during a call it is a perfect resource.

But I wanted to focus on the benefits for those of us who may not have enough people to use this app on scene.  This app is an excellent tool for as soon as the ambulance is in park on post or back in the station.  I installed it on my iPad and began to look through it immediately realizing it was a resource, not a tool.

The app opens to a screen with 7 basic parts, Airway Anatomy, Airway Algorithms, Predicting the Difficult Airway, RSI calculator, Pearls of Wisdom, Video Clips and Additional Resources.

The anatomical notations are what you’d expect and are a great refresher for the salty dog medic who claims to have seen it all as well as the green medic student or EMT wondering why it’s so hard to put the little tube in the mouth.

The algorithm section is the only draw back of this app in my opinion, because it is an over simplification and vague guide to the other algorithms which are again over simplifications that can’t really be studied.  For example, one asks “Intubation successful?” and if “No” we are instructed to keep bagging and try again.  I see the reason to lay out every step of the process, but like many of the algorithms in EMS, the patients have trouble sticking to them most times.

But this minor issue is made up for with the Predicting the Difficult Airway and RSI calculator.

Predicting the difficult airway is a group of mnemonics that can be used to reinforce proper techniques when encountering a difficult airway.  When appropriate, they also include pictures to reference things like the 3-3-2 and Mallampati scales.  These were a welcome refresher to the usual dry text at refreshers.

One feature I see used over and over again in the front seat of the ambulance is the RSI calculator.  The guide opens asking the general weight of the patient and immediately has a link to the 7 Ps Preparation, Preoxygenation, Pretreatment, Paralysis, Positioning, Placement, and Post Management.  This screen is a welcome reminder that there are a great many steps to securing and maintaining a patent airway.

The calculator also takes into account variables such as obesity, blood pressure and possible asthma or ICP and calculates a dose for a variety of medications used for rapid sequence intubation.  I imagine two medics challenging one another to calculate the proper dose, then using this app to check their work so that on the scene of a difficult airway they’re not removing their gloves to reach for their pockets to get their phones and actually use the app.

In review I like the app and am glad I took a look at it.  I recommend it to new and student paramedics as well as the dinosaurs who could use a bit of a refresher sometimes.  The app is easy to use and read and has no annoying music, sounds or cheesy animations, just good solid airway information.

The price of $14.99 (at the time of posting) seems a bit steep at first but considering you likely spent half that on a game at one point you should grab it before you have an airway go south and wish you had it ahead of time.

I give it a 6.5 on the 8.0 ETT scale.

You can learn more and purchase your app HERE or on itunes, just search difficult airway app.

An AHA employee is in hot water today after the discovery of his lost laptop containing controversial recommendations for new CPR guidelines was found in a coffee shop in Atlanta.
Authorities were quick to deny claims that patient data had been compromised, but new guidelines had already been leaked.

HMHQ has obtained a link to the data.  This is going to change everything.

It was a crisp morning, I remember that much.

There were three of us assigned that day, the Medic, me the EMT and the firefighter who happened to also be an EMT.  We had decided to ro-sham-bo to see wwho took the day on the ambulance and who got to man the tender.

I lost and began to check out the ambulance, having no idea that by the end of the day I would thank the heavens I had chosen scissors instead of rock.

The medic and I had decided breakfast burritos from the gas station were in order and loaded up in 91 and away we went.  Wandering the tribal roads was always interesting, dirt to gravel, gravel to pavement and finally to the highway to loop around to the border and the gas station.  As we listened to some Alan Jackson song I’ve learned to forget we heard a panicked voice come over the air.

“Isleta, Station 1, I need 91 back here code 3 and  launch Launch Lifeguard!”  Lifeguard is the one and only helicopter in the entire state.

In the movie version of this story I scream “hold on!” and execute a perfect skid turn and peel out in the opposite direction.  But in the real world we’re in between exits on the freeway, 4.5 miles to go until a safe place to turn around.  Then back.  We’re at least 10 minutes away.

“Station 1, Isleta, Lifeguard is not available “  maybe 30 seconds pass.

“Station 1 10-99! 10-99!” Our code for officer down.  One of 2 things has happened.  Either there is an officer down or our firefighter back home needs help so bad he’ll take anything.

Minutes pass with no transmissions, we’ve started an intercept from the north, they’ll arrive in about 20-30 minutes.  With an unknown situation and no cavalry, we tended to err on the side of getting help on the way.

As we finally hit the exit to get to the station I’m varying the siren to let him know we’re coming.  On the PD channel an officer states he’s on scene and there has been a shooting.

Oh fuck.

“Our guy is OK, but we need that ambulance ASAP!”

Another movie perfect skid into the dirt lot of the station would send a cloud of dirt past the Chevy extended cab awkwardly parked almost infront of the ambulance door.  Had we been in quarters, we’d be stuck.

