Guidelines of EMS #19.

The Cheerful Oncologist just tossed up a post on one of the Laws of Medicine. Sitting here, on my third beer of the night, I can't help but wonder if he knows how lucky he is to be working in an area of medicine that is stable enough to have laws. Back in my younger days, a decade or so ago, I put in a couple of years as an EMT. Emergency Medical Services has no laws, and while there are things that we might call "rules," they're more like guidelines.

Since I'm writing up this particular trip down memory lane in response to a post from an MD, it seems only appropriate to start with Guideline #19: Any physician skilled enough to help will be smart enough to keep walking.

In this particular case, I was walking home after work. It had been a very long shift (see Guideline #5, below), and when I finally got off I was so totally tired and dirty (Guideline #7) that I very unwisely left before changing out of my uniform. I'm almost home when an apparent drunk comes weaving down the street towards me, falls over, hits his head on the curb, and immediately starts to do some very impressive bleeding.

It's around noon on a hot spring day, and there are plenty of people on the street, so my immediate reaction is to look around and see if anyone is going to help the poor guy. As I look around, I realize that everyone else is looking at me, which is when it suddenly occurs to me that I'm wearing my uniform. I rummage around in my pockets, come up with a fresh pair of gloves, and get to work. I point at a random bystander, tell him to go call 911 and come back, and start examining the patient. The patient is on his back, semi-conscious, unaware of where he is and when it is, and unclear on exactly what his last name is. And he's bleeding like a stuck pig - judging by the regular spurts of blood from the fairly small head wound, he had somehow managed to pop his temporal artery. I've got nothing to control the bleeding with, but I am wearing gloves, so I stabilize his head with my knees and one hand, and apply direct pressure to the wound with the other.

Then I wait.

And wait.

About ten minutes had gone by - I think. It was hard to judge, since I really couldn't see my watch just then. The first guy I'd sent to call 911 hadn't come back, and two other people I'd asked hadn't, either. I can see the nearest firehouse in the distance, and there was absolutely no sign of action. The sun was pounding down, the patient wasn't getting any better, and my latex allergy was really starting to flare up - anytime my gloves got contaminated, I could always count on my nose starting to itch.

Just then, when I was starting to wonder how things could get worse, the doctor arrived.

He stopped, ignored me, identified himself to the patient as a doctor, and asked if he could help.

"Yes, doctor, you can," I told him. "I don't think 911 has been called yet. Could you please call for an ambulance."

"I was talking to this gentleman, not you."

"Doctor, he's not fully conscious, and oriented only to person. Could you please go and call for an ambulance."

"I said I'm a doctor. Do you have any medical traning?"

I look at myself. Yes, I am wearing my uniform. It has blood on it, but the blood definitely isn't covering the large patch on my sleeve that says "New York State Emergency Medical Technician."

"I'm sorry, doctor, I didn't catch that. What did you say?"

"I said, do you have any medical training?"

There was a bit of a pause then, as I dealt with a strong temptation to increase the number of patients at the scene by one.

"Yes, sir. I'm an EMT. I observed the patient staggering down the street. I saw him fall down there (pointing with my chin), striking his forehead on the curb, resulting in an approximately one inch long, fairly deep, jagged laceration to the left side of his forehead. Given the distance that the blood was spurting (jabbing my chin at the four- to five-foot-long bloodstains) and the bright red color of the blood, I suspect an arterial bleed. His is pulse is currently strong and rapid, his breathing is deep and regular, and he knows his name but not what city he's in or what time of day it is. He needs to go to the hospital, and I can't go call 911 without releasing the pressure on the wound. Now, would you please, for the love of god, go call 911 so we can get this man to the ER."

"I really think I should examine the patient first."

"With all due respect, doctor, what good is that? Do you have bandages with you?"

"No."

"A suture set?"

"Don't be ridiculous."

"Gloves?"

"No."

"Is there anything you could possibly do for this patient right now that I'm not doing?"

"Well, I can't find that out unless I examine him, can I?"

"What the hell good is that going to do?"

"Well, he might have some sort of relevant medical history, or some sort of pre-existing condition that might have predisposed him to fall."

"OK, but he's bleeding right now, and I think that's probably the biggest problem, yes?"

"Well..."

"Doctor. Do you have any equipment at all that you could possibly use to control bleeding?"

"No."

"Then would you fucking go and call 911, doctor?"

"There's no call for that kind of language."

Miraculously, he fire rescue truck, the bus, and the police all managed to arrive within the next 15 seconds, which distracted me from trying to figure out some way to get my hands on the obnoxious schmuck without letting go of the patient. When the whole thing finally settled down, I finally find out what the guy's specialty is - he gave his card to the cops, while bitching about the way that EMS was treating him. For some reason, he just couldn't understand why we weren't paying attention to the views of a well-respected local dermatologist.

Which brings us neatly from Guideline 19 to Guideline 20: What do you call the guy who graduated last in his med school class? Doctor.

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(a few of) The LawsRulesGuidelines of EMS:
1: You will always get a call while you are eating.
2: If it felt good saying it, you probably shouldn't have.
3: The Law of 3s. At 3 am, you will get a call that involves a 300-pound patient and 3 flights of stairs.
4: Air goes in and out. Blood goes round and round. Variations on this are bad.
5: If T = the end of your shift, you will get a call at T-60 seconds.
6: And you will pass your relief on your way to the call.
7: If the patient is going to puke, turn them toward the side of the bus with the most easily cleaned equipment.
8: If you respond to a motor vehicle accident after midnight and don't find a drunk, you are missing a patient.
9: Full spinal precautions were made for obnoxious drunks. So were nasal airways.
10: If the patient is sitting up and talking to you, the patient is not in V-fib no matter what the monitor says.
11: Bleeding always stops - eventually.
12: Never get closer to the scene than the first down cop.
13: If someone is going to die on the scene as the result of fire, electricity, drowning, or other hazard, it should not be you.
14: Never ask, "How the hell did you do that?" You really don't want to know.
15: Stupidity kills. This can apply to you as easily as it does to your patients.
16: Whatever you do, don't drop the patient.
17: Childbirth is messy, and should be kept out of the bus at all costs.
18: If the patient tells you to stop CPR, it's probably OK to do so.