I have a picture. You can’t see the ‘stache from this angle, though. You really oughta ask the Sheriff for a more comfortable cruiser, Dawg.

“You don’t take anything seriously, do you?”

That observation was made to me during a resuscitation not long ago. The comment was delivered with a smile and a chuckle, but the joke that occasioned it had the intended effect. People relaxed and focused on the job at hand rather than what was at stake.

That’s what I do.

Pediatric calls, cardiac arrests, multiple casualty incidents, anywhere feces are flung by spinning blades…people seem to look to me to take the leadership role, even when there are those present who are much higher on the medical pecking order. It’s not a role I actively seek, but it seems to be one I fill quite often. And then those same people make the observation that perhaps I don’t approach the responsibility with the proper degree of gravitas…

They want me to put on The Paramedic Face. The one that is confident, but serious. Competent, but compassionate. Perhaps from watching ER, Third Watch and the like, people are conditioned to think that leadership in crisis situations involves people barking terse, clipped orders:

“Okay, I need a CBC, lytes, chest film and a thoracotomy tray STAT! Let’s move, people!”

Riiiiiggghhhhttt….

I’m more likely to ask for something than order it. I’m more likely to say “Thank you” and offer encouragement than I am to bark at people to hurry up. I make eye contact with people and give specific instructions. I use the word “we” a lot. I’m more Tony Dungy than Mike Ditka.

That’s just the way I roll, people. Sorry it doesn’t make for good television. Barking orders doesn’t inspire good performance, it just makes people tight. It increases the pressure in an already pressure-packed situation. Shouting at people to work faster just makes them work slower. Smooth is better than fast any day, and smooth is fast all by itself. It seems counterintuitive, but slowing down can make things happen more quickly and efficiently.

So when someone is struggling to get an IV on the sick, crashing kid…I may throw in a tension breaker.

“Good news, everybody…(long pause and wait for the expectant looks)…I just saved a buncha money on my car insurance by switching to Geico!”

It’s that spotlight that cuts through the fog of panic. Everyone can go about their tasks with a clearer head. But while everyone else is chuckling, I’m working on that intraosseous line. I’m preparing to secure that airway. Thinking, planning, assessing…

Never mistake the smile on my face for a lack of appreciation for the gravity of the situation. I have always thought of Patch Adams as a bit of a quack, but the man did realize the value of humor – for the patients, staff, everybody. If you can make a sick patient laugh, you have Done Some Healing.

If you can make yourself laugh, you’ve added another layer of armor to keep your soul from getting scarred. Like Matt G said in his blog, sometimes you just have to thumb your nose at The Reaper.

You know who my medical role model was? It wasn’t Johnny and Roy.

It was Hawkeye Pierce. He was the most brilliant, gifted and committed surgeon in the MASH 4077th, and he never stopped cracking wise. Plus, he nailed every nurse in the outfit. He was a swordsman without peer. Hawkeye Pierce was my hero in more ways than one.

I have never found an employer who would allow me to set up a still in the ambulance station, but I’m still looking.

Once upon a time, I treated my best buddy’s wife when she had a heart attack. He was a paramedic, she was an ER nurse/EMT, we worked together frequently. My buddy and I had similar leadership styles. We didn’t shout or bark orders, but we asked for something to be done, it got done. Right the hell then. It didn’t occur to people to question us.

But on her worst day, I was the one to respond in the ambulance to my buddy’s wife. Of all the medics she could have gotten, the only one she would have preferred over me was her own husband. You could see the relief in her eyes.

That relief was replaced by fear she realized from my expression just how sick she was.

AD, I wasn’t scared until I saw you put on your Paramedic Face. That’s when I thought I might die.

I didn’t panic. I didn’t shout. I did everything I was supposed to do, and frankly the only person who noticed my change in demeanor was the patient. But when I Took Charge – capital letters – she knew it was bad. And the fear made her condition worse.

So when you find me joking around and being a bit silly during a bad call, it’s not because I don’t take this stuff seriously.

It’s because I do.

Ambulance Driver

And think of the money they save on informational pamphlets! It’s been so long since someone sent me this that I’ve forgotten who did, but I believe the hat tip goes to GaryS….

I look at our healthcare system in much the same way I do our legal system. Both of them are the most inefficient, poorly designed, unfair, expensive and flawed systems in the entire world…

…except for everybody else’s system.

Flying Flo has some snarky, insightful and downright funny stuff to say on her blog about a proposed national healthcare system.

