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Layout

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Sunday Fun - Get MotivatedIn my opinion the most important person on a hoseline is the layout man.

Some departments staff 3 to an engine, meaning there is no layout man unless the Officer goes back down the line to make things right.

Not mine.

We run 4 to an engine and for good reason: You need 4 people to mount an effective primary fire attack.

Driver/Engineer: Operates fire apparatus, engages and monitors pump and water supply.  Good so far, we have a way of getting water into the hoses, that’s a plus.

Officer: In command of the team. Calls for type, length of hose and where it is to be deployed.

Nozzleman: Operates the valve at the end of the hose, points it at the fire.  Really more complicated then that, I know, but than again, so is…

Layout: Ensure the hose is properly deployed from the apparatus and unkinked entering the building.  Follow the attack team around corners, untangling and advancing line as needed.  Block open doors and move furniture so that when the line is charged it isn’t trapped under something.  Stay back from the firefight to pull line back so the nozzle team can redeploy to another location without standing on a load of spaghetti in the hallway.  And, possibly THE most important role of the layout position is to slow additional responding companies if conditions are unsafe ahead of you.

Even though the Officer has a good view of the seat of the fire, and a good officer knows the conditions around them, they can’t see what the layout person sees.  From a safe distance, possibly at a corner, ready to pull hose while the nozzle gets the “glory,” the layout can scout conditions in other rooms and maybe even get some ceiling fall on them when the truck cuts a nice hole.

The layout knows all the trouble spots that line may encounter if it needs to move through that area again.  The first two folks through had their attentions elsewhere.

The layout is also the one who will be assisting the nozzle team should the conditions warrant an evacuation.  From that position you know where the exits are, not just where the line goes out, but also rooms of refuge, should they be needed.

When the fire is out and overhaul continues, the layout man needs to make sure that line is still available to knock down hot spots in the ceiling and walls by looping it into an unburnt room and placing the nozzle, with nozzleman still attached in a position to redeploy if necessary.

We should never leave the engine without a tool of some kind, but as the layout we need full flexibility so a sheathed axe can really get in the way.  A pump can can also get in the way but makes an excellent door chock and point of no return doorway device.  That little can can keep an advancing fire from getting through a doorway if teams are retreating behind you for at least 2-3 minutes when used properly.  So what to bring?

Depends on construction, location of fire and your Department’s SOPs.  A cop out answer I know, but the truth.

So next time someone else “grabs” the nozzle, remember that they have it easy, now you’ve got the most important spot on the hose line.  If the fire goes out you did your job right.

Now get those kinks out and feed line up to the third floor!

The Premiere Party is LIVE!

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The Car, The Wall and The Game – Day 3

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chroniclesblogThe alarm seemed to be timed better this morning and I was bright eyed and bushy tailed for my second day on Mark Glencorse’s Rapid response Car in Newcastle.  The coffee was ready when I got out of the shower and I watched a bit of news while getting ready.  When I was in England a frightening wave of flooding was literally washing away parts of the western side of the country and numerous Fire and Rescue resources had been mobilized.   It was a topic of conversation in passing throughout the morning with the Vehicle (ambulance) crews we saw and hospital staff we talked to.

The check out on the car was much quicker since my first day orientation and away we went to our first post.  On the way Mark asked if I was hungry and I had to remind him I don’t often eat breakfast.  In the back of my mind was another McDonald’s run but in the front of Mark’s was taking my for a proper Geordie breakfast.  The term Geordie refers to the people or speech from the Tyneside region of England, which is where Mark is from and where we were.  Similar to referring to someone as a Lonestar or Southerner here in the US, a dialect of speech and set of stereotypes is set into your mind.

The car weaved through the light morning traffic to a take away trailer in a light industrial park.  The aroma from this man’s trailer was like heaven.  The odor of bacon, along with other smells, changed my long standing no breakfast clause and my mouth was watering.

As with many of our other adventures this day, Mark in the car had folks wondering where the emergency was.  No one thought he was the Police coming to get him…until they saw me in my navy blue.  When Mark ordered my meal and the fellows standing nearby read the back of my jacket, which said “Firefighter/Paramedic SFFD” they were curious to ask all the questions we’ve been asking each other for months.

“Is it true you have to pay to go to the Doctor?” “yes.”

“If you can’t pay do they send you away?” “No, you get a bill later.”

“What about an ambulance? Is it true you’ll leave me to die if I can’t pay?” “No, we’ll help you out no matter.”

It was a great conversation with locals about their neighborhood and town.  Keep in mind this town has been here more or less FOREVER.  It’s not like some guy wandered through 200 years ago and started a farm.  There are castles and churches still standing despite centuries of wars.

It was in the middle of a talk about a nearby castle that my breakfast was ready.  Mark’s smile widened as he handed me what can only be described as heaven with a side of LAD.

Bun, mushrooms, brown sauce, black pudding, eggs, sausage, bacon and it was glorious!  Along with a true cup of coffee and some good conversation it was a wonderful way to start the morning.

But like so many things on this job, wouldn’t you know it a motor vehicle accident has been reported just a few blocks away.  Chomp, gulp, a thanks and away we go to the 2 car accident.  There was an initial need for extrication so Mark called in the Brigade.

The ambulance arrived quickly, as did the brigade and everyone went to work doing their pre-determined roles.  It was refreshing to see firefighters not distracted by assisting with patient care, but simply having a task and seeing to it that it was done.  This scene was more what I was used to.  Ambulance, fire engines, police, a proper job.  Although the injuries minor and the damage to match, the resources in the community worked seamlessly together to get the job done.  After the patient was transported I had a quick talk with the firefighters about their roles and responsibilities on this assignment, since there was not the usual bickering or fighting for the glory of the jaws that I have seen all throughout my career.  The firefighter assigned to cribbing was working just as carefully and quickly as the two sets, yes I said two sets, of hydrolics that were being prepared.  We discussed my role as dual trained and they gave a polite smile.  I think just below that was two distinct thoughts.  First, “That’ll never happen here” and the competing, “Oh God, what if they do that here?”

