Posts Tagged ‘ambulance’

Shipping a patient: difficult, not impossible

September 22, 2017

There’s a thing or two that I’ve found

By plane, by chopper, or ground,

To move a patient who’s sick

I prefer it be quick

So as to arrive safe and sound.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed. I just finished 3 months in northern British Columbia, getting a first-hand look at the Canadian system. I’m now back picking up an occasional shift in northwest Iowa.  Any identifiable patient information has been included with permission.

3:00PM: within 30 seconds of meeting the patient I know he’s sicker than he thought, and within a minute and a half I know he belongs not in the clinic, but in the ER. (He gave me permission to write the information in this blog.)

Then I think to ask the nurse, “Wait. I’m on call.  Which means that I’m covering ER, right?”  She nods.

In the current jargon of real-world medicine, the word “dump” means transferring a patient to another service without proper work-up. In this case, though,  I can’t call it a dump if I hand off to myself.

While I wait for the ER gurney I finish my exam, and get as much history as I can.

Two nurses, pulled from the inpatient service to ER, arrive to transport the patient. I hand them a list of lab and x-ray requests and IV orders, and return to the other walk-in patients on my schedule.

3:40 PM: I quick step to radiology to look at images.  In the ER the nurses hand me copies of the lab results, giving me the start of a diagnosis and confirming that the patient needs an ICU.  I discuss findings with the patient and family.  I strongly recommend transfer.  They request a hospital 3 ½ hours distant.

4:00 PM: I weave through the hospital switchboard and phone tree to the consultant’s phone crew, who use a handset that renders speech almost unintelligible.  The consultant is not available.  Would I prefer to wait for the nurse, to leave a voice mail, or to provide a call back number?  I ask for the nurse.

4:10 PM: I run through the case with the nurse, who puts me on hold.

4:20PM PM: I present the patient to the consultant.  I run through the presentation, context, past medical history, lab, x-ray, and my working diagnosis.  I finish with a request to transfer the patient, and the consultant agrees.

In 21st century USA, a doctor cannot legally transfer a patient without a physician accepting the transfer.

4:30 PM: back in the ER to get consent-to-transfer signed.

4:50 PM: the accepting hospital calls to tell us they won’t have a bed available till tomorrow.

The nurses tell me if the patient needs fluids during transfer, we’ll need a Paramedic crew out of Sioux City, because no nurse can’t be found to accompany the patient.

I think that they want me to back off on the IV fluids, but I can’t.

Return to ER: I advise a transfer a hospital two hours closer. The patient and family agree.

5:00 PM: I have the hospital operator put my call-back number into the consultant’s pager, asking how long I should wait before calling back.  The hospital operator assures me she rechecks every 15 minutes.

The nurses point out that if I ask for a helicopter I can get the patient to the destination a lot faster. I look at the ground-transport time from Sioux City (90 minutes) and then the time to hospital, 1 1/2 to 3 1/2 hours.  I agree to the helicopter.

5:10 PM: The closer consultant calls.  My cell phone has enough signal strength to ring but not enough to keep from terminating the conversation.  The nurses usher me to a spot by a window, and I call the consultant back.

5:15 PM: I reach the consultant, who agrees transfer is appropriate, but tells me I have to call the hospitalist.

I call the hospital back to try for the hospitalist.

I didn’t ask for the helicopter lightly.  In this case the geography and gravity of the situation changes the risk/benefit ratio.

5:20 PM: the hospitalist picks up. I make my presentation, with updated vital signs and report on response to treatment.  He accepts the transfer.

5:30 PM: in the ER with the patient (who looks better but not well) and family again, I outline the progress and have them sign an updated consent-for-transfer specifying a new accepting physician and hospital.

I make small talk in the ER, then wander back to the nurses’ station.

5:45 PM: I ask, “When is the chopper due?”

The nurse shrugs. “They said 20 minutes 25 minutes ago.”

5:50 PM: the helicopter crew arrives, with a small bag of Dove chocolates.

I make sure they take the necessary papers with them.

At five minutes to six, the sweet thump-thump of the rotors reaches my ears. In less than twenty minutes, I know, the patient will have access to the personnel and services he needs.

The nurses note that I don’t look upset.  I tell them it might have taken 3 hours, but I’ve seen worse.


A very long taxi ride back

July 26, 2017

The day sure started out slow

It went fine, but wouldn’t you know

To make the trip back

I caught a ride in a hack

And the driver made satisfactory dough.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

The day on call went smooth and slow to start, with fine, solid naps in the morning and afternoon, caring for 5 patients. On the brink of leaving for the day on time, I knew I had to stay when the ambulance radioed in news of two injuries from the highway.

