other people's emergencies: random thoughts of an urban paramedic

For more than twenty years I've worked as a paramedic for the city of Boston, Massachusetts. The opinions expressed in this diary are mine alone, and do not represent the views of Boston EMS. Names, dates, locations, and physical characteristics have been changed to ensure patient confidentiality.

Tuesday, June 02, 2009

Injured

The man was homeless. He suffered from multiple sclerosis, and that's why he was confined to a wheelchair. He'd called us because of chest pain, although he was quick to point out that he wasn't having a heart attack. Several times he'd been treated for the same kind of pain, and each time a doctor had given him a clean bill of health.

A nurse at the shelter's clinic had called 911 on his behalf. As unlikely as a heart attack may have been, I couldn't really fault her for that. Patients who claim to know that they are definitely not suffering from heart attacks don't always know what they're talking about.

We examined the man and decided that the pain was more likely coming from some other condition. He winced as my partner applied the EKG wires. Asked if he could locate the pain by pressing on his own chest, he did so easily. While this doesn't necessarily eliminate the possibility of a heart attack, it certainly makes one less likely. His EKG was normal, as was his blood pressure. It was beginning to look as if he'd injured his chest in some way.

My partner stood behind the wheelchair. I stood in front of it, and together we lifted him onto the stretcher. As we did, I felt a twinge of pain in my lower back. As we pushed the stretcher to the ambulance, this pain shot down my right leg. It wasn't excruciating, but it was definitely noticeable. I must have been wincing--just as the patient had been wincing--because my partner asked if I was all right.

Not really, I told him. I think I did something to my back.

By the time we'd run the patient through triage, and settled him into a room, my back was feeling pretty tight. I mentioned it to a nurse, who arranged to have me examined. A short time later, a doctor declared me the victim of a herniated disk. "Nine times out of ten, these things heal on their own within a month," he told me. "Take it easy, and stay out of work for a week, and go to see Occupational Health. Surgery is an option if it doesn't get better, but I suspect that it will."

I thanked him and went home. That night, I did some Internet reading the subject of disk herniation. Sure enough, back pain coupled with pain in one leg was listed as a cardinal sign of disk rupture. Imaging tests, such as an MRI, aren't necessary to make the diagnosis, it said, because the nature of the symptoms corresponds so perfectly to the diagnosis.

The next day, I reported to Occupational Health, as ordered. The nurse practitioner performed the same tests that the doctor had done, but reached a different conclusion. "I don't understand why that doctor thought you had a disk herniation," she said. "He didn't even order an MRI. I think you have a muscle strain."

She wrote something into my chart. Then she looked up at me from across her desk. "There's no reason why you can't work with this," she said. "I mean, you're a paramedic, right? You wouldn't be lifting patients all the time, would you?"

For a moment I was speechless. How could a nurse practitioner be so clueless about the nature of a paramedic's job? It's bad enough that the public tends to have no idea what EMTs and paramedics do, but it seemed to me that a nurse practitioner should be fairly well versed in such things--especially when she was the one responsible for making decisions about whether I was physically able to perform my job.

"Actually, we have to do these kinds of lifts several times during each shift," I told her. "We frequently carry people down three or four flights of stairs. Sometimes they are very heavy people. We have to climb over things, and crawl under things, too."

"Oh," the nurse practitioner said. "I had no idea that it was such a demanding job. I thought you had people to do that for you."

At this, I practically fell off the chair. Like who exactly? A valet? A baggage handler? Oh, Jeeves, the man on the third floor appears to be suffering a heart attack. Be a good fellow and fetch him down for me, will you?

Yikes.

I wanted to tell her about the last time I was injured on the job--the time when a heroin addict woke up unexpectedly and fought with us as we carried him down three flights of stairs. Unable to let go of the chair, I supported the guy with one hand while fending him off with the other. We'd just about made it to the street when he latched onto my wrist with both hands and cranked down hard, causing a painful snap in my shoulder. The patient went to the emergency department, where he recovered from his overdose and was promptly discharged. Meanwhile, I went to the operating room, to have my damaged arm repaired in three different places.

But I didn't tell her about that. There didn't seem any point. She was already on the phone, arranging for me to get into physical therapy. "I have an EMT here who needs to work on his back strength," I heard her say. I couldn't be bothered to explain the difference between an EMT and a paramedic, or to explain just how physically demanding our job really is. I got the impression that she wouldn't have cared.

