Repeat Customers

Repeat Customers by Joe Moore

How many times do you respond to a home where the same person has the same problem over and over and over again?  Doesn’t that make you angry that they call for the same thing time after time?  Don’t you get tired of helping people that don’t know any better than to get them into the same problem time after time?
The answers to these questions may be different for someone else, but my answers are really very simple.  “As many times as they ask for help, no, it doesn’t make me angry, and no, I don’t get tired of helping people who have health issues.”  I simply can’t believe that anyone purposely gets sick, is ill, or gets hurt on purpose.  That’s just not part of my make-up.
I believe that each and every emergency response is a new, completely different circumstance for each and every patient.  My job is to determine what is wrong to the best of my ability, to do my best to help resolve the patient’s issue, or to get them to the hospital or definitive care for hopefully resolving whatever issue that they have.  Perhaps an example might help you understand what this means.
There is one patient on Beaver Island that I have responded to more than thirty times over the last twenty-eight years.  Each and every single one of those thirty plus emergencies have been different in one way or another.  The first patient is having serious breathing problems, and never calls until they are in serious trouble.  It doesn’t matter that they smoke for many years.  It doesn’t matter even if they continue to smoke.  They have chronic obstructive pulmonary disease.  This disease can be either chronic bronchitis or emphysema or a combination of both.  If you remember a time in your life when you had a really hard time getting enough air into your lungs and you were fighting for every breath, you might then understand what this person is going through when they have an acute attack of a chronic disease.  Chronic means that it never goes away completely, and the condition tends to repeat itself.  Acute means that it comes on unexpected and usually very quickly. 
If you would like to experience the feeling, try to do the following for about thirty seconds.  Now don’t try this if you have other medical conditions including breathing problems or heart problems.  If you are healthy, try this just once.  Close your mouth tight.  Then pinch your nose so that only a little bit of air enters your nose, and none enters your mouth.  Try to breathe like this for about thirty seconds and you’ll experience what a COPD patient lives with when they have an acute episode.  You will find yourself getting a little light-headed after about five breaths done this way, and you’ll quit the experience because it is scary.  Just remember that you were doing this to feel the way these kinds of patients feel when they have an acute onset of difficulty breathing.  You get to stop whenever you feel like stopping.  The COPD patient having an acute episode needs help, and they need emergency help as quickly as possible.  They can’t just let go of their nose and open their mouth to catch a good breath.
They may have trouble getting air into their lungs or they may have trouble exhaling the air from their lungs, or they may have both issues going on at the same time.  These patients may present in many different ways, but the issue is usually difficulty breathing.  Then, since the brain and the heart need oxygen to continue to function properly, there could be a neurological issue or a cardiac issue.  It is simply not just an easy situation to deal with, and the patient or family member has called 911 because they can’t handle the situation alone anymore, and they need help resolving the issue.  It doesn’t matter whether the problem is a severe allergic reaction, a severe infection, or an asthma attack.  It doesn’t matter if this patient has been visited thirty times or this is the first time.
We are paged to this residence for a 45 year old male patient having difficulty breathing.  The residence is quite a trip down the island, one that takes twenty minutes on the winding, dusty roads of island life.  The emergency response vehicle is in route almost immediately after the pager notifies the crew, “Respond to Lake Geneserath for a 45 year old male patient have difficulty breathing.  They are breathing, but are not able to speak more than two or three words between breaths.  There is no family member in the residence at this time, and the patient is unable to get to the bathroom to reach their medication in the medicine cabinet.   This is a priority one call.  Respond lights and sirens.”
“Echo four is in route!”  I respond.  It’s springtime with lots of dust brought into the air with the vehicle as I turn off the pavement of the Kings Highway onto the gravel road leading east.  The windows have to be closed, even though the temperature isn’t cold, because the dust will be drawn right into the echo car.  The emergency lights are flashing, and the siren is blaring.  The computer receives the GPS coordinates of the location of the residence and points a red arrow at the residence as well as showing the echo car location with a green arrow that moves as the echo car moves.
