Ambulance Driver Answers


Marooned in Massacusetts writes:

When you’re in the ambulance, and there’s some braindead mouthbreathing shmuck completely ignoring the sirens and lights, do you ever wish there was a Browning .50 cal machine gun mounted to the hood? Or do you subscribe to the rocket-propelled grenade school of gene pool cleansing through idiot removal?

Dear Marooned, you have unwittingly described the First Maxim of Emergency Driving, which states: When on responding with lights and sirens, any motorist traveling slower than you is an idiot. Any motorist traveling faster than you is a maniac.

Personally, I think twin water-cooled .50s mounted on the grill and a snowplow bumper would work better than lights and sirens, and provide us much-needed stress relief and practice in hand-eye coordination, to boot.


A
round here, most of the brain-dead, mouth-breathing schmucks fall into the maniac category. You can easily spot them because they drive new black Dodge Ram pickups and constantly curse their fellow motorists. What kind of vehicle do you drive, by the way?

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Cat Herder writes:

My wife is sometimes very moody — yelling at me, finding fault, just not able to be happy. We’ve been married ten years, and I’m thinking of leaving her. My question: Is it really, really fun to drive that truck fast?


Dear Cat Herder, running off to the EMS circus will not solve your marital problems. Besides, our profession already has enough clowns.

I’d recommend that you honestly consider what it is about you that bugs her so much, and work to change your behavior. Try paying her little compliments and doing thoughtful little things for her, just because. Take the vacuum cleaner from the closet, plug it in and park it right next to her side of the bed so it’s the first thing she sees when she wakes up in the morning. When she’s mowing the lawn in this summer heat, get off the couch to bring her a refreshing glass of lemonade now and then.

Chicks dig chivalrous shit like that.

PS: Yes, it is fun to drive the truck that fast.

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Pixie Dust asked:

What is your opinion on patients’ labs being drawn in the field? In the county where I run, we don’t draw labs in the field; in the county where I work in the ED, EMS does draw labs, and we do use them in the ED for analysis. However, we’re the last hospital under our parent system to do so, and the OMD has had to fight with our lab to keep the practice going. I gather the issue is that we in the ED weren’t there when the blood was drawn, so we can’t swear it’s from the right patient … WTF? EMS does have a procedure whereby they apply an armband with a unique identifier to the patient, and stickers from the armband are applied to each tube … seems sufficient to me. Is it a lack of trust in the EMS system? Seems to me that the patients get results and therefore treatment a little more quickly this way, if there labs are already drawn upon arrival …

Dear Pixie, I feel your pain. When I was on the rig, I routinely drew a rainbow of blood tubes whenever I started an IV, if time and circumstances allowed. Most hospitals accepted the blood willingly for their own lab to analyze, but a few holdouts stuck in the last century routinely discarded the blood.

I believe to a large extent it does exhibit a lack of trust in the EMS system. Whenever I encountered such ignorance, I did my best to educate the ED and laboratory staff by stomping my feet, holding my breath, and loudly demanding “You will respect my authoritay!”

Because, you know, nothing spells R-E-S-P-E-C-T like righteous indignation and behaving like a petulant child.

I’d ask your laboratory director how he ensures that labs drawn from nursing home patients or any other out-of-hospital setting is actually from that patient, since he wasn’t actually there when it was drawn. Laboratories do assays every day on blood drawn at remote sites. The “we didn’t draw it ourselves, so how can we insure the integrity of the sample?” argument is a straw man, much like some ED’s practice of restarting all prehospital IVs because they are inherently “dirty.” That practice is based on some rather flawed and very outdated research, by the way. What they’re really saying is, “Blood draws and laboratory analysis is our turf, and EMS should know its place.”

I’d suggest organizing a little CEU session on blood draws for the local medics. Have the EMS services education director organize it, and have the lab staff at the hospitals teach it. It’s a win-win situation: the medics get CEUs and the hospitals still get to protect their turf because they control the curriculum.

If the EMS system resists the blood draws because of cost issues, inform them that the hospitals can resupply them with Vacutainers, needles and other supplies, and still bill for the procedure just like they normally would. Check out the latest OIG opinion regarding ambulance restocking and safe harbors.

I hope this helps. I’m in favor of anything that saves the patient an extra needle stick and speeds their door-to-needle time.

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Forlorn Boater asks:

Do you think the hemostatic agents like Quikclot are useful for (1) EMS (2) police (3) just plain folks?

I think I can see their usefulness in a military setting (the Blackhawk Down scenario) and, where the situation allows, for a popo who is first on the scene at a trauma. (I don’t know what magic the EMS folks bring for trauma, so I don’t know when / if you would need it.)…

Dear Boater, to answer your question in order:

(1) Yes

(2) Maybe

(3) No

I don’t want to sound like Joseph Mengele by saying this, but Operation Iraqi Freedom is proving to be one huge, immensely valuable field laboratory for research in trauma care. Never before in recorded history have soldiers had such good chances of surviving their initial battle wounds. Many of these advances have EMS applications, not the least of which are hemostatic agents like Quikclot, and the re-emergence of tourniquets.

