Ambulance Driver

On January 6th of this year, the StarTribune’s Whistleblower team ran this article concerning the Minneapolis Downtown Post Office’s reluctance to allow a donated Automatic External Defibrillator (AED) to be placed in the facility. This report followed months of efforts by workers  to obtain permission to obtain the device after the on-the-job cardiac arrest death of a long time employee.

My agitated response appeared in Ambulance Driver the same day as the Whistleblower report.

Whistleblower has a follow-up today in which Erica A. Brix, senior plant manager at the Post Office, refuses to throw away the shovel.

She essentially gives two reasons for denying the request. The first is the 3.5 minute reponse time for EMS to arrive at the scene. This is a bogus response time. She is referring to the average time it takes for an ambulance to pull up to the curb, after the call is received by the ambulance. It does not take into account the amount of time  to actually place the call to 911 after the patient collapses, for the call taker to process the call, for the call to be transferred to the ambulance dispatcher, for the dispatcher to determine where the closest ambulance is located and the amount of time for the medics to load their gear on the stretcher (after they pull up to the curb) and walk into this large facility and to the patient’s side.

Now don’t get me wrong – all this happens fairly quickly. But to assert that EMS can arrive at a patient’s side in 3.5 minutes after a person suffers cardiac arrest shows just how clueless Ms. Brix is about this issue – even after months of study.

Cost is the second factor, it is contended. They claim they are going to need 18 AED’s to adequately supply the facility. Now think of that. The Postal Workers asked to place ONE DONATED machine in a central location and the bureaucrats said, “Nope, we can’t afford 18.”  What does that tell us about bloated federal programs? Government thinking if I ever saw it.

Ms. Brix also indicates that the facility already has a CPR and First Aid program. As far as I know, any CPR training that I am aware of requires training for AED use.

I don’t know where the National Medical Director of the Postal Service came up with his numbers for cost, but if the device is donated, all you need is an extra set of batteries, which have a life expectancy of several years ($200 bucks) and an extra set of pads for $20 – which need replaced every two years.

They admit the training program is already in place,  they have at least one machine donated, and their understanding of response times is flawed.

Give these folks their AED, you look like a bunch of fools.

It was 3pm today and I was between calls. We had 15 ambulances on duty and 11 emergency responses were listed “on the board.”

1. A female who was so short of breath she could barely speak to the 911 operator.

2. A patient with multiple medical problems was experiencing rectal bleeding. This illicited a chuckle from me because the medic on this call has a well known aversion to anything coming out of the rectum.

3. An elderly patient suffering from a seizure.

4. A nosebleed called in from a physician at a clinic. This is a rare call, doctors would usually have no problem with this complaint.

5. A nosebleed from an elderly man calling from home. This is a very common 911 cal.

6. A person in their 20’s found unconscious. The caller suspected a drug overdose.

7. A transfer from an emergency room to a hyperbaric chamber.

8. New confusion in a nursing home patient.

9. A patient of middle age having chest pain and shortness of breath.

10. A fall in a nursing home with a suspected fracture hip.

11. A call from a physician asking that police and ambulance respond to a  home to place a mentally ill patient on a transportation hold for evaluation.

The Daily Snapshot is intended to demonstrate the varied patient complaints that EMS personnel are called upon to care for.

As a follow-up to yesterday’s post found here, I had promised to continue my discussion concerning the chronic inebriate and the cost they impose upon society. Today I’ll give a second example and wrap up with some editorial comments that tend to make a lot of people uncomfortable.

We were called to a “Wet House” (which I will describe below) and found an intoxicated individual lying in his bed. There were stool and urine all over the floor and his bed clothes were soaked with the same. He was awake, spoke in a monotone and had just awful color. He gave us a history of pancreatitis and GI bleeds that were associated with his chronic alcoholism. His main complaint today was black stools (indicating the presence of blood) and abdominal pain probably caused by the pancreatitis.

He had been having pain, diarrhea stools and vomiting for several days. He admitted to a 2 week binge of drinking a liter of vodka a day, though it is likely the time frame was closer to 2 months.

We got him on the stretcher without getting “dirty” ourselves – which was quite the trick considering that he been rolling around in soiled bedding, fully clothed for quite some time.

We then asked him about any medicines and he pointed to a couple of bottles on a bed side table. On reentering the room, I found that it was going to be impossible to reach the bottles without stepping in stuff I’d rather leave behind. It was then that I noticed a few boxes, plastic garbage bags and paper sacks at my feet. Inside were found at least 200 prescription bottles, every one of which appeared to be full.

Now we frequently see folks that are non-compliant with their meds, but never have I seen so many medicines left untouched.

 My immediate thought was: “I don’t care what the Department policy is, I’m not going to write all these down.”

We were left with three options:

1. Declare a hazardous materials emergency and call in the Fire Department.

2. Pretend we didn’t see the bottles and just leave them behind.

3. Bag everything up and take them with us.

 I asked the staffer if she had a garbage bag – a Big garbage bag. She soon returned with a bag the size you would use to rake leaves into in the Fall. We filled it up beyond half-way. As my partner slung it over his shoulder, I swore he could’ve passed for Santa Clause, except Santa has more hair on his head.

 To make a long story short, we got him to the hospital.

 ”Wet Houses” are facilities for the destitute chronic inebriates who have failed time and again to dry out. The purpose is to give them a safe place to drink. In fact, this place has a sign posted by the elevator that reads, “Drink if you want to. Stay sober if you have to.” 

They are assigned to a space about the size of a college dorm room. There is no meals provided. There is a staff that oversees the operation. If memory serves, the cost to state government is about $1300/mon. They are also provided a type of bank card in which the state deposits about $150 a month for food. In addition, they are provided a little over $200 in a monthly payment.

