Chronic Dyspena

Hello all, good to be typing to you again. Here is another case study for your input.

Can't breathe. Consider this:

You are called to an assisted care facility (nursing home) to transport a patient to the local ER for difficulty breathing. When you arrive on scene you are met by the staff that tell you that "Mary" has been having more trouble breathing than usual.

As you approach Mary and try to talk to her she presents as an elderly female in her mid to late 80s with a Hx of COPD and heart failure. The staff tells you that her SP02 has been 89-90 % all week and now she is down to 74-79%. She cant complete even the shortes sentence and is working hard to breath.

You follow your local protocol and take mary to the hospital, providing her O2 and a breathing treatment. On 15lpm of O2 you manage to get her to 93-94% after a breathing treatment. IV established at KVO. Monitor shows sinus tach at 140

About 4 hours later the ER calls you to return Mary to the nursing home. When you arrive you get the report from the nurse and you load Mary into the back of the squad.

Here is the problem. Mary is returning to the nursing home on her standard 2 lpm O2 by cannula. She now has DNR papers. She might have had them before, but they were not presented to you at the nursing home. She tells you that she feels a little better but her heart rate is in the mid 120s and her color is ashen and grey at the hands and arms. She is still breathing with pursed lips and appears to be struggleing very hard to maintain air. SP02 will not come up above 88% at 2lpm.

What are your thoughts? Do you return to the ER and tell them that she is still having trouble? Surely they know, they are releasing her to go back. Do you continue your transport to the nursing home and transfer care to the resident nurse? Surely they will send her back out, because she appears worse now than when she went in. Do you call your supervisor for advise? Do you call your medical control and ask for clarification?

You know she has a DNR, therefor you KNOW what you can and can not do. You KNOW that she wont be able to sustain life long working that hard to draw breathe.

So now it's your turn. What would you do?

Colder Weather

The weather is turning here in Ohio. I think we are getting some of the backlash from all the hurricanes down south.

I was in the squad the other day and I think I might have saw the first of many leaves fall on my squad as I was pulling away from a scene where there was a DOA. Kind of strange for that to happen right at that instant and it got me thinking of something I wanted to discuss with you guys.

Has anyone ever "worked" anyone just for the bystanders?

Today's EMS Lesson. Consider this.

You arrive to the scene of a 65 year old male. You origional call was for patient unresponsive not sure if they are breathing.

As you approach the scene you notice several vehicles in the driveway. You enter the home to find a 65 year old male down on the bathroom floor (like this has never happened before). 4 or 5 people are standing around screaming and crying. They yell at you to "DO SOMETHING!" , "Help Him!"

Upon your inital AX you notice dependent lividity and it is apperant to you that this man has been down for awhile. Cardiac monitor reveals "almost" perfect asystole. You could turn the gain up a bit and maybe get what "looks" like fine v-fib.

Suddenly in walks a 16 year old child, presumed to be the pt's grand daughter and she begins to sob uncontrolably.

You are faced with a difficult decision.

In my carrer I have faced this situation a few times. Every time the situation comes up I struggle with it. We have done both. We have worked them and we have called them. It seems that you can never have a preset thing you will do. It seems to me that the decision must be made on a case by case basis. Tell me what you do. Tell me how you deal with the situation.

Fall is comming and with fall comes cooler weather. Be sure to switch your duty gear to a light jacket and be mindful of the rain. Rain will get you sicker and quicker than cold weather alone. Wear a ball cap if your company approves one, and keep heavy rain gear up front with you behind the seat rather than packed away in an outside compartment. Watch the tread on your boots and keep them shined.

The rain always makes a mess out of your professional appearance. Be mindful of your squad, remember the appearance of your squad and your uniform do a lot to put the patient at ease. If you show up dishevled with dirty truck dont be surprised if your patients are less than trusting of you.

Talk to you guys soon.

Well.

I would like to thank the 70 or so people that have sent me email concerning recent events. You never really know how you touch people until they tell you.

I have enjoyed writing a blog emmensely for the last 2 years, but there comes a time when you have to be real. Here are the things that are real.

1) 4 children under my roof.
2) House Payment
3) Monthly Bills
4) Food
5) Clothing
6) Motorcycle payment
7) Child Care costs (those of you with kids in daycare know EXACTLY what I mean)
8) Ex-Wife
9) Girlfriend (2 of the the kidos are hers)
10) Education expenses

We are pulling all the ends to meet in the middle on 2 EMT's pay along with some side work. This in it's self is not an easy task. It requires at least 10 hous of OT out of each of us a week just we have some "mad" money as well as meeting the bills.

