Placebos, Tricks, Disasters, and Other

by Joe Moore

Placebos, Tricks, Disasters, and Other

I am not familiar with how often urban ambulance services are called to the scene or home or a situation where the person wants help, but doesn’t really want to go to the hospital.  The readings I have had involve mostly those people who want to use the ambulance like a taxi ride to get to their doctor, or, if they don’t have one, to the emergency room.  I read most every week about the ER’s of our cities being overburdened by the clinical, non-emergency patients.  I read about patients waiting hours upon hours trying to get diagnosed and treated.  We have some people who want to be diagnosed and treated right in their home or right at the scene of the emergency.  BIEMS does not carry a hospital laboratory or an x-ray machine in the back of the ambulance.  We do not have antibiotic for bacterial illnesses, nor do we have the ability to distinguish chronic bronchitis from viral or bacterial pneumonia.  We might have a good idea about what is going on with a patient, but we really don’t have the facilities, equipment, or specialty experience to diagnose and treat all possible conditions.  EMS providers in general can become so busy in the urban areas that they truly don’t have enough time to think about diagnosis and treatment for the long term especially if the ambulances are making 8-10 runs or more in a 12-hour shift.

In this rural location, we sometimes have to take quite a long time to convince our patients that they really need to go to the mainland of Michigan to get the definitive diagnostics and the definitive treatments that they truly need.  Most people will understand this analogy.  In the rural areas, even with a good staff of very well educated, caring medical providers whether physician or mid-level providers like FNPs, trying to treat some conditions in the rural environment is a little like trying to use a band aid to stop the bleeding on a patient with a recently amputated leg.  There simply aren’t the resources available to do the job period whether we are evaluating the job by correctness or efficiency or by some other evaluation tool.  Some of our rural patients have complete confidence in our abilities, sometimes a fairytale confidence in what we are able to accomplish.   Don’t get me wrong, we all want them to have confidence in our abilities, but we also sometimes have to convince them that what we can do for them is limited.  Sometimes we have to go to great measures to convince them that they need to get to a hospital.

I remember one patient who was having chest pain down the East Side Drive about halfway down to the end of the island.  We arrived and the patient had classic signs and symptoms of a heart attack.  We put the oxygen on the patient with a non-rebreather mask at 12 liters per minute, and the patient’s pain pretty much disappeared.  He was now pain-free, and he didn’t want to go to the hospital.  The pain was the reason that he had called for an ambulance, and now the pain was gone.  We tried and tried to talk him into going to the ambulance.  We even suggested that he might die, and his comment was, “If I’m going to die, I want to die in my home right here on Beaver Island.”  Well, even his wife could not convince him that he should go to the hospital.  We did not have a 12-lead EKG to show the patient at the time.  Now that we do, we can show the patient the writing on the EKG that might say, “ABNORMAL EKG”, and this sometimes will convince them to go to the hospital.  The chest pain patient was very adamant about not leaving his home.  Here is what we did, right or wrong. 
We took the oxygen off the patient, packed up our equipment, and then sat down to talk to the wife about the weather, the children, and the tourist season on Beaver Island.  We waited until his chest pain returned which didn’t take very long without the oxygen, and then we said, “Here, let us help you get rid of that pain,” and we put the oxygen back on and continued to wait until the pain subsided.  After the pain had greatly decreased we said, “Well, it’s been nice seeing you, and we’re sorry that you don’t want to go to the hospital.  We have to get back to the station to be available for our next patient.  We’re going to have to leave now, and we’ll have to take the oxygen with us.” 
The wife spoke up, “Can’t you just leave the oxygen with us?”  “Of course we can,“ came our answer, “but that tank will be empty in about 20 minutes so it’s just easier to take it with us now.  We really don’t want to just get back to town and have you call us again.” 
And then to the patient, “Did the oxygen help get rid of the pain?  He said, “Yes.”  “You know there is an endless supply of oxygen at a hospital,” we continued.  “No matter what we do to help you here at your house, the oxygen will run out very soon, and the pain will come back and continue.”  He finally said with resignation, “Okay, I get your point.  I’ll go to the hospital.”  By the way, I flew across with this patient and got him to the hospital safely around 9:30 p.m.  I found out the next morning that his heart slowed right down and almost stopped that night in the intensive care unit.  If he had stayed on Beaver Island that night, we would have attended another funeral.  Instead the ICU staff and physicians got him through that crisis so he could come back and enjoy his East Side home on Beaver Island.

