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I love Dave Barry, he has been called the most influential humor writer since Mark Twain. If you haven’t read any of his stuff, you really should. In fact, I’ll even provide a link to his web site here: www.davebarry.com. Yes, I’m providing that before what I’m sure will be my well-written, extremely interesting content below. He’s that good. I put that up there because I am going to use a quote of his that he put into one of his columns; he asks his readers if they are saying to themselves “Hey, I can do this! *Any* random person can do this!” And he counters that they are wrong, because “It takes a very special kind of random person to do this”. And that’s how I’m tying this into EMS. I work with a few EMT-Intermediates (I-99 curriculum) and some EMT-IV Techs (WI has a version of a basic that can start IVs with NS and give a few IV meds) that are very sour on the fact that they aren’t paramedics yet. They’re not sour on the fact that they do not yet wish to sit through the required education to become paramedics, but they’re sour that there are skills that they can’t do that they see their ALS counterparts doing. They see us “paragods” performing ALS skills and say, “Hey, I can do that”. And it may indeed be true. I see these days that they keep pushing skills that were once only the domain of paramedics down to the BLS providers. Heck, that’s what EMS is entirely built upon. In the far beginnings of our profession (and we’re still really in the beginning phases) the skills that Paramedics and EMTs perform were once only the domain of physicians. If you would have asked a physician in the 70’s whether a non-physician could interpret an EKG and give relevant medications and treatment as well as he could, you probably would have gotten a very incredulous answer. EMS is all about proving to the medical profession that treatments once firmly entrenched as only for use in the hospital have a demonstrated benefit to the patient when used quickly at the patient’s side close to the onset of symptoms. EMS personnel were trained for that most probably because it just isn’t cost effective to have doctors sitting around manning ambulances. However, the question that has come up in my mind is where the bottom of that lowering of educational requirements for advanced skill performance ends. I have seen in my career a paradoxical movement in educational standards for paramedics and EMTs. There are a smattering of disparate and yet somehow complimentary certifications in some states, but while some educational standards have improved, most of them have decreased. While a good argument can be made for EMS levels between the Paramedic and the EMT-Basic, such as the I-99 and the IV tech in WI or the Iowa Intermediate in Iowa in the sense that they allow rural communities to be able to perform some advanced skills without having to shoulder the full breadth of costs and responsibilities associated with full paramedics, they also don’t take into account that a lot of those skills require a whole heck of education to be safely performed in the outlying patient that can be harmed by inexperienced providers. The debate that I got into with an EMT-IV Tech over breakfast the other morning went something like this. He brought up the fact that EMT-IVTs could administer Narcan to reverse heroin OD’s or other narcotic overdoses. His statement to that was that they ought to be then able to give Morphine for pain control “since we already carry the reversing agent” (in case they give the patient too much or the patient has a reaction). My thoughts are that they should not be able to, because the administration of a narcotic for anything requires a requisite knowledge of the pharmacologic, physiological, and social actions of the drug. And while yes, that could be covered in a module I could assume, why should it be? I brought up that it takes physicians years of experience to be able to tell how to identify drug seekers who want to get a high from the legal, medically prescribed narcotic. Contemporary medical journals in family practice and emergency medicine have written volumes on the topic, and still physicians can be fooled. The extrapyramidal reactions possible with morphine, including respiratory and other Central-Nervous-System (CNS) depressing features of the drug have other treatments and symptoms that can be hard to recognize for an inexperienced provider. An EMT-IVT just doesn’t have the breadth of background knowledge needed in order to judiciously use the drug safely in all cases. The fact that most of the time it would work out fine does not withstand the certain percentage of patients that could and would be harmed. I ended the argument with him by bringing up something that I’ve always remembered from paramedic school. Our lead instructor told us that our drug bag was nothing but “A big bag full of poison” if you didn’t know how to use it. Remember, every single time any medical care provider performs any treatment of any kind on a patient they’re making the statement that “Right now, I know better than your body does. I know better than your brain, your nervous system, and better than all