Have you ever been a patient in an ambulance, before or after becoming an EMS provider? Have you witnessed a loved one become a patient? How did it alter your perception of patient care? EMS World’s newest series, “The Patient-Provider Experience,” shares the stories of both patients and providers who have been impacted by their respective experiences with EMS—on or off the cot—and how these experiences changed the way they provide care.
“Daddy...can you come here?”
The call is coming from my daughter. She's been playing in front of the house, and I'm working in the side yard. Her voice has some forced calmness. We all know that voice—we hear it from our patients and use it ourselves. Something is overwhelming the senses or our ability to cope, and out comes that forced calm tone. It helps our patients, and it definitely helps those working with us, but we can hear the difference between real and forced calmness. I have an armful of sticks and leaves and figure she may have broken a toy or found an injured bird.
“I’ll be there in a second,” I say as I drop the load in the trash can.
“No, Daddy, you need to come right now.”
My inner voice recognizes something more serious. My daughter continues, “I think I broke my arm!”
It's been less than three seconds since her first call, so I start making my way around the corner of the house, changing my mind-set from lawn duties to pediatric emergencies.
I find her holding her arm at her side, her forearm hanging loosely. She is looking at her wrist. I ask her what happened. She explains she was running and kicking a ball when her feet slipped out from under her, and she fell back. She says her arm wouldn’t work when she got up and hurt when she moved it. I take a look and determine she has a Colles fracture. Tears well up in her eyes as she tells me she's sorry she broke her arm. Being careful not to touch the arm, I give her a hug and tell her I don’t mind. That stops the tears. I tell her we will have to go to the hospital and get a cast. The tears come again. I assure her the cast will come off soon.
I call to my wife inside. I tell her to bring the big first aid kit from the trunk of my car. She comes running with a panicked look and no first aid kit. She asks what happened. I really want to tell her to get the first aid kit and I'll tell her when she gets back. I’m the paramedic and the father, and if the family of this patient needs to know anything, I'll just tell the father—myself.
Just before I say something to that effect, I realize my wife is also the mother of this child and actually does have a right and need to know. I tell her what happened; she remains there looking, stunned and helpless. I tell her again to go get the kit, and she finally goes. She returns with the kit, and I carefully splint the arm, then sling and swathe it. As we start for the car, she looks at me and asks, “Shouldn't we call the ambulance?” I keep walking, but it's an excellent question. I'm also not sure how to answer it. I tell her that if we call the ambulance now, there will be extra waiting. She thinks about it and says, “OK, let's go.” I clip her into the car seat and sit next to her in the back.
We walk into the emergency room waiting area. It's a weekday, summer, and early evening—in other words, not busy. A receptionist greets us and begins asking basic personal information and insurance questions. She looks nervously at the splint and finally gets up and goes into the back, returning a couple minutes later with a nurse who gives me a short nod, then smiles and talks to my daughter and wife. She looks at me and says she’s never seen a splint like that, but she’s read about them. It's a ladder splint, about 15 years old, but in brand-new condition. It's properly bent, formed and secured so the bone ends are in line. Yes, it's old, but I've never thought to replace it, and now the nurse is calling me old too.
We moved to this area about six months ago. At my previous address I was friendly with all the local medics, firefighters, and ER staff. I've worked in EMS and have been teaching for some time. I’ve seen people come into the emergency room claiming to be nurses, medics, and other healthcare professionals and demand special treatment. They never get it and just make the staff angry, so I decided to stay mum on my profession.
The nurse takes us to a room and tells us we will be seen very soon. My wife takes care of the administrative details with the receptionist while I discuss things with the nurse, who then pulls out her scissors and heads toward my daughter’s splint. I ask her what she’s doing. She says she’s going to take the splint off. I ask what she's going to replace it with, and she says my daughter can just hold it. I explain why that’s a bad idea using terms like Colles fracture, traction, and inline stabilization. She tells me she will remove the splint now, and my daughter will get another after the x-ray. I decide I need to be a bit more direct. I tell the nurse she will not remove the splint and there will be pain medication before the x-ray and an appropriate replacement splint waiting afterward. This gets her flustered, and she goes for a doctor.