In the urban environment, have you ever started a fake nitro-drip?  I have done it, and I did it on purpose.  Some patients are convinced to go to the hospital by the technology that we have at our disposal.  Some patients are so used to having an IV started on them that it simply is not convincing enough to get them to go to the hospital.  However, if you get out a bottle of D5W and IV pump tubing, have a discussion with the other providers about how to mix the drug in the D5W, spike the bottle, hang it, and actually hook it up to the existing IV through an IV pump, discuss the rate that the pump should administer the “drug”, and then begin to have a conversation with the patient about going to the mainland for the services that the hospital can provide them, it makes a difference in the patient’s perception of the seriousness of the illness or injury.  The “placebo” effect can sometimes be absolutely amazing.  If the discussion provides the patient with the ability to overhear the conversation, “It will probably make the pain go away,” the “drug” (which is nothing more than sugar water) may actually make the pain go away.  Now, I am not suggesting that we would withhold treatment of a patient who was truly in pain.  We would provide the needed treatment, but sometimes “fake” treatment is required to get a patient in the rural environment to agree to transport to the needed facility.

One of our chronic users of the BIEMS system was a respiratory patient down toward the south end of Beaver Island.  In one year, we transported her 5 times within a forty-five day period of time.  She would be transported to Charlevoix Hospital, and her crisis would be resolved.  She would come home, and then she would have another crisis, and BIEMS would be called to transport her again.  This patient did not need to be convinced to go to the hospital, but after the first three times of transporting this patient, having her crisis resolved, and then having another crisis, we delayed the transport on the fourth call.  We had a conversation with the patient.  “This just doesn’t seem to be helping you.  You have an acute asthma attack.  We take you to the local hospital.  You come home, and then you have another acute asthma attack.  Something has to change.  We can’t change your location, and you don’t want to move anywhere else.  The only thing we feel that we can change is your transport destination.  Maybe it’s time to go to another hospital, to a pulmonologist (specialist in lung function and lung problems), and try to get a different mode of treatment going to help you out.”  After getting the patient’s consent to try this, we contacted our medical control for permission to bypass the local hospital and take this patient to Northern Michigan Hospital (NMH).  We wanted to establish a doctor-patient relationship between our chronically ill patient and a pulmonologist.  We got the permission from medical control.  Medical control called NMH to get the ER there to accept the patient for this purpose.  The fourth transport of this patient didn’t turn out to make any significant difference in the pattern mentioned above, but now that a physician-patient relationship existed, it was not difficult to convince the patient on the fifth transport to go to NMH.  It was not difficult to convince medical control to let us bypass them.  We were not called to this home again for nine months.  Somehow we had broken the pattern.

Another trick that we do in the rural area here on Beaver Island could be called “using Karma” or tricking fate.  Here is an example.  We have a patient whose heart rhythm is really unusual, but not so unusual that the patient is going to die.  Let’s just use the example of a really slow heart rate without any drugs slowing it down.  EMS carries just one drug in the drug box to increase the heart rate.  Here is our trick.  We get the IV in place and continue to do all the things that will help the patient remain stable including oxygen and monitoring vital signs.  The “Karma” idea is simple.  You just get out the first and second line drugs, draw them up so you are ready to administer them, label them, and have them in your shirt or jacket pocket ready to give to the patient. 
You say outloud, “If the patient’s heart beat goes down below 50 (or whatever number would cause you concern), we are going to treat this aggressively.  We will not wait.  We will give the drugs.”  Whether this is placebo effect again or not, more often than not, we will have to waste the drugs after the ambulance run because we will not have to give them to the patient.  Some people would just call this “being prepared”, but it truly goes beyond this in 20 years of rural EMS experience.  If you are ready for the worst, the worst seldom happens. 
Did I just say that?  I am the pessimist of our rural BIEMS organization.  I am the one that wants to be prepared for the worst with the drugs drawn up, handy, and ready to be given.  I think I share this with at least one of the current FNP providers at the rural health center.  I think we both look at this with the thought, “If it is needed, we are ready.  If it isn’t needed, it is so much better for us and for the patient.”

I guess that what I am saying in the rural EMS environment is simply this.  We will trick, cajole, threaten, and do what is needed to get our patients to the location that will best be able to provide them with the patient care that is needed.  I am not sure where this falls within the ETHICS discussion, but in the patient care discussion, we will continue to use this whenever needed to get our patients the care they need.

My two close paramedic friends, the deputy Mark, and the RN/paramedic Bee, have graduated their last child from the Beaver Island Community School, and are now moving off the island to establish another residency back down in the Battle Creek area.  We will miss them greatly, not only in the EMS area, but in the areas including political discussions, holiday celebrations, and friendly get-togethers.  Thank you, Mark and Bee for your help getting through this eleven year period on Beaver Island.  You have been true lifesavers and wonderful friends.

