Thank You for Sparing Me

Dec. 15, 2019

Several years ago, we sat across a table from each other. She, a young paramedic (and nursing student) of a different generation, was trying to figure out whether I should live or die.

Re-emerging into the field of EMS after venturing off into corporate America and the world of IT (information technology) for several years, I had renewed my paramedic credentials and was meeting my new colleagues at Holy Name Hospital MICU. Like feral dogs displaying dominance, Meg and the rest of the staff surrounded me, sniffed and checked under my tail. They vetted and questioned to see who I know, did my audio match my video; "should we allow him to live or die?" 

Newly minted NAEMT AMLS Instructors
(Advanced Medical Life Support) at UMDNJ
Thank you Tracey Loscar

I know, tough crowd right? Not really. They didn't behave any differently than all the other co-workers in all the other places my career had taken me to over the years. Perhaps a little more exclusive as they were a small group with little tolerance for imposters.

Meg immediately established herself as an intellectual as only she could. Meg had a penchant for prose, a gift with analogy and was a repository of factoids and detailed information, often deemed extraneous, unless you too were a consumer of oft useless (unless appearing on Jeopardy) -- facts.

Aboriginal Tribes of Australia

Meg told me a story comparing her inquisitorial demeanor to the behaviors of some aboriginal tribes of Australia (of course, she knew their name and region). She spoke of them as if they lived down the block and she had first-hand knowledge of their history, culture and mores. She explained that if a hunter-gatherer of one tribe captured another, that could often result in death- unless - unless after their form of vetting, the captured knew someone the capturers knew. Having that common denominator, could spare the hunter's life. Fortunately for this hunter, my deep roots in the EMS systems of Hudson County (Jersey City and Union City) provided enough names in common to grant me a pass. It spared my life.

That rigorous ritual provided me with a friend for life. Two days ago, that beautiful, vibrant, exciting candle of life dimmed for us all. But like all of history's great stories and characters, not without leaving behind a great and beautiful legacy.

Thank you Meg. Thank you for being a friend, an inspiration and mentor. Thank for adding to the collective beauty of the world around us.

Until we meet again.

Steve

Meg Chandler - so full of life - so full - of life

A rare moment, when Dave saw the picture of Meg belly-to-belly with Tito, he burst into an explosive laugh. This intrepid photographer was able to capture - the anomaly.

 

Due Diligence - When reporting an incident isn't worth the keystrokes and calories burned to create it

Your patient is one of the dozens your system will encounter this week who's had an adverse reaction to an opiate ingestion. The patient is revived by law enforcement prior to your arrival with intranasal administration of Naloxone ® (Narcan), the popular opiate antagonist cited in every news feed in the U.S. The rest of the call is a ground ball, an all too familiar, routine transfer to the local hospital where your patient is likely a frequent consumer of health services.

Transferring Care 

 

When your team arrives, there are several ambulances in the ER bays dropping off, picking up, doing the business of their trade. You roll your stretcher inside with your now awake, and visibly annoyed, patient (annoyed because you ruined his high), get him registered, and attempt to give the triage nurse your patient report. A neighboring volunteer EMS agency is also giving report on their patient (completely unrelated incidents) when their "leader" happens to overhear your partner give the patient report. He interjects and confronts your partner with his strong political opinion about the opioid crisis and how he is against the now strongly encouraged public use of Narcan. Further, he actually blames your partner (and thus, all first responders) for "enabling" these people to overdose again and again without fear of consequence. He states that we (EMS and the public) are "perpetuating the opioid crisis." Your partner, now visibly disturbed, attempts to de-escalate the conversation as it is getting louder, and the pontificating EMT gets more emotional. It appears he enjoys hearing the sound of his own voice as he continues to badger your partner and loudly display his strong beliefs.

Eight to ten feet from this tirade, safely strapped to a stretcher and flanked by your BLS team, is your patient, who is now completely awake, alert, and aware of what's happening around him; his privacy and promised confidentiality-- breached. Three feet from his stretcher is the volunteer agency's patient, a young female in some form of emotional distress, evidenced by her crying, sobbing and increased agitation at the hospital's delay in her care. She's in a small, wheeled chair, unsecured and unprotected. The other three EMT's that are "caring for" her are scattered about the lobby, seemingly disinterested and not engaging with (or protecting) said patient. A crescendo is reached between her sobs and his blathering. His abject disregard for patient privacy and narcissistic passion for the, sound of his own opinions are on full display. Now hysterical, the female patient jumps up from her chair, rushes the sliding doors and knocks them clearly off their tracks as she elopes from the emergency department and races out into the night.

