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.

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

Um…yes please?

Laura Landro from the Wall Street Journal asked the kind of questions I wish more reporters asked.  Not just asking for our survival rate, but the more important question:

“Why is your number improving?”

We discussed continuous chest compressions, training the entire department to AHA standards and ensuring our BLS fleet can anticipate ALS interventions.  We discussed esophogeal airways, CPAP, see through CPR (from ZOLL), end tidal capnography, so many different tools that come together to make a 9% into a 23%.  And that was all before I got my job at HQ.  It’s nice to highlight the work of those who came before including Jeff Myers, Seb Wong, Brett Powell, Pete Howes.

Hopefully this is just the beginning of a conversation with the public about how EMS impacts their daily lives, not just when they, for lack of a better term, drop dead.

The Ultimate Lifesaver

I’ll link to his site in a minute, but he’s been in the sidebar for a few weeks.

Joe can better tell you about his past, I’m more interested in Joe’s present.

You see, Joe is recovering from the amputation of his left leg above the knee.  Had this been me, I would just curl up in a ball on the floor and ask for water occasionally.

But not Joe. Joe smiles, gives a double thumbs up and asks the Universe, “Is that all you’ve got!?”

To say that his spirit to overcome this tiny lifestyle change is an inspiration does not do justice to how I feel when reading his day by day accounts of living with and around having only one leg.

Recently a child began to ask what happened to his leg and the child’s parent whisked them away without an answer.  He’s been called a cripple.

I call him brave.  There isn’t another word to describe someone who faces this kind of setback and charges forward, guns blazing, kicking ass and taking names.

When life seems rough at HMHQ I often think back to the days before kids, or maybe when we lived in the City, perhaps even before this staff job finds me in traffic 5 of 7 days, but I can get up, walk somewhere else and change my life if I want to.

That is what Joe is teaching me as I read his accounts of life with one leg.  Sure there are awkward moments like,

How do I pee without falling down?

Do I need a wheelchair?

Will I wear shorts again?

But it makes me step back and wonder what in my life is really bothering me.  Joe didn’t set out to inspire me to reevaluate what’s important in my life, but he is.  My take on his story is a selfish one for sure, that’s just who I am, but this story has really set into my mind to make me think more about what I have, and less about what I think I want.

Joe is about to walk into a whole new chapter in his life with his head held high and I’m honored he’s letting me come along.  You should too.

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.

…and here’s why.

I made patient contact, completed my assessment and cancelled the ALS ambulance instead opting for the more appropriate BLS ambulance.  We don’t usually have this kind of flexibility, but the system was so overwhelmed, the local EMS Agency brought in additional cars from additional companies in the area.

The BLS unit arrived from a company I had seen, but never worked with.  The EMTs seemed a bit excited to be responding to a scene instead of a facility, and I was trying my best to a)stay awake and b) keep my patient in good spirits.

I completed my hand off and helped walk the patient to the back of the ambulance and after double checking they were OK accepting the patient I said good morning and began to walk back to the buggy.

“You’re that blogger aren’t you?” she asked.  I turned.

“First time anyone’s called me that while at work,” I cryptically answered.

“Yeah, I read your stuff. I used to think you made it up but,” she motioned towards the ambulance, “you can’t make this stuff up.”

“The blog seems to write itself most days.  Be safe.”

We cooked a batch of beer with the blog stalker, got invited for dinner and recorded a show.  When it was time to write the witty intro, he asked me to do it.  I didn’t respond.  Then he challenged me to either write the intro or wash the dishes.

So…

Yup. You read that right. I talked HM into doing the dishes so I could get this post out to the lot of you. I am a modern day Huck Finn.

In this, our last teenage episode, we talk about collisions and when they are documented, evidence-based medicine, and some pretty kick ass Kilted to Kick Cancer news.

Enjoy our last episode before we hit that crap year between being teenagers and being able to drink. What a dumb year.

