Professionals, Ambulances, Compassion, Exigencies

EMS levels

An overview of the three levels of training are as follows:

A Basic EMS must know:

• Oxygen administration
• Use of basic airway devices
• CPR
• Use of an AED (Automated External Defibrillator)
• Emergency childbirth
• Spinal immobilization
• Application of splints and traction splints
• Vital signs, patient physical assessment and history taking
• Care for amputated parts
• Control bleeding
• Dealing with special patient populations (pediatrics, geriatrics)
• Assisting the patient with self-administration of nitroglycerin, EpiPen, or metered-dose inhalers and oral glucose preparations to the conscious patient experiencing a diabetic emergency

An Intermediate must also know:

• ECG monitoring (limited rhythms)
• Manual defibrillation
• Advanced airway management options (per protocols)
• Limited medication administration (most with On-line Medical Control direction)
• Intravenous (IV) insertion
• Intraosseous (IO) insertion
• Continuous positive airway pressure (CPAP)
• 12-lead ECG acquisition

In addition to the above, a Paramedic must know:

• Endotracheal intubation (oral, nasal, or digital)
• Needle cricothyrotomy (emergency airway puncture)
• Surgical cricothyrotomy
• Needle thoracostomy (insertion into the chest wall)
• Synchronized cardioversion (resetting of the heart's rhythm)
• Medication administration
• 12 lead acquisition and interpretation (electrocardiogram)
• Transcutaneous pacing ( temporary means of pacing the heart externally)
• CPAP (continuous positive airway pressure)

Vial of Life

The Vial of Life is a nation-wide program which allows individuals to provide medical information in advance that can be used by emergency personnel in the case of an emergency.

Vial of Life programs are usually sponsored and promoted by senior citizen's organizations and local fire departments, or hospitals. The materials required are available for free.

The program consists of a vial (empty pill bottle or other container), labeled with a Vial of Life sticker, inside which is placed a medical form which has been filled out stating the health status of the individual and current medications being taken.

The vial is placed in the refrigerator, usually recommended to be on the top shelf of the door, because it has been shown that the refrigerator's contents are preserved in the event of a fire.

Stickers are placed in the front window of the home so that responding emergency personnel will know to look for the vial.

Photo:

Vial of Life

Photo: A.M. Sheehan

TRAINING — Training never stops at PACE. Bob Hand, right, PACE director, trains on-duty PACE staff in the use of new restraints.

NORWAY — You've heard them – sirens wailing past your house perfecting the Doppler effect. If you live near Stephens Memorial Hospital you may hear them more than those who live rurally.

In fact, if you live rurally, you probably perk up, listen and wonder where it's going ... is it a crash, a heart attack, a friend, a neighbor?

But if you live near the hospital you probably tune the sound out ... just another ambulance.

Far from it. Rarely is it just another ambulance call and certainly not to the person awaiting  its arrival.

What could be minutes seems like hours if you are lying on the cold, wet ground in pain. If you are having trouble getting each breath, if you are in your car surrounded by broken glass and crushed metal.

Then, the sound of a siren is as welcome as the sound of a mother's voice. Comforting, reassuring.

As well it should be.

Because the siren is simply the harbinger of what's inside – highly trained Emergency Medical Services personnel.

There are multiple EMS or rescue squads in the area. Buckfield Rescue, Oxford Rescue, Tri-Town Rescue, Stoneham Rescue, United Ambulance Service, Bethel Rescue, Med-Care and PACE are some of them.

Some of these are town-owned such as Bethel, Buckfield and Oxford and others are "stand-alones" or independent services such as United, Med-Care and Paramedic Alliance for Community Emergencies commonly known as PACE.

Following the siren 

To fully understand what you get when you call an ambulance one must spend some time. So we did – with PACE.

PACE Paramedic Service is a department of Stephens Memorial Hospital which is part of Western Maine Health which is part of Maine Health which operates a network of health care facilities in a number of counties including Oxford, York, Waldo, Knox, Lincoln, Sagadahoc and Cumberland.

PACE employs 45 staff of which 14 are Basic, 11 are Intermediate/Advanced and 20 are Paramedic level.