of your body’s self healing systems do what you need to keep living and get better”. Any time you put on a bandage, you’re telling that patient that you know better than their body does that they need to stop bleeding. Every time a paramedic or other provider uses an airway management technique they’re saying that they know how to breathe better for the patient than the patient’s own body does. Every time you give a medication to a patient you’re telling them that you know how best to control their body’s systems. Think about it. Every treatment, every time. It is a HUGE deal to be able to do this stuff, and you dang well better know your stuff. Physicians are rooted in the quest for knowledge. Their reputation as learned individuals goes back to prehistory in one form or another. They’ve earned their vaulted place in society due to their quest for knowledge and reason and their caring for others above all else. EMS people came from physicians. I can think of no other medical profession that has a downward pressure on their educational standards. I’m saying that, because I think that EMS does. We have elements in our own ranks, and external forces that are continuously working to make us into skills monkeys that can be paid very little and know very little. This is a big statement: Not everyone can be a good paramedic or EMT. It takes a certain intellect, sound ethical reasoning skills, and a level of professionalism that not everyone can attain. This is another big statement: There are groups in our society that want to make it so that any random idiot can become a basically qualified one. This keeps us all down and lowers the quality of patient care… a lot. Yet another: Us good EMS people should be really ticked off that educational standards are so dang low these days. Fight for excellence. Respect ourselves. If you and or your service want to be able to perform advanced skills, earn the requisite knowledge through your studies and earn the level that it takes to do them. Enough is enough. I don’t believe that we should lower any more educational standards. No other group would do this, not the nurses, not the PA’s, and certainly not the physicians. Why should we? Yes, I understand that with the advent of Urban Fire Based EMS the IAFF and IAFC want to put more paramedics on the streets to increase their influence and their revenues, and that in order to do this they need to match the intellectual skills of medics with the intellectual skills needed to be a good grunt firefighter, but EMS is a MEDICAL profession built from the quest for knowledge. It should not be relegated to the technical performance of skills if X equals Y. Heck, I think that the current level of Paramedic should be the basic level, and that Paramedics sh Thanks everyone for the support and the well wishes, tell your friends about the blog. As always, I invite commentary here on the site and E-mails to: proems1@yahoo.com
ould be as independent as Physician Assistants. In a later post I’ll share my belief that we should be providing family practice type primary care on the streets.
Somehow I’ve become the go-to site for information on the EMS Narrative Report. I’m very much OK with that. I believe that the Narrative Report and the EMS Report is the most important information-sharing tool for the Paramedic or EMT.
Here are some of the things I’ve written concerning the EMS Narrative Report, and for EMS Charting general.
“Soapy Pictures – The EMS Narrative Report” – This article is about the evolution of my narrative style, and shows how I went from just writing something into actually charting about the patient in the best way that I can. It shows how I fuse the “Chronological Narrative” reporting style with “SOAP Charting” (using the SOAP method to write the EMS narrative) – There’s a lot of tips in here.
http://proems.blogspot.com/2009/06/soapy-pictures-ems-narrative-report.html
“More on EMS Narrative Reporting” – This article is a more in-depth “nuts and bolts” how-to guide for the paramedic or EMT to use in designing their narrative reporting style. I emphasize how to properly place information and how to share it with the user of the information. Emphasis is placed on using the SOAP charting method.
http://proems.blogspot.com/2009/06/more-on-ems-narrative-reporting.html
“Six Tricks you can Use Today to Improve your EMS Narrative Report” – Don’t have time to read due to your call volume? Use these tips and tricks as a quick tutorial and begin writing professional EMS narrative Reports today. Whether you’re a paramedic or an EMT, these tips will have you writing your ambulance run sheet like a pro.
http://proems.blogspot.com/2009/07/six-tricks-you-can-use-today-to-improve.html
I found a site that caught my eye the other day and signed up for it. It’s called EMSLive.com, and no, they’re not paying me to write about it. I posted some articles there and I think that I’ll post anything that I’m particularly proud of on that site so it gets more exposure. I posted The Shine Factor there today. Let’s see if anyone reads it. Oh, and THIS LINK RIGHT HERE may be my favorite comic strip ever. Thanks to Dave Barry and the Miami Herald, and of course, Calvin and Hobbes.