You may not know this, but for a long time in EMS, tourniquets were a Bad Thing, and only to be used as a last resort. The experiences of combat medics in Iraq have taught us that often tourniquets should be the first resort for life-threatening bleeding. The tourniquets used by combat medic today are of a far superior design to the improvised jobs we used back in the day. It’s not your Daddy’s tourniquet any more.

Hemostatic agents like Quikclot and Celox serve to stanch blood flow by rapidly forming an artificial, external “clot.” In the case of Quikclot, the clot is formed by means of an exothermic reaction, which has been shown to cause thermal burns and tissue necrosis in some patients.

Celox doesn’t cause an exothermic re
actions, but in any case, these agents both require that the bleeding first be controlled so that the agent can stick to the wound.

In other words, you first have to use the tried-and-true direct pressure, elevation and arterial pressure points to slow the bleeding enough so that the arterial spray doesn’t simply wash the agent away before it has a chance to work. Some of the Marines who used Quikclot in Iraq were unimpressed because without direct pressure and tourniquets, Quikclot wound up everywhere but the wound. For the average citizen and most cops, the usual methods of hemorrhage control should be sufficient until the arrival of EMS. Modern tourniquets are extremely effective, but require a little training to use effectively and safely.

One promising development is the advent of chitosan bandages, which use a bandage impregnated with chitosan from shrimp shells to form a clotting matrix. When last I checked, they were only available to the military, but the manufacturer had plans to market them for civilian and EMS use as well. Buy yourself a few of those.

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UK Wheezer writes:

What are your views on expert patients? By that I mean the people who suffer from a chronic condition like asthma that requires emergency care by you guys. Do you listen to what they have to say about the treatment they require. For instance the size of cannula you can use. Or do they just plain bug you?

Dear Wheezer, the only expert patients who bug me are the ones with nebulous pain complaints who happen to be allergic to Toradol, Tylenol, Ibuprofen and aspirin, who then proceed to tell me precisely what narcotic analgesic and dosage to use to alleviate their suffering.

Strangely enough, those patients are experts on their symptoms, but not expert enough to read a calendar, count their pain pills, and arrange for a refill in a timely fashion.

However, no one knows the effects of the disease like the patients themselves. I pay very close attention to most patients in regards to what works and what doesn’t, and the severity and progression of their symptoms. Only a callous, jaded fool of a medic wouldn’t.

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Hootie Mac writes:

What is the most efficient method of communicating medical information when you cannot speak for yourself? The medic alert bracelet? A card in the wallet? Do you really need to put ICE number on your cell phone? Give us some basic guidelines to use.

Dear Hootie, try all of the above. Modern technology has also come up with an answer, in the form of an implantable chip that can be read with a special scanner. They’re not readily available yet, and there is still a great deal of justifiable concern about abuse of patient privacy.

If you’re a little afraid of Big Brother being able to potentially track your movements (not a legitimate concern with this device), or having your records placed in some vast database with questionable security (BIG concern), you might try the Vial of Life, particularly if your medical history and medication list is rather extensive. You put a copy of your medical history, allergies, medication list, DNR, old EKGs or whatever in a ziploc bag and stick it to your fridge. Then you put a decal on the fridge and your front door to tell the paramedics where to look. A similar arrangement in your car with decals on the glove compartment and rear window is a nice touch.

Speaking of rear windows, I loved Cracked Rear View. How are the Blowfish, by the way?

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Sleepy in South Carolina asked:

Do you think it’s about time that “Paramedic” in it’s broadest should become an (AD- lol) Associates Degree and be a Licensed Program as opposed to a Certificate. In our Urgent Care we used to start IV’s – now someone pitched a fit jealous nurse) and it has compromised patient care – our Nurses are all for us doing as much as possible) and now we can”t. Walk outside an you can do an EJ stick or run a full code—But IV’s? Come on!! Anyway- Question- Associate Degree vs. Certificate and expanding scope of practice to help fill the Nursing Shortage?

Dear Sleepy, I am somewhat lucky in that, at Podunk General Hospital ER, I can function under my full scope of practice as a Critical Care Paramedic. We accomplish this by making the medic directly answerable to the ER doc as a physician extender, thus bypassing the delegation of practice issues the state board of nursing is so snippy about.

It’s pretty short-sighted to deny medics the opportunity to practice in the ER, particularly in light of the current nursing shortage. Incidentally, the nursing shortage is a bit of a fallacy. There are plenty of registered nurses to go around. What is lacking is a number of them willing to actually practice direct patient care, rather than education, administration or case management.

To be fair, however, for a medic to think he can function at the level of an experienced RN in an Emergency Department shows a lot of hubris, in my opinion. We are effectively a comparable skill set without a nurse’s knowledge base. I’m not saying one is superior to another, but as far as initial education is concerned, nursing is both broader and deeper.