My photographer for the day obliged for a photo of the brigade that responded drawing my caption, “One of these fireman is not like the other…”

After a couple more jobs we were released from our roll area and directed north to the Arsenal/Sunderland football match.  The trip started as a chance to show a lifelong soccer fan a proper football match in his adopted country, but it would turn out to be an EMS learning experience.

But first, Mark had something special planned for me.  We grabbed our sack dinner, lovingly prepared by Mrs999, and hit the road to see the proper section of the old Roman Wall I was so interested in.  The drive through the countryside was amazing.  Rolling green hills hiding in the fog, unchanged since ancient times, save for the occasional 200 year old farmhouse with it’s trailing smoke from the chimney proving someone still inside.  The park rangers (or the UK equivalent) came out of their warm office to meet us when the RRC pulled up and we got out.  They wondered if a hiker had been hurt on the wall, why else would the ambulance be there on a foggy, rainy afternoon?

After a climb and a brief hike I was able to take some video and one of my favorite pictures from this adventure.  smallerThen I got to do what my Grandmother never did, stand on Hadrian’s Wall, where her hero Arthur may once have stood.  There was a connection with that place I can’t really describe.  I have the book she was reading when she died, Stories of King Arthur, a book she received as a child from her grandmother and I display it proudly in my living room, bookmark still in place and soon a photo of this part of the wall will accompany it.

It was an experience I hope to share with my young girls when they are old enough to appreciate what the wall means to the family.  Folks have been known to walk the whole length, camping as they go, and I plan to do the same in good time.

And now for something completely different.  If you’ve made it this far, I thank you.  Like Mark has said, so much happened on this trip, so many interesting and exciting things we shared with each other and with all of you, these day by day accounts are long winded.  If you skipped this far to read about Event EMS you are truly a Fire and EMS nerd and I salute you for that.

The Sunderland stadium can hold, at capacity for a football match, 45,000 impassioned fans.  The perception of many of you in the US may be “Soccer Hooligan” and the stereotpye is fitting in many cases when it comes to premier league football.  I was treated to not only the game, but a tour of the medical facilities made available for players and fans alike.

The stadium has an impressive command center encompassing the EMS team co-ordinator, Fire safety specialist, CCTV team and the police commander, all in two large rooms.  From this unified command center a response can be co-ordinated and a plan followed by radio.  The CCTV cameras also allow the leader to call in extra security if it appears an EMS fly team has unrest around them.  Help can be on the way before they even notice what is happening.  There were 4 teams on staff, dispersed around the stadium with assigned seats and radios, ready to respond as well as 2 pitch or field teams ready to respond to an injured player or person on the ground level.

Behind the scenes are two levels of care.  The teams have physicians on staff to deal with injuries to their people and outside the stadium, tucked in with the snacks and beverages are a number of doors marked First Aid.  Behind these doors are the service I know little about from my travels there, St John Ambulance.  (Not St John’S ambulance, St John.  I learned that one real quick.)  In these almost clinic areas are basic care givers, EMT’s, Paramedics, RNs and an entire medical community, all volunteering to help out.  While Mark and I sought refuge there to eat our dinner before the game, a woman came in, was assessed, treated, medicated and released, all in the span of 10 minutes, all by the St John staff.  It all happened before I could finish my Dr Pepper.

Upstairs in the control center I had a chance to peek at the emergency response plan and these guys have it all figured out.  I learned later that a number of previous events led to a mandate that each stadium have an action plan and the resources in place to react to those emergencies.  We also talked about rotating the teams if more than 1 fly team was mobilized, the extent of the St John involvement, their ability to staff a team and a number of other things most laymen would have fallen asleep thinking about.

The match was brilliant.  We stood just outside the command center, which was near the visitor’s seats.  Arsenal fans are passionate fans.  When I applauded a good play, which is common in this sport, Mark grabbed my hands just as one of the visiting supporters turned to see who was clapping.  Just what I need 4,000 pissed off drunk football fans chasing the American who clapped because the home team goal keeper made a nice save.  Tragedy averted.  And good too, because we were heading out on the town later.

We’re meeting Mrs999 and Fiona for a night on the local scene to give me an idea what Geordies do when the sun goes down.  Well, a while after the sun goes down.  OK, late at night.  I was treated to some local color and had a chance to talk to Mrs999 and Fiona about the person I was shadowing this week.  We talked, danced, twittered and had a wonderful time.  Mark loved his new iphone, since the old one died in San Francisco and at one point he fell asleep updating all the Chronicles of EMS followers.  OK, not really, but it made for a fun twitter update.

As the evening continued on the famous Millennium bridge over the river Tyne, I had a chance to reflect on where I was and why.  It was a big deal to be where I was, with Mark and the NEAS, learning how to deliver care in the front loaded model.  We should have called it a night there, but we had one more stop.

Bachelor and bachelorette parties in Geordie country take themed dressing to the extreme.  In Las Vegas, the girls may dress in pink shirts with the bride to be in some kind of white head dress and veil, letting all the single guys know exactly what she is celebrating.  But here, the entire group dressed to match.  There was a group of guys dressed as 20’s gangsters, pinstriped suits and fedoras.  Why? Stag party.  Groups of girls wearing matching tight shirts all wishing their engaged friend luck in cleverly worded phrases on the front. Why? Bachelorette party.  In came a group of girls wearing black and their names on he back of their shirts.  One of them we know.  Steph Frolin is the name my co-workers use to alert me to a scene that is not what it seems.  Imagine we are investigating a person who says they just came in from a terrible car crash.  As I’m assessing them my partner discovers witnesses in the next room who can confirm no such thing ever happened.  They will refer to me by my BS name: Steph (Pronounced Steve) Frolin.  as in “hey Steph, can you have her describe the car again?” Now I know something has changed and that I need to speak to the partner ASAP.

So Mark turned on his ambulance charm and talked the poor girl into standing with the only guy wearing a jacket for some reason involving an American and a blog.  No doubt she has erased this moment from her own memory.

As I mentioned earlier, we should have cut the evening short at the bridge.  The jet lag, the drink, Mark’s dancing, a long day and an early alarm clock would spell disaster early the next morning for our last day on the car.

Taking it easy on the drink is a suggestion that carries through all situations and this one is no different.  Not that I went to excess this night, no where close, but the combination of the time change, new diet and excitement of the Project would lead Mark to getting me off the streets the next morning.  And I’m glad he did.  Details on my nap next time.