The first three miles of pavement seemed to scream past the windows, but now the dusty and bumpy gravel roads slow down the emergency response.  The fifty-five to sixty miles per hour is now down to thirty or thirty-five in order to maintain control of the vehicle.  I think to myself, “I hope I don’t pass anyone else out here.  I won’t be able to see anything,” and just as these thoughts pass through my mind, a vehicle headed north pulls over on the opposite side of the gravel road, and the echo car enters the cloud of dust that this vehicle causes.  I have to slow down because I can’t see anything in front of me.  As the dust begins to clear from that vehicle, I speed up to thirty-five again, and carefully execute the curves in the gravel road as they are encountered.
“Crap!” I say out loud as I come up behind another vehicle, this one heading south.  I turn the siren on wail and hope that they hear it and pull over.  They must be listening to music loudly because they don’t see the flashing lights or hear the siren wailing behind them in the dust cloud.  Between the dust cloud blocking the view and the road noise from their vehicle, they don’t even know that I’m behind them, and I don’t know how far in front of me they are.  I start tooting the car horn, “BEEEEEEEP  BEEEEEP  BEEEEEEEEEP!”  All of a sudden I see a vehicle pulled off the side of the road, and I swerve the echo car barely maintaining control of the vehicle as I pass them and quite literally leave them in the dust.  I pick up the microphone of the radio and say, “57 Alpha 2 from Echo 4.”
The ambulance answers back “Go ahead Echo 4.”
“You have two vehicles to watch out for on your response behind me.  You have one headed north that will blind you for about twenty seconds.  Then there is another headed south about a quarter mile farther down the road.  You’ll have to use the horn as well as the siren to get them to pull over.  At least that’s how I got past them,” I respond to warn the ambulance with the EMTs in it.  “Be careful, it’s really bumpy and dusty out here.”
“Roger, Echo 4.  Are we going to the xxxxxxx ….residence again?” 
“That’s what the GPS suggests,” I answer.  “Echo 4 clear.”
I begin to go over the dispatch information in my mind.  I begin to wonder how bad of shape the patient is in.  I wonder why there isn’t anyone there to help the patient do a breathing treatment.  The echo car hits a pothole, my head hits the ceiling of the vehicle and I do an S-shaped shimmy from one side of the road to the other.  “Crap!  That’s was close!”  I holler to no one but me.  “God, that was close,” I think out loud as I slow down from the forty-five miles per hour that I had crept up to.  “Only about another mile or two to go.  Make sure you get there, idiot,” I say to myself.
“Central, 57 Echo 4 is one scene.  57 Alpha 2, how long before you are here?”  I ask as I head into the house with a jump kit, oxygen, run box, and drug box. 
“Be there in about five minutes, Alpha 2, clear,” the ambulance responded.  “Echo 4, clear,” as I opened the door.
“Hello, its Joe from EMS.  Where are you?” I ask.  “Here……in……the…….bed……room,” my patient responded with one word dyspnea, a measure of ability to breath by the number of words that can be spoken before another breath is taken.  I enter the bedroom to see my patient sitting upright leaning forward in what we call the tripod position.  “I…….can’t……….breathe,” my patient states. 
“Have you done a breathing treatment?”  I ask, quite concerned.  The patient shakes his head meaning he hadn’t done one.  “Did……..use my……,”  he said, “but it…..didn’t….seem to……help.”
“I’m going to set you up with a breathing treatment called a duo-neb.  It has two medications in it.  Are you allergic to any medications?”  I ask as I assemble the nebulizer mask, hook it up to oxygen, and put the two drugs into the reservoir along with some inhalation saline to dilute the meds.  The oxygen is on 8 liters per minute, and I place the mask on the patient.  “Exhale as slowly as you can and take as deep a breath as you can,” I say as I get out the blood pressure cuff reaching to feel his wrist for a pulse.  The pulse is racing at a little over a hundred beats per minute.  I put the pulse oximeter, a method of measuring oxygen content in the blood, on his finger, and place the blood pressure cuff on the arm and prepare to take a pressure. 
“Alpha 2 on scene, Central.  What do you need in there, Joe?”  the EMT Gary asks on the radio.  “I need the monitor and the CO2 set up as soon as possible,” I responded.  Gary comes through the door moving to set up the cardiac monitor and the CO2 monitor and the pulse oximeter on the monitor.  The medical first responder, also a registered nurse, enters and I start rattling off information to be recorded on the run report form.
