We Cannot Do That

We Can’t Do That
By Joe Moore

There are some things that EMS providers are allowed to do that primary care providers might shrink from, and vice versa.  There are several things that I have helped the medical center provider do that there is no way that I would want to do with EMS providers, and I know that there are things that I do that primary care providers wouldn’t want to do.  They wouldn’t even want to do these things in the sterile environment of a room inside the medical center.

Do you remember the old-fashioned TV show called McGyver?  That seems to be what most of these situations ended up being.  Let start with one inside the medical center, back in the old days before the new facility was built.

A young man called the medical center provider after having a fall.  In the breaking of the fall his left shoulder was dislocated.  My phone rang, and Jorge was on the line asking for help.

“Joe, I’m going to need you to come to the medical center.  The weather is too bad for anyone to fly tonight.  I’m going to need some help from you and one more EMT.  Who should I call?” Jorge asked.

“I’d call John.  He’s not an EMT, but I know he’s able to follow instructions and will do whatever you ask him to do,” I said.  “Do you want me to make the call?”

“Go ahead.  I’ve got to get an IV started, and we need to be ready for you when you get here,” Jorge stated factually.

The phone call was made, and the arrangements were to head to the medical center.  It only took a few minutes for both of us to arrive, one from half mile away and the other from about six miles away.  The weather wasn’t just bad.  It was truly nasty with blowing snow, cold temperatures, and true blizzard conditions over the entire tip of the mitt of Northern Lower Peninsula of Michigan from Traverse City north.  It took me longer to get out of the driveway due to drifting snow than it did for John to get to my place.  John actually stopped and helped me get out of the driveway and then followed me to the medical center to make sure I got there.
The medical center parking lot was plowed, or, at least it had been plowed.  It had a couple of inches of snow on top of the already plowed area with a few drifts of snow up to ten inches, but, at least, it was not wet snow, so going through it was easy.  I pulled in with my old Ford station wagon followed by John in his four-wheel drive truck.  We both entered the front door of the medical center building and took off our winter coats, hats, scarves, and gloves.  We were ready to help.

I said to John, who had a full beard, “You might want to brush back your hair because right now you look like a hippy, and your hair is standing on end.”

“You might do the same,” John said, “since your hair is longer than mine, and standing up straight due to your sweat from being stuck in your driveway.”  He said this with a smile, and a good jibe was taken all in fun.
Jorge was in the very first exam room.  He had had the doctor in the ER in Charlevoix on the phone, and had gotten suggestions on resolving this issue from the doc.  Jorge had grabbed two sheets, and also moved the exam table all the way to the opposite side of the room from the doorway.  There was just room for one person to stand between the exam table and the window with about two feet to spare.  Jorge assigned John to get on that side of the bed, and told me to just wait for a minute.

“John, when I tell you, I want you to take the sheet that I have under our patient’s chest and tie it around your waist.  This is what your job is.  You will then lean backwards to provide counter-traction.  You need to lean back enough to make certain that the patient’s chest does not move away from you.  Do you understand?”  Jorge said.

“Yup, got it.  If I need to, can I also use my hands to help pull traction?”  John said.

“Yes, you can, but let’s try it with just the heavy lean to start,” Jorge said.  “Okay?”

“Got it,” John said.

“Now, Joe, your job is to take this second sheet.  You’ll be putting this one around the patient’s elbow.  Do you notice that I already have a couple of triangle bandages holding the patient’s arm and hand from allowing the sheet from slipping off?”  Jorge said.

“I understand, so far,” I said.

“Okay.  Then, Joe, you are going to tie this second sheet around your waist just like John does.  Then when I tell you, both you and John will lean back putting traction on the sheets.  We will need to keep the traction for a while.  Do you both understand what we are going to do?”  Jorge asked.  “Oh, and, by the way, the patient will be in a great deal of pain, and he may scream, but your job is to maintain the traction until I tell you to stop.  Got it?”

