What Did You Say 20

By Joe Moore

Sometimes, in the rural areas, the local EMS gets called repeatedly to the same address, most frequently for the same reason as the prior calls.  For some volunteers, this can get very frustrating, and you can’t blame them.  As a volunteer, they are usually leaving a fairly well paying job to respond to your emergency.  Most often, these are truly emergencies, and those responding recognize that and act in a very professional way.  There are times when this is not the case, and those are the ones that frustrate me as, more than likely, the person that taught them the skills of EMS, and specifically the affective domain goal and objectives on working with patients.  Even those that have alcohol related, drug related, and mental illness related emergencies deserve to be treated in a professional manner.

What did you say?

As I have taught in every single medical first responder class, every EMT class, every EMT-Specialist class, and even the paramedic classes, every single emergency patient deserves the benefit of the doubt.  Just like the individual that has a broken leg didn’t break his leg on purpose to get attention, any other patient with an alcohol, drug, or mental issue, didn’t want this situation to occur either.  That’s truly the bottom line for me as an EMS provider.  Even the person that is attempting to shoot himself or someone else is not in their right mind or they wouldn’t be doing the behavior that is taking place.  A suicide patient is not in his/her right mind either.  Why would a caring EMS provider treat them in any negative way?  Why would any negative judgment be made about that person?  What did you say?

I said it as clearly as I know how.  There is no excuse for treating patients any different than if they were your family members that you truly care about.  There is no excuse for any negative comments while in the presence of the patient or the patient’s family.  There is no reason on this earth to agree with negative comments being made by neighbors or family members regarding the patient that you are responsible for.  You must be professional enough to treat this patient no matter how many times you have encountered this patient for possibly self-induced problems.  We need to be more professional than this.  We need to stay out of the blaming game.  It’s not our job to be judgmental.  It’s our job to wear the hats of assessment, treatment, and caring provider.

Today, the local EMS was paged to an address that I have frequently been paged to for a person who is weak and has fallen down.  This same person deserves a complete patient assessment to help determine what is the cause of this falling down and/or of this occurrence of the weakness that caused them to end up on the floor. 

If I were designing the affective (emotional) domain objectives, and if I were designing the requirements for becoming an EMS provider, this domain would be equally important as the brain domain and the skill domain.  I believe that in this busy world of urban EMS being adopted by the rural EMS and forced upon them, that this most important skill of caring about our patients is the first to disappear.  We get too busy to have time to care, not that we don’t do our jobs using our brains and our skills, but the emotional needs of our patients get put on the back burner because we don’t have time to develop any relationship with them.  In the rural areas of our country, many of these rural patients are our friends, relatives, neighbors, or acquaintances, and very few are strangers, so this previous relationship comes into play when we are working with them when they are having an emergency. 

What did you say?

Yes, I did say it.  I believe that we have to take the time to work with the patient and his/her emotional reactions to the emergency that they are experiencing.  Now, obviously, time to definitive care must be decreased to as short of time as possible, but, if we are going to be with our patient, there are going to be times when we are not physically busy doing assessments and/or treatments, so why not work on the affective domain during those down times?  Why not hold your patient’s hand?  Why not talk to them and really learn something about their experiences, related to this emergency and otherwise.  We, in the rural areas, do have this time, so why not use it for positive relationship building?

Now, let’s get back to the repeat patients reasons for calling for help.  Could it be possible that they don’t remember if they took their medications on time this morning?  Could it be possible that they were no longer ‘in their right mind’?  Perhaps, we could make this situation better by stopping by their homes and having a conversation with them when they haven’t called our emergency dispatch center.  Perhaps, we could help arrange for others to visit them if we can determine the time of day or any other aspects of the frequent flyer schedule of their ‘cry for help.’

As an example of what it means to not to gain any negative or positive ideas about a particular ambulance run location and/or patient, I would suggest that every EMS provider should enter each with an open mind, and, even if there is some background information to consider, to set it aside and remember that today is a different day from the last time you were called to take care of this patient.

I have responded to one patient with many responses to the same residence over the years, usually a couple or three times every year.   This patient is a summer resident, and he is only on the island for three or four months each year, which basically means that we were called to his home about once every month.  His problem was dizziness and fainting.  We would go to his residence, find him on the edge of alertness, and do the normal work-up and normal assessment searching for a cause to his problem.  We’d do a 12-lead EKG.  We’d find him in normal sinus rhythm with no unusual electrical activity.  We take his vital signs, and they would be normal.  We’d write down his list of medications, and we’d ask him all the medical history questions about what led up to this event, and each time his answers were the same.  He didn’t have much memory of the event.  We’d offer to take him to the hospital for follow-up tests and evaluation, but he would consistently refuse to be taken to the hospital.

