Two very different calls

I’ve mentioned in previous blog posts that I currently work for a BLS service that responds as “transport” with several different fire departments. In my district, we are the primary truck for a full time municipal paid department and a department that is staffed by career guys during the day and vollies on nights and weekends. Both of these calls occurred during my last tour, and while I wanted to write about them a couple of days ago, it took me a while to figure out exactly how. I figured I’d just show the good and bad.

There have been a lot of  stories in the news and a lot of chatter in the blogosphere about how firefighters don’t want to do medical calls. I don’t think it’s necessarily true. I know plenty of firefighters who are great EMTs and medics. Unfortunately, I know others who should stick to putting the wet stuff on the red stuff. There’s a great post from TOTWTYTR‘s blog about fire based EMS.

Speed is not the primary factor in treating resources. Getting people to the scene with the knowledge, ability, and desire to treat sick people is more important. Four firefighters standing around a sick or injured person administering the “Stare of Life” while the officer asks for the ETA of the ambulance is not medical care. Frankly, it’s not even the appearance of medical care. Nor is giving oxygen to everyone, whether they need it or not.

Amen, brother. I don’t lump all firefighters together, but if you read both stories below, you’ll see the difference from my perspective.

1-

We had just cleared from the hospital when, on the fire radio, we heard an engine dispatched on a aid call for difficulty breathing at a SNF right around the corner from where we were. We radioed our dispatcher and told them we’d take the call. As we waited in traffic at a red light, the engine came around the corner and the officer waved us in. We pulled up right behind the engine. The firefighters went in first, we grabbed our stretcher and followed. When we got to the second floor, there was a flurry of activity. Nurses and aides were running around, an ancient suction machine was on a cart outside the door and inside the room a 65ish year old male was laboring to breathe. He was still moving air, but not much. The firefighters quickly got medics en route and put the patient on a NRB and started an assessment. I ran down to the rig to grab an extra O2 bottle and when I came back up, the firefighters had a 3 lead and Pulse Ox set up. The patient looked like he was going to crash and the lead firefighter asked me to grab the BVM from their airway bag. I pulled it out and connected it to the O2 just as the patient became apneic. We started bagging and heard the medics coming down the hall. There were now 7 us in the room, three firefighters, 2 medics, my partner and me. We all managed to stay out of eachother’s way and we all knew our job. One medic tossed me a bag and I spiked it as he got the line and he got some Etomidate and Sux on board. As the second medic went for the tube, he grabbed his McGills and fished out a ginormous hunk of food that had been sitting just above the cords. I had never seen a medic clear an obstructed airway with McGills before, so that was interesting. It was a mix of quick BLS followed by rapid response ALS. The patient was extubated in the ED shortly after, and following a night in ICU, was discharged the next day. That call went pretty well. On scene time, 22 minutes.

2-

We respond with Fire at 2130 for an 85 year old female, vomiting and weak. We arrive on scene (non emergent) about 6 minutes behind fire and they were just getting a first set of vitals and history. There were 5 firefighters on scene. The patient had a hx of IDDM, hadn’t taken her insulin or eaten due to a minor outpatient procedure earlier that day. I started doing some snooping and found discharge paperwork that showed the patient did receive some versed for sedation, and the side effects of vomiting, weakness and confusion were consistent with that. However, this patient did have a cardiac history as well, and the firefighters rightly called for a medic eval, even though the pt did not have any chest pain or SOB and we were close to 25 minutes into the call when they decided to holler for ALS.  As we were moving the patient down a flight of stairs to my truck, she vomited a copious amount of juice (which her spouse had given her prior to our arrival, thinking her weakness and tremors were from hypoglycemia.) The patient also stated she had to go to the bathroom badly and couldn’t wait. So, my partner and I carried the patient to the toilet while the firefighters followed us and we helped her stand and pivot to sit. I pulled off her vomit covered clothes and grabbed a robe for her. She was slightly short of breath from all the moving around and a little anxious. The lead firefighter said, “I think I’ll put her on some Os when she’s done.” I suggested not waiting. He told one of his guys to put the patient on 8 lpm on a NRB. 8 liters? Really? How did you come up with the magic number of 8 liters? I said to him, “She’s been vomiting and her sats are fine (98% on room air). She’s kind of freaked out and I don’t think she’ll tolerate a mask, how about a couple of liters on a cannula?” The firefighter putting the pt on O2 looked at me and said, “Uh, no. My boss told me 8 on an NRB and that what’s she going to get. And who are you, anyway?” I shrugged my shoulders and watched as they fumbled their way through a 3 lead EKG, patches not sticking and the patient shaking from chills because they removed the robe I had wrapped around her. As I was peering at the monitor over the shoulders of the three firefighters in turnout gear crammed in the bathroom, one guy saw me looking and turned the monitor so I couldn’t see the screen. After they ran about 2 feet of strip, one firefighter in the bathroom said loudly, “This looks like an arrhythmia to me.” A few minutes later, when I was out in the hallway, I asked if I could see the strip. The lead guy handed it to me and I asked him if they had been trained in reading EKGs. He asked why.  “Just curious,” I said, and handed him back the strip. (It was afib at a rate of about 80 or so, with loads of patient movement artifact.) The poor firefighters were paralyzed without the medics on scene and were afraid to do anything, including moving the patient from the bathroom to my truck, and they certainly were not going to listen to me. Talk about the “Stare of Life”. So, I grabbed the vomit covered clothes and tablecloth, put them in the laundry and cleaned up as much of the mess as I could. I then went into the living room and kept the husband company and distracted him from what was happening down the hall.
The medics showed up and while the rookie medic did the evaluation, the lead medic and I, who had been on several calls together that day, chatted for a few minutes. I watched the rook stick his head in the bathroom then pop right out to say, “Why is this woman on a mask? Switch her to a couple of liters on a NC please.” My partner, sitting in the living room, snorted with laughter, because she had heard the firefighter earlier when I suggested the same. The lead Fireguy sauntered over to us to give report and an overview of the history and said, “Also, we ran this strip and it looked fishy, so we wanted to get you out here for an eval.” The lead medic looked at the mile long strip and asked, “What do you see on here that’s fishy?”  The FF replied, “uhhh…” The medic then handed it to me and said, “You’re going to medic school in a couple of weeks. Have you been reading Dubin’s book? What is this?” I looked at the strip and said, “Looks afib with a lot of artifact to me, but I may be wrong.” The medics got a clean 12 lead and, as expected, the patient was cleared for BLS. Our on scene time was an incredible 1 hour 17 minutes.

I enjoy running calls with the first department, I dread calls with the second.

TOTWTYTR says:

To add insult to injury many in the fire service tell members of the public that all the ambulance does is “give them a ride to the hospital” because “the firefighters do the real treatment” … Some fire departments do a good job of EMS because the people at the top understand that it’s important and that attitude filters down through every level. Unfortunately, a lot of them … provide crappy fire based EMS while claiming they are helping.

‘Nuff said.