Now I don't know what to think. Two professionals, two conflicting opinions. Only time will determine which one is right, I suppose. I'll go to physical therapy, and either my back will get better, or it won't.

We'll see.

38 Comments:

Blogger Mr. 618 said...

Kinda makes you wish there were a requirement that the NP rides with a crew for a week before making little determinations like who gets time off and who doesn't.

On the other hand, everyone has to deal with these morons at one point or another - when I was on the PD, we had one supervisor (I refuse to call anyone my 'superior') who thought I was talking about Carmen Miranda when I suggested Miranda warnings one night when he was riding with me.

8:51 AM  
Blogger TS said...

A police supervisor thought that? That's incredible.

9:09 AM  
Anonymous Anonymous said...

TS-

Feel better soon. I've had a chronic back injury that has kept me out of EMS for almost 12 months now. Be safe and be your own advocate for your care; unfortunately there are far too many medical professionals who will evaluate you quickly and be then either toss you some pills, a PT script, tell you nothing is wrong, or recommend surgery.

Do some reading and don't give up until you feel better, not when they say you are better.

9:10 AM  
Anonymous Dani said...

The NP may have said that cause she has CNA's that do all the heavy lifting for them. Good luck and enjoy some time off, feel better!

9:43 AM  
Anonymous Anonymous said...

I think that the key words here were "occupational health" NP....had that been an NP working under a PCP the diagnosis may have been similar to the initial diagnosis...common malady..herniated,or bulging disc between L4-L5 for people who use their backs a lot...hopefully conservative treatment works for you...good luck!

9:45 AM  
Blogger Baris said...

Ouch, sorry to hear the bad news. Hope you feel better soon. Seeing a new entry in your blog is a bright spot in my day. Good stuff, sir.

9:52 AM  
Anonymous Gabor said...

Sorry to hear that TS, hope you feel better soon. I'm not sure what physio is like over there but if you can, try to find a good sports physiotherapist, some of them can work wonders when it comes to recovery from injuries.

10:19 AM  
Blogger Michael A. Burstein said...

I hope you feel better soon.

The pain you describe sounds to me like you herniated the L4/L5 or L5/S1 disk. I had that exact same pain years ago, and needed surgery to get it fixed. If you can lie flat on your back for a week, by all means do so.

10:42 AM  
Blogger Norma said...

Bum deal, TS. FWIW, I had a herniated disk (C5) in my neck about 3 years ago; the symptoms were neck pain/stiffness and numbness/tingling radiating down my right arm. It was confirmed by an x-ray and treated (with about 90% success) by 6 weeks of PT and then monthly chiropractic adjustments...still flares up now & then. Hope you get your "real" diagnosis soon and some effective treatment; anything to avoid surgery! PS When Jeeves is done fetching your patient, can you have him kick the clueless NP in the face?

10:50 AM  
Blogger Herbie said...

Feel better. Rest your back up.

10:58 AM  
Blogger TS said...

Thanks, everybody.

It's feeling better already, just 48 hours later. And who knows? Maybe the nurse practitioner was right. Maybe it's just a strain.

Either way, the concensus is that it will almost certainly heal on its own--sooner, hopefully, rather than later.

11:04 AM  
Blogger brendan said...

And this is the person deciding who goes back to work and who has to book off?

Fantastic.

3:12 PM  
Anonymous Anonymous said...

Not good for snorers, but thin camping mattress on tiled floor works wonders. If your house has a landing a more extreme option is to hang upside down, just make sure you don't fall or the back injury is somewhat higher up and worse than the original
j

3:17 PM  
Blogger Renee said...

ne of the problems with Occupational Health NPs, PAs, and MDs is that in many cases, their job is to mitigate costs of workers compensation. The upshot is that they tend to minimize an injury to get folk back on the job quicker.

In her case, she truly seemed clueless, but either way, TS, be careful. And I sure hope you heal quickly. :-)

7:02 PM  
Anonymous Lee said...

TS - A paramedic IS an EMT, an EMT-P. There's no need to correct someone who calls you an EMT unless they specifically call you a Basic.

7:03 PM  
Anonymous Anonymous said...