Every single time, this became the pattern, and some of our EMS people got tired of responding to that location.  They even grumbled about responding to the “automatic refusal” of transport.  One even said that the next time the pager went off, he would not be responding down to that address.  I guess it was a source of frustration for him.

On a Sunday morning, I was out on the golf course.  I was playing hooky from church, deciding that I was going to find more of God out on the golf course than in the church building.  The ‘frustrated’ EMT happened to be at church that morning.  The patient that had been the cause of the frustration stood up during one of the prayers, and the next thing you know he was down on the floor of the church.  The page went out over the radio from this same EMT, “EMS, respond to the Holy Cross Church for a ‘frequent flyer’ patient who appears to be having a seizure.  The patient is not responsive at this time.” 

Well, the ambulance got to the church before the emergency response vehicle that I was driving because I was on the golf course as far away from the clubhouse as was possible. Fred, the ‘frustrated EMT’ had immediately placed the patient on his side, and had almost immediately put on the cardiac monitor for just four leads, and he printed out the electrical cardiac activity.  I got there about two minutes later, and the patient was having yet another seizure, at least it appeared to be a seizure with shaking all over his body.  This time, we didn’t let the patient have a chance to refuse care.

We loaded him up onto the ambulance cot.  Put on the 12-lead EKG and captured some really weird looking electrical activity.  It only lasted about one minute, but accompanying that minute was something that looked a lot like a seizure.  We started an IV, kept constant monitoring of his vital signs and his heart, and arranged for a flight to get the patient to the cardiologist as soon as possible.

While we were in the middle of the flight from Beaver Island to Harbor Springs, the patient woke up and asked, “What the hell is going on here?”

I calmly, even though I had to raise my voice to be heard in the plane, explained that this time was different than the previous times.  I explained that we were taking him to be evaluated at the hospital by the cardiologist.  Boy, was he mad.  He got red in the face.  He started to swear at me, and the next thing you know, he was unconscious again.  We monitored his airway, breathing, and circulation, and kept his vital signs during the periods of unconsciousness.  When we landed in Harbor Springs, he woke up again.

I said to him, “John, you need to relax.  It seems that every time you get very upset, your heart goes crazy with some unusual electrical activity, and you appear to have a seizure, and then faint or pass out.  I’d like you to just relax, and pretend you are lying on the beach on the island at your vacation home.  Pretend that you’ve just had a wonderful dinner, and that you are feeling stuffed just like your previous Thanksgiving dinner.  Pretend you don’t have a worry in the world.”

Guess what?  His heart rate and his heart rhythm settled down into normal sinus rhythm, and the crazy electrical activity went away.  We didn’t see it again even when we transferred the patient care to the LifeLink ambulance crew.  His wife went with him to the hospital.  After LifeLink left, I called my report to the hospital explaining the unusual cardiac electrical activity, and the seizure like activity as well and that they seemed to be related. 

We didn’t hear back from the hospital or the other EMS agency, but the patient did spend some time in the hospital in the cardiac care unit.  The next summer, we didn’t get a single call down to this patient’s address, and we were wondering if everything had turned out okay the previous summer.  I was sitting in the EMS office and I called the “frequent flyer” John’s island phone number.  John answered the phone.

“Hello, John, I know this call is going to sound unusual to you, but this is paramedic Joe.  Do you remember me?” I said.

“Yup, I remember you,” John said.

“Well, I hate to ask you this, but, since we haven’t been called down to your home all summer, we were wondering if you were okay.  Did you get your issues resolved last summer?” I asked.

“You’re the one that made me go to the hospital last summer?” John asked.

“Yes, sir, I know you were mad at me for taking you over,” I said.  “But, I was sure you needed to be evaluated by the heart doctor.”

“You made me go through quite the series of tests,” John said.  “They had me do a stress test.  Then they made me do a tilt table test.  They did test after test after test, but I guess I have to stop giving you a hard time.  The neurologist and the cardiologist told me to tell you something when I saw you again.”

“Oh, oh, am I in trouble?” I said.  “Did I do something wrong?”