Now, I feel I need to tell you that even though we don’t have a lot of trauma on Beaver Island, when we have trauma, it is usually overwhelming and satisfies the definition for a disaster.  We are paged to a Jeep Tracker rollover accident involving four teenagers.  At first, the call was only for the local deputy sheriff, but when EMS hears about a rollover accident, it just generally has to respond.  BIEMS and the Beaver Island Fire Department were eventually paged to respond to the school.  On this particular date, we actually beat the deputy to the scene.  Some deputies are quicker to respond than others, but we were there quite a bit ahead of this deputy.  Upon BIEMS arrival at the corner where Donegal Bay Road makes a southern turn right at the beach at Donegal Bay, we found three patients. 
Patient number one was a 17 year old male who was unrestrained in the back left of the Tracker.  He complained of generalized neck pain and had a bruise to his left thigh with small bruises also to his right forearm.  The patient had a history of leukemia.  He had vital signs within normal limits.  This patient was assigned to the paramedic PA and an EMT. 
Patient number two was a 14 year old male who was found outside the vehicle.  The patient stated that his right arm hit something during the rollover.  He complained of generalized neck pain and right arm pain with bruising to his right arm.  He had normal vital signs as well. 
Patient number three was a 15 year old male who got out of the car on his own.  He was found walking around and had no complaint of pain at first.  The mechanism of injury suggested that he might have some injuries so just before the cervical collar was placed, the patient complained of neck and back pain just below the shoulder blades.  His vital signs were also within normal limits. 
Patient number four was a 17 year old female who complained of lower back pain.  She had pulse, movement, and sensation in all four extremities, but there was pain on palpation to the lower back.  The patient complained of this pain while still on the ground with an 8 on a scale of 0 to 10.  After moving the patient onto the backboard with a logroll, the patient complained that the pain was now “the worst” and at least a 9 on the 0 to 10 scale.
Each patient is assigned to two EMS providers for treatment with firefighters to help.   All four patients needed to be completely immobilized on a backboard with cervical and complete spinal immobilization to protect them from the possible effects of the rollover accident.  All four patients had low flow oxygen also.

Now we have an interesting situation.  How do we get four patients off the island and to the hospital?  We only have two ambulances.  We only have three ambulance cots, but we have a folding cot in each ambulance.  Thank goodness we have plenty of EMS people and help from the fire department.  The deputy sheriff was providing traffic control and crowd control, and he had his hands full doing just this on this busy August day.  We managed to get each patient loaded into an ambulance, two at a time, and transported to the local airport for a local airline flight to Charlevoix Airport.  Four planes were used for four patients with each patient accompanied by two EMS providers.  I was the only one required to fly twice.  Here is how the timeline stacked up. 
We were dispatched at 18:43 and arrived at 18:47.  Our first two patients were enroute to the local airport by 19:25.  They were loaded simultaneously into two airplanes and flown to Charlevoix.  Charlevoix EMS met us with two ambulances.  Our cots came right out of the aircraft and were immediately placed into the back of the Charlevoix ambulances with a quick ride to the hospital.  With the prevailing winds helping us, we managed to get the patients to the hospital by 19:50. 
In the meantime, the second Beaver Island ambulance had two patients aboard and was making its way to the local airport at 19:51.  One patient was put on the first returning aircraft which took off and this patient was at the hospital in Charlevoix by 20:18.  The last patient needed to await a quick mechanical issue on the second returning aircraft and left the island at 20:28 and arrived at the hospital at 21:06.  So no matter how you figure this all out, we assessed, treated, and transported four patients from an Island in Lake Michigan, 32 miles away from mainland Michigan, and accomplished this all in two hours and twenty-three minutes after fully immobilizing all four patients on spine boards.  I think this is quite remarkable for a small rural EMS group.  It took us about the same time to get these four people off the island as it took them to get to the island on the ferry that runs from Charlevoix to Beaver Island. 

Now I realize that, by urban EMS standards, what we accomplished is not such a fantastic accomplishment.  For Beaver Island with a forty minute aircraft turn-around time due to the water between us and Charlevoix, I don’t think it is such a bad accomplishment.  As a matter of fact, I am very proud of this.  I don’t think anyone could have done it any better.  I don’t think anyone could have done this more efficiently.  I think the Beaver Island EMS teamwork was superb in a very noisy, confusing beach environment on a busy island during the tourist season.  It also happened two months after my best friends and fellow paramedics, Mark and Bee, had left the island.