Stunned, your team escorts your patient into the ED, transfers the patient to the hospital staff and the story ends -- one would think.

Having witnessed this constellation of poor care, patient abandonment, and flagrant violation of patient's privacy rights, you - are -furious.  "This can't (shouldn't) happen" you think to yourself. "We're professionals. Professionals don't behave like this" you reason. Your mind on fire with equal parts frustration and embarrassment, knowing that if this event turns tragic (something happens to the eloping young lady), your hospital will likely point the finger of blame on EMS since that patient's care hadn't been officially transferred to them yet. Shortly thereafter, the media, with its penchant for getting the facts straight, may conveniently forget to name the agency involved, might even misreport this as an event involving your agency. It would be a disaster for sure.

Reporting

 

You do "the right thing" and report the incident to your supervisor. In turn, your supervisor conducts an investigation. He/She questions your team individually and later, questions the nursing staff that was there. This is an obviously open and shut case you think to yourself. 

• There was an incident. 
• There were witnesses. 
• There's video recorded on the security cameras for Christ's sake! 

We're not expecting miracles here, but one can hope that in such a case, justice can be delivered swiftly and accurately. The offending EMT needs, at the very least, to be re-educated - and probably a better option - to have his privilege to be around patients revoked given his exercised poor judgement and lack of respect for patients and privacy.

Follow-up

 

Almost forty days later, your supervisor responds to your incident report. In their brief message, it states that your case has been closed/resolved. They report that management is working on a plan to deal with agencies outside of their control. In short, nothing has happened. Nothing is going to happen. And you used your precious time and energy burning calories writing the stupid thing up in the first place for absolutely - nada. Tell me again why I should ever escalate anything to our "leadership team" when leadership is the last thing we can/should expect. They obviously have not the stomach or political will to engage one of these volunteer agencies, even when their people make an egregious error such as this.

My suggestions?

 

• Your job probably requires that you report incidents you witness or are involved in. Don't jeopardize your employment. Do what they ask and do it well. 
• Keep in mind that some management teams have the ability to make things go away. Sometimes complaints seem to just vanish into the ethos, particularly when convenient or expedient for someone - other than you. 
• Documentation is KEY! Make notes. Record times, dates, locations, what happened, witnesses names. 
• Make copies for yourself. Write them down. Record them digitally. Make a voice recording. Leave nothing to chance.
•  Consider escalation or alternative reporting. When it involves a reportable incident such as the one described here, these behaviors are violations of policies/laws far beyond your agency's control. If they're unwilling/unable to follow through on this, perhaps your Dept. of Health or regulatory agencies may. Kick it up to them and see if anything comes of it. One thing you can be certain of is that your complaint gets memorialized there. If enough similar complaints, or something suggesting a pattern of behavior is noticed, they don't have an option to squash it. Rather, they're obligated to protect the public and hopefully can take action.

In Summary

 

This post can easily be misconstrued as anti-management and nothing could be further from the truth. I've spent over three decades working very hard at being an exceptional employee and role model for others. What I am guilty of is being:

• Anti-cowardice
• Anti-ineptitude
• Anti-complacency 

People do stupid shit that can jeopardize all of us. You say document and escalate to "leadership." If I do that, I have a reasonable expectation that you might actually follow through (and I mean more than have a very concerned, high-level meeting). Use all that education I see appended to your email signature and execute! When you don't, we're left feeling like your team is more symbolism than substance; and like what we're writing is not worth the keystrokes or calories burned creating it.

"I'm the guy that does his job...
You must be the other guy."  - The Departed

• In New Jersey, to file a complaint about a provider of emergency medical services, contact the Office of Emergency Medical Services at 609-633-7777, Monday through Friday, 9:00 a.m. to 5:00 p.m. https://www.state.nj.us/health/ems/reg-enforcement/
• To verify if someone is provider in the state of New Jersey: https://njems.njlincs.net/jsp/verify_credential.jsp?type=search#

The ED Gauntlet - A ring of sometimes irrelevant fire

Sitting in our station last night, the local cable channel showed a commercial of an unnamed, regional, academic medical center that is known for excellence in many specialties. We'll call it "Big Hospital X". I felt it was a good piece of marketing, liked the imagery, the aerial views of the facility, the smiling faces of the competent within. It was -- good marketing.