Until next time…

First installment in an ongoing effort to apply the principles of Evidence Based Medicine to the practice of EMS. You read it here first, folks.

Journal of Interventional Cardiology. 2007 Jan;54(8): 678-681.

A New Approach to Arrhythmia Suppression: Use of the “poised finger” technique in management of cardiac arrhythmias.

Grayson SK, LeGros WL, Pace R, et al.

Department of Cardiology, South Louisiana Medical Center, Chackbay, Louisiana, USA.

OBJECTIVE: to evaluate the efficacy of the “poised finger technique” in suppressing cardiac arrhythmias. METHODS: Prospective observational study of patients suffering symptomatic cardiac arrhythmias in the out-of-hospital setting during a one-year study period. The setting was a rural ambulance service transporting to a community hospital, rural health clinic and convalescent home. On odd days, patients received the “poised finger” arrhythmia suppression technique and on even days received conventional pharmacological and/or electrical intervention according to current American Heart Association ACLS guidelines. Paramedics were instructed to hold their index finger as close as possible to the PRINT button on a standard Medtronic/Physio Control LP12 at the first indication of cardiac arrhythmias. Paramedics were asked to record their observations. RESULTS: 17 patients were excluded from the study because the paramedics were able to actually make physical contact with the PRINT button and record a strip. 194 patients were included in the study group, 38 (19.6%) of which exhibited atrial fibrillation with rapid ventricular rate and 156 patients (80.4%) had another narrow complex tachycardia of greater than 150 beats per minute. 134 patients were included in the control group, of which 107 (79.9%) exhibited a supraventricular tachycardia of greater than 150 beats per minute, and 27 (21.1%) patients exhibited wide complex tachycardia. Arrhythmia suppression was defined as reduction of heart rate to the point that the paramedic noted “nothing cool” to see on the monitor. Of the 194 patients in the study group, 178 patients (91.8%) sustained a measurable decrease in ectopic beats, and 165 patients (85.1%) achieved full arrhythmia suppression as defined in the study parameters. In the control group, 54 patients (40.3%) exhibited a measurable decrease in ectopic beats, with only 23 patients (17.2%) achieving full arryhthmia suppression as defined in the study parameters. 68 patients (50.7%) received adenosine, 14 patients (10.4%) received diltiazem, 40 patients (29.9%) received amiodarone, and 12 patients (89.6%) received synchronized cardioversion or defibrillation. Of the treatment methods used in the control group, the electrical interventions were by far the most effective, achieving arrhythmia suppression 78% of the time. 6 of the 12 patients had a post shock rhythm of asystole. CONCLUSION: The “poised finger” technique is markedly better than the antiarrhythmic therapy currently in use. EMS systems should review their current practice of arrhythmia treatment accordingly.

In an informal interview following the release of the study, author Richard Pace was ebullient in discussing the results of his research. “This just proves what we’ve known all along – that the act of reaching for the PRINT button on the monitor makes the arrhythmia go away. Finally, we’re applying the principle of EBM to the practice of paramedicine, finding out what really works as opposed to just blithely accepting the next wonder drug that hits the market. Amiodarone, schmamiodarone! I got yer antiarrhythmic right here, baby!” Pace crowed, one finger held aloft in a gesture of triumph.

When asked to give his prediction as to whether the poised finger technique should be adopted as an EMS Best Practice, Pace answered, “Absolutely,” wagging his finger for emphasis. “I predict that PFT will become the standard of care for life-threatening arrhythmias. It’s safe, it’s effective, and it’s cheap. All you gotta do is extend your booger hooker toward that PRINT button, and people magically get better. Hey, the abstract doesn’t tell the whole story. Read the entire study and you’ll see. Our numbers would be even better if Grayson hadn’t shocked all those people. Of the 12 people who got the Therapeutic Electrocution, he was the medic for 10 of them. I think those patients could have benefited from PFT as well, but what are ya gonna do? The guy loves to shock people.”

“We need to do more research,” Pace went on to say. “One thing we discovered was that the effectiveness of PFT tends to increase in direct relation to the proximity of the fingertip to the PRINT button. Our best results were obtained with the index finger poised about one inch from the button, but it’s difficult to hold that posture in the back of a moving ambulance, especially the way LeGros drives. We also discovered that positioning yourself more than arm’s reach from the SHOCK button on the monitor triples the likelihood of a lethal arrhythmia, but that’s the subject of a whole other study.”