I have to confess my ambivalence when it comes to airbags. Front airbags don’t add much safety to modern seatbelts, too often they activate when they shouldn’t.  Side airbags, on the other hand, provide another layer of protection that saves lives.

I have never before attended survivors of crashes where airbags deployed. I developed the term “bag rash” to denote an abrasion from the airbag, and the patient gave me permission to write about it (and more).

Right when most people would sit down to dinner, the ambulance brought in another patient with problems exceeding our hospital’s capacities; in fact, requiring trained escort for the trip to Prince George.

The responsibility fell to me because nursing staff could not be spared from the hospital.

The back of the ambulance amplifies a road’s imperfections. I did my best to meditate through my nausea as we sped down the highway.

We stopped at the EMS station at the halfway point. Not all stretchers (in EMS-speak, carts) can lock securely in all ambulances (EMS-speak, cars).  I can’t detail here the complications that demanded a change of ambulances and crews, but I got to stretch my legs and breathe in the cool pure air, and ride in a much more comfortable seat.

I turned the patient over to the ER doctor, we volleyed a bit of French, and then I had to confess to the staff I’m not really Canadian. I have been working on my accent, after all, and I don’t obviously sound like an American at this point.

Then I called a taxi: the ambulance that met us would only go back as far as the halfway point.

A very long time ago, my pre-med biology lab partner drove cab, I rode with her a couple of times. She clued me into the details of the business.  In the States, the cab company rents cars to drivers.  The drivers don’t start making money till they’ve made up the fee, and some shifts they don’t make any money at all.  Bidding on the best cabs goes by seniority, and the new drivers (at that time) drove uncomfortable, unsafe vehicles.

As we rode, I interviewed the driver, just like I interview patients. He speaks fluent Punjabi and Hindi and a bits of Tagalog and Mandarin, but has forgotten the French required of all students in Canadian schools.  His English carried a perfect northern British Columbia accent, but I found out he’d been born in India and at age 10 moved to the very town we were headed to.  As the daylight faded into twilight, and as the long northern twilight deepened to dark, I listened.  He worked in the pulp and paper business till age 55 and started driving cab a couple of years later.  He doesn’t rent the hack from the owner; he keeps 45% of his fares.  He makes good money in the winter, but not in the summers.

We came into town in the darkness, talking about aurora borealis. He pointed out places from his youth, but had to be directed to the new hospital.  He showed me where the movie theater used to be.  They changed the films three times a week, he said, and he went to all the movies, and that’s where he’d learned English.

When he dropped me off at the hospital, I looked at the fare on the meter, and I was glad that the trip had been worth his while.

I dropped the unused morphine and the crash bag at the nurse’s station and walked back to the hotel. I hoped for a glimpse of Northern Lights in the moonless sky, but the clouds hid the stars.


The diversion of patients because of forest fires

July 12, 2017

The forest, it seems, is on fire.

And the wait can sure make me tire

When our referral facility

Has maxed capability

And my patients have problems most dire.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

As I write this, 183 wildfires rampage through the wilds of British Columbia. The smell of wood smoke permeates the air and a haze hangs over the nearby mountains.

We have been lucky during this last week of fires, with 3 days of solid, soaking rain. But with complex topography comes complex weather patterns, and nearby valleys have had no precipitation at all.

Yesterday I had call. I took care of people with problems in their skins, bones, throats, lungs, hearts, eyes, abdomens, fingers, toes, brains, ears, and genitals.  Two came in close together, with problems exceeding our facility’s capability.  I ordered blood work; I like to sound prepared when I speak to a doc in a referral center.  Then I waited.

And waited. When I got results back, I called the hospital in Prince George to speak to a couple of consultants and to formulate a plan, then I had the central ambulance dispatching service called.

Theoretically, the dispatch centralization makes sense; practically, however, it means a terrible delay in getting patients into the ambulance.

I had hoped to send both patients in the same vehicle to Prince George, but in the course of making arrangements I found out that the number of injuries coming in out of the forest fire had overwhelmed the schedule for sophisticated diagnostic tools, and couldn’t I please send the second patient to Dawson Creek?

It meant a longer delay for the second patient, but I agreed, and called the ER there with a bizarre, creepy history perfect for the opening of a horror movie.

Of course, in the hours between the arrival of those two patients and their departure, other patients came in for treatment.

At six I walked to the hotel to eat supper with Bethany. I had been continuously occupied for the previous 10 hours.  I wolfed my food, napped briefly, and walked back to the ER.

