Tag Archives: EMS

Closest Most Appropriate 7/7

Now that I’m committed I pull my cell phone out and punch up the direct line to the University Emergency Department and give them a detailed description of what’s going on and what Josh’s condition is right now. The RN on the other side understands the situation and tells me that we’ll be going directly to the pediatric unit and she’ll have cardiology standing by when we get there.

The rest of the trip is somewhat uneventful as all of our tasks had been completed and it’s just a matter of monitoring Josh and reacting if anything were to change. Towards the end it’s obvious that he is starting to decompensate. He is more lethargic than before, he’s nodding off more frequently, and we have to keep him stimulated with questions and idle talk. His heart is starting to fatigue from the accelerated pace it’s been keeping for the last 45 minutes. His initial rate of 178 has now dropped to 52 and throwing consistent premature atrial contractions (PACs). Josh’s heart was bouncing from bigeminy PACs to trigeminy PACs. This means that he has normal conduction beats interspersed with abnormal beats in which the electrical conduction starts in the wrong place on the heart. This makes the contraction ineffective.

If his heart rate drops any more we’ll be turning on the external pacing pads to override his faulty electrical conduction with stronger electricity that his heart can’t ignore. It’s really an unpleasant thing to watch as someone is rhythmically shocked every second to force the heart to do its job. If I have to do it I already have the sedative ready so I can at least take the edge off of Josh’s pain, but I can’t risk sedating him too much as it will encourage the decompensation that has already started. Nothing to do now except continue the IV fluid bolus to keep his blood pressure up. We even have the pressure bag on the bag of normal saline, compressing it to push the fluids in faster.

Looking out the back window I can see we’re on University campus grounds as the large stadium and athletic fields pass through my limited field of view. The siren has stopped the constant wail and now only chirps at intersections as the cars pull to the right to let us pass. Unlike in the hood, the people here actually know what to do when the flashing lights appear in the rear view mirror.

Pulling into the ambulance bay I see the once familiar Emergency Department at University. My first ever code-3 return was to this ED. Three weeks into my new career in EMS I was working as an EMT doing inter-facility transports in this county. A skilled nursing facility (SNF) called us for a resident with a fever. Upon finding the patient in her room it’s obvious that the SNF called for a basic transport rather than calling 911 so they are not tagged by the county. The woman was septic, hypotensive, and altered. Our protocols said that if we had a transport time less than 10 minutes to the ED that we were permitted to take the patient in code-3, rather than call for an advanced life support (ALS) unit. That was the first time I called up to the driver telling him to light it up. Five years later I’m taking a crashing 8 year old for a 40 minute code-3 drive. It’s a different world yet still very much the same.

We unload Josh and wheel the gurney towards the receiving entrance. The ED charge nurse sees us coming and redirects us to the pediatric unit. There’s a team of six people waiting by the first critical room for us. As we unsnap all of our wires and transfer Josh over to the bed I’m giving a basic run down of how we found him, how he changed during transport, and an overview of his medical history. The pediatric cardiologist sees the 20 foot roll of EKG strip on the gurney and starts from the beginning, evaluating each printout and 12-lead sequentially captured during the last 40 minutes. Mom has her stack of papers and starts talking to doctor who she recognizes and is familiar with Josh.

As I’m about to leave, I look over at Josh, nurses busy connecting him to their monitoring equipment, I wave to him across the room, he gives me a thumbs up.

Closest Most Appropriate 6/7

“Don’t worry about it, just head for the bridge and I’ll get you the address.” This is not the thing that Mom needs to hear right now. We’ve got twenty minutes before we get on the bridge so I have time to make it work.

I pull out my cell phone and call our dispatch center. One of the dispatchers answers and I ask her to send out the University address to our pagers. A few seconds later my pager is vibrating on my hip. We’re on a pretty straight freeway so John is able to program the address into the GPS while driving. I hear the dry female voice of the GPS say, “In fourteen miles take exit on right.”