But the $20,000 a year described above does not yet cover their expenses. Folks like this are huge consumers of health care services. The program that this patient and the one described in the last posting has over 30,000 enrollees that have incomes of less than $7500 a year. They incur health care costs to the state of over $1000 per month per person. But that still isn’t the whole story. The reimbursements the state pays to the providers of this care is significantly less than the total cost of the service.

So how does the provider make up the difference? They charge everybody else more. That’s you and me folks. Our insurance premiums are higher and our out of pocket expenses are higher due to care given to those who cannot pay and depend on government.

 I’m not claiming that every one of those 30,000 people are drunks and beyond help. But I will assert that a significant percentage of them are and it is costing a fortune. In this instance there were several thousands of dollars of medicines in that bag which will be simply thrown away – paid for with taxpayer money.

The cost of this particular program is rising at a rate of 18% a year. Simple math tells us that the cost will double every 4 years with that level of yearly increases – and it already is a $1 billion item in the state budget.

What we are doing here is not working. The sad part is that society has tried every reasonable (and unreasonable) way to try to help people like this and none of it works. We simply end up enabling behavior and calling it compassion.

Urban paramedics see a lot of drunks and I’m not talking about people who are merely alcoholics. Those who are able to hold down a job and navigate through life in a half-way decent fashion are not the subject here.

I want to talk about the Hall of Famers, the chronic inebriates, those who have not seen a sober moment in years and attempt, if they have found themselves sober, to do everything they can to remedy the situation.

Two patients in recent weeks stand out in the annals of drunkedness and merit some discussion. The first will be dealt with in this posting

This was a fellow that was found unconscious lying on a sidewalk.  He reeked of alcohol. His best response to hard pain stimulus was to raise his head and grunt. Despite this, his blood pressure, pulse, ventilations and oxygen saturation were normal. He had no sign of trauma and the blood sugar was normal. Given that my partner and I have over 70 years experience, we were able to quickly diagnose the patient’s problem.

He was drunk.

Now I know what you’re thinking – “Those medics are sharp as tacks.”

Well, its not quite that simple. Yes, he was drunk, but this is where a little discernment is required. This patient is not one of those who can just be taken to a facility where he can sleep it off. His level of consciousness was so decreased that he was in a potentially dangerous situation. It is also possible that my partner and I had completely missed something obvious – although we try not to let that happen, as a rule.  At any rate this patient needed to be taken to an emergency room where he would be monitored closely.

And I’m not talking about just any emergency room. Patients such as these need a place where the personnel are used to dealing with those deeply intoxicated and understand the need for close monitoring. Not all ER’s can be trusted with this in my opinion.

A lot of things can happen as they detoxify. They could vomit and aspirate at any time. They are in danger of hypoventilation, where they are so neurologically depressed that their breathing becomes so inadequate that they stop altogether. They can awake in a 2-3 hours and not fully appreciate why they are lying on a hospital bed and start throwing things around – like nurses.

So what we did was to initiate our protocols for an unconscious patient of unknown origin and transported to an appropriate ER. Once there we were asked if the patient could go to the area where the less intoxicated go to sleep it off.

Our answer was “no”, not until he is evaluated by a physician. The Doctor soon appeared and agreed that the patient was too “down” and needed admission to the main ER.

Up to this point, all of this is fairly routine. It’s what we found out next that makes this a little more interesting.

I don’t know how many of you have seen how a breathalyzer works but here is what they look like:

What you need to do in order to get an accurate reading is to blow HARD into that little plastic tube until the operator tells you to stop.

Well, for this patient, having him to blow hard was not going to happen, so they merely stuck the tube in his mouth and obtained a “passive BAC.”

Which resulted in a measurement of 0.419%.  This is the mark of a true professional.

But that’s not the end of it. A nurse walked in and shook her head stating, “He was in here 2 days ago with a blood-drawn BAC of 0.80%.”

Now over the years I’ve found that 0.50 isn’t all that rare. I’ve had several patients over 0.60 and even one who measured 0.65 who was standing erect, swinging his arms around and loudly telling everyone he was going to kick my ass.

I’ve heard of 0.75% at my hospital – but I’ve never heard of 0.80% BAC.

Think of it. First of all this guy had to drink enough to get to 0.80, which is quite an accomplishment in and of itself, but then he had to live through it. In addition to that, he had to sober up in the hospital, (and I’m sure that was an all-day thing)  gather his wits, get discharged from the hospital, get outside and say, ” Ya know, that was fun. I think I’ll do it again.”

Now, my readers not in the medical profession may chuckle and shake their heads. My colleagues may shrug their shoulders. What we all need to think about, however, is the impact of folks like this on our health care system and the costs incurred in taking care of this patient over a course of years.

It ain’t a pretty scenario. It is also something that no one wants to talk about.

My next posting will drive this point home.

As a native born Hoosier I was very pleased to watch Butler’s win over Kansas State yesterday. It was not an upset.

Butler entered the ranks of top-notch college programs years ago due to its performance against teams from the major conferences. Having Butler on your non-conference schedule has generally  proven to be a losing proposition.

Butler also has the honor of playing in what I consider to be the finest basketball arena in the world. Hinkle Fieldhouse was built in 1928 and its large size helped transform basketball in the late 1920’s and 1930’s. It is the oldest of the major college basketball fieldhouses and still the largest at a private institution.

In my youth I was a frequent visitor. I saw Pete Maravich play there and saw Adolph Rupp and Hank Ida coach there. Last summer, my youngest son and I walked in the door. It was my first visit in over 30 years. While some renovations had been made, it was the same old place.