Telemetry: Orders from Above

He was autistic, muscular, and in the bouts of a serious asthma attack. Walking into the room, I noticed the sweat glistening from his brow in large, irridescant drops.

Aww shit, this is gonna be a bad one, I thought.

We had a student with us, who listened to his lungs. "He's tight," he said, reffering to the severity of his wheezing.

Instantly, I reached for a nebulizer setup. Screw the hand-held thing, this kid needed a mask strapped to his face.

As my partner got vitals and my student got more of a history, I setup an IV and thought about what I'd ask for on the phone. Ahh, the phone. As paramedics, we can do a lot, but at some point, to do some things, we must call and confer with a doctor. The doctor, of course, is sitting somewhere cozy and quiet and far from our chaotic little scene. The good doctors cut us some slack when we need it, the bad ones just don't understand how things work in the chaotic field environment.

There was as issue with the kid. He was 19, a big, strong boy, and he didn't like us putting things in his face. The air hunger was making him frantic and combatitive, exacerbating the strain of being exposed to strangers. Autism is a hard disease to deal with. You must be patient, very patient, a quality rarely attributed to Paramedics. We practice medicine hard and fast. If you don't like what we're doing, we really don't care. Most people don't like what we're doing, and after a while, it makes you numb and impatient to people's varying sensitivities and complaints. I'm not saying it's a good thing, but it's reality, it's life on the streets, and god knows it's a far cry from utopia.

The kid didn't want the albuterol, by mask or any other way. Albuterol, though, is the first line treatment. It's that misty stuff they give you when you have asthma, and it works wonders, sometimes.

I got on the phone. Ok, I wanted Solu-Medrol--a steroid to decrease inflammation--and Magnesium Sulfate--a muscle relaxant used in moderate to severe asthma. Wait, it was Doctor Silverman, #80249. Damnit.

I told him the story.

"Unless you have an IV established right now, you need to stop what you're doing and initiate transport," he responded.

Jesus. This wasn't going well. We were on the 5th floor of a walkup apartment building with a narrow staircase. If we didn't stabilize this kid and get him to cooperate now, he might have to stop breathing or die before we could move him.

"Sir," I said, "this patient is autistic and extremely uncooperative. There's no way we're going to transport him unless we stabilize him first."

"I want you to start transporting immediately," he said, growing annoyed.

I glanced into the other room. The kid's uncle had convinced him to accept the albuterol treatment, an important success. Our student was struggling with the IV.

"Look, well, how about this," I suggested, rolling my eyes. "What if we start transporting right now and get an IV en route, can we then go ahead with some Mag and Solu-Medrol?"

"Well," he paused. "Okay, just as long as you start transporting right away."

Ahh, relief.

I stepped back into the living room, where my partner, my student, and the family stood huddled around the boy. He was looking better. The albuterol was working, thank god.

"It wasn't easy," I proclaimed, "but I got us Mag and Solu-Medrol...Oh, and Doctor Silverman wants us to transport right away."

My partner shot me a dirty look. "Yeah. Well, Doctor Silverman can wait," he said.

The boy was mostly calm by the time we finally go the IV. We decided to hold off on the big gun--the Mag--because the albuterol had worked so well. The Solu-Medrol would help prevent recurrence, at least for a day or so.

It was still a bitch to carry the kid down the stairs. He felt like dead weight, something that was intensified by the strange forward leaning position in which he sat. We carried him down five flights. Man, if he he had been fighting us, it would never have happened. Maybe he would have died, who knows, but we did out job, despite the ill-conceived orders from above.

Comments

[Jim Without an Inhaler]

Don't know why the only treatment for asthma that gets recognized is drug oriented. I have been a severe asthmatic my whole life and have just gone 5 years drug free. I use simple breathing excercises that allow me to overcome even severe attacks, sometimes before I am even aware that an attack is happening.

[Steve]

"The good doctors cut us some slack when we need it, the bad ones just don't understand how things work in the chaotic field environment."