To answer your question directly, I see eventually all paramedic programs moving to a minimum of an Associate Degree. I think that’s the direction we need to go. That’s not to say that there aren’t excellent proprietary, certificate paramedic programs out there, because there are. Some of them produce better medics than the college programs. But for our profession to achieve the pay parity and recognition we feel we deserve, we must improve our stature among the rest of the health care professions. The first step in that is improving educational standards, and it needs to be a college program if we’re to achieve any semblance of legitimacy as medical providers.

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Ray in West Texas asked:

When is a person declared dead? Does it have to do with heart beat or brain activity? Example, a person is declared brain dead and on a ventilator and the family wants to pull the plug, I argue that if the heart is beating without the aid of a machine then the brain is functional as it is telling the heart to beat. I look forward to your answer.

Dear Ray, the heart does not require signals from the brain to beat. Cardiac muscle possesses a special capability known as automaticity, which is the ability to generate its own electrical stimulus, and thus a heartbeat, independently of any input from the nervous system.

As long as the heart remains oxygenated, it may continue to beat on its own. This may require an artificial ventilator to breathe for the patient in the event that the brain is not generating any breathing impulses, or there may be enough brainstem function to maintain spontaneous breathing.

The brainstem cont
rols our basic, most primitive bodily functions such as breathing and blood pressure, and some limited control of the rate and force of the heart’s beating, but rest assured that it is not absolutely essential to maintain a heartbeat. It is not at all uncommon for a patient with a devastating brain injury to have preserved vital functions, but be incapable of higher brain functions. They cannot see, think, communicate or sense pain.

I have seen a suicide patient who had blown his head completely off with a shotgun, who still had a pulse, a blood pressure and respirations for several minutes. There was just enough of the patient’s brainstem left to stimulate these functions, but by no reasonable measure was he alive. He was, at most, a candidate for organ donation.

Brain death can be confirmed by clinical exam and several diagnostic tests. Some people may not be brain dead, yet have no hope of recovering higher brain function. Many people, in those situations, choose not to be kept alive by artificial means.

I don’t know your personal ethical and religious beliefs, but mine tell me that death is sometimes a mercy, and many people do not wish to live in a persistent vegetative state with no hope of recovery, even if they are not technically brain dead. I have a hard time believing that “pulling the plug” in those instances is a sin in the eyes of God. I also believe God wouldn’t want us wasting organs that are in short supply.

Hope that answers your question.

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Outside of Apex asked:

Are you guys really busier during a full moon or what?


Dear Outside, the idea that call volume, patient acuity , and the oddity of EMS calls is somehow tied to the lunar cycle is a myth. Pure fallacy. There is no scientific evidence that the number of EMS calls or ED visits increase during the full moon, nor do we see a higher number of psychiatric patients.

Now if you’ll excuse me, I’m going to go chant, burn some incense and sacrifice a small nurse to the EMS Gods, lest they smite me for my blasphemy.

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U.P. Medic has a twofer, which I will answer in order:

Your thoughts on physician assisted suicide. With Dr. Jack getting out of prison soon, just wondering your thoughts on the subject.

Here’s my Libertarian, lapsed Episcopalian, bastardized medic view on the subject:

1. The government has zero business deciding life or death issues for its citizens. You want to die, off yourself. It’s not for man to judge your actions.

2. Death is sometimes a mercy, and nobody should suffer needlessly if there is no hope of recovery. If death is their choice, so be it.

3. Jack Kevorkian went from noble advocate for suffering, terminally ill people who needed a voice, to a zealot who crossed the line into murder. In his zeal, he assisted in the deaths of a few people whose conditions were not foregone conclusions. Some of those people had options other than suicide. Jack Kevorkian was too focused on his quest to help them explore those options.

Second, your view on the scope of practice for medics (in the hospital).

Personally, I think medics should operate as they were intended, as physician extenders. They should not be subordinate to nurses, nor dependent upon them for delegation of practice. They should work with nurses, as equals. That means they be allowed to utilize their full scope of practice.

That said, it’s pretty arrogant of a medic to assume that he can work in an ER with no additional education or training. Imagine how you feel when you hear of nursing organizations advocating nurses staffing ambulances, without any requirement of additional education in prehospital care.

In a broader sense, I kind of like the way Texas addresses the scope of practice for its EMS providers. The scope of practice for the EMTs, of any level, is limited only by how much liability the physician is willing to accept for the EMTs he directs. Theoretically, an EMT-B in Texas can start central lines, insert chest tubes, and perform a surgical cricothyrotomy, provided the medical director accepts the responsibility and trains the EMT in the procedures.

That’s one reason I dislike the new National EMS Scope of Practice model. We need a nationwide scope of practice for all levels that defines the minimum education, training and skill set for a particular level. In other words, a floor, not a ceiling. As currently written, the National EMS Scope of Practice is a de facto ceiling that will prevent our profession from growing and adapting to future changes in the health care environment.

I’d like to thank all of y’all who submitted questions to Ask Ambulance Driver. If my answers provided at least a modicum of education and entertainment, let me know if you’d like to see more. Feel free to submit more questions, and as always, comments are welcome.