 “One word dyspnea, wheezes, inspiratory and expiratory, on both sides, mixed with moist sounds, oxygen is on at 8 lpm with a duo neb running using a mask.  SPO2 read 78% before the neb was started, the pulse rate is 106, blood pressure is 160/98, and respirations are 24.  Please prepare a BVM, and be ready to use it with 100% O2.  Thanks, Gary, for the monitor set up.  It reads Sinus Tachycardia.  We’ll switch over to the monitor for the pulse oximeter.  Thanks, for the CO2 setup.  I’ll put it on under the mask using the nasal prongs.  Okay, the CO2 reading is 55 for the initial reading.  The SPO2 is up to 80%, and we’re ready to assist with ventilations if necessary.  How’s your breathing, Mark?”
By the way, the patient’s name is Mark.  He responds, “It’s a lit….tle bit….better.”   I look at his skin and note that his nail beds are slightly grayish blue.  I ask him about the day, the time of day, and where he is, and he answers slowly with stops, but correctly.  That means that he is getting oxygen to his brain, and he is alert and oriented. 
“Okay, Mark, I’m sorry to tell you what you already know, but you are going to need to go to the hospital,” I say to my patient.  “There is a definite need to see your pulmonologist up at Northern.  Is there anyone that we can call for you while we get ready to transport?”
Mark responds, “Already….called….my kids….So…”
I ask Gary to start the process of arranging emergency air transport.  You see, we are located on an island that is thirty-two miles minimum away from a mainland airport, and our worst enemy is the weather.  Gary calls our local airline using the patient’s phone, and they will get the plane ready for us to use as an air transport vehicle.  At this time, we were not a licensed air transport service, and the method of loading a patient was quite simple.  We simply moved our patient, who stayed on the ambulance cot, into the ambulance and strapped the cot down to the floor of the aircraft.  Once in Charlevoix, we simply wheeled the cot out of the aircraft, dropped the wheels, wheeled the ambulance cot over to the Charlevoix EMS ambulance, and loaded our ambulance cot into their ambulance.  Pretty simple and easy.
Central Dispatch calls us on the radio, “57 Alpha 2, Central.” 
“Go ahead, Central, “Gary responds to the radio traffic.
“Call the local airline,” Central Dispatch advises.
Mark is finishing up on his nebulizer treatment with the two drugs mixed and diluted with inhalation saline as Gary uses the patient’s home phone to call the local airline.  Gary says, “They are telling me that they don’t have any pilot.  All of the pilots have timed out.  What do you want to do now?”
“We can try Northflight,” I say, quite disappointed.  “Its daylight, and the weather doesn’t appear to be an issue.”
“Okay, I’ll give them a call.  In the meantime, we might as well wait here, or we could head in to the medical center,” Gary suggests.
“Let’s find out when and how and where we are going first, “I say, getting a little frustrated.  “Mark, how is your breathing now that you are done with the neb treatment?”
“I am getting…….a little……..better, I think,” Mark responds with two to three words between breaths now.  “And I’m less…..scared now than……I was before.  But I’m not back………to normal by……any means.”
“Glad to hear that you are doing better than before,” I responded.  “We’re trying to arrange your transportation to the hospital.  It might take a little while to do this, but I have more things to do to finish your assessment.  I’m going to set up an EKG, keep the blood pressure, pulse, and respirations monitored, along with the oxygen saturation and CO2 monitoring, and, if these aren’t getting any better, I’ll be calling the hospital for some recommendations.”
To our MFR RN, “The SPO2 reading is now 88, which is likely approaching normal for this patient.  The CO2 reading is 48, so we have a little more to do with this.  The pulse is now down to almost normal with a regularly regular rhythm.  The respiratory rate is down to 20, the pulse rate down to 98.  I have the patches all ready for a 12-lead EKG, and the neb treatment was completed.  I am getting ready to give an injection of Solu-Medrol.  I’m giving it intramuscularly, and I’ll be preparing an IV shortly.  Do you see anything that I might have missed?”
“You’re doing great,” the RN says, and I’m setting up your IV for you.  Gary just told me that the Northflight aircraft is out on another transfer and possibly six hours before they can respond here.  Now what do we do?”
“I’m pretty sure that Gary has already moved down the list to the USCG for an emergency evacuation.  Is that right, Gary?” I asked.
“You bet!” he answered.  “I’m waiting now for a return call from the Flight Surgeon.  What can I do to help you?”
“How about you set up the EKG 12-lead, and I’ll get this IV started,” I answered IV tourniquet in hand.
“Sounds good,” Gary answers.