“Okay, now, I’ve got to be ready to help manipulate the arm in either up or down, and I need to make certain that the patient keeps breathing.  We are doing what is called a conscious sedation.  Everyone get into position while I give this patient some drugs.” Jorge stated.  He leaned over to me and whispered, “I’ve never done this quite this way before, so we’re doing our first shoulder relocation here on Beaver Island.  Are you ready?”

Both John and I got into position and tied the sheets around our waists.  Jorge gave the drug after telling the patient, “This may hurt some, but you are not going to remember it.  You’ve already had some medication to relax you and to help with the pain.  Are you ready for this to begin?”

The patient said, “Just get it over with.”

Jorge then gave the patient the IV drug, and it appeared like the patient was sleeping on the bed.  Then he said, “Okay guys, get yourselves in position.  Now, we’ll start just very gently leaning backward to put a little traction on the shoulder.  Ready?  Lean gently back.”

The patient began to groan a little bit, which kind of made me a little uncomfortable, but I didn’t stop the gentle traction.

“Okay, lean a little farther back to put a little more traction on the shoulder,” Jorge said.  “A little more….okay, stay right there.”

“You’re the boss,” John said.

The patient was groaning a little louder and had a grimace on his face, but his body was not moving from his belly button to his head.  Jorge was up near the patient’s shoulder, feeling with his fingers, and he said, “Okay, guys, the muscle spasms are beginning to subside, but we can’t take a break right now, or we’ll have a harder time the second time.  Lean back just a little bit more….more…..MORE…”
I felt the sheet do a little release on my tension, and Jorge said, ”We DID IT!  You can stop leaning now.  Joe untie yourself and check a pulse as I continue to feel and make certain we are back in the joint.  John, you can untie and get a set of vital signs for me please.”

The patient had a nice radial pulse on the affected side.  I got a pulse rate from that, and John got a blood pressure, while I got a respiratory rate.  I said, “Jorge, his respirations are down to 8.  You want me to bag him?”

Jorge said, “Give him a minute or two, and then we’ll check it again.”  In EMS, our rule had been to ventilate the patient if his/her respirations were below 12, but we weren’t out in the field right now.  We were in a controlled atmosphere.  “Joe, give him some O2 by nasal canula.  His respirations are coming back up.  I’m going to call the doc back.”

John and I kept monitoring the patient, taking vital signs every five to seven minutes or so, and then Jorge came back after talking to the doc.  “Well, congratulations, on a job well done.  Dr. XXX said we did a good job, and he is very joyful that he didn’t have to take care of this tonight in the ER.  He said to tell you both that we all did a good job.  The patient will begin waking up shortly.  Once he’s awake, you guys can head home.”

The patient woke up in about a half an hour.  He said, “When are you guys going to take care of this shoulder.  I thought you were going to do something.”  He was immobilized with his arm across his chest, tied in place with a triangle bandage for a sling and another for a swathe.  He also had his IV still in place and low-flow oxygen on.  It was kind of funny to me that he didn’t remember anything about what we had done.  He didn’t even remember us causing him pain that he groaned about.  That Versed is a wonderful drug. 

“WE got you all fixed up,” Jorge told the patient.  “These guys helped us get you back to normal.  Your shoulder is back where it should be.  We’ll  know what damage, if any, has been done when you come in tomorrow.  I’m going to set you up with an appointment with an orthopedic physician to check your shoulder, and we’ll do an x-ray in the morning.  You need to keep your arm in that position all night.  Sleep with your undershirt on, and DON’T take this off until after you come in to see me in the morning.”

To John and me, “Thanks for coming in and helping on such a snowy day.  I appreciate it.  The patient won’t remember that you were here, but I will.  You guys can head home now.  Thanks again!”

Off we went.  This was just one more adventure that we had had the opportunity to participate in.  This was just as successful as some of our other adventures, even though they all weren’t perfect.  EMTs and paramedics aren’t allowed to do what we did today for that patient, but being isolated on the most remote inhabited island in the Great Lakes can sometimes require you to do some things that you’ve never done before.