As I was reading that article, and the original he linked to I was taken back to my days in Newcastle upon Tyne with (then) UK Paramedic Mark Glencorse.  I didn’t like the ambulance layout at all, but the full access around the patient and forward facing seat in the back were great.  But it works for the patients they treat, which is one of the hallmarks of EMS 2.0.  That each community has unique challenges and needs unique solutions.  We treat heart attacks the same all over this nation, unless you take into account the training, equipment, vehicles, staffing, location, hospital capabilities, transport times…you get the idea.  With this in mind each community will look slightly different, much like they do now, only we hope to strengthen what is working and eliminate what is not.

Finishing TOTW’s review of the “advances” the littlest of the HM JRs, Miss Eliza, was playing in the room with the ambulance bin.  We call it that because these girls have a lot of ambulance toys.  Go figure.

I peeked over my shoulder to see her little ambulance company lined up for her inspection.

Asking why she did that, her reasoning was to make sure everyone knew what to do today.  But then I began to look at some of the “non-ambulance” toys that had made the lineup.

Then she blew my mind.  Her description of why each vehicle was in the lineup sounded like a research project from my college days.

I give you Miss Eliza’s Ambulance Company LLC.

Miss Eliza staffs 8 distinct apparatus in her fleet

1.  Emergency Ambulance – “I like the noises”  A standard 2 person reclined van ambulance.  This rig likely carries most of her clients, is painted in distinctive colors for safety and has an impressive warning lights and sirens package.
2. Heavy Rescue (for tiny things) – “It does lots of sounds. It has Happy on it.”  Indeed this truck does have the markings “Happy Medic” and a license plate of “Free Ride” (all thanks to the Angry Captain).  But with decreasing budgets at the municipal level, Miss Eliza may be unable to call another agency for extrication or rescue.  It also allows her to train her people with her own equipment instead of having to rely on other agencies.  She’s thinking ahead.
3. Light Duty Transport – “The back opens for the bed in the back.”  This unit is short and narrow, clearly for use at special events.  It fits one provider, who can then drive while the patient reclines in the back.  A great use for tough to access patients.
4.  Advanced Care Clinic -  “I like it colorful” She likes the colors on this rig and the irregular shapes, but I like what’s inside.  Cabinets, sinks, an x-ray machine, hospital type lighting, it really is a clinic on wheels.  Even better, the entire side folds down to reveal a treatment area.  Park this rig at a special event and all those treatment dollars the hospital is getting are now to Miss Eliza.  Added benefit, no need to staff multiple ambulances at the event.  Just call one if you need it.
5.  Rapid Response Car – “Because the car can go fast.”  Jimmy Johnson will be surprised to know he’s been flexed into active EMS duties, but Miss Eliza sees the benefits of getting ALS eyes on scene first to guide the remainder of the system depending on the patient’s presentation.  Perhaps there is a better vehicle available, but she opted for #48, so who am I to judge.
6.  Ladder Truck – “I like the fire truck and the ladder” I see where she’s going on this one, but really, the ladders should be fitted to your heavy rescue squad.  I don’t think we’ll need that 100′ stick nearly as much as she thinks.
7.  Tactical Response Vehicle – “It does new tricks. Goes fast and has guns.”  The SWAT has a giant armored vehicle, we need something too.  Maybe the Green Hornet car is a little much, but pull up in this baby on the scene of a violent assault and the crowd will not only part, but disperse…and fast.  Added bonus?  Competing companies won’t want to meet you at the intersection trying to grab the same call!
8.  Ambulance (Non-Emergency) – “I like that its white.”  At first I thought she was just looking at the colors of the toys, but then I realized…that’s exactly what she’s doing.  The white rigs are passenger vans for non-emergent patients and clinic appointments.  If the little blue van can get me to the airport with 2 hours notice, surely we can apply the same design to scheduled transports to appointments.  Put a modified ramp on the back for wheelchairs and I think she’ll corner the market.

So there you have it.  She didn’t design the inside of an ambulance, that will take a complete redesign from the patient out, not the walls in, but she does bring up some interesting concepts in response models that I think should be considered moving forward, especially if municipalities keep cutting back.

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.