“You’re all set up for the IV,” the RN said.  “I’ll hand you what you need as you need it, okay?”
“Sounds great to me,” I answered.
“Here are the gloves.  They’re extra large, just for you,” she stated. “I have a couple of sizes of catheters for you.  I have an 18 and a 20, but I can get you anything else that you might need.”
“Great,” I responded putting on the tourniquet.  “Here we go, Mark.  I’m going to start your IV.  Right at this moment, all I’m doing is looking.  I’ll let you know when I’m ready to put the needle in.  You can watch if you want, or you can look away, but, more than anything else please don’t jerk your arm away when I poke with the needle.” To the RN, “You see what I see?  There’s a good vein in the left AC (the inside of the elbow).  Ready, Mark, there’s going to be a poke in your left arm.  It’s shouldn’t hurt very much.  Are you ready, Mark?”
“Yeah, do what you ……..have to do,”  Mark answers.
“It’s in,” I respond. “Let’s get him hooked up and, we’ll just run it to keep the vein open.  The vein tried to jump out of the way, but the catheter is in and hooked up now, so let’s get this secured, so we don’t lose this great vein.  How you doing, Mark?”
“I didn’t even feel….that needle.  Did you really…… get it so fast?  They usually poke me ……three or four times…… in the hospital……. before they get one,” Mark exclaimed with more normal speech than before.
“I’m glad I got it on the first try.  No worries, but don’t let them pull this one out at the hospital until they have another one.  Your veins have a tendency to move even when they are secured before the needle goes in,” I told him.  To Gary, “Okay, now let’s get that 12-led EKG.  I haven’t heard the phone ring, so we are still on hold, I guess.  Mark, put yourself in your happy place.  Relax and close your eyes.”
“Got it,” Gary said.  “Mark, you are 48, aren’t you.  I think that’s what I figured.”  Mark nods yes, and Gary hands me the 12-lead.
“Good,” I say as I look at the EKG, “its normal sinus rhythm with a rate of just under 100.  It’s probably up a little bit due to the difficulty breathing and the IV start.  Gary, can you call back and find out what our status is?  Can we get another set of vital signs, please?”
The RN began getting the vital signs, and Gary began the process of re-contacting the Coast Guard.
“United States Coast Guard, Group Soo, may I help you?” Gary hears on the phone.
“This is Beaver Island EMS and we are trying to schedule an emergency medivac helicopter for a patient with difficulty breathing,” Gary stated.  “We haven’t heard back from you, and it’s been a while.  Can we expect this flight to be approved by the Flight Surgeon?”
“Okay, Beaver Island, we’ve been having trouble locating the local Flight Surgeon for some reason,” the Coast Guard clerk stated.  “I have located a flight surgeon in Alaska, and I was just getting ready to conference you in.  Will you hang up and let me call you back so I can continue the process of setting up the conference call?”
“Roger, Group Soo.  We’ll await the return call.  I’ll have the paramedic available to give the report when you call back,” Gary stated.  To me, Gary said, “Be prepared to give a report to the Flight Surgeon who will be on the line in a few minutes.”
Our monitoring of the patient and vital signs continued for about ten minutes when the phone finally rang.  It was the Coast Guard Group Soo.
“Beaver Island EMS, this is Group Soo, and I have conference in the Flight Surgeon who is in Alaska, you can go ahead and give him the report and your request”
I provided the USCG Flight Surgeon a report of the patient’s condition and the assessment and treatments that were provided along with the current status of the patient.  “We believe that this patient needs to be in a hospital where he can receive definitive care,” I ended my report.
The Flight Surgeon stated, “You have provided the definitive care, and I assume you will be providing the patient another Duo-Neb treatment in the next thirty minutes.  That should last the patient until he arrives at the hospital.  I agree that this patient needs to be evacuated, and I also agree that this patient can’t wait six hours.  I will authorize this medivac.  Make sure that you are prepared to intubate the patient and bag him if he decompensates any further. You patient is in respiratory shock, as you know, and the outcome will depend on how his treatments continue.”   
“By the way, I recognize your name and I’m sure you would recognize me if you could see me.  I was previously the Flight Surgeon out of Traverse City Air Station, and we jointly put on a hypothermia class for your EMS people on the island.  I also have taken several of the Beaver Island patients while flying in the helicopter out to Beaver Island.  So, Joe, you can relax, stop hyperventilating, and prepare your patient for the helicopter.  Group Soo, I authorize this flight, and have them get moving.  This patient needs to be in a hospital,” the Flight Surgeon finished speaking.