I started in on documentation, typing directly into the Electronic Medical Record. I continued between the patients who kept trickling in.  I ran into a surprising number of patients with back pain who adamantly spoke against narcotics (and I agreed with them).

I finished at ten, and returned to the hotel. I had attended 21 patients.  The emotional fatigue of waiting to transport those two critical patients far exceeded the physical tiredness.

And then I had no calls for the rest of the night.

A 200 kilometer wild goose chase. I don’t mind. Really.

June 2, 2011

It was late when I got the call

About a person, a car, and a wall.

     When I did arrive

     After quite a long drive

My skills were not needed at all.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places.  Right now I’m living in Amberley, and working the last week of a four-week assignment in Waikari, less than an hour from quake-stricken Christchurch, in New Zealand’s South Island. 

Yesterday my clinic hummed along at a steady pace.  I saw a lot of farmers and a few teachers and school kids.  The younger children make up a fair chunk of the patient load.

Now in the last month of Southern Hemisphere autumn, the sun goes down early, and I loaded the PRIME medical kit into the car for my last night on call here in Waikari/Amberley.

I stopped off at the clinic in Amberley to pick up my two beepers; one of the receptionists informed me that, under the mistaken impression I would work an evening clinic, I had a patient at 5:45.

I don’t get annoyed with one-time (or, as the Kiwis say, a one-off) flubs any more.  I nodded, waited for the patient to arrive, had a great conversation, made some lifestyle modification recommendations, and refilled a prescription. 

I drove home in the dark. Bethany and I went to the Thai restaurant and afterwards played Scrabble.  I was about to start practicing my (borrowed) saxophone when one of my two beepers went off.

The St John Ambulance dispatcher sounded a bit abrupt over the phone, and in places, hard to understand.  A motor vehicle accident, she said, and specified a location.

Without geography you’re nowhere.

I had her repeat the location, which still didn’t make any sense, but, hey, OK, not mine to reason why.  After all, I have a GPS.

Hold on, I told her, and I called my back-up.

You’ll do fine, she told me, if you have your ATLS certification that’s more sophisticated than PRIME.

I called the dispatcher back.  The more I tried to find out where I needed to go the more annoyed she got with me, but, darn it, I’m not about to set off in a hurry to an undisclosed location. 

I didn’t recognize the name of the town, and she had to spell PARNASSUS.  But, feeling it an emergency, I had no time for internet map research.

Bethany, thankfully, volunteered to come with me.

With the revolving green light on the roof we set off north.  Ten kilometers out of town, I had Bethany call the ambulance people again.  Where?

“Ten kilometers north of Parnassus, which is ten kilometers north of Cheviot,” I heard Bethany repeat as I passed the sign saying CHEVIOT 59K at a speed in excess of the 100 KPH limit.

As the kilometers whizzed by at the rate of 1.6 to a mile, I thought things through and realized that minutes wouldn’t make a difference.  I fell in behind three semis and had Bethany unplug the light.

North of Waipara the road grows tight curves and a one-lane bridge.  We sang some Bob Dylan songs.  We passed Cheviot and Parnassus, and 11 kilometers later came to the scene.

Three fire engines and four police cars flashed their lights.  I drove on the wrong side of the road past the backed-up traffic, announced myself to the cop with the STOP sign, and parked behind a fire truck.

As I got out of the car, a paramedic came to me from the ambulance.

The patient, already aboard the helicopter, would take off at any moment. 

I stood on the asphalt as the chopper lifted, fingers in my ears, clinging to the bill of my cap, with walls of limestone setting the stage for the brutal reality of theater in the streets, grateful the patient hadn’t needed my services.

We drove back at a more sedate pace.  I filled the tank in Amberley in case I received another 200 K round-trip call.  After three hours on the road we came back to the flat with jangled nerves, and slept poorly.

Adrenaline kept me going through the day; at my exit interview this evening I learned I could have refused the call for being too far away.

A drunk with a cut

May 19, 2011

The laceration was open then shut.

Quiet? It was anything but.

     To sew up a drunk

    Took a two-hour chunk

But it was really quite a large cut.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance back from the brink of burnout, while my one-year non-compete clause ticks off, I’m having adventures and working in out-of-the-way experiences.  Right now I’m living in Amberley and working in Waikari, within an hour of Christchurch in New Zealand’s South Island.

I had call last night, taking the four bags of resuscitation equipment in the clinic car.

At bedtime, I checked the two beepers and the three cell phones. Then I told myself, lying, that I wasn’t on call. I slept marvelously for two hours.