Swalwell 405 – Day 2 in Newcastle

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chroniclesblogThe iphone rang so early I thought I was still dreaming.  Sure it said 5:15 AM and Mark would be along to pick me up in 30 minutes time, but I felt destroyed.  My body still thought it was 10 PM and was gearing down for night.

NO! I yelled to myself and turned the lights on.

This was going to suck.

I got cleaned up and dressed, then went to make a cup of coffee.  Coffee in England is different than in America.  In America you get a nice drip brewed cup of joe from perhaps a Peet’s, or even a Starbucks or gas station.  In room 501 of the hotel, my HMHQ for the week, there was a water kettle and a baggie of freeze dried coffee.  A taste I choked down at first and then missed as soon as I was on the plane ride home.  I had come prepared for the coffee situation, however, as you may recall from this video I posted later in the day:

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Mark took me over to his station, the sun yet to rise.  Inside I met a few of the night shift going off duty in the ambulance room of the Fire and Ambulance Station.  It immediately took me back to microwaving 25 cent burritos and drinking tap water during my internships.  There was a TV in the corner, 4 very nice green chairs (green is the color for EMS there) a couple of side tables, small kitchenette with sink and a microwave.  We really are the same.

Craving more coffee I went to fire up the kettle and prepared another cup of the freeze dried goodness as Mark took me out to the floor and to Swalwell 405, our Rapid Response Car for the day.

It was exactly as I had imagined.  A ford station wagon, appointed with safety markings, emergency lights and the ever important aspect to the RRC, the label “Ambulance.”

The RRC with the Appliances at Swalwell Station

The RRC with the Appliances at Swalwell Station

Mark led me on a quick overview of the equipment kept inside and what I could carry on a job and what I should stay away from.  We talked about interventions I could perform, such as assisting persons to stand or to walk, the basic stuff we all do, but at no time was I to use his giant Lifepack 12 to cardiovert someone in unstable SVT.

As soon as we were checked out we were sent on a system status post in a nearby neighborhood.  Not to get Mark in trouble, but I needed more coffee (some have cocaine, others a hobby or “life”, I have coffee, let it go) and the only place that pours a cup is a place I hadn’t been in over two decades, the McDonald’s.

We were on post for an hour when we were called back to the station.  You see, Mark and his co-workers are given a rotation back to the station each hour for bathroom trips, food and what not.  When we left our area, another vehicle or car would fill in.  This seemed simple enough at first, but a few days later, while watching the allocators try to juggle all the breaks and rotations, I wondered just how important that 1 hour mark was.

At the station Mark’s point to point radio came alive.  I had trouble understanding the accents at first to decipher our assignment and there was no station alarm or alert system.  Perhaps it would have awakened the firefighters upstairs?  We climbed in the car and away we went, blue lights flashing to a reported fall victim.  Specifics aside this was the perfect first call for me to see the NHS in action.

I in my station duty uniform with badge of office and Mark in his now famous green jumpsuit made our way in and found a run we EMT and Paramedics handle all the time, a minor muscular injury.  Mark went into his comfort zone, patient care, and I handed him the BP cuff and placed the stethoscope across his shoulders to have it in reach.  That got me a look I often saw as a small child when I would break something expensive.  No one over there stores their stethoscope around their neck.  I only do it on scene, mainly so I don’t lose it, but throughout my trip I never saw one ’scope around one neck.

As I recovered from that faux pas a walking Saturday Night Live memory came through the door.  The patient’s neighbor was a Scotsman, a true Scotsman, and when he found out I was American he began to tell me a story about an American he knew back in the 60s.  I know this because Mark translated for me later.  I could only make out a few words here and there, no unlike watching TV in a foreign country.

The Scotsman was ignored when I heard Mark tell the woman she should take some Peracetamol and the ambulance will be along in a moment.  He is allowed to let his patients medicate themselves for new conditions.  Now, I can create a gray area and make it work, but imagine telling the receiving facility that you let your patient dose up on Tylenol (acetomeniphon/paracetamol) for a new injury.  The ambulance crew arrived and away the patient went and we were back in service.  Nothing extraordinary, a simple run of the mill job we both encounter all the time.  The only difference was arriving at the scene in a car, and alone (without me) would be challenging at first, but some days, with some crews, I am kind of am responding alone.

In my next post I’ll describe the odd moment when we were waiting in the middle of the highway for a second ambulance as a fire engine drove by, not assigned to the accident and something I think the NEAS needs to change immediately to better serve their citizens.

Chronicles of EMS Trailer

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Here is the long awaited trailer to the pilot episode of the EMS Series Chronicles of EMS.

Watch it full screen, Ted Setla did an amazing job.

http://www.vimeo.com/8235377

Do you think Mark Glencorse and Justin Schorr should visit your system?  Drop a line to the Chronicles of EMS and tell them where and why.

System Abuse: What are WE doing wrong?

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There are many things I wanted Mark to see while visiting the SFFD EMS system.  Not once during his trip did he experience the mad shuffle that is our resource allocation when we drop to level zero.  What he did get to see was the rampant abuses in the SF 911 system and the paramedics helpless to do anything about it.

I don’t want to ruin the pilot episode of the Chronicles of EMS by telling you about specifics that Mark was able to witness (All with the patient’s full permissions of course), but I wanted to touch on something I didn’t see in the UK system in my short time there: 999 abuse.

Of all the calls we ran, I can think of only one that didn’t have a legitimate need for medical evaluation by someone higher trained than a Paramedic.  Notice I didn’t say ambulance, because of the versatility of the NEAS Pathways system.  This one person claimed to have a condition that he clearly did not, yet wanted the ambulance to take him in regardless.  It was clear to everyone on the scene that it wasn’t necessary, but away we went anyway, just to be sure.