Jump ahead a few years to 1999 during paramedic clinical, and I had another chance to do a conscious sedation.  The ER doctor was a frequent visitor to Beaver Island, and I was doing my clinical hospital ER time with him.  He invited me up to the doctor’s break room for a cup of coffee.  We were chatting about the many emergencies that Beaver Island EMTs have seen over the years.  We were talking about how long an emergency would last on the island compared to the amount time on the mainland.  We’re talking a factor of four or five.  Let’s say that the common average emergency time for transport of patients in Charlevoix was a half hour.  The same patient on Beaver Island might take four or five times that or two to two and a half hours.

He said, “But that will change when you become an advanced service with paramedics.  You won’t need to stop at the medical center for every patient to get treatments since you’ll be able to do a lot of those things in the field on the way to the hospital.  If you only had a local air transport licensed, you could sometimes even beat a rural call in Charlevoix County.”  Little did he know that we were working on that exact thing.  It might take ten or twelve years to get it done, but it was a goal even in 1999.

While talking in a relaxed atmosphere, the phone rang.  It was the ER.  An ambulance was on its way in from Antrim County.  There had been a motorcycle accident, and the driver had been thrown from the motorcycle, did a flip in the air and landed on his right leg.  He was completely immobilized on a spine board with cervical collar.  My job in the ER, assigned by the nurses, was to take vital signs, and, if the doctor ordered an IV, I was assigned that task if they didn’t already have one.  Apparently, this job was to change over the next few minutes.

As the patient was wheeled into the exam room, I noted that the patient’s foot was pointed outward at a ninety degree angle from what it should have been in.  It pointed directly to the right on the backboard and not toward the ceiling like it should have been.  I listened to the EMT’s report about the accident, and I asked a question, to which the nurse gave me a dirty look.

“Did you backboard the patient due to the mechanism of injury or because of the injuries you found in a head-to-toe exam?”  I asked.

The nurse said, “That doesn’t matter, Joe.  We’ll take it from here.”

The doctor, while looking directly at me, said, “Just a minute.  I’d like to know that answer also.”

“We never did a head-to-toe exam due to the mechanism of injury,” the EMT said.

By the time we got this answer, the other nurse in the room had the patient cut free from the backboard, the straps off, and the cervical collar removed.  I wasn’t very happy about that, but it was not my patient, until the doctor said, “Okay, Joe, show me your head-to-toe exam.”  Boy, did that make both nursse angry.  They both gave me dirty looks.  They knew that I was getting special treatment by this doctor, and they were not happy about it.

I began my assessment by checking the airway, breathing, and circulation of the patient, and I found nothing abnormal.  I then did a nose-to-knees trauma assessment, including doing a log roll with help from the nurses, after cutting off the patients clothes, finding nothing that was abnormal including the spine.  The patient had no pain on palpation of any part of his body above his knees.  I then gave my report to the doctor, after taking vital signs.

“Doc, the patient has no obviously serious injuries, other than the abrasions that are obvious.  There is no abnormality in his vital signs, his breathing, or his pulse.  He is not in shock, unless he is compensating well.  He has no pain on palpation of anything in his trauma including his spine, his abdomen, or his chest.  If he were my patient, I’d start an IV at to-keep-vein-open rate, KVO, and be prepared if he starts to decompensate.  Then, I’d defer to you to take care of his obviously dislocated foot at the ankle, but this is not life-threatening,” I said.

“Well, I’d say that was a pretty good report,” the doc said.  “Now, since we have the ability, we will have the patient go down to get cervical and spinal x-rays.  We’ll also do an ultrasound to verify that there is no injury in the abdomen, but not until you start the IV, Joe.”  To the nurses, “Will you get these scheduled, please, AND I’d like Joe to accompany the patient throughout these tests, so he gets some experience.”

The nurse in charge of the ER said, “Yes, Doctor, we will do that.  What size IV catheter do you want and what drip rate?”

“Joe was right on in his assessment, but I’ll bet that he’ll start an 18 gauge catheter with a saline lock, hooked to a 1000 cc bag of normal saline, because that’s what he’d do in the field before getting here.  That’s good enough for me,” the doctor said.  “I’ve got another patient I need to see on the floor.  Page me if you need me.”