Moving back to Josh and the fire medic I grab my “Oh Shit Bag.” It’s the bag I clip to the net in the back of the ambulance every morning that has my seldom-used but really critical in a situation like this personal equipment. I pull out the Broslow tape and county protocol book. The Broslow tape is a measurement tool for pediatric patients – you stretch the tape out along the length of a child’s body, and it tells you approxmiately how much the child weighs based on height. Most drug dosages, as well as joule settings for defibrillation and cardioversion, are determined by weight for children, so getting a reasonable weight estimate is really important.

The Broslow tape tells us that Josh is 30kg, so his specific dose of Epinephrine is 0.3mg (as compared with 1.0mg for an adult). The fire medic and I pull out a strip of two inch cloth tape and write down Josh’s specific doses on all the medications and joule levels we could possibly use if we have run a code. In times like this it’s extremely helpful to have two medics double checking math and procedures. A misplaced decimal point can result in the patient getting ten times the dose they should get.

Glancing at the monitor and Josh every few seconds I can’t help but wonder if he is aware of what we’re doing: making a cheat sheet of medications in case his heart stops. I place the tape on the cabinet over the gurney so we can both see it. Josh looks up at the tape with its cryptic abbreviations and numbers, his eyes follow the IV tubing as it winds its way down the wall and into his little hand. “Josh, how ya doing buddy?” He holds up his tiny thumb. Wow!

One last thing to do: open the pediatric defibrillation stickers. It’s just precautionary but if I need them I don’t want to waste time attaching them, much less interrupt CPR to do it. The fire medic leans Josh forward as I place one on Josh’s back and then one on his chest, covering all of the cardiac surgery scars.

I’m keeping a mental note of our position in the county and which hospitals are closest in case Josh decompensates or codes and we have to abort the plan to go out of county. Looking out the back window I see the land fall away in the distance and our freeway turn into a bridge. Well, we’re committed now. Once on the bridge, University is now the closest receiving facility.

Closest Most Appropriate 5/7

I carry Josh down the front stairs of the house to my gurney waiting by the gate, get him settled in, switch over the oxygen to my tank and get him loaded into the rig. The fire medic jumps in behind me and starts reassessing a blood pressure while I hook Josh up on my EKG monitor. Meanwhile, John is getting the mother settled in the front passenger seat.

I don’t usually run a 12 lead on an 8 year old but this is cardiac etiology and I really want to see his electrical conduction from the additional points of view just to make sure I’m not missing anything that might change my transport decision. To get a clean tracing I need take the 12 lead before we start moving to avoid any interference from a moving ambulance.

As soon as I start to get a rhythm on the monitor I get my first piece of good news on this call. The fire medic’s monitor is only able to see one heart lead at a time, my monitor is preset to see two leads and one of those leads is showing me an organized complex of electrical conduction, not the even lumps of atrial flutter. I’m staring at an irregular rate from 150-180 but at least it’s organized.

It appears that all of the heart surgeries and the original defect have altered Josh’s electrical axis – his electrical conduction starts in a slightly different place on the heart and takes slightly different paths as it stimulates the contraction of cardiac muscle. As a result, in the default view of Lead 2 it looks just like atrial flutter but in Lead 1 and Lead 3 it looks much better. I’m starting to feel a little better about the drive ahead.

Everything else can be done en route, so with the EKG done, it’s time to go. I look up and see John and Mom looking back at me. “The 12-lead is good, let’s go.” As we start to exit the neighborhood with lights flashing and the siren making its familiar noise I’m almost starting to feel a little confident that this call will have a good outcome.

John says something from the front and I didn’t quite hear it so I move closer to the pass-through. We’re on the freeway in the far left lane. John flicks off the siren as the traffic is clear in front of us. In a slightly concerned voice he leans back so I can hear him. “I’ve never been to University, I don’t know how to get there.” Crap!

My GPS is sitting on the front dash. I can get to most places in the county without it and definitely to every hospital in the county. It’s occasionally good when we are off in the hills or if I have an inexperienced partner. But I didn’t program in the out of county hospitals.