Most of the other persons who dialed 999 and got the tall American Fireman were simply looking for medical advice when they were scared or frightened.  Does anyone remember the last time someone called 911, you responded and THEN they made their decision based on your assessment and advice?  It sure as hell was more than 11 months ago, I’d wager even more than 11 years ago.

the Project has shown me how we in the EMS Profession have allowed our abilities and responsibilities to be hijacked.  We are no longer help arriving in a time of need, but a means to get into the ER.  Granted, the few instances when we have to say, “No, always call us if this happens” through gritted teeth to the old man who fell out of bed aside, I have been told to do my job and take someone to the hospital for the last time.

My job is not to take someone to the hospital, but to assess their complaint and devise an appropriate treatment, if necessary.  Not drive someone to the hospital, especially in my new fire engine only capacity.

Imagine you drive a tow truck.  Someone calls stating their car is broken down and they need a tow.  When you arrive you find their stereo is broken, but they want the car towed to the shops, just to be sure.  You’d hook that car and be glad you can bill them, right?  But what if you ran a free towing service and other cars were actually broken down, needing you more?  Another one of my bad analogies for sure, but one that always creeps into my mind when I  meet folks who decide to go before I tell them otherwise.

No longer should we let our clients dictate their transport options without a complete assessment and history, condition permitting.  In an emergency, we will obviously default to transport, but what about the other 95% of our business?  The ones who decided to goto the hospital hours ago, but waited to call us for their stubbed toe, or cough, or fever of 101, or sprained wrist?  They have grown accustomed to a level of service they do not need.  They are entitled in their minds and it is not just a certain generation, this cuts across all economic and age levels.

ALS units flying through traffic to meet that magical response time, and for what?  A sprained knee?  Painful for sure, urgent certainly, an emergency…debatable.

Somewhere along the line lawyers wiggled their way into the medical care field, willing to pull the trigger and sue any paramedic who flinches and tries to tell their car accident victims that going to the ER when uninjured will not help them in court.  I find myself practicing defensive EMS all the time, it was witnessed by Mark more than once, most notably on a minor scooter accident he can elaborate on.

But it’s easier to C-spine everybody than to learn how to clear, prove to your medical director you can be trusted, and then do it right?

Enough of what’s easy.  Enough of playing to the lowest common denominator.  Enough of listening to someone with ZERO training and education tell me about how the shoulder articulates, not even able to name a single bone, muscle, nerve or blood vessel in the area.  Tell me what happened, what hurts and what doesn’t and let me do my job.  Answer my questions honestly.  At the end I’ll tell you what I think and discuss with you your options and what I believe is best.

“That will never work!” You shout at your computer.  I saw it work.  The problem is convincing the newly retired man that he can drive to the ER or clinic himself for the insect bite from 2 days ago, provided he stops scratching it to make it red every time I can’t find it on reassessment.

We are the reason our clients are so poorly informed.  There is abuses of the 999 system, there have to be and reading Nee Naw, we know there are, but I didn’t see it in my 4 days with Mark and the NEAS.

So what can we do to make people understand we are more than a flashing lights taxi service?

That is what we need to focus on and something I hope to expand upon in the very near future.

3…2…1…Action! – Providing care with cameras rolling

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chroniclesblogThe Chronicles of EMS Reality Series was filming Mark’s visit to the SFFD, in case you haven’t been reading this blog.  Or twitter.  Or Facebook.  OK, I think everyone knew that, but did you know being filmed while doing patient care is tough?

Our pal Mark has had cameras along for the ride before. This was my first time having non co-workers and non-family members in the back of the ambulance with me.  Having a preceptor in the back is hard enough, but having these guys back there can really make you sweat.  In case you’re thinking it’s no big deal, keep in mind how many little things you do that might not be the exact prescribed method.  Little short cuts and tricks that help you do your job better, but might need a little explanation can give the perception that you don’t care.

I hope I don’t come off that way on camera.  Having Mark, a fully licensed Paramedic, watching was OK, but directly over Mark’s head was a large mounted camera capturing the entire patient compartment.  Next to Mark, near the pass through  was Producer/Director and also licensed Paramedic Ted Setla, camera moving to capture my movements as I treated.  Then at the edge of the bench seat was Camera Stud (My term, not his) Chris Eldridge moving his camera around as well, making my wonder what they were capturing.

At a motor vehicle versus pedestrian accident, I made my scene survey and made patient contact, Mark close behind.  As I got a report from the engine company I took another look at the car involved and there on the other side of it, looking at me, was the Dridge and his camera.  Turning a quarter to my right, there was Ted, doing the same.  I didn’t want to be that Medic we all hate to see, doing something stupid on camera.  “Just do what’s right and nothing goes wrong,” was all I could hear in my head.  Could they see me sweating hoping I don’t screw up the IV or make a wrong decision?

It turns out, on that run at least, I appeared calm and collected, even though I was screaming on the inside.  Ever had one of those patients that just needs to calm down and relax but won’t stop crying?  Mark stepped in, sexy accent (Her description, not mine) and all to calm her and hold her hand while I worked.  Strong work, Mate.

No pressure.  Just act natural.

No pressure. Just act natural.

It’s easy to say “just be yourself” here in my recliner, but saying that over and over again at the time made me even more self conscious of the cameras and what I was doing.  It didn’t change any treatment, everyone got what they needed, but it really made me focus on the little details.  Where normally I would leave a sharps down (our caths auto retract for safety but I like to get a sugar off of it later) on the chux until later in the run, I now swiftly secured it.

Times when I would tell patients, and especially clients, that they need to stop smoking, drinking and shooting heroin to get better, I made more of a broad speech about personal responsibility.  My usual speech comes off a bit preachy I’m told, so I left it behind.

And it’s not just the emergency calls that makes having the film crew along rough, it’s the down time.

Let me choose a better phrase than downtime, “Interviews.”

After every run and most spare moments we talked on camera about our experiences to that point.  If we had nothing to say, we were updating twitter and facebook with photos and thoughts, always trying to keep you guys up to date.

On the ambulance the cameras were pretty easy to get used to, but on the engine it was just the Dridge.  He would go running to the engine when the first bells hit, climb in my side and across to the other side of the engine, staying as out of the way as you can with 4 people in a 4 person cab.  After the Dridge, Mark would climb in, giving me room to turn out or in case of a medical, just climb in and take my jump seat.  Getting dressed for a fire in a moving fire engine is a learned skill.  Doing it with a camera rolling isn’t much different, but with all seats full and gear all over, it took a few runs to get the hang of it.