Tonight I would like to take a few moments to hit on what is one of my top-ten all-time use-a-lot-of-dashes-in-between pet-peeves in EMS and probably in health care in general. It’s the “DNT” or “Do not Treat” order. It might just as well be called the “DNC” or “Do Not Care” order, or “Do Not Comfort”, or “Do Not Be Humane”, “DNBH” Order. Yes, I’m talking about DNRs here. They’re “Do Not Resuscitate” orders and if you’ve been in EMS for longer than a minute or two you’ve heard about them. DNRs serve a good, humane purpose in a lot of cases. We all know that even though we’re improving (GO CCR!!) CPR and ACLS are largely rituals that we perform for the dead in our society. They rarely bring people back if they happened to be sick enough to die in the first place. They’re also very traumatic things to do to a body. DNR Orders are a humane way for patients and families to say “Enough. When God or whom/whatever I may or may not believe in says it is my time, it is indeed my time”. I can respect that. I happen to be a Christian and I believe that we go to a better place once God decides that it’s time to punch our clocks. If I had a hopelessly terminal disease I would probably be pretty ticked off if some young kid with a shiny new EMT card brought me back to face more of the disease progression with a couple of broken ribs for the trouble. I get it. What I don’t get, and what just drives me crazy is people who treat DNR orders like they’re “DO NOT TREAT THIS PATIENT BECAUSE THEY’RE JUST A DNR” Orders. I know that I will hear this again, and probably tomorrow because I heard it three times today and I’m on a 48hr shift here, but I think that I might say something unkind to the next person that says, “well.. They’re a DNR” when I ask them why they’ve let their patient suffer in agony for hours before they decided to send them to the ER. Yes, I um… occasionally go to “Skilled Nursing Facilities”, can you tell? Here’s what a DNR order does NOT mean:
Don’t think that I’m just picking on the nursing homes here.
I once had a transport where I took a young infant with a horrible medical condition from a small ER to a tertiary Childrens’ Hospital. (A different one from the one in a previous post). This poor little baby was now living with a set of very nice foster parents but just didn’t seem to have much chance in the world due to his/her terrible start in life. The child was on oxygen, needed regular suctioning, and was being sent to this tertiary facility to replace his/her feeding tube, which had become dislodged. Because of that, the patient was having some increased breathing difficulty and was actually pretty challenging to take care of for the hour long transport. The foster mother had brought the baby into the pediatrician’s office for this condition, and the pediatrician had set up the direct admit to the tertiary facility after sending the kid to the ER close to his office.
The foster mother was a very nice lady who seemed genuinely concerned and caring about the kid. I asked her why if the kid was in that bad of shape did she not call 911. Her answer? “I thought I couldn’t call 911 because he has a DNR order”. Someone, and I don’t know whom… but someone had told this wonderful foster mother that this child was NOT WORTH EMERGENCY CARE because he had a DNR order! Yea, not in so many words I don’t think… but that’s the general idea she had. I corrected it. Told her to call 911 whenever she felt she needed to and let her know that the ambulance crew where she lived would love to come visit her to learn about and help take care of the child. I cannot believe that someone would lead a person to believe that… I just can’t.
Oh, and yes, today I had a SNF patient that fit my whole DNR/DNT pet peeve thing… and yes, an ER staff person may or may not have given the “Just a DNR” comment. In fact the whole healthcare system may have failed someone today that chose to have a DNR order and neither he/she nor his/her family knew about it. But I did, and I fixed it.
And I just ranted about it.
Someday soon I may turn this blog post into a coherent article, got any rants you’d like to post? I like comments. As always: ProEMS1@yahoo.com
Grumblemedics, you know them. You’ve seen them. Heck, you may even be one. Whether they’re a Grumble Pee or a Grumble Bee, there’s an apparent glut of them in the profession and I’d like to know why. See, to me, EMS is the greatest job in the world. Sure, there’s the great pay and benefits, but there’s also the great hours, plentiful time off, and comfortable ergonomic working environment. I can’t tell you how many times I’ve been just left with a warm-fuzzy feeling after a shift…
Ok, so that could have been an exaggeration, I know that there are things in this profession that just plain ol’ stink. But I gotta tell you, EMS really is my favorite job. I really can’t imagine doing anything else. While there are times in my career that I’ve wondered if it was an abusive, co-dependent type of relationship, I realize that I would not want to be anything other than a paramedic.