“Thank you, Doctor, I remember you and your excellent program and I appreciate the additional help,” I said.  “Group Soo, will you have Traverse City Air Station call us at this number when they lift off, please?”
“Roger, sir.  Authorization has been received, and the helo is on the tarmac ready to depart.  We will have TC Air Station call you on lift-off. “
I handed the phone back to Gary, who finished the conversation and the arrangements.  I spoke to the patient, “You are going to be flying in a Coast Guard helicopter.  We will take you out to the township airport to meet them.  I’ll be setting you up with another breathing treatment while we take our time getting to the airport.”
Mark, relieved, said, “I’m sure glad….you guys know……how to get this…….stuff arranged.”
The phone rang and Traverse City Air Station stated that the helicopter was in the air in route to Beaver Island Township Airport and would arrive in approximately thirty minutes.  We loaded our patient into the ambulance, and began a second breathing treatment in route to the airport.  The patient continued to be stable, but still in need of hospitalization.
“Central Dispatch, 57 Alpha 2,” we radioed our dispatch center.  “We are at the Beaver Island Township Airport and await a Coast Guard helicopter.  Please advise Traverse City Air Station.”
“57 Alpha 2, we are clear on your traffic and we have the air station on the phone at this time.  They are requesting that your paramedic accompany the patient because they only have a first responder swimmer on board.  Their estimated time of arrival is five to seven minutes,” dispatch states over the radio.
We have a lot to do in order to get ready for the helicopter.  First of all, we need to go into the airport terminal area and move the patient off the ambulance cot since it won’t fit into the helicopter.  We have a folding cot just for this particular purpose.  Inside the terminal we go wheeling the patient and carrying the folding cot.  The ambulance cot is moved down to its lowest level because the folding cot only sits about six inches off the floor.  We get two people on each side of the ambulance cot with a concentration of weight to be in the center.  Reaching down and grabbing the lowest blanket, the one the farthest under the patient, we ask the patient to fold his hands and lock his fingers so he doesn’t get his hand or arms injured during the move. 
“On the count of three.  We move on three,” I say as I am at the head.  On three we lift the patient up and move him over to the folding cot.  Immediately as others begin to strap the patient to the cot, we put the head of the cot up because the patient can breathe easier when sitting up.
Second, after moving the patient to the folding cot we have to decide which pieces of equipment that I need to take with the patient while we are in the helicopter.  The helicopter has limited space and not much room for patient treatment.  That’s why we do everything we can do to stabilize the patient before getting on board the helicopter.  At this point, I decide that we will take the cardiac monitor because it has an automatic blood pressure machine, a pulse oximeter machine, and well as the cardiac monitor.  I also choose to use the carbon dioxide monitor to make sure I can monitor the patient in the noisy interior of the helicopter.  Of course, we also have to take the oxygen tank and be prepared to do another breathing treatment as well as being prepared to ventilate the patient in case he turns toward the worst.  The worst is that the patient quits breathing, and then I’m there with just a first responder to help me.
All the airway and breathing stuff is able to sit between the patient’s legs on the folding cot.  The monitor will have to be carried out to the helicopter.  We are as ready as we can be, and we hear the approach of the helicopter.  That sound is really quite welcome with its “duo whop whop whop.”  Or it sound something like that anyway.  The helicopter lands right on the east/west runway and taxis up to the tarmac.  We wait for the helicopter swimmer and another crew member to join us in the airport terminal.  After agreeing on the approach to the helicopter, we place the patient on the folding cot into its position on top of the wheeled ambulance cot.  I’m holding the IV and the cardiac monitor as we head out on the tarmac to approach the helicopter.  The blades are still turning and we have to approach the helicopter in just the right way.  The rotor wash blows down hard on us, but we manage to get the ambulance cot up to the helicopter and slide the folding cot off the ambulance cot onto the deck of the helicopter.  Luckily the folding cot has wheels on one end that makes that process a little easier.