Ambulance Driver sez, I’ve known about PFT for 14 years, but it’s nice to finally see the science catch up with me. I saw that Grayson guy talk at a conference once. Don’t remember much about him – I was still hung over from the night before…

A retread from the book while I deal with a mild case of blogger’s block. Enjoy…

It would be so easy. Just start the line, and forget to flush the air out of the tubing. They’ll look at it like a terrible accident. A tragic mistake. Such an easy one to make in the heat of the moment. So why don’t you do it, Mr. Gutless? Just bolus the critter with a tubing full of air and put him out of everyone’s misery. At most you’ll get sued, and Podunk Ambulance Service’s liability insurance will cover it. You’ll get counseled and remediated, at most. A slap on the wrist. Which is all this subhuman piece of useless protoplasm is going to get for killing three people…

“Hey, I need a cigarette!” the drunk slurs.

“No smoking in the back of my ambulance, sir. There is oxygen back here.”

Which you are currently wasting, you hopeless excuse for a human being. Your only worthwhile contribution to this planet is providing green plants with a CO2 source.

“Fuck you, sumbitch!” the drunk yells. “I need a cigarette NOW!” He reaches into his shirt pocket and extracts a pack of Marlboros.

“No smoking back here, sir,” I say again firmly, grabbing his hand. He doesn’t want to let go at first, but I deftly twist the pack from his grip.

“Hey Goddamnit, that hurt!” the drunk protests indignantly. “You like to broke my fucking wrist!”

Like that, big boy? Thank the Pardner for teaching me that little trick. If you hadn’t let go, I’d have had you squealing like a little bitch. Pity you gave up before I had the chance.

“I oughta kick your ass,” the drunk threatens, reaching for the strap that secures his torso to the spine board.

“Why would you want to do that?” I ask mildly, pulling his hands away from the buckle. “I’m just trying to help you.”

And what I want to do is let you unlatch that buckle and swing at me. It would be the perfect excuse to kick your ass. I’ll beat you to death, and claim self defense. No jury in the world would convict me.

“Sorry little cocksucker,” the drunk says spitefully. “I got rights. You can’t take me nowhere I don’t wanna go. I got rights!”

You don’t have the right to drink and drive. You don’t have the right to drive with a suspended license. And you don’t have the right to kill a mother and her two kids. They had the right to make it home from the grocery store alive. You violated that right. You need to die.

“Sir, I’m going to start an IV on you. You may be severely injured, and I may need a way to administer medication or fluids.”

Or air. Just don’t flush the line. One big air embolus, and he’ll never drive again. He’ll never wipe out another family. If he lives, he’ll just be some turnip in a nursing home that someone has to turn every few hours. No, better to kill him. No sense in making him a burden to his family.

“Fuck you, sumbitch!” he yells, snatching his arm away. “You got no right to touch me! I pay your fuckin‘ salary!”

No asshole, I’m paying for your medical care. You were driving with a suspended license, drunk, with expired tags. This isn’t your first DUI. You have no insurance. My tax dollars are going to be paying for your medical care, three square meals a day and a warm bed, and your fucking cable television. You might say I’m paying your salary. But not today. Not this time. This time, I’m going to save the taxpayers the bill. You will die tragically on the way to the hospital.

“Sir, I’m going to restrain you for your safety and mine,” I inform him as I tie his wrists to the board with cravats. I spike a bag and hang it from the ceiling hook, and start a 14-gauge IV in his left arm. I am not gentle. I hook up the line and open the roller clamp.

Enjoy your last bit of consciousness, asshole. Hell awaits…

Five minutes later, we’re rolling into the ER at Podunk General Hospital. My patient is still breathing, still threatening, still drunk.

I give the doctor a terse handoff report. “35-year-old male, head-on impact at high speed. He was driving a full size pickup; the people in the compact car are dead. Vitals are all stable and within normal limits. No idea if he lost consciousness at any point. Aside from the split lip and airbag rash, I can’t find anything wrong with him. Other than being drunk and belligerent, that is.”

The doctor says nothing, just frowns and waves us into a trauma room. This is simply another chorus in a song we’ve heard too many times. The singers may change, but the tune never does.

Outside, Female Pardner asks me, “How do you keep your temper with belligerent drunks like that? I mean, he killed three innocent people. I heard him threatening you and yelling, but you just stayed calm. How do you do it?”

I look her squarely in the eye. “It’s not personal. I’m a professional caregiver. It doesn’t bother me.”

“You never think about dealing out your own justice to guys like that? Not even a little?” she asks dubiously.

“No, I never think about it.” I turn my head away and stare at my reflection in the window as we drive home.

Right…