I hope the footage they got gives you the story of what we went through.  There wasn’t a lot of helicopter action, no MCIs, and nobody fell in love.  As far as I know.  So it’s not the usual EMS show that has been thrown at us before we could duck.  I’m excited to see how the Chronicles team puts it together and shows it to you.  Although you already know what is going to happen, since you’ve been following along the whole time.

More updates on the Project and Chronicles of EMS to come, including my thoughts about the NEAS Administration, giant patient compartments with extra space and something I like to call a bad ass training facility.

You Make the Call…Restaurant…What Happened

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You Make the Call...Line UpThis was the situation I gave you on friday, standing at the top of the stairs, no smoke, no fire, only an odor of burning paper.

We had all our PPE, including air of course, and multiple companies arriving behind us, so we took our pump can and went in search of the odor.  Back under the stairs in what likely passed for a store room 100 years ago, we found a small section of charred drywall at the floor level.  Opening up the wall led us to a large section of brick which likely went all the way up the inside of the building, but all the drywall was clear.  Oddly enough the other side of the brick wall had a large amount of trapped smoke so the Truck went to work opening it up.

In the end the conditions were such that having a charged line before going down there would have gotten us knotted up for sure.  Turns out the source of the smoke may have been above us, at the street level in an alley where a man was seen smoking prior to our arrival.

If you said have a look, but be safe, you made the right call.

Report from England – Part I

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I’m not sure how many parts this report will have.  I’ve been writing pages and pages of observations, recollections of discussions, talks with patients, staff, Doctors, other Paramedics, all in the hopes of learning something from the 23 days that I so hoped would open my eyes.  We can occasionally get caught up in the details of what we do without seeing the broader picture, the entire system, with all it’s players and pieces.  I found that visiting other systems around the US helped, but the same obstacles presented themselves.

When blogger Mark Glencorse an I dreamed up the Project, it was initially partially for fun.  Then we began to talk even more about what we did differently and I had to see it first hand.  And I did, for the most part.  Just as with Mark’s visit to San Francisco didn’t show him everything we do, I know I missed a lot of the problems with the NHS system.  That being said, I was able to burst many of the myths of socialized medicine and an ambulance service run by bureaucrats.

My experiences with Mark here and also in England taught me that there are all the same people in EMS no matter where you go.  There are the flirts, the nerds, the jerks, the dirty guy and the OCD fellow.  Some want to be there, others are on the way somewhere else, but for the most part people were genuinely curious as to what we might learn from the Project.

What did I learn, you might be wondering?  It boils down to this:

We are two countries separated by a common language.

Not sure who said it first, certainly not me, but it is true.  For example, in the North East of England a Chips Buttie is a nice afternoon snack.  Here it is called a french fry sandwich with butter.  There things are made with sugar, here High Fructose Corn Syrup.  There the EMS system is seamlessly joined to the hospital and clinic care, here it is a fight to get triaged in a timely manner.  In both places family means family, I now have a new one 9,000 km away.

Looking over my notes from this Project, I have a boat load to tell you about and a lot I hesitate to tell you about since it may appear my mind was made up before I went about socialized care.  I do have some suggestions how to make that system more efficient, but things there are so completely different when it comes to health care, it will never work here.  Not because of the administration, or government, or labor unions, but because Americans have come to expect instant gratification from their EMS systems.  They refuse to believe their sprained wrist can wait more than 4 minutes for a fire engine and ambulance.  It is this basic understanding of what EMS is that is lacking in America and I know who is at fault.

We are.  Anyone who has been in this business more than 2 years is responsible for the complete lack of understanding that grips the common American about their emergency medical systems.  It is time we recognized this fact and did something about it.  Exactly what that is will depend on those above us in this machine to recognize their part and help us educate our “customers” (I hate that term in this business).

For my short career I’ve been repeatedly discouraged by people using EMS as their free taxi service when more appropriate, far less expensive methods of treatment are available.  I did see, in my short time there, EMS abuse in England, but not nearly at the rate I see it here at home.  I believe it stems from the belief that people have a “right” to an ambulance whenever they want.  And not just the entitlement generation, but those who have paid into the system and want something, anything, back from it.  We need to show these people that they are entitled to help when they need it and an honest discussion about what is best for them.

I also learned from my experience that my system is not being as efficient as it could be, nor is Mark’s.  Believe me when I say that each of those statements could have their own volume, and likely will, since most of the things I want changed there, labor will never allow and the same here.

Before I start boring you with the countless posts about what I did, saw, learned and learned to avoid, I want to take a moment to thank a few people that made this trip everything it turned out to be.

To Mrs HM – The woman who sat next to a burnt out EMT on the tailgate of the rescue truck  in rural New Mexico and said, “You don’t belong here.”  She is the reason I got off my ass and got serious about going back to school full time.  I graduated 3 years later.  She’s been right here with me this entire time and made this whole thing work.

To Mrs 999 – Who I’m sure had just as many headaches as my Mrs while mark was away, you welcomed me into your home each night for tea and made me feel at home.

To Firegeezer – For noticing a little blog about the joys of 911 abuse.

To Lt Talmadge and her UK counterpart Fiona – Meetings, dinners, etc, all went to plan.

To anyone and everyone who donated to help make the Pilot episode of Chronicles of EMS.  Having the cameras along was unlike anything else I have ever done, I hope you all like it.  And I hope that Ted mentions I hit every IV first try with three witnesses and three cameras rolling.

And finally to Mark – Thanks for being so easy to get along with, bad jokes aside.  and sorry all the nurses liked my uniform and accent…wadda ya gonna do?

I’ll get more specific on my observations over the coming weeks, keep an eye out here and at Mark’s blog.  Thanks for following along.

A true close call

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broad street bulliesIn my confused and sleep deprived state I neglected to include an article in this month’s Handover from one of our favorites, Lt Morse from Rescuing Providence. An oversight I have come off of my break to rectify.

“It’s a three mile trip from the Rhode Island Hospital Emergency Room to the Allen’s Avenue Fire Station. ETA six minutes. I could probably make it. Everything was going great, light traffic, perfect weather conditions, no road construction in sight. I could see the promised land in the distance, a little more than a minute away. I started to relax.”