The tricky part of this transfer is that the monitor and the IV are both connected to the patient and the wires and the tubing are of limited length, so as soon as the patient is begun to be loaded into the helicopter, the monitor and the IV have to also be loaded.  The only way to do this is to put the monitor on the patient’s legs and the IV somewhere in that same location until the patient is fully in the helicopter.  Then I have to climb into the helo alongside the patient, untangle any tangled wires, make sure that the equipment that I might need is in reach, and verify that the IV is still running.  If you want to get a feeling of what this is like; get down on your knees next to your couch, not where your head is and try to figure out how to get on your couch without raising your head any higher.  Then try saying, “Duo whop whop, duo whop whop, duo whop whop,” at the top of your lungs.  Then reach back after you are on the couch on your buttocks and try to get the keys out of your pocket and then get the wallet out of your back pocket.  Oh, and the real test is to try to what I suggested with your eyes closed or blindfolded.  That really will help you understand the difficulty of this procedure even though it looks easy for the side of the tarmac while spectators are watching the procedure. 
Anyway, the patient on the folding cot is in the helicopter.   I am in the helicopter, and the two crew members climb into the helicopter and close the sliding door.  I’m handed a headset with headphones and a microphone and the swimmer uses sign language to show me how to make it work.  The swimmer, after showing me how to make the intercom work, says,”Let me know if you need my help.  I’m a first responder, but I can follow instruction to the letter.  If you need something, and the intercom does not work, just wave your hand at me and I’ll do whatever you ask me to do.”
“Okay,”  I say, “we are headed to McClaren Northern Michigan Hospital via Harbor Springs Airport, correct?” 
The pilot broke into the conversation, obviously on the same intercom system, and said, “We got the hospital to clear out an area at the hospital in a parking lot. So we’ll be landing right there at the hospital.  They will have an ambulance waiting to load your patient and take him to the Emergency Room.”
I’m sure that my jaw must have dropped quite a bit because I was completely blown away with these arrangements.  We always had to land our plane at Harbor Springs Airport, and then the mainland ambulance service would take the patient to the hospital taking ten to fifteen more minutes.  Here we were landing right next to the hospital and there would be a couple of minute trip from the helo to the ER. 
We lift off from the airport, and I am getting back to monitoring my patient.  The oxygen level is improving.  The CO2 level is improving.  The patient’s breathing is becoming more relaxed.  The heart rate is dropping from fast back down to normal.  The blood pressure is a little high, but, what do you expect?  We are in a helicopter.  I bet my blood pressure was a little high too.
Before I know it, the swimmer is saying that we are preparing to land.  I’ve been so busy monitoring my patient and recording vital signs and all the information that didn’t get written down, that I really didn’t take note of the time nor look at my watch.  The next thing I know I see that we are going down below the tree tops into the parking lot, but it’s not the hospital parking lot.  “Where are we?” I ask over the intercom.
“The parking lot was needed by the hospital, so we are landing in the Elks parking lot just around the corner from the hospital,” he answered.  “There will be an ambulance here in just a minute or two.”
I’m thinking to myself, “Wow, things change pretty fast in these situations, but I’m going wherever the pilot of the helicopter decides to take me.”  The patient is resting quite comfortably on the folding cot.  His breathing issues are seemingly much better.  His vital signs are within normal limits.  His oxygen level is now in the nineties and his CO2 levels are within the normal range for adults.  And as I record this information, the helicopter touches down in the Elks parking lot.  The helicopter rotors begin a shutdown procedure, and fairly soon an ambulance pulls up; the swimmer opens the door and motions for me to get out of the helicopter.  I do so, leaving my patient resting inside.  I walk over and give my verbal report to the other paramedic and, the ER physician who is coming on shift.  She shares a fascination with emergency medical services, and she wanted to meet the patient outside of the ER.  The paramedic receives my written report and hands it to the ER doc, who peruses it quickly.
The ER doc says, “You have done an excellent job in providing care for this patient.  The verbal and written report are complete and very informative.  Thank you for what you do!”
I’m completely speechless.  I turn around and start walking back to the helicopter and the paramedic from Petoskey joins me with the Petoskey ambulance cot.  We move the patient from the helicopter, still on the folding cot, and place the folding cot and patient on top of their ambulance cot.  We wheel the patient over to their ambulance and load the patient into the back of the ambulance.  The monitor electrodes are left on, but the Beaver Island EMS cables, probes, and other pieces are removed and replaced by the Petoskey equipment.  The Beaver Island equipment is packed up and handed to me.  The Petoskey paramedic says, “Have you got everything?  Did we forget anything?”