The beeper went off about 12:30AM.

The first problem I faced was not knowing which beeper went off, the second was trying to figure the beeper out. Eventually, I got the info from the parasitic collection of semiconductors and realized that I didn’t know what to do with the terse codes and abbreviations, followed by an address in a municipality I didn’t recognize.

I hate waking doctors in the middle of the night, especially when they’re not on call, but I had to phone my back-up.
He received the call graciously, and told me whom to ring.

By this time Bethany was wide awake.

With the full moon light streaming in the bedroom window, I explained to the dispatcher that I didn’t understand the system. She asked for my phone number. I realized I didn’t know it.  I heard her clicking keys in the background, and then she agreed to call me back

Ten minutes later I talked to the ambulance crew.

The problem involved a drunk and a laceration, and a ten minute ambulance ride.

Back home, I’ve figured out a system to slip out of the house with minimal family disturbance when I get called out in the middle of the night; here I still stumble around with the lights on.

The ambulance beat me to the clinic.

Having the key to the clinic and the code to the alarm system doesn’t mean I know where to find the key pad or light switches or how to actually disarm the system. I triggered the alarm, a deafening experience.  My ears are still ringing.

The St John ambulance crew, marvels of professionalism, kept the intoxicated patient calm.  I eventually found everything I needed.  I anesthetized and scrubbed the 7 cm (3 inch) gash and stitched it back together. 

After the laceration, the EMT’s worked with the patient to figure out disposition (not an easy task) while I wrote a note to the receptionists about billing and filling out the ACC45 form. 

I enjoyed driving through the sleeping town in the full moonlight, alone with my thoughts.

I got back to the flat two hours after I left, to find Bethany sleeping soundly.

I did my best in the moonlight not to need to turn on the light.  I dropped one of the beepers in the dark, discovering that I couldn’t really handle five pieces of electronics without pockets. 

I arranged them on the bedside table.  I could lie to myself again about my on-call status only because I trusted the multiple layer redundancy of my communications equipment.

I slept deep till the alarm went off.

An extremely short commute and a frightening first patient.

April 21, 2011

Sometimes I need to talk fast

When the ambulance is tuned up and gassed

     It’s like a commercial,

    But not controversial,

It resembles a blast from the past.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  On assignment on the North Island of New Zealand, I’m living in an apartment attached to a clinic in Matakana, north of Auckland.

I got up early for my weekly meeting with Care Initiatives Hospice; with a seven-hour time difference, my 6:00 AM corresponds to Iowa’s 1:00 PM.  The meeting went well; we got through the material for two dozen patients efficiently, and when things ended I stayed online, tidying up email and doing some literature research. 

I stepped through the clinic door at 7:00, before arrival of staff or patients, to shower.  We breakfasted with time to savor our food, and at 8:00 sharp I walked ten steps from my breakfast table to my desk and booted up my work computer.  The first patient showed up at 8:30.

Within one minute I suspected a problem requiring prompt treatment in order to avoid death, walked the patient across the hall to the treatment area, requested a diagnostic test and an IV, and said, “Call the ambulance.”

Four minutes later I had proof of diagnosis.

I called the medical registrar (the equivalent of a US senior resident on the internal medicine service) at the North Shore Hospital, an hour away in Auckland, and a minute later she had accepted the transfer. 

In the late ‘60’s I dedicated three years to college radio, and in the process learned a great deal about human communication, lessons which have served me well.  Presenting a patient to a consultant by phone resembles a sixty-second radio commercial; I can communicate everything in a minute if I’m organized.  By now I have had a great deal of practice.

My colleague at the end of the line came across as crisp, professional, knowledgeable and friendly, and agreed with my diagnosis and plan, much like every transfer I’ve arranged here. 

By contrast, I remember during my Indian Health Service days when I had a patient with Reye’s syndrome.  I had the diagnosis in the first thirty seconds, forty-five minutes later I had the lab tests to prove it, but it took me two hours to work my way up the hierarchy ladder to the overworked chief resident.  I repeated the clinical story, the history, physical, and lab results for the fourth time.  At 2:30 in the morning, the remote hospital quiet but for a life-and-death drama, with no other connection than the telephone, I could hear the break in the overworked doctor’s voice, along with it something shattering in his soul, when he realized he couldn’t dodge the admission. 

I think the difference between the two scenarios boils down sleep deprivation; pediatrics residents in the early ’80’s worked 110 hour weeks when things went well, and the medical registrar I talked to sounded rested and motivated.

Twenty minutes after I called the patient back to my exam room the EMTs wheeled him out the front door, oxygen and IV going.