I started the IV, and headed back to the ER nursing office, and decided to sit down for a minute.  I hadn’t been seated for more than a minute when the head ER nurse wanted to talk to me.  The head nurse in the ER waved me over and said, “Well, you just got a compliment from the only doctor in the ER that never gives compliments, and he wants you to accompany the patient, so let’s you and I wheel this patient up to x-ray.”  And off we went.  “You can be a big help.  This bed is heavy.”

So we wheeled the patient down the hallway and over to the x-ray where the technician was ready for us.  He said, “I assume this is the stat-spine series that I’m supposed to do, but the patient doesn’t have any c-collar or anything.  What’s up?”

I spoke up quickly and stated, “I’ll gladly hold c-spine throughout the series if you want.  I’m an EMT and studying to be a paramedic, and I know how.”

“Okay,” the technician said.  He handed me a couple of gloves and a lead-shielded suit to put on.

The x-rays were completed, and we continued down the hallway to get the ultrasound.  I got to watch, just as the doctor had ordered.  And we headed back to the ER exam room to find the other two nurses standing there with the doctor.  He was just saying, “You need to know that this paramedic student has been doing EMS on Beaver Island longer than either of you have been in nursing school.  He has at least five years more experience prior to your starting your pre-requisites for nursing.  I don’t want him sitting in the office watching.  I want him doing things that he will have to do in the field.  His diagnosis of this returning patient was 100% correct.  His assessment exam was more thorough than half the doctors that work here in the ER.  You will treat him with respect.  Now to show you how much that I trust him, he is going to help me with the conscious sedation.  You will hand him the drugs that I just ordered in the proper order and assist him in giving the drugs per our protocol.  Is that understood?”

Apparently, the nurses had complained to the doctor about my being able to do things that they would not have been allowed to do.  The doctor was just telling them that I would have to do a lot of this stuff without a doctor’s supervision, and he wanted me prepared to be able to do the job outside of the ER, in a ditch, or on a bathroom floor.  At least, that’s what he told me he told them after the fact.

I helped the doctor by giving the drugs that he had ordered for the conscious sedation.  He had me move to the proper side and told me to grab on to the patient’s leg, raise it up and pull gently on the femur while the leg was propped up on a few pillows.  Before I knew what happened, the foot was right back where it truly belonged, and the toes were facing the ceiling like they are supposed to.  The doctor said, “Joe, you deserve another cup of coffee for your work on this patient.  I know you need to write up your report for this patient contact, and you are welcome to use the doctor’s lounge to do so.”

Off we went.  Luckily, there was a shift change of nurses while he told me his conversation with the nurses, and I finished my coffee and my report after helping do a relocation of a foot.  I was able, for the first time, to get credit for doing a complete trauma assessment, a successful IV, and administer drugs.  It felt really good to go back to the island and report my experiences to the medic class.

This chapter is going back to the old days in the late 1980’s.  The provider was a nurse who had worked emergencies in the Upper Peninsula, but he was aware of the need for help when it came to doing emergencies.  Jorge was quite a hard worker, and he cared about everyone.  He helped no matter who or what was going on medically.  He wanted to have excellent outcomes, no matter how unlikely, and he made the unlikely become more likely with his optimism and skills.

On this day, during the summer, one of my high school students was playing around, and ended up burned with a somewhat serious, but not serious enough for hospital burn center burn.  He was a joker.  He had this habit of carrying around some fire crackers, and, when some buddy of his was least expecting it, he’d light one off and scare the “bejesus” out of them.  Then he’d laugh and laugh.  Everyone knew that he did this kind of thing, but nobody was expecting them to be the target of his interesting sense of humor.  He used a cigarette lighter to light the fire crackers.

Now, my mother-in-law and her family have this saying, “It will work out.  You just have to be patient enough to wait for it to work out.”