So why does it seem like there are so many Grumblemedics? Could it be the long hours with little chance of getting a day off? Could it be the fact that we must get up at all hours of the night to take care of someone in better shape than we are? Tangent: The other day another crew transported a person with a chief complaint of “Dry Feet”. When they asked him if he really wanted transported, he said “Yeah! I got dry feet!” Or, the one last night where a woman had an NSAID pain patch fall off at 4am and called us because she thought that she was going into withdrawal. End Tangent.
OK, heck with the ending the tangents. There are a whole heck of a lot of calls that can be filed under “They called us for THAT!?” Why do people do this? Why? I mean, I’ve been called for things that I wouldn’t even take an aspirin for more times in my career that I can count (And I know that’s more than ten because I have ten fingers and if you think that I’m going to take off my boots after working in them for all of these 24 hour shifts you’re nuts). Why do people call us when they have a muscle cramp? Why did the guy call me when he got a fish hook in his finger? Why do people who happen to be type 1 diabetics drink themselves into a stupor and then call me first thing in the morning to wake them up? Seriously, I once spent a few months going to some guy’s house every shift bright and early in the morning to squirt him with a little D50 and he’d sign the refusal that would send him on his way. It ended when we began putting him on the cot and starting to drive to the ER before we sugared him up. He’d wake up in the rig just as we were backing into the bay doors and be mad at US for transporting him. Sorry guy, but you obviously need more help than we can give you.
So, there may be times in my career that I’ve been a Grumble Pee, but that might be expected. Heck, if I worked in a factory I’d probably be complaining about the lack of adequate ventilation and the fact that I couldn’t sit in the crew lounge and watch TV for a few hours of my shift. We all complain about things we can’t change or our own perceptions of injustice. I would guess that any profession has those things that the people in the profession just hate. Heck, would any of us want to work retail during the holidays? They don’t even get to jab strangers with sharp objects or have their own keys to the leather restraints.. Now THAT would suck.
You know what my absolute, all-time, worst pet-peeve is in EMS? No? I’ll bet you don’t care either but this is my rant and you can’t seem to stop me. My biggest, all-time, worst pet-peeve in EMS is: People who don’t call us when they need us. Yep, I would gladly take a hundred 3am “lost condom” calls rather than have one potential patient have that occult MI and lose any percentage more of heart muscle than they have to because they didn’t want to call EMS and bother us. You see, I work in rural EMS these days where people are nice, and they don’t want to bother their local EMS service with getting up out of their chairs, and they don’t want to bother their neighbors with having to look out their windows at the pretty flashing lights, and they really don’t think that the fact that the left side of their body is numb is any reason to be alarmed. These non-calls that should have been calls bother me more than any of them, and we all grumblemedics are somewhat on the hook here.
If you’ve read any of what I’ve written, you’ve probably seen my statement that “PR Saves Lives”. It means that the more positive Public Relations an ambulance agency has, the more people trust them, and the more people are apt to call them when they truly need them. I haven’t seen studies on what an effective PR program does in reducing so-called “nuisance calls”, but I have seen recent studies that say like 60% of patients having heart attacks make their first call to a friend or family member upon the onset of their crushing chest pain. I’m here to tell ya, I’m jealous. I want to get that call.
So maybe grumblemedics like I probably will be about an hour from now when someone calls me at 3am for something that I would take pepto-bismol for need to remember that we are blessed to do this job, and that EMS professionals need to approach this business with the heart of a servant. Because that’s what we are. We aren’t here for our health, we’re here for everyone’s health. Sometimes people get scared and call us because they’re scared and it is our job to make them feel better by telling them they don’t have to be scared anymore. Sometimes we need to haul them in so someone with a whole-heckovalotta medical education can tell them that same thing. I decided a long time ago that if I ever got to a point in my life where I had to call the ambulance just so I could get some human contact because my real chief complaint was loneliness that I didn’t need some punk kid with a pulse and a medic card judging me.
Us grumblemedics need to realize that the nuisance calls are never going to go away. We’ve got to realize that there are, however, ways to combat them:
- Check your Ego at the Door: You serve the public. Not the other way around. You are blessed and dang lucky to be the person that this person asked to take care of them in their or their loved one’s hour of perceived need and you best not forget it, because your mental health is at stake, and their life could be too. The best EMS people approach this job with a servant’s heart.