I suffered the same type of injury about ten years ago. Not to scare you, but I'm now permenently disabled after 9 lower back surgeries! I herniated a disc and had a surgery. I went back to work a little early and herniated the next level, and had yet another surgery. The other surgeries were for scar tissue removal, a membrane of some sort put in, a usion on the lowest 2 levels, and a fusion onthe next lower 2, and finally loose hardware removal. I may have missed a couple of surgeries somewherein there! My advice is to get an mri if the pain persists. If you need surgery of ANY kind for yor back (or any joints for that matter-knee,shoulders, etc.) go to New England Baptist hospital! They are by far he best in an area where we have nothing but the best care available (if that makes sense!). I wish you good luck with this, and hope you don' end up like me. Chiropractors are only a band-aid IMHO. Once you go you may need to keep going forever. chiropractic ended up hurting me more than helping. PT is a great way to strenghthen your ABS. Do the exercises regularly (even when no pain), and you will be able to workanother 20 years! good Luck.

7:41 PM  
Blogger TS said...

Lee:

Having been an EMT, and then an EMT-paramedic, for 27 years, I have a pretty good understanding of these terms and their meanings.

What troubles me is that hardly anyone in America--outside of the people who work in EMS--know the difference between a basic-level EMT and a paramedic. To some extent, that's understandable. But I would expect a health-care professional to know better. I'm reasonably certain that the nurse would correct me if someone referred to her only as a nurse, and not as a nurse practitioner--which she'd have every right to do, given the additional training she had to endure to get that title. I'm merely asking for the same consideration. I worked hard to advance from EMT-Basic to Paramedic. When speaking to someone who should know better, I'd like to be called by the proper title.

8:14 PM  
Blogger TS said...

Anonymous:

You're not exactly making me feel better!

Just kidding.

Actually, it feels a lot better already, so maybe this was a big deal about nothing. I'm going to PT tomorrow. The important thing is that it was caught before it had a chance to get worse, and it's been documented, in case anything bad comes of it.

8:18 PM  
Blogger TS said...

Renee:

Thanks. That may be true. Hopefully, this will turn out to be a small enough injury that it won't matter.

8:21 PM  
Blogger KC said...

Ths old nurse has walked that crooked walk.... Try ice and NSAIDS. A good PT will help determine an accurate diagnosis, help direct your recovery and also teach strategies to prevent this from happening again. Good luck, TS and please keep the stories coming!!!

9:28 PM  
Anonymous scannerbuff1 said...

I'm so sorry to hear about your injury. The ironic thing is I found this blog after reading an article in Pravda on the Boulevard, aka the Boston Globe, about the injury rates in EMS. I hope your recovery is quick, and that there isn't too much red tape when you're out to get workmen's comp, line-of-duty injury certification, etc. I'm always suspicious about "occupational health" employees- seems like they're just an extension of management, not really concerned about health as much as the bottom line.

I'm always interested when the EMT/paramedic issue comes up. Do we have "intermediates" here in MA, and if so, what are they? I've seen references to "EMT- intermediate" and "ALS-Intermediate", but usually only hear about EMTs and Paramedics, as if there's only two levels.

11:19 PM  
Blogger TS said...

Scannerbuff1:

Years ago, Massachusetts certified 4 levels of EMTs. If I remember correctly, the scheme went like this:

EMT-A (ambulance): Basic-level EMT.

EMT-I (intermediate): Permitted to intubate and start IVs.

EMT-C (cardiac): Permitted to intubate, start IVs, and use cardiac monitors/defibrillators.

EMT-P (paramedic): Permitted to intubate, start IVs, use cardiac monitors/defibrillators, administer medications, and perform other procedures.

I seem to recall that the few EMT-Cs in the state all were upgraded to EMT-Ps several years ago. I haven't seen any EMT-Is recently, so the state may have done away with that designation as well.

Does anybody know for sure?

11:30 PM  
Anonymous JAM said...

At least the "ill informed" nurse practitioner didn't call you " the ambulance driver!!

11:54 PM  
Anonymous MichiganEMT said...

Same story here. I injured my back five years ago lifting a patient. I went to our OH Nurse who sent me to a clinic. I was told muscle strain and that it would heal. A year later I re-injured my back in the same place again lifting a patient. This time there was an audible "pop" as I fell to the ground. My partner and the patient both heard the "pop". The OH Nurse stated that I could have injured my back anywhere doing any number of things and that it was not work related even after I reminded her of the previous injury. I had to go to my pcp who diagnosed a herniated disk. I was told that it would never heal. I have almost constant back pain and need to start PT but my insurance company is giving me a hard time about it. I was on m ex-wife's insurance when the first injury occured and this is a preexisting condition according to my insurance. Screwed either way I guess.