A Basic EMS must know how to administer oxygen, deliver babies, immobilize a patient and take vital signs, amongst other things. An intermediate/advanced must also know ECG monitoring, IV insertion and defibrillation, and a paramedic must additionally know intubation, administering of medication, emergency airway puncture and regulating heart rhythms.

Basic training encompasses 240 hours of training plus 16 clinical hours. Intermediate/Advanced is 120 to 150 more hours of classroom time and 120-150 hours of clinical time. Clinical time is split between ambulance time and hospital time. A Paramedic has an additional two years of training.

To say these EMS professionals are highly trained is an understatement. They are not only initially trained but they undergo continuous spot checks, spot tests and continuing education. They must renew their licenses every three years via 54 hours of additional training, continuing ed hours as well as training on new equipment and methods of treatment.

There are monthly Quality Insurance peer reviews where careful attention is paid to how calls and specific medical issues are handled. For example, how ECGs are read and how often there is disagreement with an assessment.  Through this peer review process, needs are identified and training is scheduled.

And they all need to know how to safely drive an ambulance at high rates of speed.

PACE provides 24-hour service each and every day. Its crews are on duty at its base next to Stephens Memorial Hospital in Norway where it houses six ambulances.

During the day in the warmer weather, a crew is stationed in Woodstock at the Woodstock fire station. This cuts travel time for PACE to outlying areas. During the cold months, PACE is stationed at Sunday River.

Whenever PACE has responded to multiple calls and all of its on-duty crews are busy, any available back-up is called in. PACE has recently begun a policy where back-up  crews are actually assigned shifts when they must be available if the need arises. They are paid as back-up.

And while all of PACE personnel are paid, all but one work multiple jobs. There are three area fire chiefs on the PACE personnel roles and many of its EMS staff work for other rescue squads as well. Some work in others fields as their second or third jobs.

Overseeing all of PACE is its director, Bob Hand.

Fondly given the moniker of "desk medic," Hand is a Paramedic with years of boots-on-the-ground experience. He joined PACE in 2004 and, through his expertise, PACE has evolved into a top-notch paramedic service which is called upon daily to assist other services with advanced emergency treatment.

But PACE isn't just called for emergencies. Frequently their services are needed for other things, such as assists. Someone falls out of bed or out of a wheelchair. They are not hurt but they can't get up by themselves. PACE responds to help.

Frequently PACE is called upon to transport. Often this is for elderly patients either from nursing homes or private homes. They need help getting to and from SMH. Sometimes a patient may need to be taken from SMH to CMMC or Maine Med or, occasionally, to Boston to Brigham and Women's Hospital.

And, sometimes, PACE is used more as a taxi service than as a necessary medical response team.

However, what sounds like a minor injury when the call is dispatched may, in fact be something else all together ... and may not be.

A Friday night

Late afternoon on a recent Friday, PACE personnel could be found gathered around the conference table in quarters watching a demonstration on the proper use of new restraints that had been added to the equipment on each ambulance. According to Hand, restraints are rarely used and only if there is a risk of the patient hurting himself or rescue personnel.

Nevertheless, all personnel need to be trained to properly apply them.

There is a great camaraderie amongst the very different personalities working for PACE. Gentle teasing, stories of experiences, concerns, discussion of upcoming shift transports already scheduled all form the shifting conversation. A patient to Maine Med, a patient back to Market Square, another to their home.

The first that comes up is a transport to a patient's home from SMH.

This happens when the staff at SMH feel a patient needs the services of a PACE crew as opposed to a local taxi or private transportation.

In this case, the patient was elderly and frail and has ongoing medical issues.

The crew are kind and gentle. They load the patient into the rig, drive to the patient's home and settle the patient making sure there is nothing more needed. A neighbor is on hand to tend to any needs.

A quick look into the refrigerator assures paramedics that there is food on hand. Rescue crews often check refrigerators in case a patient has a Vial of Life. These give important information about medications a patient might be on and medical issues they might have.

A quick "good-bye" and reminder to call if help is needed and the crew is back in quarters to await the next call.

A crew member replaces sheets on the stretcher and makes sure all is ready for the next patient.

The next call was quick in coming. A 911 call requesting an ambulance for a sore elbow. The patient is four blocks from the hospital.

When the ambulance arrives the patient is walking around outside. Happy to see PACE, the patient climbs on board for the short trip to the ER.