The doctor arrives fairly quickly. I explain everything, and he does a brief exam. He causes a bit of pain but apologizes immediately to my daughter. Then he says to me, “We can absolutely do all those things.” A few minutes later two nurses and a tech arrive. Expecting a small dose of fentanyl, I'm pleasantly surprised when the nurse uses Dilaudid. She takes the cap off the needle. My daughter pulls away from the nurse, who says, “This isn't going to hurt.” My daughter looks at the needle, then gives the nurse a look that says, You're an idiot, get away from me. If a 5-year-old gives you that look, stop what you're doing. And this nurse does. My daughter looks at me questioningly. I tell her it will hurt and she’ll feel a sharp pain, but it won't last long, and the medicine will make her arm hurt less. My daughter settles into me and braces herself. I signal the nurse to give the shot. My daughter looks up after it's over and says, “That wasn't too bad.”
Now the nurse says my daughter needs an IV. She's just had a shot and does not want another one. She cries and pulls away. “If you don't stop crying, we are going to make your mom and dad wait outside,” the nurse tells her. My answer to that is, “No, you will not,” perhaps more forcefully than I intend. But everything stops. I tell the staff we can go to x-ray, and by the time we get back, the Dilaudid will be in full effect. Sure enough, after the x-ray there are no problems with the IV. The doctor comes in a while later to show us the x-ray and says he has an orthopedist on the way.
By now it's after 9 p.m., and we are just in waiting mode. Then in walks a young female dressed in scrubs. She says she will be doing the anesthesia for the operation. I have not been told there will be an operation, so I'm a little torqued. The anesthesiologist looks my daughter over very closely, checking her throat, mouth, and nose and asking about weight, medications, and allergies. She asks if I have any other questions, and I say I’d like to know what operation is going to be done. She says she doesn't know and will discuss it with the surgeon. I ask what she's planning to do for the operation. She says it will depend on procedure, but she's planning to give my daughter some “sleepy medicine” and progressing as necessary.
At this point it’s been a long day for me, longer for my daughter, and probably even longer for my wife. “Sleepy medicine” doesn't feel like enough of an explanation—you're going to have to tell me more than that. About that time the surgeon comes in and explains his plan, which I think is good. Shortly after that my daughter is off to the OR. An hour and a half later, she wakes up with me beside her and a bright blue cast. It barely fazes her the rest of the summer.
How did this change my practice?
After it was all over, I thought about the question, “Shouldn't we call the ambulance?” I know ALS in my area is provided by full-time paramedics, but I believe the BLS is provided by firefighters. The firefighters I work with have to maintain their EMT certifications. They don't like doing that, and they don't like EMS. As a result they are bad at it. I really don't want them working on my family. I'll take someone interested in doing good medicine rather than a firefighter forced into a day on the ambulance.
I’ve never told parents to leave their children. Sometimes I would step out of the room, but now I just explain what I’m doing and let them stay nearby or hold their child, even if the child is unconscious. I try to explain things at a level the parents can understand, though I'm sometimes too complex and they have questions. For pediatric transports I always bring a guardian for the child in the back of the ambulance. It's good to have a companion in the emergency room, regardless of your age.
Now I also spend more time developing trust with the child (the same goes for the parents). I never tell them something won’t hurt when it will. If you lose their trust, you will never get it back, and you may need it later. You also cast a pall over everyone else they come into contact with as a result of this incident and others.
Jim has been involved in EMS since the mid 1980s as an EMT, instructor, and paramedic. He has worked as a Critical Care Respiratory Therapist. He currently works as a full time paramedic in northern Virginia. He has been teaching EMS for 28 years. His daughter is now a junior at Penn. State. Her arm is straight and strong.