In the front passenger seat, covered in blood of varying ages and degrees of clotting, is the patient, shot in the stomach with a shotgun at close range.  My friend tending to the patient had him on oxygen and was applying pressure, about all he could do.  It didn’t do much.

The weapon has been secured, and is in the back of the truck, by the patient’s 12 year old son.  And now we understand why the truck is parked so awkwardly.  In a community where middle school aged boys are expected to work in the fields, it is not uncommon for boys as young as this to be comfortable driving on the farm roads.

While mending fences on the eastern border of their land, dad always carries a shotgun for defense from animals mainly.  On this day Dad set the shotgun down against the fence barrel up.  It was a simple thing to do, perhaps he always did it that way, maybe it was just this once, but when he reached over from the other side of the fence to carry it back to the truck it discharged.

A 12 year old boy took off his shirt, dragged his father into the pickup, stuffed his shirt over his father’s wounds and drove a good 20 minutes to our ambulance station.

The transport was a fast one, understanding what little we could do in the back of the ambulance would help this man.  He needed “bright lights and cold steel” as we used to say.

The look on the face of that boy has been burned into my memory.  I hope I’m that brave one day.

No one.  Skilled nursing facilities have always fascinated me.  I’m not entirely sure why.  It has nothing to do with the first two words though, they’re nowhere to be seen.

THE EMERGENCY

A nurse has called asking for a code 2 transfer from the facility to the local ER for a possible bowel obstruction.

THE ACTION

We’re out the door code 2 after stopping for a quick piece of bread at the now completely set dinner table.  The salad is about to be served.  No wonder we caught a job.

Wandering through the streets we wonder why a skilled nurse at the skilled nursing facility can’t remove an impaction, but assume they know something we don’t.  Stop laughing, this is a serious story.

Arriving on scene a middle aged woman is in the street doing the parking valet dance.  Both arms over her head waving, then pointing us to park where we always do.  Does she not know we’re here so often we could classify as residents?

“What floor?” I ask, expecting a response with a number.  Instead she gives me letters.

“They’re doing CPR!”

Grabbing the red bag while my partner grabs the O2 and monitor I key up the radio and ask if they have a second call at this address.  They do not, just our code 2 bowel impaction.  It appears to have worsened.  “Send me an engine” is my report and I hear the dispatch come out while we climb the stairs.

Upstairs in the cafeteria is a man in his late 80s being physically assaulted by two young Asian women.  Sitting somewhat upright in a wheelchair, his chin is down against his chest almost as if trying to hide.  He may have been since they were doing the most bizarre chest compressions I have ever seen.  On a man seated in a chair.  Go ahead, think about it.  It’s weird.  A third woman is nearby holding a cup of water just in case, I’m assuming, he bursts into flames.

“What happened?” I ask while pushing myself through the throngs of robe wearing elderly who have come to see something new for once.

“He stopped breathing!” One of the women shouts.

“Give him more water!” Suggests the one with the glass and she hands it over.  Like a good EMT partner should the glass has been intercepted and he’s along the patient’s other side ready to move him to the ground.

As we do the water is pouring out of his mouth like a babbling desktop water feature and it is now readily apparent that he has cleared the bowel impaction without our help.  Amazing what the body can do when stressed.

The sirens outside have stopped and I hear familiar voices coming up the stairs, they must have been nearby.

He is log rolled and suction begins to gather the fluids forced on him by his skilled nurses.  To say his airway was compromised was putting it lightly.  The decision was made to transport him on his side, feet elevated to try to keep as much of the water out of his lungs as possible.

Down in the ambulance I’ve got the medic from the engine and my EMT with the EMT from the engine driving us the short 8 blocks to Saint Closest.

My radio report was short and we had just filled our only spare suction canister.

After transferring care I approached the woman who so kindly showed us where to park and asked her what had led to her father being nearly drowned.

“I think he choked” she sobbed “and they were trying to wash it down.”

Skilled my ass.

Remember the discussions we’ve had in the past about pain?

And when I shared what my 10/10 was? (Photograph removed by request)

I’m updating my 10.

On Monday afternoon I was enjoying a day off after the holidays and tidying up around the house.  Cleaning up Christmas decorations, washing out the keg, you know, usual post holiday stuff.  As I walked back into the garage and began to close the door I noticed the sprinkler bin outside still had the lid open.  I had gotten it out to assemble a keg washer from old PVC pipe and a sprinkler.  Very clever I thought.  Half a step from the bin it felt as though my left foot had gone into a hole.

A bright light flashed in the back of my head and a bolt of lightening struck my lower back.  At least, that’s how it felt.

I collapsed to the ground faster than you could say “WTF?”