- Evangelize EMS: You want the general public to know how to properly use EMS, right? Then what have you personally done to help teach them. Get out there and get the word out. Don’t hide in your station, or in the parking lot you’re posting in. Get the message out about what you’re there for, what you’re capable of, and how friendly you are while you are doing it.
- Everything is PR: Every single, solitary thing an EMS person does affects the publics’ perception of them, their service, and the profession in general. Really. When you meet up with another crew for breakfast in the morning and talk about how wasted you got last night at the bar don’t think that the people around you aren’t listening. When you swear in public don’t think that the kids who are looking up to you in your shiny uniforms with your neat big truck aren’t filing that away. Take your public image seriously. Exude professionalism at all times because it saves lives. The more comfortable everyone is with your professionalism affects how apt they are to call you first, call you fast, or call you at all in a life or death situation. That can make all the difference for a lot of potential patients.
There’s a lot more that every one of us can do, but I’m tired here and I still have the last 8 of my 24 to do be
fore I have to get up in the morning and do 8 hours with my other full-time job and then do a 4 hour training with my volunteer department. Hey! I have an idea!! Maybe if there weren’t so many grumblemedics and the public took a more positive view of our value to society we could maybe squeeze some more pennies out of them at budget time and get paid better so we wouldn’t have to have so many freakin jobs and work so many hours to feed our families! Yea, wouldn’t that be great!!
As always folks, comments and flames are welcome. Public commentary is most appreciated, but I may always be reached privately at: proems1@yahoo.com
Some time ago I was working a shift in a clinic on a particularly busy day when I had a few moments to sit down, have a cup of coffee, and talk with my coworkers. It was the usual stuff, talk about the day, tidbits about personal lives, and since most of the people I was working with were women, talk about things that I didn’t really need to hear about. After a few minutes we all had to get back up and head back onto the floor to keep up with the constant tide of flu-season sniffles.
It was all pretty mundane for me until the doc that we were working with who hadn’t been there much before, made a statement. As we were walking out, he said “Man, I really hate this! This isn’t my love, it’s not my passion!” I was taken aback. I asked him what he meant. He went on to say that he really wanted to be a concert pianist and that he only did medicine now because he didn’t know how to do anything else.
Now, I’m not you… but even though this guy was a pretty good Doctor, I immediately felt sorry for all of the patients that day. I mean, would you want this guy to be your doctor? Who in their right mind would want someone who hated taking care of you taking care of you?
It did, however, get me to thinking… Is that where we are in EMS today? I mean our profession. The profession of EMS, our careers and our industry. Are we made up of people like this doctor? Now during the day that I worked with him, he never made any egregious errors in patient care, nor did I see him do anything illegal, immoral, or fattening. However, if providers aren’t *in* to providing to care, would you want to have them providing care to you or your family? What about your service? Sure, we all know providers who love EMS, love their patients, and can’t wait to take care of any patient that calls for their help, but while I would hope that they are the majority… are they?
EMS is a profession in its infancy, we’ve only been around since sideburns were popular, but in that time we’ve gone from dedicated but untrained people rocketing around in hearses to professional providers practicing curbside critical care. It’s a great profession to be in and I’m proud to be a part of it. As a group we’re a pretty dynamic fast paced lot. I would like to ask our group though, do we have the love of providing care to the breadth of society who call us when they think that the life or health of their themselves or their loved ones are in danger? Or have we fallen short of the lofty goals set forth by Johnny and Roy?
Yep, I’m asking a lot of questions here. I just would like to open up a dialogue among the EMS professionals out there. Ask yourselves if the EMS providers in your area are advancing the profession of EMS to the place where you think it should be heading. Ask yourselves if you work with people who have the love of the profession enough so that if they were strangers and you were a patient would you want them making decisions about your life? I think that it’s high time that EMS is taken over by EMS professionals who care about advancing our profession into the future, not by people who don’t care enough to understand the vast array of issues that face our industry today. I would like EMS people to take ownership and drive our industry where we believe it should go. It’s our profession, and our responsibility to strengthen our service to meet the challenges that are facing our communities. And that responsibility starts with you, the individual EMS provider.