Down here, they make all the E.R. Doctors and Nurses do Clinical ride alongs, so they are forced to see exactly how things go on calls. I think thats a big part of the problem, they have absolutely no idea what goes on at a call. I know I didnt until I started my clinicals! It seems like it creates a certain measure of understanding from at least the R.N.'s

Nice blog btw!

[Just some dumb chap]

"Ahh, the phone. As paramedics, we can do a lot, but at some point, to do some things, we must call and confer with a doctor. The doctor, of course, is sitting somewhere cozy and quiet and far from our chaotic little scene. The good doctors cut us some slack when we need it, the bad ones just don't understand how things work in the chaotic field environment."

Ahh yes, the doctors. The know-nothings who're *always* sitting somewhere cozy and quiet. Who've never worked a chaotic day in their miserable little lives. Who've never ever had a clue about practicing medicine in emergency situations. Who're only "good" when they agree with the paramedic, you see; they couldn't possibly be any valid reason-at any time-for holding a different opinion than those expert medical professionals, the paramedics. Or the RN. Or the LPN. Or the tech. Or the orderly. If they ever disagree at any time with one of these great folks' recommendations, they must be "bad". *Necessarily*. Just ain't right, know what I mean? There simply is never any perspective other than a paramedic's that might be valid, that might have just a little smidgeon of a rationale behind it, you see.

Yeah, those doctors. They've hardly done anything useful in all the centuries their kind has been around: invented a couple of drugs here and there, maybe, and elucidated one or two disease mechanisms, that's all. Everything that nurses and paramedics use in their daily lives, all the conditions they confront, all the drugs they administer, all the research that underlies the whole damn medical enterprise: all of this was accomplished by your friendly neighborhood EMT. Doctors, lol. We really ought to just pack them off somewhere, the whole meddling lot of them. The paramedics and nurses will manage awesomely well.

[Tyson]

Dear Dumb Chap,

While I appreciate your point about the neccesity and centrality of the doctor to the medical endeavor, I would like to point out that yes, in New York City, the doctors who answer the phone really are sitting in an air conditioned building somewhere out in Queens. And the bad ones really are a pain in the ass to deal with. Yes, clearly, the Telemetry system has a purpose, especially when it comes to administering high-risk medications that rely on a tricky differential diagnosis. Nonetheless, just as there are bad paramedics and bad nurses, there are also bad doctors. An MD is not a seal of infallibility. So while yes, doctors are required to do a ride-a-long now & then, few have spent a whole lot of time in the pre-hospital setting and most--even the telemetry docs--are behind the curve in understanding the reality of our working conditions.

Let's think about this: let's be nice and say most telemetry docs do 3, maybe 4 ride-a-longs before manning the phones. Four ride-a-longs. On a slow bus, they might not even get a legitimate emergency in the four days, and none of the calls may require contacting telemetry. On a busy bus, the crew might contact telemetry 3 times with serious emergencies. And chances are, those three times are pretty straightforward situations.

If you want to understand the reality and the subtlety involved in this job, you need to do it for a little while. It's hard to imagine how long it takes to carry a 350lb woman--or a combatitve eighteen year old kid-- down 5 flights of filth covered stairs when half the lights are out until you've done it. It is especially hard when you are sitting in an office somewhere and you haven't been on an actual ambulance in months, maybe years. So sorry doc, while I'm sure you've dealt with emergencies and hairy situations, you haven't done it on the streets, and that changes the ballgame a whole lot.

So while doctors have made many, many strides in advancing medicine, very few truly understand or are expert in the pre-hospital care environment, even among those who do it for a living. Cuz ya see, cardiologists see cardiac patients and pediatricians see little kids and they do this all day long. But EMS docs spend only a tiny fraction of their time in the field, performing pre-hospital care. Most of the time they are in an office or a hospital, hopefully an ED. But none of those places are the streets.

And by the way, just so you know, they held a little skills competition a few years ago, pitting American-style paramedics against European-style ambulance doctors, and the paramedics kicked their asses. Just so you know.

-Tyson

[amanda]

sounds like you and your fellow coworkers could have all ended up in the ER as patients if you had taken that doctor's orders.

[Nicole]

Pretty nice site, wants to see much more on it!i

[gari]

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