Incident command

At every level of EMT training, you learn about incident command. Specifically, the fire department senior officer is in charge. Emphasis on period, regardless of the type of "incident". Most departments use the National Incident Management System because the government has decided that is the training required to get a hold of the all important $$$. This system is really intended for large incidents where you need a staging area, different operational groups and levels of command. But, working with fire departments I encounter officers with varying interpretations of their responsibility.

The vast majority of the fire officers are EMT-Basics and are happy to be involved in coordinating their firefighters with the ambulance folk, telling us where to park, how we're going to extricate the patient and helping carry them, performing the complicated and technical extrications that can be required, breaking whatever necessary to get us to the patient's side, even providing patient condition updates en route since they arrive before us, and generally being reasonably helpful and not too obtrusive. As far as actual medical care, most defer to the paramedic on scene, recognizing that the additional education and training usually allow them to make good patient care decisions. All is happy smiles in the world of intra-agency cooperation.

Then there are the other officers, and sometimes firefighters, who want to be in "command" of everything on scene. One particular officer in the city has been an on-going problem for me. Now, he is a paramedic himself, with a number of years of patient care experience prior to the FD becoming a non-transport agency and no longer working elsewhere as a transporting medic, so the issue is not one of education and training. He is in charge when he is on scene unless there is a captain or chief of some rank there, which is rare for EMS calls. He likes to directly "command" every aspect of a scene, including all decisions on patient care, to the point of actively interfering when something is not being done per his assumed course (even if he hasn't told anybody what that is). Where the difficulty lies is that he is not the medic whose ass gets chewed by the doctors if something is not to their satisfaction.

Just one quick example: The Asian and I arrive on scene for an overdose patient, unresponsive in a parking lot at night, maybe 40-45 degrees outside. When we get to the patient, the firefighters are searching the man's pockets for ID to give the police, the officer is talking to PD with the friend who found the patient trying to get noticed. I don't know what to make of this at first, is he dead? is he fine? why isn't anybody treating the patient?

I start assessing the patient, who has a pulse, is breathing adequately and protecting his airway, but is distinctly unresponsive. He is laying next to a car which is blocking all ambient light. I've got baseline vitals and tell The Asian I'm heading for the stretcher so we can move the patient into the truck where it is 1. warm, 2. safe, 3. light. As we get the patient onto the stretcher, the officer decides that we are not allowed to move the patient until we drop an OPA (oropharyngeal airway) to protect his airway. The Asian and I both pretty much ignore him and continue to the ambulance because, since we actually assessed the patient, we're not that immediately worried. When we are nearly ready to leave, The Asian asks if I can go find the pt's friend to try and get some additional information on the overdosed drug. The officer blocks my path and refuses to help locate the friend, instead demanding repeatedly, "What do you want to know?" He never offers any information, and I'm not sure what exactly the question was. Finally, I find the friend the question gets answered and off we go.

This officer follows us to the hospital and demands all sorts of attention and action, eventually keeping his crew out of service at the hospital for over an hour waiting for our supervisor to come address the issue. Which boiled down to respect. He felt we did not respect his command of the scene. Well, I couldn't really argue with that point. The problem is that you lost your opportunity for respect when the crew that you really should be in command of was not caring for the patient and you did NOTHING.

I followed up with some of the management folks on this and was told that I am to do whatever this officer says, when he says it, regardless of what I think about it. He is in charge of the scene and paramedic, or basic, or first-grade nosepicker is irrelevant because the officer on scene will always be the first one on the legal hook. I find this both ridiculous and unbelievable and struggle with it every time we encounter said officer. I don't even want to go on calls with that engine because I always wonder if he's going to be there.

Impending doom

Not that I won't try of course, but I'm not sure any description will quite do. I have this feeling right now, one of these "if I were psychic I'd be having a vision" kind of feelings. Very strong, very sure of itself. Something is coming to an end. Disturbing. Especially the complete lack of specificity. What is ending? Why? When? Do I care? Am I supposed to do something?

I don't believe in psychic powers, the ability to tell the future, mysterious forces guiding the universe. I don't have any reason to be concerned with this except that it won't go away. I was at work last night and had an awful dream about going to ManchMedic's funeral (please take good care of yourself!!). It was horrible and sad, made all the more so by reaching that state of semi-wakefulness where you know you're having a dream and I still couldn't make it stop. I woke up fully, stumbled out to the restroom, came back and went right back to that damn funeral. It wasn't just the loss of a friend, it was the sadness of all the other people there. People I know and care about and strangers too. Normally, I don't sleep enough at work to dream, last night I woke up crying.

The Asian and I went on a call that took us to the apartments where we worked our pediatric code. All I could think about as we pulled in was that call. I even commented out loud that every time we come here, I always remember. He understood completely.