Closest Most Appropriate 4/7

John, my partner, is a new medic in the county so Scheduling floated him to my unit today because my normal partner is out on light duty from an injury he received while lifting a 600 pound patient. John has to be with a more experienced medic until he gets signed off by a Field Training Officer. Scheduling doesn’t seem to care that I only got signed off last week. Although we’ve never worked together, and honestly just met a few hours ago, we had a good bonding on our last call. Stat calls can bond partners in a way few things can. I imagine it’s similar to people who go to war together but I’ve never experienced that so I can only guess.

Our first call of the day was for a teenage gang banger who got shot in the ass. The large city in our county is ripe with urban violence – gangs, drugs, and everything else that eventually ends with a trip to the hospital. Consistently ranked in the top five of the country’s most dangerous cities, it tends to be a great place for a new paramedic gain experience – fast! The baby gang banger was pretty much okay – single entry wound, no exit, small caliber bullet, able to move all of his extremities. Actually a pretty basic call for the city and John and I executed the necessary tasks and got him to the trauma receiving hospital in good time.

John and I are on the same page about Josh’s treatment and I trust he’ll make the case for the Base MD well enough to allow us to do the right thing. Meanwhile I make a quick call to the supervisor and tell him what’s going on. Company protocols dictate that I alert him if I need to transport out of county. I quickly lay out the scene for him and he agrees that it’s what needs to be done. His parting words gave me a shiver, “Good luck with that.”

I see John hang up his cell phone and I give him the raised eyebrows as I’m helping to wind up the EKG wires and put them back in the monitor. “Okay, I talked to Dr. Finch and he understands the situation. He would rather us take him to Kid’s but said if the mother is insistent then we have permission to go to University by ground or air.”

I turn to Mom, “Which hospital do you want him to go to, University or Kid’s?”

“Definitely University!”

“Okay, we’ll get him there.” Mom, who has had every mother’s worst nightmare in groundhog day repeats gives me a big smile and thanks me as she starts gathering up necessary paperwork and belongings for yet another ambulance ride with her very sick child. I’ll take her with me if I have to drive him, sitting up front of course. There is a very real possibility that Josh may decompensate en route and no mother needs to watch us run a code on her kid from a ringside seat on the bench  – where you can actually hear the ribs break from CPR.

As I’m getting ready to pick Josh up and carry him to the gurney the fire captain comes up shaking his head. “They just flew a guy off the freeway, ETA for the next closest helicopter is 30 minutes.” Crap, that’s too long!

“Okay, it looks like we’ll be driving him, I’m glad that accident was the other direction on the freeway.” The captain raises his eyebrows and gives me the tight chin look that says he understands what the next 40 minutes are going to be like. He’s a paramedic also – keeps his certs current, does the occasional IV or helps out with an intubation now and then. But he’s a captain now and the fire medic that works on his crew is supposed to do all of the advanced life support interventions. He’s put in his years and deserves his position even if he would rather be pushing the Dextrose into the vein of a gorked diabetic instead of writing down the same medications on every call and asking the same tired questions of family members. Yet I can see that this is one call where he’s happy to down his engine and go back to the station to wait for us to bring back his fire medic.

Closest Most Appropriate 3/7

I join the fire medic, my partner (who happens to also be a medic), and the fire captain for a quick huddle near the kitchen.

The fire captain starts, “Okay, here’s the deal. He’s on the list at University Hospital for heart and liver transplants – his base problem is the heart but it’s cascading to other organs and is causing liver failure. Mom wants him to go to University because they know his history. He’s had six cardiac surgeries in the last three years with the cardioversion two weeks ago. But I know you guys probably have to go to Kid’s Hospital because it’s in-county.”

“Yeah, we have to go to Kid’s, but even that is 30 minutes away doing code-3 given traffic. If he starts to crash out I’ve got to take him to the nearest receiving hospital, he’s compensating right now so we have few options. Either way I could use a rider if you can spare your medic.” He nods without having to say the words, we all know how this could play out. It takes at least two people in the back of the rig to effectively run a code.