In the middle of the night, we responded to a call for a person with chest pain who had consumed an enormous amount of nitroglycerine  (NTG) as in more than five times the prescribed dose, and more importantly, without relief. Some of our most basic training informs us that chest pain that does not respond to nitroglycerine is less likely to be angina and more consistent with someone having a heart attack.

Upon arrival we encounter a strong looking, hulk of a man in his early 60's seated at the dining room table. Long story short, he's had heart attacks in the past, has had coronary artery bypass graft (CABG), has several stents in place and is in agonizing pain. Even without a strong confirmation on our 12-lead EKG showing ***ACUTE MI SUSPECTED***, one doesn't have to be a cardiologist to suspect, he's more than likely infarcting (having a heart attack) again.

Photo Courtesy - ECG-Guru

We packaged him and gave him medications to prevent platelet aggregation (aspirin), tried 1 dose of our own nitroglycerine (not expecting miracles after all the nitro he took) and a couple doses of fentanyl to try to blunt the man's pain. 100 mcg of fentanyl usually does a pretty decent job of blunting your pain (or at least makes you not give a f' that it's there). We had about a half-hour transport time to Big Hospital X, consulted with the ER physician about what we saw and verified if there was anything else they may want to give. The hulking patient with a soldier's tattoo across their muscular arm was unfazed by anything we gave him. He was in agony.

Finally we arrived at Big Hospital X (the one's with good marketing) and faced "the gauntlet" (intake registration and triage nurse). No, they're not a real gauntlet. They do have an important function to register and screen patients according to severity, available resources and other factors. Sometimes however, they really appear less like a part of our team and more like the healthcare equivalent of an offensive line in football; their principal function being  -- keep intruders out -- and protect their quarterback (the docs). 

 

The Denver Bronco's offensive line

 First stop was the registration person. Usually, with acute patients, we bypass the gauntlet and head right back to the resus (resuscitation) room. A registration person will follow us and do a "quick reg" on the fly. Our patient was acutely ill by my assessment, but lacking the horrible ECG finding mentioned above, I suppose, didn't quite fit into their little box as "critical."


After dealing with that slow process came the triage nurse. She didn't seem to be grasping that we likely have a candidate here who is evolving before our eyes into a "STEMI" patient (the most critical type of heart attack). She asked her battery of questions as the man writhed and struggled to contain his pain on our stretcher. Then she comes over and asks "what are his vitals?" and "let me see the 12-lead." This is where this began to approach surrealism. Generally, nurses lack the training to accurately read EKG's other than the obvious label across the top. Second, we have already:

1. Interpreted the EKG ourselves 
2. Relayed our findings to the physician and gave the drugs the physician ordered
3. Already transmitted a hi-fidelity copy of the EKG to said physician.  

Lady, this doesn't need your approval or interpretation! Move!! (Inside voice)

Armed with only a partial story, she then vanishes into another area of the ER to relay her findings to the ER physician and decide whether this patient needs the resus room (most critical area) or a regular ER bed. This was the entire reason WE already consulted with the ER physician. Meanwhile, precious time and quite possibly heart muscle erodes away as we deal with fifty questions.

We're standing in the ER for easily over 10 minutes now or about 9 minutes longer than we should have been there. She re-emerges and begins asking more questions. "Did you call the doctor?"

Lady, we're fucking paramedics. Yes we called the doctor; move! (inside voice)
"Yes ma'am we did." (actual voice)

"Did the nitroglycerine burn?" she asked. My head almost exploded right there.

Are you kidding me? That's a novice's question aimed at ruling out suspicion that the patient's nitroglycerine may have been expired, an old prescription, or exposed to sunlight to degrade its potency.  What do the journals say about this? JAMA 1972 Dr. Copelan on the topic; taste "had no value as an index of freshness."¹  We already confirmed and reported (to the doctor on the phone and now the gauntlet nurse at the desk) that this is a brand new prescription for NTG that was picked up at his pharmacy today!  

For God's sake get out of the way and let us through! (again inside voice). 

We finally began walking slowly toward (wait for it...) the resus room. Again, she badgers my partner since, out of frustration, he didn't adequately answer her the first time: "Did the nitroglycerine burn?" Breathless and with an eye-roll, he answered reluctantly; "We didn't ask that" but assured her it's a current prescription. 

She pressed my partner as if the presence or absence of a burning sensation from nitroglycerine is of any diagnostic value. It's not. This man needs a cath lab, and if not that, at least needs to not be here in the hallway answering your fifty irrelevant questions!

Before we left, his EKG evolved and they now had their ominous ***ACUTE MI SUSPECTED***

Did I tell you they have great marketing?