“No, sir, paramedic Joe.  You saved my life,” John said.  “I’d sure be honored to have you and your crew come down this Saturday night, have a few beers, and have some barbecued ribs with my wife and I.  We want to show our appreciation.  My wife has a letter for you from the cardiologist that she’s been sitting on, but I know it’s here.  We’ll give it to you when you get here.  I hope to see you Saturday night at my house, unless you have another emergency.  Will you please come?”

A wonderful thank you party was had by all including our ‘frustrated’ EMT, who was really the one that had been there to see the real serious issues with our host’s crazy electrical cardiac activity, somehow related to the seizure like activity.  I got a letter given to me from the cardiologist.  The cardiologist gave our local EMS credit for getting the patient to definitive care.  He also explained the relationship between the neurological activity and the crazy electrical activity of the heart.  Of course, this case is so unique that I can’t write what this was about without the patient’s and his wife’s permission.  The commendation letter was placed in the files of every single EMS provider involved with this patient.

We all learned a lesson about the situation of frequent flyers.  We all learned it quite well on this one ambulance run.  We all learned to be patient and keep track of all the things that might help the patient.
The second example is even more interesting from a medical point of view.  This is one of those situations in which there are really only two possible field diagnoses, or at least some would say that.  I don’t agree.

“Beaver island EMS, respond to xxx Road for a patient with difficulty breathing,” Central Dispatch calls.

This location is the same location that we have responded to many times.  We know this patient has chronic obstructive pulmonary disease (COPD) caused by smoking for many, many years.  This person is no longer smoking, but the damage has been done to her lungs already from the many years of this habit.  Just about everyone who responds to this call has the same treatment regimen in mind. 

It takes us quite a while to get down the island to this residence.  We have the emergency response vehicle (ERV) headed out first with a paramedic and an EMT responding from the EMS garage.  The ambulance will follow with a first responder and another EMT.  At this point, we still have plenty of volunteers that are willing to put in the time, when they are not working, to help out their friends, relatives, neighbors, and visitors to the island.

The ERV that I am driving arrives at the mobile home first.  The EMT, whose name is John, grabs the jump kit out of the back seat, and I grab the cardiac monitor from the other back seat, and in we go.  We find our ‘frequent flyer’ patient sitting in a chair in the tripod position, meaning leaning forward allowing gravity to help with the breathing effort.  So far everything is normal.  John puts on the oxygen and gets ready to set up a nebulizer treatment.  I do my normal head to toe assessment, checking things out, marking them off the list of things that could be wrong with the patient, even though everything looks like it’s the same problem as always.
The pulse oximeter reads 85, which is low.  This is a percentage of the amount of oxygen that the blood is carrying to the extremities.  Most people, even when somewhat ill, will have a reading above 90, and the cut off point for oxygen administration at this time was 94.  If the patient has a reading above 94, your protocol told you to NOT administer oxygen instead of just doing it because you can.  So, this patient’s oxygen level is at least five, if not nine, percentage points below normal.  This would be consistent with the chronic COPD, but there was one thing that bothered me about the assessment.

This patient normally had breath sounds that were musical, called wheezes.  Now, wheezes were present in the upper part of the lungs, but lower there were sounds, muted as they were, that indicated there might be fluid in her lungs.  This could indicate some problem with the right side of her heart.  So even though this was not a normal part of the assessment for this patient, I immediately looked at her ankles and her legs.  Sure enough, there was pitting edema, the situation where you push against the skin toward a bone and the hole made by your finger or thumb stays visible instead of going back to normal.

Now, the patient could have heart failure going on, or she could have pneumonia, or she could have both combined with her COPD.

I asked the patient, “Isabelle, is this feeling different than before?  What brought this on, this time?”

She said, “This is a different feeling.  My heart feels different, and has for a day or two.  I’ve been nauseous.  I didn’t even drink my one beer last night.  I only had chicken noodle soup last night and I didn’t keep that down.  I even did my breathing treatments every four hours like I’m supposed to do, but they only worked for a little while, and I didn’t get much sleep last night.  I almost felt like I was drowning when I lay down.  What’s going on this time, Joe?”

“I’m not sure, Izzy, but I don’t think you’ll be staying in your home this time.  I think you need to get evaluated in the hospital.  I’m going to do an EKG and fax it to the hospital using your home phone after I talk to the doctor on the phone.  Are you going to give me any flack about this?” I asked.

“Well, no,” Isabelle stated. “You know best.”

