Let me paint the scene. It’s a dark, overcast, cold day in December. I’m the first to arrive at the small paramedic station, so I turn on the lights, pour a cup of coffee, and start preparing for my day. This year will be my 25th as a paramedic, so yes, I’m old, stuff hurts, and there is a lot more grey on my head these days. For the past five years I’ve been a Community Paramedic (CP) in Grey County, Ontario. Like every other paramedic, I go through the usual ‘start of shift’ routine—checking the vehicle, equipment testing, restocking supplies, answering e-mail, etc.
Working as a CP means I work alone in a ‘Conditional Availability’ or ‘CAV’ paramedic response unit. If we’re needed for first response or emergency coverage, the communications officers or operations supervisor will phone us so we can make ourselves available. Otherwise, we are self-dispatched. I carry all the usual paramedic gear, plus some extra specialized equipment and medications. In Grey County, CPs carry an iStat blood analyzer, which allows us to perform point of care INR and basic blood chemistry testing. The CP drug bag includes a selection of antibiotics, potassium, furosemide, prednisone, ipratropium bromide, and nitro patches, on top of the usual symptom relief medications that all paramedics carry in Grey. We work with a local Family Health Team (FHT) and have around 100 patients on our current roster.
For the next hour I’m reviewing patient charts, replying to messages, making phone calls, checking vitals on our remote patient monitoring system, and planning out my day. It should be an average one, with six home visits on the schedule—but that will change. It’s 8:22 am when the CP cellphone rings. It’s an 82-year-old female patient, who lives around 30 km away in a winterized cottage on a small lake. She has a bad cough that’s been getting worse all week. I access her FHT patient chart online to review her history. She’s a complex COPD/CHF/Diabetic patient who is on home oxygen and has a list of medications and allergies that would make a pharmacist cringe.
I call the first scheduled patient to advise them that I will be late for our appointment. The following 25 minute drive is uneventful. The roads are wet with a few snowflakes falling to remind me that winter is coming. I hear the patients small terrier barking upon my arrival, but I don’t forget the most important thing: a dog treat = a quiet dog.
Now that the pup and I are best friends again, I can focus on the patient without interruption. She tells me of the ‘wonderful’ visit she had last weekend from her two-year-old great-grandchild with a runny nose. A few days later, the patient started coughing more than usual. She stopped taking her ‘puffers’ a while back, “because they don’t work anymore”. Her husband unilaterally decided to up her home oxygen to 5 lpm to help. It must feel like a jet exhaust blasting from her nasal cannula. I start my exam: BP 128/60, P 102 irregular, R 20, SPO2 89%, Temp 38.2. I can hear the congestion in her chest from across the room. On auscultation I find decreased breath sounds on R mid-lower lung with an expiratory wheeze and some congestion in both bases. She starts another coughing fit, so I instruct her to spit it out onto a tissue.
For the record, we all have that one thing that can make us gag; a sight, a smell, vomit, poop, etc. Mine is phlegm. She shows me what she just coughed up and I stifle my gag response. It’s thick, yellow/green and gross (I’m sure that’s a proper medical term). I ask when she last took her salbutamol puffer; she says last night and it didn’t work for her breathing. I check the inhaler. It’s empty. So I give her one from my drug bag and get her to take four puffs with an aero chamber. If she can’t take the medication on her own, I’ll know it’s time to have her transported to the hospital. She inhales the medication while I send a text message to her physician, “It’s Rick, AECOPD pt, can you give me a call?”
While I’m waiting, I reassess the patient, while reviewing the importance of taking medications as prescribed, and avoidance of sick people (especially cute little toddlers). The wheeze and her work of breathing has started to decrease. I’ve dropped her oxygen back to 4 lpm while her SPO2 has increased to 92 per cent. Then the phone rings. It’s been 15 minutes since I’ve arrived.
A short conversation ensues. I give a quick summary of my findings and ask for an antibiotic and prednisone for the patient. The physician orders moxifloxacin 400 mg and prednisone 50 mg immediately for the patient, to be followed with a prescription for another six days of the moxifloxacin and two more days of prednisone that they will send to the patient’s pharmacy for delivery later today. I provide the initial medications to the patient as ordered and instruct the patient to increase her salbutamol use to every four hours until I reassess her in a few days. When I prepare to leave, her breathing is significantly better, and her SPO2 is up to 94 per cent with her oxygen set at 3 lpm; where it should be. Both the patient and her husband are very thankful for the help.
The next two home visits are routine. First, an uneventful visit with a little elderly Scottish lady with CHF who loves to chat about local politics. She’s feisty and doing well now that she’s following the treatment plan we initiated about 2 years ago. Prior to her enrolment in our CP home visit program, she was a regular at the local ER and had been hospitalized twice / year on average. She’s now on our remote patient monitoring system, her vitals have been stable, and she hasn’t seen the hospital for over a year. I schedule our next ‘chat’ in 3 months.
The second visit is with a couple. He’s a retired farmer with COPD and she’s a diabetic who says her occupation is ‘professional grandma’. I review their medications, perform physical exams, and answer some general healthcare questions, taking time to remind her of her dietician’s instructions as she has been ‘indulging’ in anticipation of the holidays. They tease me that they think I’m gaining weight too. I decline the offer for the cookies.