Only the hardcore providers among us have been in this situation and survived. I once ducked into a patient’s bathroom to puke, but I had been feeling bad all day and the timing was right. But never have I been a block from release only to be…well…read for yourself.

And then read all about the Lt’s movie situation, and follow along to see if I play the love interest, the cranky Captain or cross the street in the background.

This was almost a letter in my file.  Phew.

the Handover – Close Calls Edition

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Last call for the HandoverThis month’s handover draws from our friends across the interwebs stories of close calls. Times when they or their patients, colleagues or family almost didn’t make it. I was inspired to make this the theme not just because of the holiday weekend here in America, but to remind us all that we are fragile and put ourselves out there sometimes. Hopefully one of these links rings back when you’re in an unsafe or curious situation.


Found with the Where did the angry guy go files-

“What do we do?” asked Eric, his eyes wide.

“I don’t know about you two,” I said, “but I’m about to jump through that window over there.  I don’t know if that guy’s getting a gun or what.”

by Buckman who runs Gomerville

From the I don’t think you should be driving file-

“I was overwhelmed by the dreadful realization that I had just accepted a ride from a highly intoxicated snowmobile rider and we were hurtling through the dark northwoods at 70+ miles per hour.”

from Greg Friese of, among many, Every Day EMS Tips.


From the Thank God you’re driving category-

“This was a serious incident. This was no routine, boy, we almost had an accident. This was my death.

I don’t know if my partner would have stopped on his own if I hadn’t shouted. Maybe. Maybe he had it all under control and was already getting ready to hit the brakes.”

from Peter Canning, a new contributor to the FireEMSBlogs family, at StreetWatch:Notes of a Paramedic

In a section titled simply Gulp

“Jill and I found him lying on the floor, fully clothed and in a coat, eyes shut, but eyelids flickering. An almost certain sign of pseudo-unconsciousness. A fake. I took a step back and called out to him. Jill was still standing by the front door, uncertain how to proceed. Something still felt wrong, so I asked her to go and call for police back up. With hindsight, I should have gone with.”

writes Ben Yatzbaz, resident Insomniac Medic


Found in the Basement selection

“This moment, this intense moment, was where I made a decision the likes of which I hope I never have to make again. I knew that if I stayed more than a few moments longer, I would suffocate and burn to death right there on that floor.”

from our pal Chris Kaiser at Life Under the Lights


From the lost in the snow pile-

Dear God, they’re working a search pattern. Please, not tonight. It’s not mutual aid to another fire department; they’re working a grid search with the police. I grab my boots, then pad to the garage to check the fluids in the IV warmer. Anyone caught in this weather without shelter will be near death, if not there already.”

by Mack505 at Notes from Mosquito Hill


From the trust your guts file-

“I give my partner the “time to leave pronto” hand gesture. “Code 3, hurry up”. I give a little oxygen and attempt the IV enroute with no success. I realize that something is not going well for this patient and I don’t have the means to diagnose or fix the problem.”

by Rescue Monkey of Paramedic:Life on the Streets


From the Old School section-

“The smoke level now was to the floor as I grasped the hose line to find my way out. The urge to rip off my mask was strong but my training had taught me this would be fatal for sure.”

by HMHQ Contributor the Angry Captain


and finally, from the Hmmm…that looks wrong category

“A back board was brought up and one of the other Paramedics on the engine teams attended to him pulling off his jacket.  Justin asked us if the building was still on fire. We we told him that yes, it was still on fire, he asked us to put his jacket back on. Not completely out of it.”

from yours truly and the event that launched me into the blogosphere.



Next month’s handover will be hosted by Ambulance Driver, theme TBD, watch his space for details as they develop and, above all else, be safe.

HM Clear.

the Handover – Call for Submissions

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Have to get in a bit about the Handover before I pop along to England next week.

 the Handover - 8th Edition

This month’s blog carnival the Handover will be hosted here at Happy Medic Head Quarters.  For those of you not sure exactly what in the world we’re handing over, one of our good blog buddies, 999medic.com, founded a blog roundup of sorts called the Handover.  It started as a collection of favorite posts collected by a volunteer host and is now the largest and widest read blog carnival for and by pre-hostipal EMS and ER staff.

 

Past hosts include

  • Emergiblog
  • Happy Medic Headquarters
  • Life Under the Lights
  • Medic999
  • Rapid Response Doc
  • Rescuing Providence
  • Trauma Queen
  •  

    For November’s theme I have chosen “Close Calls.”  The theme is inspired with my own close call, which I have mentioned as the driving force behind starting this therapy experiment we now call the Happy Medic.  I want you to send me a blog post you authored or have read that made you say, “Wow, that was close.”  Perhaps a time you caught a patient right before something happened, maybe a time when you almost got hurt or, perhaps when you did get hurt but it could have been worse.  And as Mark introduced a bit back, feel free to send in anything EMS or ER/A&E related you wrote or enjoyed.  Share.

    A little different than other months, I’ll be busy with Mark for a few more days then off to the UK for my turn in the passenger seat, so get your submissions in early.  The deadline for submissions will be Novmeber 25th, and i will save all submissions to my handy new laptop before boarding the plane home to the USA.  I will arrive home on Thanksgiving, hopefully with a good group of posts to share and be thankful for.  it will be published on the 27th of November.

    Preparation for tomorrow

    Comments

    I am finally at home after dinner with Mark, sipping a scotch and thinking about tomorrow’s first day on the ambulance.  I am wondering if Mark will be able to contain himself the first time someone abuses the 911 system, or the second, or the third, when he sees we are required by law to take folks in.

    My mind imagines Mark in awe when we apply our CPAP to the woman who would normally need to be nasally intubated and she not only stabilizes but improves.

    What will he think if we get a chance to pace a symptomatic unstable bradycardia or convert an unstable SVT.

    Will Mark search through my kit looking for pain medications when I have only morphine and oxygen for pain management.

    I have so many things I want to show him about the fire based and private tier model we use that I almost forget about the ocean between us in capabilities for patient care.  Fire engine and rapid response car aside we make differences in different ways, don’t we?