We did a 12-lead EKG, which showed some possible lack of oxygen to her heart.  I called the ER physician on the telephone at Charlevoix Hospital and gave him my report.  He certainly agreed that there might be something else going on with Isabelle than her normal COPD.  He ordered us to bypass Charlevoix and take the patient to Northern Michigan Hospital because “they have a cardiologist on site to evaluate the patient.”
I then asked him if we should give the nebulizer treatment or not, and he told us to go ahead on do so, but continue to monitor the patient’s heart.  If we saw any changes, we were to stop the breathing treatment immediately.  So, now I had to call the Northern Michigan ER and give report.

John started the Duo-Neb, two drug breathing treatment while I was on the phone.  At some point here, the ambulance arrived and the cot was brought into the trailer.  John turned the nebulizer treatment over to the arriving EMT, and he used the phone to make the call to the local air transport operation to make arrangements for a patient evacuation.

I did all the normal things as far as monitoring the patient’s vital signs, starting an IV, and preparation for the flight off the island.  John was still waiting for a call back, even though we were pretty much ready to load the patient into the ambulance, but we stayed in the trailer.  We were waiting to find out to which airport we were going to take the emergency patient.  The route of travel would be different, so it made more sense to find out where we were going instead of going somewhere and having to relocate.

The nebulizer treatment was over.  The patient’s breath sounds were better as far as the wheezes, but the moist breath sounds  were actually increased as the patient was able to get air down deeper into her lungs, at least that’s my logic for the more audible fluid sounds.  We waited another ten minutes for the return call, and I asked John to call them back. He did.

“Joe, there is fog in Charlevoix.  There is fog in Harbor Springs.  There is fog everywhere from just south of Charlevoix all the way up to the bridge.  There is only one break in the fog and that is south,” John said.
“We need to get this patient to the hospital.  Can they fly to Traverse City?” I asked.

“I’ll ask them,” John said.  “Yes, there is no reason to prevent a flight to Traverse City.”

“Then let’s get moving before that changes,” I said.

John arranged the flight to go to Traverse City.  I had several communications to make, but I wanted to get moving before the weather changed, and we were without a transport destination at all.  So, enroute to the airport, I got on the radio and called the two hospitals that were part of the original arrangements.

“Charlevoix Area Hospital, Beaver Island EMS, Medic Joe,” I called.

“Go ahead, Beaver Island,” they responded.

“Due to weather, the Beaver Island patient reported to Dr. Combie will not be able to be transported to either Charlevoix or Harbor Springs for Northern.  Our only choice is to fly south to Traverse City.  Would you notify the physician of this, and ask him for any possible different orders?” I called.

There were no additional orders, and, of course, there wasn’t anything else that we could do as far as getting this patient to the hospital.  I called Northern Michigan on the radio and gave them the same information, but I added a little to their radio traffic.

“Would you please send the patient information and the 12-lead EKG down to Munson Hospital for us?  We are not in a position to be able to fax this information since we are on the road.” I stated to Northern ER.
“I will do this personally,” the ER nurse stated.  If you monitor this frequency, I can verify that it has been completed.”

“Roger, we will monitor this frequency during the flight,” I stated.

John called on the dispatch frequency, “Central, we are enroute to the airport for a flight to Traverse City.  Will you notify Northflight that we will be enroute to that location in approximately ten minutes.”

“Traverse City? The radio traffic suggested Harbor Springs.  Now the destination is Traverse City?” Central asked.

“Yes, Central.  Weather issues for any other destination caused the change.  We’ll let you know when we take off,” John said.

“We will make the call.  Clear,” Central Dispatch closed the radio traffic.

So, we arrived at the airport with the equipment, the drug boxes, the patient, an EMT, and a paramedic—everything necessary to monitor and treat the patient that any air transport operation might have at their disposal.  We loaded all of the above into the aircraft with special care in loading the patient.  We made certain to have the portable radio headset and any pieces of equipment that we might need.  We climbed into the aircraft, taxied to the end of the runway, and took off headed for Traverse City.

I held the patient’s hand on and off during the flight when I didn’t need to be doing assessments or treatments.  I talked to my patient about what we were doing, and where we were going, and the process of getting from the Traverse City Airport to Munson Hospital.  When we landed, the patient was relaxed, had even taken a short nap, and ready to move on in her treatments.

While the patient was taking her nap, I gave my report to the Munson ER.  They really cut it short.  Munson ER said, and I quote, “Have the ground ambulance give us a report after patient transfer of care.”
Well, I wasn’t very happy about that because there had been improvements in the patient’s condition that the ground ambulance would not know about, but I took the extra time to write this all into the patient care record that I would turn over to the Northflight ground crew, and later put into the computer record of this emergency medical transport of the patient.  We landed in a smooth, comfortable landing, and the patient didn’t even wake up, it was that smooth.