1:25 AM  
Blogger Matt E. Warren said...

You know, I always thought that it was a much better idea to listen to an NP rather than a doctor. Doctors...like they know anything. Pshaw. It's also why I take all my financial advice from my unemployed friend, not my banker. *end sarcasm*

8:19 AM  
Anonymous Beverly said...

TS, I love your posts but don't you hate it when people say things like: 'It'll never get better, man, in fact mine was so bad that...' or "You have to see MY chiropracter" or "12 operations later..."
Hey, America!!! Every single back problem is unique unto itself. My Aunt Betty's bad back is way the heck different than your Uncle Pete's bad back. There are as many treatments and theories for bad backs as there are bad backs.
My occupational health 'bad back experience' came when I wanted to return to work after being out 6 weeks for a non work related injury and OH wanted me to sit home another 6 weeks. I won and have worked every day since.

5:38 PM  
Blogger Last Angry Man said...

TS, take care of that back! I've had mine go on the job, the last time took five weeks out of work to rehab. Never fun.

(And ironically, now more/less rehabbed from why I left my last job, I've applied at the Night Center - God help me)

5:47 PM  
Anonymous Anonymous said...

I have enjoyed your blogs for a long while, but notice you don't mention a family. It would be interesteding to know how your job and things like you being hurt doing it affects your spouse (if you have one, or girlfriend/partner), kids, etc.

7:18 PM  
Anonymous scannerbuff1 said...

Thanks for the info.

One more think- was the junkie who injured you last time charged w/ assault? It'd be great if we could lock those types up, keeps them off the street and not tying up ambulances, and might make the other junkies think before attacking an EMT or Paramedic.

Hope you feel better soon.

Oh, and Lee, when you have a heart attack/stroke/serious trauma incident, tell us how similar EMTs are to Paramedics, when you have an EMT make all the treatment decisions on you. I have great respect for EMTs as well as Paramedics, but EMTs simply don't have the same training.

8:27 PM  
Blogger hakamadare said...

TS: I just finished my EMT-B training in MA, so this is still fresh in my mind:

EMT-B = Basic
EMT-I = Intermediate (still exists)
EMT-P = Paramedic

I'd be happy to be corrected by someone who knows better, but this is what I was just taught.

My state practical exam is this weekend; wish me luck! :) I hope you recover quickly.

-steve

9:08 PM  
Blogger TS said...

JAM:

Well, that's true. It could have been worse. :)

10:24 PM  
Blogger TS said...

Michigan EMT:

Sorry to hear that. Fortunately, my injury doesn't seem to be as significant as it first appeared.

The points made by you and the other readers who warn to take treatment for back injuries seriously is a good one, however.

10:28 PM  
Blogger TS said...

Matt E Warren:

I smiled when I read your comment. That's all I'll say.

10:29 PM  
Blogger TS said...

Beverly:

I don't want to insult those who offered there personal experiences, because I know they were trying to help by warning me to take the injury seriously (which is a point well taken), but yes, I am glad to read at least one comment with a positive outlook. Thank you.

10:36 PM  
Blogger TS said...

Last Angry Man:

The Night Center? I give you credit. If you do end up working there, then please, exercise common sense. We're counting on you.

10:40 PM  
Blogger TS said...

Anonymous:

That's intentional. Yes, I do have a family. But I don't feel that it would be right to involve them in this forum. Some of the comments directed at me have been pretty nasty, and I don't want to let the same thing happen to any of them, even once.

Sorry.

10:46 PM  
Blogger TS said...

Scannerbuff1:

No, he wasn't charged with anything. The incident happened as he was waking from an overdose, and he really didn't know what he was doing. While the voluntary use of an intoxicating substance is no defense to a crime, it sometimes makes it difficult to prove that the defendant intended to commit a crime. In this case, the DA's office looked at the situation, and decided that the charge would be too difficult to prove.

10:57 PM  
Blogger TS said...

Hakamadare:

Thanks. Obviously, EMT-Is still do exist in Massachusetts. At one time they were more common than paramedics. Now, in the Boston area, at least, you hardly ever see them.

11:00 PM  

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