You, as a caring EMS professional actually have the tools to do this. First off, realize that EMS is a profession all its own, truly a dynamic industry that has earned a place in the very fabric of country. Think about it, our generation and the generations to come have grown up with the notion of 911. They know that when the unthinkable happens, all they have to do is call the magic three numbers and someone will come and help them. It’s a powerful piece of the American psyche that people rarely give second thought to… but they all know what they’re going to do the next time they find Grandpa unresponsive. I think that if EMS ceased to exist (and contrary to what it may look like from the dashboard of your ambulance some days, it’s not all that likely) our society would look a lot different than it does now. People need to have the notion of EMS. And make no mistake, we’re darn privileged to have the role in society that we do. It is, however, up to us to awaken the public to what it is that we do, to educate ourselves to our own potential, and to show the medical establishment what we’re capable of. Ask yourself, really ask, if you want some other group to decide where we’re going for us, oh… say like the nurses’ lobby, or the IAFF, or the DOT, or the (insert non-EMS acronym here). You are sitting right now in an industry on the cusp of a watershed change, and it’s up to you to take ownership and steer EMS where you want it to go.
Here’s what I’m doing, and what I would like to suggest to you all. First, recognize that EMS is indeed a profession; and a good one at that. Second, evangelize EMS to all you meet. You can’t complain about the system abusers (or worse, the people who truly need us and yet don’t call us) if you aren’t out there educating them about what we’re here for. Third, realize that “PR Saves lives” and make sure that the information out there about EMS in your community is projecting the message that you think it should, and if it isn’t, write something up and get the word out to change that. Talk with everyone you can and let them know just what it is that we do, who we are, and what we’re capable of. Take ownership of EMS, because if we don’t, someone else out there will.
As always, post publicly if you want public discussion, or contact me at: ProEMS1@yahoo.com
So the other day I was taking this cute little 9 month old to a tertiary specialty childrens’ hospital. It was a nice place, big, clean, bright, state of the art equipment, people scurrying about looking busy, cute nurses, etc.. It was a class act. The patient was stable and quite pleasant actually. We had been playing in the back for the last hour to the extent that a 9 month old can play while in a papoose restraint. Yes, he was papoosed, but only because he had a fractured femur and needed the tight immobilization. I happen to like kids thankyouverymuch.
What got me about this is that when I got the patient into the ER room, a bunch of slightly older kids walked in wearing scrubs. My first thought was that they had a new crop of ED techs that were in training… however, much to my horror they identified themselves as surgical residents. Oops. Looks like the last ten years or so that I spent driving fast and breaking things could have been spent in a cramped room looking at books and developing my student loan debt. It got me to thinking that if new doctors were starting to look young, and if I was starting to feel grandfatherly in the ambulance, maybe I should consider advancing my career.
The problem with this is that I’m an EMS addict. Really. No I don’t have 25 warning lights in my personal vehicle and my physique is free from star-of-life tattoos… But I just have always liked getting up every morning and being plum lucky enough to be a paramedic. I can’t imagine doing anything else for a living. It has struck me that whenever I hear coworkers talk about career advancement it usually involves leaving the streets and taking time away from patient care. If you’re on the fire side, you can become a lieutenant or captain and get off the “box” away from the “gomers”, or if you’re not you can become a nurse and increase your income while diminishing your clinical decision making skills (Yes, I pick on most nurses here). However, I’ve been thinking about what I could do to “advance” my career while feeding my addiction to making sick people feel better in the way that only medics can.
So here it is, after a shift or two of kicking it around, I have decided to decrease the amount of my time that I used to spend sitting around on duty watching Internet videos of people hurting themselves and looking up pictures of cats with funny captions (Yes, I’m more of a man because I love my fluffy-wuffy lil’ Kitty-Witty) and spend some time writing useful tidbits of ambulance crap that I have garnered through the last ten years or so of riding under the lights and being smacked around by what the streets have served me up. What follows on this blog is one of my first pieces for the enjoyment of a wide audience. If you like it, I’d love feedback here or at: proems1@yahoo.com.
Oh, and for the web crawlers: Paramedic, Firefighter, EMT, Boobies, ambulance, fire, medic, EMS.
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