Back at the base the ambulance is cleaned, stretcher coverings replaced.

An hour or so goes by. There is a transport to Maine Med for a heart patient. Another crew takes this. It will tie that crew up for a few hours.

A lot of discussion ensues about what to have for supper. PACE crews have to slide meals in when they can as they have no way to plan for them. Consequently they usually eat on the run, a lot of fast food is consumed and meals half-eaten.

Just as they are about to call to place a food order the tones go off. Dispatch instructs that another rescue service has requested an intercept for a child with a dog bite.

PACE responds to many intercept requests asking for ALS (Advanced Life Support) as PACE has multiple paramedics on duty each shift and other area squads may not have that level on duty when a call comes in.

The ambulance heads out and the intercept is made. A paramedic climbs on board the other ambulance and both ambulances head to SMH. The dog bite has been well cared for and the patient is stoic.

Back at PACE base the idea of the meal comes up again. By now it is late and all the first choices have closed. A quick trip to Burger King staves off hunger pangs.

Back at the base crews have a comfortable scenario for a shift. There are computers, televisions, a weight/exercise room and two four-bed dorm rooms – one for men and one for women – and a kitchen.

A couple of crew members are taking an online state test, something required periodically.

One is watching TV.

Another is studying a textbook with EKG graphics. A copy of a written test sits on the table with complicated math questions. The formulated answers will tell the medic how to determine the amount of meds to give.

The tones go off. Blood in the stool. Arriving at the scene, on the second floor, paramedics are greeted by a cheery patient who is confined to a wheelchair. A family member is concerned by the amount of blood in the stool and feels the patient needs to be seen.

Paramedics bring up a special chair that is designed for transport over stairs. They quickly and easily load and deliver the patient to SMH. The family member follows in a private vehicle.

Back at base it is about 11:30 p.m. The tones go off. An injured person lying on the side of the road in the rain.

Arriving at the scene, paramedics are greeted by a large group of people surrounding a patient lying on the side of the road. A slip has resulted in extreme hip pain. Noting the odd twist of one leg, paramedics ascertain that the patient may have broken a hip.

They carefully insert a backboard under the patient then apply what appears to be a hefty strap across the hips which must surely bring more pain. However, surprisingly, the strap brings immediate relief to the patient as it immobilizes the hips so the movement and jarring ceases to be painful. Blankets help warm the patient who could have rapidly suffered hypothermia from lying in the cold rain.

The patient is calm and answers all the paramedic's questions en route to SMH. An IV is established in case ER doctors need to be able to quickly administer medication.

On each call out, paramedics communicate with ER staff via radio informing them of patient condition, vital signs and answering ER questions and, occasionally, getting instructions from ER doctors.

Safely and caringly delivered to the ER, the crew returns to base, cleans and readies the rig for the next call.

Then the paperwork begins. For the next hour, Hand catches up on the paperwork – reports filed online with the hospital and state for each call.

It is close to 1 a.m. Hand has been on since early morning so he calls it a night.

A Sunday

Sunday began bright and cheery. It is 9 a.m. and the day shift mills around at PACE base anticipating a slow day and talking about their weekend, should one member buy a wood stove and a birthday party another attended.

A discussion is had about "back in the day" before the Stryker stretcher when crews had to actually lift patients and the effect that had on backs. The Stryker operates on battery power and does all the up and down. Crews now simply have to push, steer and operate the buttons.

The shift begins with relocation to Woodstock. At the empty Woodstock fire station the PACE crew settles into chairs. Occasionally someone might show up but mostly they wait in solitude. One pulls out her laptop, the other relaxes.

Today the Woodstock fire chief arrives and a discussion about an upcoming drill ensues.

After a couple of hours, another crew arrives to relieve the first crew which heads back to base.

A call comes in to base requesting a transport from an area nursing home for catheter issues. Arriving, the crew is greeted by friendly "hellos" from both staff and residents.

The patient in question is cheeriest of all. Climbing onto the stretcher, the patient waves at residents and chats with paramedics on the way to SMH.

This patient will need a transport back to the nursing home once tended to by the ER staff.

The tones go off for a call for a bloody nose. Sounding innocuous the crew nevertheless promptly responds.