When we were taxiing over to the private civilian aviation terminal, the patient woke up and said, “We must have landed.  Joe, I want to thank you for your help.  You are now my family, and I’ll make sure they let you find out how things are going with me while I’m in the hospital.  Thanks, Honey.”

“We are here, and we’ll be turning your care over to the Northflight crew,” I said.  “We’ll make sure that they know what’s going on before we head back to the island.  I’m the only paramedic there right now, and I’m sorry I can’t go to the hospital with you.”

“I understand,” Izzy said.  “Keep in touch.”

We taxied up to the area, and the ambulance was waiting for us.  As we got to the transfer of the patient, the mainland paramedic said, “Is this the COPD patient from Beaver Island?”

I said, “Once we get the patient in your rig, I’ll give you a report and turn over the paperwork.”

We loaded the patient moving her from the aircraft cot to the Northflight cot and put the patient inside the ground ambulance.  I climbed into the back of their ambulance and said, “This is Isabelle.  She is a friend of mine and family.  She has a history of COPD, but today her presentation is different.  Here is her 12-lead EKG and her hand written patient report which shows that the nebulizer treatment has helped with her breathing, but her breath sounds indicated something else is going on.  Before we take off my equipment, would you please listen to her breath sounds in her armpits.”  The paramedic did. 

“I believe that you heard the moist breath sounds, and if you look at her legs and her ankles, you will find pitting edema.  This indicates the possibility of right sided heart failure or an infection, such as pneumonia, but more likely heart failure.  I would appreciate it if you would relay that in your report to the hospital, since they did not want to listen to my report.  They said they wanted to wait for your report.  Just so you know, I will be documenting that I made this report to you, which will become part of the permanent record of this patient in the state’s database.”

“Izzy, this young man is going to take really good care of you on your way across town, after we get our equipment exchanged.  I’m going to have to head back to the island before the weather closes in.  I’ll keep track of your progress,” I said, and squeezed her hand. 

She pulled me down and gave me a kiss on my cheek.  The mainland paramedic said, “Obviously you have a relationship with this patient.  I’ll do the equipment changeover while you two talk.”

Once the equipment was changed over, I checked to make certain that the IV was patent and running okay.  I also said to the paramedic, “This IV is clean and was started in a sterile environment.  She is not an easy IV start, so I would appreciate it if no one pulls this IV out until such time as they have another IV running or another saline lock in place.  She may need some IV antibiotics or other drugs, and the IV should not be an issue.”

“Goodbye, Izzy,” I said.  “I wish you well, and I will call to check up on you after they have had a chance to figure out what is going on with you.”

“Bye, Honey,” Izzy said, and I climbed out of the back of the ambulance to meet up with the EMT and the pilot.

The pilot said, “We have to wait until I check the weather.  There is a storm moving through.”

We went inside, and the pilot showed me on the computer the storm coming across the lake.  He said, “If we leave right now, we might be able to fly around the storm.  Luckily the storm has eliminated the fog with the wind chasing it away, so the worst that can happen is we land in Charlevoix to wait out the storm.”

The flight back toward the island was a little bumpy.  It was easy to see the storm coming across the lake.  It took a bit longer to return to the island after a stop at Charlevoix Airport, where we waited a little over an hour before flying back to the island.

As luck would have it, we weren’t on the ground for more than ten minutes when the pager went off again for another ‘frequent flyer.’

This patient had been awarded the most frequent response person on the island, but it really wasn’t a correct label.  We had certainly responded to this address more times in my thirty years of EMS experience than any other address.  Once again, having made over thirty responses to this address, we had to be careful that we didn’t immediately decide the diagnosis before doing a complete assessment.  Most often, this patient was in insulin shock due to being a brittle diabetic on insulin, but it was important to not begin treatment until this diagnosis was confirmed.  On this response, the field diagnosis was not insulin shock.  The opposite condition was the fact that this patient’s blood sugar level had only the reading on the meter of “HIGH.”  This made it likely that the patient was in a diabetic coma due to high blood sugar.  His other symptoms confirmed this.

While this patient most often was treated by increasing his blood sugar to somewhat normal levels.  Then this patient would refuse transport.  This patient was very ill and actually needed to have his airway protected, and he received that airway protection.  This patient was transported to the Harbor Springs Airport and spent over a week in the hospital.  Once again the patient’s condition did not match previous responses for this ‘frequent flyer.”