Well, this statement seems to have been a truism on this particular day.  Jimmy, he will be called, was walking down the street on this particular summer day with the firecrackers in his pocket.  When he got ready to head into town he had put both his firecrackers and the lighter in the same pocket.  He came downtown, parked, and began walking around and headed down to the public beach.  He ran into a couple of bikini clad high school girls at the beach, and they chatted, and Jimmy felt pretty cool.  The girls continued to talk to him, and he was engaged in quite the conversation with them for a while, but there were a bunch of people at the beach, and he decided he should leave when the girls decided to go in for a swim.

Jimmy got up, headed up the beach, and felt the lighter in his pocket.  He reached into the pocket and the result was a flame from the lighter.  The five or six firecrackers in his pocket started burning and exploded.  Jimmy was the recipient of his own trick, but this was not just a scare.  He had a dandy burn on his leg and his shorts were on fire.  Jimmy was so startled that he didn’t react very quickly, but eventually put the fire in his pocket and on his shorts out.

Luckily, the medical center is just up a little hill from the public beach, and Jimmy began walking up that hill.  Now, it so happens that I was doing some volunteer work at the medical center for Jorge, our RN provider.  I was also learning from Jorge, practicing vital signs, and doing whatever I was asked to do, including filing and answering the phone when the office manager was gone on an errand.  I happened to be the first person that Jimmy saw when he came in the door.

The smell was truly nasty.  Burning human flesh combined with burning corduroy shorts was what alerted me to go to the waiting room.  Jimmy was standing there with tears running down his face, and he said, “The fire crackers went off in my pocket.  It hurts like hell.”

“Oh, my God,” I said, “Jimmy, I’m so sorry.  Come right into room 1.”  Room one was the only room that didn’t already have a patient.  The first thing I did was poor some sterile water over his leg because my training on burns was to “stop the burning” and that’s what I did.  Then, the next thing I did wasn’t in the EMT book.  I took a pair of trauma scissors and cut up the shorts on the burned leg splitting the leg of the shorts on both sides.  Then I cut above the burn from the left cut to the right cut and pulled the burned piece of shorts off and set it aside.  Of course this hurt, when I did it, but the smoldering shorts were the cause of the continuing burn.

When Jimmy screamed, Jorge came down the hall from another exam room and said, “What do we have here?”

Jimmy said, “I set my own pants on fire.  Isn’t that stupid?  I did this to myself.  Crap!”

Jimmy had been obviously clicking the lighter in his pocket until one of the firecrackers caught and exploded.  He had a third degree burn of about one percent of his body surface, or the size of his palm.
EMS would normally stop the burning, bandage the burn, and transport the patient with an IV to the hospital.  This burn was not serious enough for transport to the hospital, so Jorge said that we would have to clean it up, debridement of the burned area, and then put some antibiotic cream on the bandage and bandage it.   In EMS, we seldom work in a sterile environment, even though we try to do our work in as clean as an area as possible.  Jorge had decided that it was time for me to learn to work in a sterile environment.

We don’t do debridement in EMS.  We can’t do that because it’s not in our protocols.  Today, I was going to learn a skill that was quite a challenge.  Jorge had me start an IV, and then Jorge gave the patient some drugs in the IV, which pretty much put Jimmy to sleep.  We scrubbed the leg around the burn area with some dark colored liquid.  Then we put a sterile drape around the burned area.  Jorge got me some sterile gloves and a set of sterile tools that I was to use to clean and do the debridement.  Then Jorge and I both put on the sterile gloves, and went to work.

Jorge said, “Do you see all the burned flesh there in the center of the wound?  We need to cut that and removed the charred flesh.  I’ll pick it up with the tweezers, and you’ll cut it and remove it to the dish over here.  Be careful to not touch anything except the dish with the sterile tweezers.”

“Okay,” I said with my hands shaking.  I know I should have felt some satisfaction that Jimmy was getting something in the way of a payback for all of his pranks, but I couldn’t feel that.  I couldn’t feel good about anyone’s hardship, no matter whether they deserved it or not.  We worked together for more than forty-five minutes, removing dead tissue and cleaning as we continued.  Finally, we were done.