The pain caused me to begin to writhe on the cold concrete not 3 feet from the house.  As I writhed in pain, my back continued to burn and tingle, which was causing me to contort in small jerky motions.  Each time I did my back sent lightening up to my shoulders and down my legs.  Even the wind blowing by seemed to make it worse.

“h…elp” was all I could get past my clenched teeth.  For a brief moment I thought back to my burns and wished I could have them back instead.

Slowly my eyes opened and I was able to look for the hole I surely stepped in, but there was none.  I needed help, but couldn’t move.  The clothes dryer had just started and the vent was nearby.  that combined with the sounds of my girls playing loudly in a nearby bedroom meant that no one was going to hear me for some time.  I had to move.

Each and every motion except blinking sent shock waves out from the searing pain in my lower back.  After 3-4 minutes of grunting, crying and twisting, I was able to get on my hands and knees and start crawling back to the house.  Those 3 feet felt like miles.

Crawling is not as easy as you remember it.  It is very easy to lose your balance when you’re not in shape, which I apparently was not.  Each hand movement became a slide instead of a lift and my knees also never left the ground.  The movements were telegraphed from the pain in my back and I could have traced the entire nerve system through my body had you needed to know it.

An unknown time later, the 2″ tall metal door threshold behind me, I was in the garage and able to raise my voice.

“help”

“KIM!”

She came running and found me in tears, on all fours and trying to explain what happened.

A few moments later she had a cushion, ice pack and ibuprofen ready and the decision was made to move me onto my back.  A decision I would curse until supine.

Unable to stand, Kim got under my left arm and helped me shuffle into the house and onto the couch.  I would spend the rest of the day there, eventually able to get up and shuffle around the house and head for bed.

The next morning my alarm went off and I sat up to get out of bed for work.  Well, not exactly.  More like I started to sit up and the lightening struck again.  Back to sleep, no way I can go to work like that.  Awaking at 830 to a busy household, I decide a shower sounds nice and the family is off to their regular weekday routine.  As the water is turned off and I feel 100% better my hand instinctively reach to dry off my feet.

Flap!

And I’m on the floor again in worse pain than the initial injury.  Nowhere near a phone, the family gone for at least another hour and naked, and I’m wondering how long I’ll be lying there.

No way.  I have to get moving.  Crawling is worse that yesterday but I make it to the dresser and somehow am able to manage getting some clothes on, then look down the hall towards the phones.  It was a good idea yesterday to leave all the phones I need on the couch.  Now I’m wishing I had brought at least one into the bathroom with me.  Now we know why the fancy hotels put phones in the bathrooms at least.

A long crawl down the hallway and I make it to the office where my cellphone is.  On top of the desk.  Barely able to reach up and pull it down I dial the wife’s cell phone on speaker while collapsing onto my side.

Then I hear her phone ring.  She forgot to take it with her.

As I hung up I saw the number I should call and sighed.  Did I really need an ambulance?  It sure would be nice to not have to crawl anywhere anymore.  One more try first.  Able to reach the wife at one of the places she told me she was going, she advised a 15 minute ETA and I decided to call my insurance company to see about a handicap van or other transport to an urgent care.

It was there on the office floor, alone, that I realized that even though I was willing to jump off a cruise ship to get pain management for my chemical burns, I was willing to hurt someone for muscle relaxers.  For pain management I would have done more.  Thinking back to the floor of the bathroom, it clearly became my “10″ on the 1-10 pain scale, pushing the burns to a close 2nd.

When we discovered the clinic was by appointment only and no openings for 4 hours we chose to get me to the ER for an assessment and some medication.

After an excruciating walk to the car we arrived at the ER and got me in a wheelchair.  The ER Doc came in and saw my knuckles white from holding onto the rails of the wheelchair, splinting my body from resting on the soft chair.

“Bad back?” he asks.

“Since yesterday, yes.” I answer, now pushing my head against the extended rails behind the chair.

“Can you show me where?” His question is answered by my strange jerky repositioning, trying to create space for him to look at my back.

“That’s far enough. You need some meds.”  When he returned not 3 minutes later I was given a Zofran tablet, Valium and muscle relaxers IM and the bad news.  I was going to be useless for at least 2 more days.

After a brief wait at the pharmacy we were home and my Valium was kicking in.

That was yesterday.  Today finds me finally able to sit up enough to get on the ol’ laptop instead of holding the ipad over my face to get my social media fix.

The decision to share my tale was to remind all that we ALWAYS need to qualify a patient’s 10 out of 10 to properly dose them based on their level of discomfort.  When I checked into the ER I rated it a 3/10.  To me that meant it hurt when I hold still, but walking, standing, most anything else instantly became an 8 or 9.  Looking at the happy faces chart now used, my inability to stand or care for myself meant I was always a 10.  Hogwash.  Get a baseline, it’s the only way to know what a 10 really is for the patient, not the provider.

And make sure to exercise your core, not just your arms, legs and cardio.