Late Again: Coping With Those Schedule Headaches

EMS Reruns is an advice column designed to address dilemmas you may have experienced in EMS that you did not know how to handle. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we’ll pay you $50. Send ideas c/o Nancy.Perry@cygnusb2b.com.

It’s Friday night and you should have been off duty half an hour ago. You and your partner are supposed to meet your spouses for dinner, and you’re on your way to quarters when you get a call for a woman down, post-fall. You did not get lunch and you’re wishing you could get out of this, but there’s no way. It’s four miles to the station, you’re right on top of the call, and nobody else is even close.

You enter a two-story, single-family dwelling and follow a nervous 12-year-old girl up a single flight of stairs to a front bedroom where you encounter a 40-year-old woman wedged between a double bed and a wall. She’s lying on a hardwood floor, and she’s silent. The girl indicates that her mom had complained of a severe bifrontal headache an hour earlier, had taken some Tylenol and gone upstairs to lie down. She says she called 9-1-1 when she heard a loud thump and ran upstairs to find her mom unresponsive to anything. She says her mom has been healthy and has no history of diabetes, seizures or fainting spells, but has been having headaches and double vision for the past few months.

An engine company arrives and together you stand the bed against the opposite wall to clear some space. Your findings reveal a well-developed woman in early middle age with deep stertorous respirations of 15, who does not respond to her name, but who moans when you insert a nasal airway. Her skins are normal, and she has a one-by-four-inch linear abrasion on her right parietal scalp. Within a couple of seconds after you insert the airway, she localizes it and tries to retract it with the fingers of her right hand.

Q. What do you think is going on with this lady?

A. Whatever it is doesn’t sound good, does it? She needs a thorough neurologic assessment (including a CAT scan), but that history of headaches and diplopia really suggests a brain tumor.

Q. We know this lady has fine motor control over the fingers of her right hand. Is there an easy way to assess the function of her other hand?

A. Maybe, if she’s persistent enough about removing that airway. You could try holding down her right hand and see if she can retract the airway with her left hand. Pay attention to how well she grasps the airway with her fingers. If both sides are about the same, we know something about her cortical and cerebellar function on both sides. If she doesn’t move her left hand, that’s a lateralizing finding, until proven otherwise.

Q. If the patient can remove the airway with her left hand, does it still need to be there?

A. Probably not. Might as well let her remove it—and chart how she does that.

Q. Does she warrant c-spine precautions?

A. You would think her neck is OK, wouldn’t you? But that’s a big abrasion on her scalp, and abrasions make you think energy. And since she isn’t answering questions or obeying commands (only localizing noxious stimuli), a smart EMSer would probably be moved to think twice: C-spine is probably not a bad idea.

Q. What can we say to the patient’s daughter?

A. What you say to her may not be as important as recognizing the fact that if her mom has no history of previous similar events, the daughter is probably scared. Considering the time of day, make sure the stove and the oven are turned off, and encourage the 12-year-old to refrigerate any food that Mom might have been cooking. Most of all, offer her a hug and encourage her not to be afraid. Ask her if she’d like to ride in the front seat of the ambulance, and during the ride explain that the hospital will try to determine the cause of her mom’s headaches.

Q. My department is constantly having us stay late, and they just assume we’ll keep sucking it up. Isn’t there something we can do to make them take our personal lives a little more seriously?

A. Not when you’re actually faced with a call. But your four S’s—spouse, schedule, sleep and safety—are important. They’re the things you and your colleagues are most within your rights to insist on protecting, if necessary. It’s not a difficult fix, either. You just add coverage at times of the day when people are chronically being held over late. Sometimes that doesn’t cost a thing. But if it does, just complaining may not get you the results you want. Instead, do some homework, propose a solution and base it on facts. How many people are being held over, how late and how often?

Remember, this is the emergency biz. Some emergencies will always happen when people least expect them to. But reasonable, ethical leaders don’t deliberately stick with schedules their people can’t live with. Of course, that stuff about being reasonable and ethical is important. You wouldn’t want to work for people who don’t know what that stuff means. If that’s the problem, I’m pretty sure you can’t fix it without freeing up some futures. Short of that, you may just want to find yourself another employer.