I look and note that the IV is hanging and still running just fine.  I say, “No, I think that’s all of the equipment.  Do I ride with you to the hospital or do I get out now?”
“Climb out, and we’ll take your patient to the hospital.  The ER doc is already planning his treatment, and we’re only two minutes away from the ER,” the Petoskey paramedic says, so I climb out of the ambulance, and the ambulance begins to roll off.  I turn around and see the helicopter blades begin turning and within a couple minutes the helicopter takes off headed toward another mission assigned to them from Group Soo.
I am now standing in the parking lot of the Elks Club in the city of Petoskey with an $18,000 monitor, a drug box, and an oxygen tank.  The ambulance is gone.  The helicopter is gone.  The patient is gone.  I’m the only person in the parking lot.  I pick up my equipment and begin walking out of the parking lot toward the fast food restaurant a little less than a half block away.  I get myself a burger and a drink and sit down and contemplate the “What do I do now?” situation that I am in.
I knew that the Coast Guard never brings us back to the island.  I knew that I had turned the patient over to the Petoskey ambulance crew.  I just didn’t quite know what was going to happen now.  I’m in Petoskey.  I need to get back to Charlevoix.  I need to get a motel room for the night.  AND, I need to get a flight back to Beaver Island in the morning.  Those are the things that need to get accomplished.  Now just how do I get this accomplished?
Well, it jumped into my brain and the answer became clear.  You dummy, you have a radio.  USE IT!  “Central Dispatch, 5743,” I called on the radio.
“5743, this is Central. Go ahead with your traffic,” Central responds.
“Central  5743 is in the Elks parking lot here in Petoskey where I turned over a patient to Petoskey EMS after flying here in the Coast Guard helicopter.  The ambulance left with the patient.  The helicopter left for another mission, and I am currently without transportation.  I need to get back to Charlevoix for a morning flight back to Beaver Island.  Can you arrange some transportation for me, please?”  I asked.
“Stand by, 5743, we will see what we can work out for you,” Central responded.
About fifteen minutes later, Central Dispatch called me back on the radio and told me that they had arranged my transportation.  An Emmett County EMS ambulance picked me up and took me to the Emmett County/Charlevoix County line.  I waited there for about ten minutes, and a Charlevoix County Sheriff’s Deputy car picked me up there and took me back to Charlevoix.  The deputy dropped me off at the motel, and I checked in to spend the night.
The next morning I called the local airlines to arrange a return flight to Beaver Island.  The weather was beautiful outside, and I began to walk from the motel across the bridge in Charlevoix when the Charlevoix EMS echo car stopped and picked me up to take me to the airport.  Isn’t it pretty amazing and completely different experience for this one particular emergency?
I got back to the island, and the Echo 4 car was waiting for me at the airport.  All  the equipment had been replaced except for what I had carried with me.  I put it all back in the echo car, and headed home.  My wife was at work, and my kids were in school, so the empty house was kind of lonely, but I had a report to write.  I had just finished the report and got paged once again.
“Beaver Island EMS, respond to XXX East Side Drive for a diabetic emergency.  Patient is breathing, but is unresponsive and is bubbling mucous from his nose and mouth,” Central stated.
“57 Echo 4 is in route to that location, Central,” I responded on the portable radio as I walked out to the vehicle.  This was another patient with several responses to his home.  Some people even had the audacity to call them ‘regulars.’  Once again, I don’t think about these emergencies in that way.  I view it as someone is in need of help, and I have the education and the skills to help them.  Off I go lights and siren down the King’s Highway to the end of pavement and turn onto the first of the continuous gravel roads on the island.
A full six minutes after the page, I arrive at the residence and notify Central Dispatch, “Central, 57 Echo 4 is on scene.  I haven’t heard anyone else call in.  Do I have an ambulance in route to this location?”
Central responds, “Yours is the only radio traffic we have heard.”
“Please page it again for any available EMS personnel to respond with the ambulance to this location,” I state.  “I’m going in to assess the patient.”
This patient is a repeat customer as well. But with a diabetic, there can be two completely different conditions, one is low blood sugar, and the other is high blood sugar.  Low blood sugar is life-threatening, but the high blood sugar problem is also serious.  Both conditions are emergencies.