I do some quick math and take stock of what I have in front of me. Josh’s cardiac history is so complex that even Kid’s Hospital would be calling for a transfer rig as soon as I walk in the door, yet county protocol says I need to take him to Kid’s. He’s still compensating, and therefore somewhat stable for the moment. Yet kids stop compensating very suddenly and he has a very complex medical history, so it’s tough to gauge his compensatory stamina. I can get to Kid’s in maybe 30 minutes; going to University would take 45 minutes, out of county, crossing a very long bridge.

“Do you want a helicopter?” asks the captain. Hell yes I want a helicopter! Let the flight medic take this call, they have more training and  a few more cardiac drugs at their disposal. Not to mention he can get to where he needs to be faster than I can do it. But didn’t they just fly out that motorcyclist? Crap!

I decide it’s my call to make. Josh is getting to University Hospital one way or another –  they know his specific history, they have a cath lab, they have a pediatric department, and that’s where the transplant team is in case he gets bumped up on the list because of this. If Josh’s little heart is beating its last few beats right now he needs to be in the hospital that is equipped for the transplants.

“Okay Cap, can you call for an ETA for a helicopter? If it’s too long we’ll see about driving him there.” As the fire captain turns around to talk into his portable radio, I ask my partner to call our Base MD (the doctor that we call to get permission to break or exceed protocol when we need to) and make the case that we need to drive this kid out of county if we can’t get a helicopter. I ask the fire medic to start getting Josh ready to go, unhook his monitor and secure the IV.

Closest Most Appropriate 2/7

He gives me a quick run-down of the situation.

“This is Josh, he’s 8 years old and has a birth defect in the heart. He was playing with the other kids outside when he had sudden onset 10 out of 10 chest pain described as pressure and associated shortness of breath. He had a similar event two weeks ago which required cardioversion and the Cath Lab.”

“Why cardioversion?” I’m still trying to reconcile the fact that my patient is a kid and not a man in his 50s.

He moves out of the way of the cardiac monitor which has a fast series of even little bumps where the perfect electrical conduction of an 8 year old should be. He says, “It looks like atrial flutter at a rate of 178 a minute and he’s got a blood pressure of 86 over 58 off the auto BP cuff.” All BAD!

I move around the fire medic to have a look at Josh. “Hi Josh, how ya doing?” I say hoping he doesn’t see the very real concern in my face, as I kneel down to meet him eye to eye. He takes a tiny little thumb and gives me the thumbs up. Wow! Josh is a veteran of the medical community at the ripe old age of 8. He has cardiac surgical scars like a 50 year old who’s had multiple bypass surgeries and he knows he can’t talk well with the mask on, so he gives me a thumbs up instead. I give him a smile while I hold his wrist with my fingers wondering if I’ll find the weak radial pulse tacking away at 178 miles and hour. He’s pale, cool, diaphoretic. It’s a term we use a lot yet it still astonishes me when I see it. Sweaty people shouldn’t be cold to the touch and no 8 year old should ever look like this. The pulse is there and presents as I expected, fluttering along like quick rapids in a river under my fingers. We call that thready.

The fire medic kneels down with me, “Mom said that last time he was cardioverted his heart sounded like a washing machine, and that’s pretty much what it sounds like right now.”

I pull the stethoscope from around my neck and place the bell on Josh’s exposed torso next to the fresh scar tissue. Damn, if that doesn’t sound just like a washing machine. Paramedics don’t usually work with heart tones, pretty much every heart tone I’ve ever listened to sounded just like the diesel engine of my ambulance – it’s a skill and diagnostic tool better left to the cardiologist in a controlled environment. But any paramedic could tell that this kid’s heart was not doing the normal “Lump Dump” of a healthy heart. I’ve listened to heart tones of leaky valves – on the internet anyway – and I understand the concept. But this is a leaky valve on steroids. This valve simply isn’t working.