After stopping to grab a bite for lunch, I check in with the FHT. There are two messages waiting for me—a request for blood work for a CHF patient later in the week, and a notification that one of our long term patients died last night. My light mood has just changed for the worse. The patient was one of our first in the CP program and had been in hospital for the past few days after having a stroke. I knew he had been brought in by my colleagues, but I didn’t know the extent of the stroke until I saw his chart. It’s especially sad since he was a long-serving army veteran I really respected and admired. I will miss talking to him. He reminded me of my grandfather.
It can be hard enough some days to process and cope with the ‘regular stuff’ that paramedics experience. Nobody told me that as a CP, the death of a patient would hit much harder. Each time, it can be like losing a old friend. I take a few minutes to compose myself and make a point of visiting his widow after the funeral. It’s become part of how I deal with grief now.
The afternoon starts with a visit to another retired farmer (there are lots of them in Grey County!) who has atrial fibrillation and is on 4 mg warfarin per day. I’m there to check his INR. After the usual physical exam, I find his INR is high at 3.6. Another text follows and his physician orders him to hold his warfarin today and a slight dose decrease afterwards. I’ll be back in a week to test his INR again.
Off to the next patient. An AECOPD patient who we started antibiotics on last week. It’s a follow-up visit that requires another dog treat. The patient finished the antibiotics two days ago. Lungs sound clear, breathing is good, and the patient says they feel ‘human again’. Their physician will be happy to hear the patient has recovered. I remind the patient to continue to restrict their smoking and encourage them to consider a referral to the FHT smoking cessation specialist. I get the usual ‘I’ll think about it’, but they agree to keep working on reducing their smoking. Sometimes you have to pick your battles.
By mid-afternoon, it’s snowing more heavily now and I hear the paramedic radio is getting busier. The county is down to two available ambulances, so I call the communications officer and offer to jump into the mix. I’m advised that I’m now the paramedic coverage for the city of Owen Sound for the next half hour until a couple more ambulances are cleared from hospitals. Time to grab a fresh coffee and enjoy it while parked next to the Chi-Cheemaun ferry moored in the harbour. I get some charting done without being needed for a first response, so it’s back to more home visits.
Another routine visit leaves me completely covered in cat fur. The patient has severe arthritis along with several other conditions and can’t clip her cat’s claws anymore. She’s on a fixed income, so paying someone to do it is a luxury. Thankfully the kitty is rather docile and I come out relatively unscathed. The patient and ‘Mr. Magoo’ are both happier for it. We keep Febreze and a lint roller in the vehicle for such emergencies.
The final scheduled visit for the day is with a fairly new COPD patient who is proving to be difficult. He lives alone in a large century-old house that was converted to a five-plex, likely during the Great Depression era. His apartment is at the top of a narrow staircase on the third floor. I can smell the cigarette smoke long before I get to his door. The sparse apartment is surprisingly clean and organized, despite having walls and furniture that are brown from smoke. Air quality is an issue here. The smoke detectors have the batteries removed again. There is little food in his fridge, and he’s non-compliant with his medications. His chart said he was diagnosed with lung cancer a few weeks ago. He says he’s just waiting to die now and he’s given up trying to quit smoking.
We talk for a while. He’s a huge Toronto Maple Leafs fan. He says he’s disappointed he’ll never live long enough to see them win the Stanley Cup again, then he jokes that he doubts my kids will either. I message his physician that he needs a DNR and a mental health consult. I make a call to my friend at the food bank and contact social services to get his food security problem dealt with. He agrees to resume taking his medications and I put the batteries back in his smoke detector. A referral for further healthcare supports and a palliative care assessment wraps up my visit. I set up a follow-up visit in a week.
Just as I’m heading back to base, my phone rings again. It’s the daughter of one of our CHF patients. She’s concerned because her dad’s legs are ‘swelling again’. Another 10 km trip out to the farmhouse where I find the patient sitting in his Lazy Boy. He says his legs are ‘leaking a bit’ and they are wrapped in towels. The edema is up to just below his knees, his blood pressure is elevated at 174/90, and his SPO2 is 93%. Lungs are clear and he denies any chest pain or breathing issues. His daughter tells me he ‘snuck out for Chinese’ with one of his friends a few days ago, and the swelling started getting worse afterwards. A chart check reveals he’s already on 80 mg furosemide per day. I draw a blood sample and find his sodium and creatinine levels are slightly elevated.
His physician is out of town, so I contact the physician on call at the FHT. Fortunately, she’s still in the office, so she reviews his chart and we have a conversation about the patient. She orders an additional 40 mg of furosemide everyday at noon and puts in a referral for home care nursing for his legs. We also decide to try him on a 0.2 mg nitro-patch to see if that helps with his hypertension. The patient gets another lecture on the evils of excess sodium from me. The daughter promises that “his days of sneaking out like a teenager are over” and confiscates his truck keys. We’ll be back in three days to check on his progress.
By the time I’m done with the ‘delinquent’ patient, it’s dark outside and the snow has stopped. I get back to the station, refuel, restock and wash the truck. Time to complete all my charting, messaging and final checks on the remote monitoring system. I chat with the paramedics on the 1200-2400 shift before I leave and they ask me how many cookies I ate today
Maybe I do need to go on a diet.