The flesh looked clean and there was no burned flesh left, no blisters left, and no remains of the burned shorts.  Jorge removed the sterile field now, and took a large burn dressing and cut it to the proper size.  He took some white antibiotic cream, and using a popsicle stick worked the cream into the dressing with a liberal amount of extra cream.  At this point, Jimmy was beginning to wake up a little bit, and mumbled, “It isn’t burning anymore, but it sure hurts.”

Jorge put the dressing over the burned area and wrapped it with roller gauze, and said, “You’ll be coming back here every day for us to take care of this burn.  This is the only time that you will be knocked out.  It has to be done, so the burn will heal and not get infected.  You won’t like it very much, but I hope you learned your lesson.  You won’t be doing this kind of thing again.  I guarantee it because this is going to hurt for a while and take a while to heal.”

Jimmy left the medical center after his mom was called to pick him up.  Since I worked at the medical center only one day a week, I was able to see the progress of the burn’s healing and the debridement that took place every week.  I also saw a major change in Jimmy over that that period of time.  He got a little less cocky and seemed to become more responsible in his actions.  When he and I returned to the high school classroom that fall, he was a different person.  He was more respectful to everyone.  He still had a little cockiness that came out once in a great while, but his sense of humor had changed.  He didn’t take any joy in others who got injured or scared or picked on.  He began to grow up.

I felt pretty good about being able to help him through his adventure in burns and his adventure in learning.

Another example might even help clear this questionable statement up.  “We can’t do that.”

As a limited advanced life support agency (LALS) in the State of Michigan, our local EMS has limitations on the types of patients that we are legally allowed to transport.  But, the real question that comes up is this:  What do we do when we are not legally allowed to transport a patient, but the patient needs transport anyway or (s)he will die?  The obvious answer is that we will do whatever is necessary for our family, our friends, and our neighbors, and the law will just have to take care of itself because we are going to take care of our patients.

So, it’s not legal for a LALS agency to transport a patient who has had drugs administered.  This patient needs advanced life support paramedics.  Well, we could wait a couple of hours to get some paramedics to fly to the island.  We could pick them up at the airport and drive them in to the medical center.  We could then give them our patient, who is usually a relative, a friend, or a neighbor.  We could then take them back out to the airport with the patient in our ambulance and have them fly our patient off the island.  This is certainly one possibility, and, in the late 80’s, it was the only legal option.

However, when the patient needs to get to a hospital that can give definitive care, when the patient will have serious outcomes if not transported immediately, when you care about your patients, and when this legal method doesn’t make any sense, you do what you need to do for the benefit of the patient and his/her family.  So, with only one medical center provider, who happened to be an RN, and a patient that needed transport, but had had advanced procedures and/or drugs administered, a decision had to be made.  Was it more important to be legal, or was it more important to get the patient to the hospital and definitive treatment in a hurry?

“WE CAN’T DO THAT” became a ridiculous statement on this island.  We did what we had to do to take care of our patients.  If that meant violating some silly rule that made sense in downtown Lansing or downtown Grand Rapids, but didn’t make sense here on this island, we did what made sense and what was in the best interests of the patient and the patient’s family.  For fifteen years, prior to the advanced life support (ALS) rating for our local EMS, we made things make sense for our relatives, friends, and neighbors.  We might not always have been walking the legal line, but we also did things for the benefit of our patients.  That might have included some things that the State of Michigan did not like, but it was in the best interest of our patients.

So, prior to ALS, I was already familiar with Lidocaine drips, Nitroglycerin drips, Morphine injections, Valium injections, defibrillation of cardiac arrest patients, and many other advanced skills that we were not allowed to transport according to the legal definitions.  Now, there are those that would like us to go back the thirty years to this.  Probably, this is not a good idea.  Now the state is watching with wide open eyes, looking to shut us down.

There are lots of things that we as EMTs and paramedics can’t do.  Sometimes, being on the most remote inhabited island in the Great Lakes, sometimes, we just have to do things, even if our first thought is, “We can’t do that.”