She is trying to finish school for nursing and I am trying to rebuild my reputation within the company I planned to retire from. I plan on going back to school for radiology as well, but I need to get her through school first.

I'm an instructor. I teach all levels of hazmat and WMD through the operations level. I teach various OSHA cources and of course AHA CPR and First Aid. I also teach about 6 FEMA courses along with the state extrication course. Teaching is my passion second only to my children. I love the station atmosphere and I'm equally as comfortable in the classroom as I am in an ambulance running a 911. Lately I have been teaching for various fire departments more than my own company due to the trouble I have been in. Hopefully I will be able to regain the trust they once had in me and teach for my own company more.

The people in EMS make EMS what it is. It's not the paycheck. Everyone of us that do what we do, do it because we love to do it. We like the opertunity to make a difference in the lives that we meet. We like to try and make sense of things that really don't make sense. Yes, we like the lights and sirens... but we like the routine transports just as much.

I do plan on continuing the blog, but I must warn you that I will be monitoring the content and comments section VERY closely. Please respect me and my family and DO NOT POST ANYTHING PERSONAL OR IDENTIFYING. If there is the slightest chance you think your comment might get you or I into trouble... DO NOT POST IT.

The first time this rule is broken, bent or even scratched the comments section will go down permantely and never return. Think before you speak and remember I have a family to feed.


Todays EMS lesson. A thing to consider:

You arrive to an assisted care facility on complaints of shortness of breath. As you approach your patient you notice that they are speaking in full sentences, their color is good and they dont appear to be using accessory muscles to breath.

As you get closer to the patient they seem to magicly develop symptoms, and when you walk away the symptoms seem to disappear again. In the squad the pulse ox said 97-98%


Yes, we have all been there. Consider these things the next time:
1) How old is your patient?
2) How long have they been in the facility?
3) Do they get many visitors?

These things can be gently asked in a routine assessment in the back of the squad.

Many times older people are simply lonely. Their family might not visit them much. Maybe they dont have any family. Maybe they just wanted to get out of their enviroment for a few hours. Maybe they dont get much fresh air or sunshine due to being bed confined.

Dont be mad at these people, try to be comforting. Treat what you were called to treat. A little O2 by cannula at 2-4 lpm, a couple full sets of vitals and MOST OF ALL your conversation and comforting words. Be concerned, be attentive. Remember for the next 20 minutes to an hour this patient should recieve 100% of your attention. That might be all they really wanted.... someone to listen. Be that person. Dont be the cold callous hardass that is annoyed for being called out for what you consider "nothing". It may not be what you were called for but it is definatly "Something".

I'll talk to you guys soon.

Blog Revision

Let me explain my removing the blog that used to be here.

I write a blog because I can't afford a mental health professional every time I need to get something off my chest.

I write a blog because it helps me vent to the outside world without venting to my family or my co-workers.

I write a blog to try and inform people of the little things that they miss day to day. Things that might be over looked.

I write a blog to try and get in touch with others that might feel the same way I do.


I have been informed that some of the people in the company I work for did not appreciate the content of my writings. I was told that I needed to remove any and all reference to the company I worked for from my writings.

That would have been extremely difficult. See, my blog was open access. I posted a picture of one of our ambulances and then several other people from our company and explorer post added more pictures. This was a mistake. I'm perfectly able to remove the content that I added, but finding and removing the links other people have posted and editing their comments is just too time consuming. I chose to remove the entire blog.

At no time was there any accurate information posted about patient information. Every name, street, number, hospital ETC was fictitious.

To those people who enjoyed reading and posting to the blog, I apologize.

To any of the people that I work with that might have found the writing inappropriate, I apologize. It will not be repeated.

I posted the pictures because I have an huge amount of pride in the company I work for. I'm proud of the things we have accomplished and the future ahead of us. I posted the picture because I wanted other people to be able to precieve the pride that I was trying to convey. I can only assume that other people posted the pictures they did for similar reasons.

Yes there were some stinging remarks about things that have happened to date. I will not apologize for them. This was my way of dealing with issues that I had to deal with. This was my out in the crazy world of private EMS. I would post my thoughts and be done with them. I would not need to dwell on issues that I had already addressed.

If in the course of my postings some people were offended, it was never intended.