As I enter the house, I am wondering whether this will be a condition that I can treat or whether it will be a condition that will take days in the hospital to correct.  Right on the floor of the living room is my patient.  He is lying on the floor on his back, and he is gasping for breath.   He is posturing with his arms stiffening, and I know that it will be difficult to get a vein in his arms.  I try to move one of his arms, but his muscles tighten up and will not move without my using two arms to get it away from his body and in a position to start an IV.  I run out to the echo car and get the suction unit to clear his mouth and nose of secretions.  Back inside, I suction both, but can’t suction inside his gums because his teeth are clenched tight.  I need help with this patient.
What I can do, besides clearing his airway of mucus, without someone’s help, is check to find out if his blood sugar level is high or low.  That will help determine what the treatment will be.  I poke his finger, get a little drop of blood, and put the sensor strip in the drop of blood.  As the meter starts counting down from thirty to zero, I hear the response on the radio, “5778 is on scene.”
The glucometer, the machine that measure the blood sugar level, normally gives us a number, but today, the machine just says, “Low.”  That means that we can probably fix the problem for the patient because he is a diabetic and has taken too much insulin or worked too hard or forgot to eat or some combination of these.  Gary has arrived on scene and comes in the door.  “What do you need?” he asks.
“I need to get an IV started and push D50, but I can’t keep his arms out from his body to get a chance for the IV start,” I say.  “He has been posturing, but is also combative.  Can you keep him from hitting me and keep his arm still so I can get and IV going?”
Gary lies across the patient’s chest with one of his legs holding down the patient’s legs and both of his arms holding the patient’s left arm flat against the floor.  I quickly set up the equipment for an IV, insert the needle into the vein and flush the tubing with a fast flow rate to make certain that the IV catheter is actually in the vein.  Gary is fighting a hard battle to keep the patient’s arm from moving, so that I can finish taping the IV down, so we don’t lose it.
“Keep the arm still, so we don’t lose that IV, and I’ll get the sugar ready to give,” I say, but Gary is having a hard time keeping the arm still.  I move myself into position and put one knee on the patient’s wrist and the other knee between the shoulder and the elbow to keep the arm from moving.  “Gary, I’ve got the arm.  Can you give the D50 while I keep the arm still?”  Gary’s position was quite unusual, but he managed to maneuver into a position to give the treatment as well as keep us both safe from any punching or kicking.  After all twenty-five grams of 50% solution of dextrose and sugar, the fighting of the patient, the combativeness, stopped.  Gary was able to get off the patient and I was able to move my knees from the patient’s arm.  The patient seemed to relax for a moment or two, so we could once again suction his airway.  His teeth were no longer clenched.  After about five or six minutes, the patient opened his eyes and said, “Damn it, Joe.  It happened again, didn’t it?”
I responded, “its okay, Fred.  We’re going to help you keep your sugar level up, so this doesn’t happen again today.  It looks like you were working hard, came in the house, and didn’t get your lunch in time to keep your sugar level up.”
“Damn it.   The last thing that I remember is coming in from the garage and sitting down,” Fred said.  “I’m sorry to have brought you guys out here again.”
Gary said, “It took me a while to get here because I had to get out from under the house where I was repairing a plumbing problem.  I probably need a break from work anyway.”
I said, “I’m glad that we were able to help fix the problem.  Are you willing to go to the hospital or the medical center to be monitored for a little while?”
“Hell, no!  I’m fine now.  I don’t need another bill from the ambulance, and I sure as hell don’t need a big bill for the air transport.  So, thanks, but no thanks.  It will be a cold day in hell when I will do either of those trips,” Fred spoke vehemently.
“Okay, we’ll just have to get you to eat something, and then we’ll check your blood sugar again.  In the meantime, we’ll just keep running some IV fluid into you and keep the IV in place to make sure you don’t go back low on sugar again,”  I said as I walked over to his kitchen table and made him a peanut butter and jelly sandwich.  Peanut butter for protein, and jelly for sugar are exactly what the doctor ordered, “I said.
Fred ate the whole thing, and nothing but the whole thing, drinking a glass of milk besides.  We checked a blood sugar, and it was within Fred’s normal levels, so we discontinued the IV, and wished him well.  We cleared the scene with no transport with, “Central Dispatch, 57 Echo 4 and 57 Alpha 2 are clear and available, negative transport,” and off we drove back to town to do a report on the incident and restock the ambulance.