    Tomorrow is Mark’s first day on an American dynamically deployed fire based ambulance and part of me is worried he’ll be angry we can’t do the right things for most of our patients and clients.   Another part of me hopes he sees the benefits of some of the things we’re doing he is not.  There is so much opportunity to learn from one another side by side I hope my clients don’t get in the way of our learning.

    This will also be an opportunity, with the Chronicles of EMS filming along side us, to show he rampant abuse of the 911 system in San Francisco.  How can we solve a problem that is not ours?  That’s an entirely different show indeed.

    So I’ll try not to sweat the small stuff and just do my job like I always do with that green jumpsuit close behind.

    We’ll be in the yard at 830 for our shift at 9.  See you on post,

    the Happy Medic

    the Angry Captain’s Close Call

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    The Angry Captain is on sceneThis month’s EMS Blog Carnival, the Handover, will be hosted here and the theme is “Close Calls.”  With November in the US including Thanksgiving, I thought what better time to share an experience when we had that thought go through our mind “I/they might not make it.”

    Send in your submissions about a time when you, a patient, or someone you know had a close call and I’ll put them together to share.  If just one person can use that information to make their job safer, then we’ll have succeeded.

    So with that theme in mind, here is the Angry Captain’s Close Call.

    8:30 pm February 1982

    The call:  Structure fire, “house across the street has black smoke coming from it.”

    It is a cold winter night with temperatures well below freezing; we are in a relief unit that had no inboard seats so I was belted in on the tailboard. On arrival, we found a residence with black smoke pouring from the rear.  Reportedly, no one was home.

    The home is typical for the area in that the base of the home started as a house trailer with several additions around it. As the first engine to arrive, we pulled a 200’ preconnect and forced entry on a side door that appeared to be the entry. The captain and I crawled in below the smoke and worked our way through a maze of doorways to what appeared to be a fully involved kitchen area. The ceiling was flashing over as I trained the nozzle at the base of the fire. Suddenly, my air pack warning bell went off.

    We could not have been on air much longer than 5-10 minutes. I patted the captain on the back to notify him that we needed to back out. He gestured for me to head out and took the nozzle from me. My training from my previous department was never to leave anyone alone in a fire. As I turned, my air pack quit entirely; no air at all.  The smoke level now was to the floor as I grasped the hose line to find my way out. The urge to rip off my mask was strong but my training had taught me this would be fatal for sure. Holding my breath was all I could do as I struggled to focus on following the line out amid my disorientation from lack of oxygen. As I moved along, I remember hearing a loud mechanical sound further confusing my strange journey through this black maze. The sound grew louder as I slowly followed the hose line hand over hand in the seemingly longest moments of my life.

    Suddenly light appeared as the noise grew to a roar, but I crawled out, finally ripping off my face mask, gasping for air, and collapsing in a snow bank. My next memory was lying on the gurney in the back of the ambulance.  At the hospital, they ran blood gas tests and flooded me with plenty of O2. As my color returned to normal (apparently I was quite gray), I was told that they found me outside our entry point where the truck had hung a mechanical fan at the top of the doorway for ventilation. (The loud disorientating mechanical sound.) I am not sure how long it was that I lay there in the snow bank before I was noticed.  But Mrs. AC got the frightening call about 11 pm to pick me up at the hospital….no one likes that call.

    Lessons learned:

    1.       The air pack I was wearing was found to be working properly back in a warm station house and in fact still had about ½ its air. The speculation at the time was that the moisture in the diaphragm froze causing it to stop the air flow.  Had it been checked at the scene, it could have provided the exact problem.

    2.       Never allow a member to leave alone or leave a member alone in a fire. This was long before 2 in 2 out.

    3.       Always follow your training; i.e. following the hose line out and keeping your mask on in heavy smoke.

    4.       Do not block the egress of the hose line with ventilation. Had I been on all fours coming out feeling ahead with my hands, my fingers may have been lost to the whirling fan.

    This was a true wake up call for me and cemented in my mind how important my training had been and how things can go wrong in a matter of seconds.

    EMS Garage Podcast

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    Happy was a guest on the EMS Garage Podcast, Episode 60, which is now up at EMS Garage.com.

    http://emsgarage.com/archives/390

    Come listen to me and Mark talk about the Project as well as the details to the Blogger Meet-up in San Francisco next Saturday!

    The host’s volume is low and Mark’s accent might throw you for a loop, but it is also a great conversation about using social media to further our EMS missions.

    Special thanks to Chris Montera, Carissa O’Brien, Gary Wingrave, Ted Setla and of course, Mark Glencorse.

    the Happy Medic Channel

    Comments

    It would certainly be a premium channel, right?

    What got me thinking about this was my recent experience on the EMS Garage, hosted by Chris Montera.  If you’re not listening to this forum, you need to be.  The twitter blitz that was the 2009 EMSexpo mentioned podcasts and videos, but with my trip from the refresher and trying to catch up on work and the Project, I never clicked over.

    <punishment=”bang head on desk”>Stupid, stupid, stupid</punishment>

    Neat video.  I say neat because it reminded me of one of m favorite shows, Attack of the Show.  On AotS two hosts have a great time sharing news and product reviews geared towards a specific demographic, the 18-35 year old nerd. (myself included)

    EMSexpo live produced clips from the show floor clearly designed for a specific demographic, people passionate about EMS.  Each piece is interesting and fun to watch with both Carissa O’Brien and Chris Montera clearly having fun doing it.

    Motoring in EMS the Segway Way! from Thaddeus Setla on Vimeo.

    See what I mean?  Click through and watch the series of videos from EMS expo 2009, Atlanta.  Neat stuff.

    Perhaps this can expand into a “channel” where podcasts become videocasts and learning videos become a learning series?  I can has host bloopers show?

    Notes from New Mexico

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    I love coming back for this great Paramedic refresher.  Not only is it a positive environment, it encourages the students to become the teachers.  This refresher is often full and then there are even EMT-Basics sitting in to learn more.

    This year had some great topics like Therapeutic Hypothermia, ECMO for hanta virus and H1N1, and some great A&P refreshers.  In addition we had visits from EMS vendors teaching about new products the local administration was wishing to implement.