The fire medic was watching my eyes as I listened. All paramedics are similar in one respect: they are trained observers. We get lied to by most patients – people give us conflicting information, exaggerate their symptoms and distort the facts. We quickly develop very acute observation skills with a finely tuned bullshit meter. He saw me play out this scenario half a dozen different ways, most with bad endings, and the resignation that we are on this path together for better or worse. All of that was in just one look but we had an understanding: Josh was our patient and we were going to see it through together.

“Hey Josh, we’ll take really good care of you, just hold tight while I talk to these guys for a second, okay?” He gives me another thumbs up. Wow!

Closest Most Appropriate 1/7


1 : being near in time, space, effect, or degree
2 : having a strong liking each one for the other <a close friend>
3 : very precise and attentive to details <close measurements> <a close observer>
4 : decided by a narrow margin <a close race>


1 : the determination that the service provided is suited for the condition
2 : being suitable for a particular person, group, community, condition, occasion, and/or place
3 : proper

Walking up the stairs to the front door I take in the neighborhood. Children playing next door stop to stare at the fire engine – all the lights flashing – parked just in front of our ambulance, which smells of abused brake pads. It’s a nice neighborhood, not one I’m called to very often, in a quiet suburb of the county with expensive cars parked in front of well manicured lawns. I’m heading towards the door that has been left open for us and check my pager to make sure the numerics match. It’s an acquired habit from working in the hood where walking into the wrong house wearing a uniform can be a fatal mistake.

Taking the stairs one by one I’m thinking of the patient I’ll be responsible for in a few minutes and quickly brainstorming the possible treatments as compared with the equipment I have on hand. I’m a little tired and frustrated from the delayed response time and the distance my partner and I had to cover to get to this house. Nearly 16 minutes is longer than anyone should have to wait for an ambulance and 20 miles is longer than a crew should have to drive code-3 (lights and siren) to reach a call – at least in this county. But on this day I’m in a back-roads wealthy suburb of a county that is three-quarters urban sprawl. Not surprisingly, this area of golf courses and farmland doesn’t have as much freeway access as the more populous areas.

I recall during the drive that the dispatcher said something about this area being “Level Zero” – meaning no available ambulances in this part of the county – and that we were the closest unit. I’ll take her word for it as all of the ambulances in the county are tracked by GPS and calls are automatically routed to the closest crew. While driving to the call I listened to the radio traffic talking about a collision on the freeway ten miles further away  with multiple patients, one trauma activation, and another crew taking a motorcyclist to a landing zone to be air lifted to the closest trauma center.

The dispatcher was so busy with the high call volume that she didn’t send the call information to the Mobile Data Terminal which sits on the console of our unit. Usually I can get some specifics about the patient I’m responding to from there, but not on this call. So I’m going off the pager that only tells me where to go and gives a generic chief complaint of the caller. In this case it’s “Chest Pain / Shortness of Breath.” It’s a call I’ve run hundreds of times and it can manifest in any number of causes and levels of acuity. From the frequent flyer in the hood who just needs a sandwich and a place to take a nap to the identifiable coronary artery occlusion that requires a cath-lab and a code-3 trip to the nearest Cardiac Receiving Center.

Walking through the doorway to the house I see a few children and family members taking quick awkward steps to get out of my way, the way people often do when they suddenly find themselves unusually “in the way” inside their own house. I’m heading towards the kitchen/great room where I hear the squawk of the fire fighters’ radios. Walking in I see the fire captain talking to a woman in her 30s while he examines prescription bottles and writes down details. His mannerisms are business-like in the way we all turn on the A-game when it’s a real call. I’m starting to think this woman’s husband may have had a heart attack when I turn to see the small boy sitting on the sofa with a non-rebreather oxygen mask on and a fire medic kneeling at his side staring at a monitor. Another fire fighter is standing next to him holding an IV bag – the small boy already has an IV going.

Okay, now they have my attention. Sure it was a long response time but fire medics don’t usually start IVs before I get there unless it’s serious. And children don’t have chest pain! As I walk up the fire medic stands up with a relieved look in his face. Crap, this is a very real call!