Arriving at the scene, paramedics discover far more than a bloody nose. The nose, in fact, most likely is broken, the result of a fall.

After some hemming and hawing, the patient finally decides to accept the recommendation of paramedics and transport to SMH.

Again, an IV is established, vitals are taken, a brief patient history and a call to the ER with a heads up on patient status.

On every call, there is a calm, reassuring climate in the back of the ambulance. Patients in pain relax and paramedics gently and proficiently tend to their needs.

Back at base, a quick lunch is ordered from Amato's. It is becoming a fairly busy Sunday.

Conveniently, the next call doesn't come in until the subs have been consumed. This call is a doozy. A grinder has exploded and there is a nose injury.

PACE is being called at the request of another squad. It is a long way to this call – about 20 minutes.

Paramedics are greeted with a severe injury. Apparently the patient was grinding the tops off propane tanks when one exploded. Paramedics can see clear into the nasal cavity and there is concern that a foreign object or bone could have been propelled into the brain.

They do not want to lay the patient down because of this concern.

There is a blood trail where the patient had wandered around eventually going to a neighbor for help.

The patient's finger has also been injured and has compound fractures with bone showing.

The patient, however, is coherent, conversing with paramedics, answering questions.

PACE paramedics confer with the other squad members and all agree. LifeFlight needs to be called.

Fortunately LifeFlight is flying and will be on scene shortly. The local fire department is called out to set up an LZ (landing zone).

Using a special piece of equipment that keeps the patient upright while functioning as a sort of backboard, immobilizing the neck and back, the patient is strapped on and loaded onto the ambulance for transport to the LZ.

An IV is established. Heart rate is monitored. The patient is closely watched for signs of shock. The injuries are very serious.

At one point the finger begins to spurt blood which sprays all over the ambulance. Paramedics quickly apply a new blood clotting agent that ambulance services have inherited from the military. It is remarkable and immediately stops the bleeding.

LifeFlight lands and its two medics climb on board. They listen carefully to the PACE medics and then assess the injuries themselves. They contact CMMC and determine that both a surgeon and a plastic surgeon are on duty.

This, they decide, is where they will transport the patient. Had these two doctors not been on duty they might have taken the patient to Maine Medical Center.

They explain their decision to the patient. The patient's spouse is called. They unload the patient from the ambulance and reload onto the helicopter. The helicopter pilot is ex-military and, in addition to flying, he assists with lifting and getting the stretcher into proper position. (See video at www.advertiserdemocrat.com)

LifeFLight takes off and the PACE crew return to base. This ambulance is now out of service for as long as it takes to thoroughly clean the blood which is everywhere. Walls and floors are hosed down then treated with a special agent that kills biological contaminants. The stretcher is hosed down and also treated. The staff change their uniforms.

Supplies are restocked. The day shift is almost over.

Another Friday night

Multiple shifts are on this Friday night. There is an on-call back-up crew which has been called in to the station. PACE knows it has a football game at which it will assign an ambulance and crew.

It also has a transport to Maine Med.

The phone rings. There will be a transport to Brigham and Women's in Boston. Another crew stands by awaiting notification that the patient is ready to be transported.

The fourth awaits any calls that come in.

The dinner hour comes and an order is placed at Asia Eatery. Returning to the base all is quiet and the meal is eaten. Conversation covers myriad topics.

The crew covering the game has an injured player. They bring the player to SMH.

A spouse of one of the crew members drops by and chats about current events.

Crew members exchange "remember whens." Laughs and teasing abound.

The transport to Maine Med crew arrives back.

The Boston transport crew won't be back until sometime around 2 a.m.

The overnight crew chats for a while. A dessert from the freezer comes out and is served to everyone.

Around 11 p.m. the overnight crew says "goodnight" and goes off to the dorm rooms to get whatever sleep is afforded between calls. The main radio is set so it will only broadcast PACE tones. Each crew member also has a handheld radio next to their bed.

The back-up crew goes home.

Once again, Hand has been on duty since early morning and by 11 p.m. is ready to pack it in. Not one emergency call has come in all night. Although infrequent, this is not unusual. It goes with the job.

Nevertheless, crews are ready at a moment's notice.

So the next time you hear a siren know that coming with it will be a crew in green and years of training ... far from "just another ambulance."