I heard Monday night about the sudden death of a co-worker from my time in Virginia. A day after we stopped there to visit friends.

My ambulance calls lately have been fairly mellow, no string of deaths or traumas or anything really. I've tried to keep my spirits up, hoping that a good day can keep this feeling at bay. I feel like just writing about it makes it more real...creepy.

34 hours

Is all it took to get from this (0700 3/15 in NH at 34 degrees):

To this (1700 3/16 in FL at 84 degrees):

And now I have a week without work, without class, and fairly much without care! Now if K could just get over the GI bug and the flu he managed to pick up somewhere just before we left...

Happy dance - Kitchen update

If you haven't been watching all the way to the end of the kitchen picture series, please do so. Happy dance is for having water in the kitchen for the first time in two and a half months. Reasons this is wonderful: No more dishes in my bathtub. Watson can have a bath (because we didn't want to wash the dog the same place we wash the dishes). I can get water from a faucet while holding my glass straight. The sink cabinet has doors. And more reasons I just can't think of right now.

Items remaining to do: Finish the vent. Trim around cabinets at ceiling. Toe kick on cabinets at floor. Paint. Trim windows, door, and everywhere there aren't cabinets. Under-cabinet lights. Touch up ceiling paint. Decide what (or whether) to do for curtains/blinds.

Check out the counters

It took three guys three hours, but we have something that actually looks like a kitchen. K is planning on hooking up the sink tomorrow and then I believe the house will probably be struck by lightening or something because we will finally be back to a usable kitchen.

Code

Yesterday, despite being on a transfer truck, I ended up helping on a cardiac arrest. Our company has a bariatric stretcher with a hydraulic lift system (aka "fatty stretcher"), but in order to use it on an emergency call, you have to call back and have a transfer truck bring it to you. In this case, the call was for elbow pain due to a fall. So no great hurry, but the crew was going to need help to move the >500lb patient.

Patient heads out to us and we get him into the ambulance. My partner and I are heading back to our ambulance when the crew calls us back. Patient is having difficulty breathing. Then patient is not breathing and pulseless. The bariatric stretcher takes up nearly all available floor space when loaded into the ambulance and now there are 2 911 crew members, their student, and 2 transfer truck crew members trying to perform CPR and ACLS on this patient. Not an easy task.

Unfortunately, the patient didn't make it. This is the first call I've done where I met the patient while he was walking and talking and actually watched him die. I have to say it is a lot easier to work on a patient who was dead when you got there than a patient who dies in front of you.

Edited 21Feb: Thanks to Ellie for pointing out ManchMedic's post on this call. It was informative for me to read more of what happened before we got there. I was wondering why some things went down the way they did, and I tend to assume that medics make informed decisions and try not to "back-seat" "hind-sight" "monday-morning quarterback" on calls, so I don't always ask questions even though ManchMedic would be happy to answer them.

Tired of being sick

Why does every cold have to turn into something miserable? I was feeling pretty darn good about not being sick lately, which was obviously the cue for the local virus to hop on board and change that. Lately, colds have been dropping down into respiratory infections for me, with a lovely hacking cough that won't quit. This one likes sinuses better. I spend all day feeling like someone is standing on my head. No matter how much snot I push out, the pressure doesn't stop. Decongestant won't touch it, somehow it is beyond the reach of mere pills. Stupid virus.

Follow up

One of the frustrations in EMS is that you frequently don't know the end of the story. You drop your patients at the ER and that is the last you know about them. Since our city only has two hospitals, sometimes you can follow up on your patients a little more, and being the main transfer service means that sometimes you hear more from your colleagues.

So here's some updates on a few patients I've written about recently:

• Patient our student revived was still alive in ICU 2 weeks later. Hospital did eventually find some family members so hopefully they were able to make good decisions for him.

• The Asian and I were mulling whether a Catholic nun could disconnect her sister from life support without committing a mortal sin when we saw the patient's obituary in the paper. She died within 24 hours of arriving at the hospital. My best guess would be that nobody had to make a decision like that, the patient probably went into cardiac arrest again and this time they were able to honor her wishes for DNR.


• Car accident patient who got us on the news had his legs put back together by orthopedics. Still some danger he might lose the worst one if infection sets in but a pretty darn good outcome for being crushed in a box truck.
  

I'm hoping that my string of bad luck has finally run out. I've had two 911 shifts in a row without a dead person or someone seriously circling the drain. My run of luck has been so bad that The Asian has more IOs with the new EZ-IO than anyone else in the company. He has seven and the next nearest medic has three. This streak started in September with a string of pediatric patients and has been all over the map since and I would not be sorry to work a bunch of drunks and psychiatric patients for a while.