    During the King LT tube demonstration, I shared my views since we’ve been using it for a bit, then we broke out the mannequins and started to practice.  Since I was familiar with the device, I chose to dig through the box of tubes and LMAs the rep brought and found one of the coolest things I’ve ever seen.

    First, a special thanks to EMS Chief Paul Bearce and his staff at the Rio Rancho, NM Fire Department for another great learning experience.  Second, another special thanks to Trade Rep Carl Gilmore for making my month.

    Carl brought this to class:

    This is the King Industries AIRTRAQ Laryngoscope.  I get no re-imbursment from the company, I have no connection with the company or the rep other than to want to get this in my kit ASAP.

    “Why?” you ask?  Because this will solve most of our “intubation problems”, (Aside from training and experience)

    I pulled this out of the box of King tubes and wondered what it is.  I saw the ET guide on the side, a viewfinder and an on-off switch.  The next 40 minutes were golden.

    This device allows the user to use a periscope style viewfinder to confirm visual placement of an endotracheal tube without having to lay on the ground, in vomit or blood, and wrench the upper airway into an unnatural position to place the ET.  Seems simple enough.  But what happens when you give us new toys?  We do our best to break them and see when they meet their match.

    We took this thing on a ride the manufacturers could never have envisioned.

    AirTraq

    The concept is simple.   The device is shaped in such a manner that it curves sharply at the distal end in fashion with the bend at the posterior oropharynx.  At the end is a bright light and viewing area, next to that is the guide for the ET tube.  All you have to do is put this device in the mouth, pull up and you see the chords clearly.  Then just push the awaiting tube into the airway.  All this from above the patient instead of behind them, on the floor.

    Seeming too simple, we performed CPR on the mannequin, and it worked.  No pausing for ET placement during CCR.  Then we performed bad CPR, with the head bobbing all around.  Hit it first try, no trouble at all. Everyone who tried had a similar comment. “Really?  That’s it?  How come we don’t have this?”

    So one of my classmates decided to recreate a digital intubation he performed years ago on a woman trapped in a vehicle with no extrication tools available. IMG_0087“I wish I had this then” he said as he passed the tube in less than 30 seconds.

    Each time we tried, each Paramedic in the class was able to pass the ETT on the first try with little or no difficulty.  Since we were having trouble breaking this thing, I wandered out of the classroom and onto the floor of their fire station.  I found an EMT who has had no Paramedic or advanced airway training and invited him into the room.  I handed him the Airtraq and a 7.0 ETT and said, “Intubate this guy.”  He placed the tube in 45 seconds.  That included finding the ‘on’ switch and placing the tube in the device.

    When asked how he knew where to put the tube, he said he “knew the trachea was on top and the top hole was right there, so I did it.”  I am in no way suggesting we give this device to EMTs for ETT placement, but wanted to pass along that this tool was so easy to use someone with no idea what to do or how to do it beat my time with a regular blade and tube.  And that was standing still, not with continuous CPR.

    With all the attention to the need to avoid stopping compressions during CPR, this tool is a no brainer.  Each time we tried to maneuver the mannequin or create an obstacle, we got a tube in less than 20 seconds.  Except for the EMT’s attempt.  We almost got a 7 year old to try it, but the airway heads made him scared.

    In the end, I almost begged Carl from Wilderness Medical Associates to let me share this experience with you.

    He agreed.  You can learn more by contacting Carl at the link above or at the King Industries website HERE.

    Again, I have no association with the product other than this experience.

    Does your service use this device?  If so, I’d LOVE to hear your thoughts.

    Hoseline Placement or How Not to Impress the Public

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    Trying to keep up with the flood of industry news that is Statter911 can be daunting and I missed this story not once, but twice.

    On October 7th DC Fire & EMS put on a demonstration of the effectiveness of fire sprinklers. It also ended up showing the ineffectiveness of modern firefighting.

    One of our brothers was hurt in this exercise and I hope he makes a full recovery. I’ve been hurt at fires and I’ve been burned, neither experience do I wish to repeat. Our thoughts are with our injured brother.

    This is not a Monday Morning Quarterbacking of the event, but instead some great video that will show you what happens when you are unfamiliar with how to use your equipment to its full potential.

    This first video is from farther back than the second and is a better opportunity to read the smoke and see possible flashes. As you watch it, imagine you are in the hallway of a dorm approaching this room. Heavy smoke in the hallway, intense heat and that flame dancing out of the top of the prop will be spreading in all directions along the hallway ceiling. Now, as it flashes, imagine where you will place your team and where you will shoot first.
    YouTube Preview Image

    A smooth bore at 60 psi could have knocked the seat of this fire from the imagined hallway in my earlier example, even banking it off the wall if the heat was too much. Many news outlets talk about the lack of a backup line. Huh? Don’t need one. Smooth bore from 20 feet makes short work of this fire without even having to go on air.

    Putting ourselves in a dangerous situation in public only makes me wonder what we’re doing in the dark hallways at working fires. Let’s use our equipment to our advantage. Take that fog nozzle and put it in your pocket, get smooth bore nozzles on your pre-connects so you can put the fires out. HMHQ is a firm believer in the power of water applied from a safe distance in order to make a safer environment for extinguishment.

    Another quick word on the Culture of Extinguishment. Lt McCormack, in his “controversial” remarks before the FDIC in April 2009, fought for the idea that “If you put out the fire, safety is accomplished for everyone on the fireground.” I agree with that 100%. Unfortunately, I don’t think Lt McCormack’s message is getting to firefighters as intended. The Lt wants you to safely put out the fire, not go running in without using your tools and training to your advantage.

    I speak with many firefighters in my service who heard about the speech, but never read excerpts. They make it into a call for safety to be thrown out the window when there is a fire or a rescue. Not at all, friends, not at all.
    WAKE UP! Pay less attention to which Chief or Union Leader blames who and look at what gets our people hurt and don’t do that. Don’t go somewhere your water can go instead.

    Placing a hoseline is not a simple task and I, on the nozzle, have been dragged by my airpack to a different location by my officer who had a better view of the situation. Each and every time I have them walk me through where I was, where they moved me to and why. Then I apply that next time.

    Are we all perfect first try? No. But this first try got someone hurt.