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Not EMS: Political MSM journalism at it's best

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Yay! and Hooray! for Sherman Frederick and the Las Vegas Review-Journal!

If you ever come to the nebulous area in Northern Illinois and/or Southern Wisconsin where I live and work you definitely should e-mail me, I’ll treat you to good Wisconsin Cheese, awesome Illinois steak, and cold Milwaukee beer. Don’t forget the heavenly Illinois sweet corn as well. Shoot me an e-mail at proems1@yahoo.com.

No really. When you wrote what appears on this link: http://www.lvrj.com/opinion/56171937.html I was just plain overjoyed. You earned a seat at my BBQ any day of the week.

This article, that should be read by anyone of any political stripe, is just the kind of journalism we need. I may even pay for a subscription to the paper. Standing up and speaking truth to power is what “Real Journalism” happens to be. Every Damn Reporter (and yes, I just swore for the first time ever on my blog) should read what you wrote. Every citizen should too. You stood up for all of us.

And I’ll stand up right with you. With as loud as my small voice can roar, by God I’ll stand with you.

Bravo. Cheers. and Hell Yea brother.

Here’s the link again, in case you haven’t clicked it yet: http://www.lvrj.com/opinion/56171937.html

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A sincere Thank YOU – and some behind the scenes info

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Today is a day of rest, and so was yesterday honestly, at least as far as the blog is concerned. Gkemtp(it) is making me do honey do’s all day. There’s a lot, being that I’ve been working almost 100hrs per week and haven’t had much time to do them. So there’s a lot of work being done at the ol’ Ckemtp household today.

That, and in much more interesting news, I’ve got myself into a competition with my neighbor today. He mentioned that he had two dozen ears of good, Illinois sweet corn (the best in the world, mind you) and asked if we wanted some for dinner. I did. I mentioned that I had a few racks of baby back ribs that I would cook. He wanted some so he could cook em his way… and I wanted to do my way…

And it’s on.

I’ll report more on that later. Our wives and kids are judging the competition.

And a sincere THANK YOU to all of you who may be reading this. I’ve been growing in hits steadily since I started the blog, and every month has been at least 300-400 bigger than the last. Today the blog hit OVER 1000 MORE HITS than last month, and over 1100 page views. Now, that’s not as big as AD, who just hit a million… but it’s still very flattering and I thank you all so very much for reading my stuff.

If you were coming to the cookoff, I’d let ya try my bbq.

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EMS Rule #2543

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It’s 16min till end of shift… do you know where your favorite frequent flier is?

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Linky stuff – Great EMS/Fire blog

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In case you haven’t been keeping up with the blogroll over on the side, you may have not seen that I put up “Notes from Mosquito Hill” over there. Mack505 writes it and I really am liking his stuff.

If you haven’t been there, go check it out. Then come back.. please.

http://mack505.blogspot.com/

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The Handover is coming! The Handover is coming!

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Coming soon to Life Under the Lights, The Handover Blog Carnival!

Yes, Medic999 has convinced me to put my money where my mouth is and host an edition of the Famous EMS Blog Carnival. Hopefully I can live up to the heavy expectations of the readers and fill the big shoes of the bloggers who have hosted before me. The Handover is the biggest and best blog carnival featuring awesome bloggers from the world of the Emergency Medical Services and The Emergency Room (US) and Accident and Emergency Room (UK).

Yep, it’s an international EMS blog carnival featuring the best in Emergency Medical content from around the world. It is published monthly. There are Paramedics, EMTs, firefighters, Nurses, and Doctors that participate. If you haven’t read it before, you should. In fact, head on over to Medic999’s place – http://medicblog999.wordpress.com/ and check out this month’s edition. The theme for his edition is “My First Call” which promises to pull out the emotional, the macabre, and the flat out hilarious stories that we all share as members of this crazy profession we call EMS and Emergency Medicine.

Oh, and you’ve all been waiting for the announcement, so here it is…. The theme for my edition will be:

“Funniest. Call. Ever.”  The deadline for submissions is Monday, Sept 21st and it goes live on Friday 9/25.

Yes, that’s right. Pull out the best call you’ve ever had, the one that you tell in the coffee shop to other medics that still makes them wet themselves laughing or scratch their head wondering how we could ever make this stuff up. We can’t, and that’s what makes it so funny.

Can’t wait to see this month’s edition and I can’t wait to get started on the submissions for my edition next month. Stay Safe, everyone.

Oh, and in case you haven’t seen (and I hid it when I posted it) Here’s the story of my first that I submitted for this Month’s Handover:

http://proems.blogspot.com/2009/06/my-first.html

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Still more Everyday EMS Ethics – Gkemtp(it) is born

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I’ve been on this kick lately for medical ethics in EMS. So, I’ve decided that “Everyday EMS Ethics” is going to be a featured area on my blog. I think that It’s annoying my wife Gkemtb who, by the way, is starting Paramedic school today and is now becoming Gkemtp(it). The (it) means, “in training”.

The unfortunate thing is that she’s now reading her paramedic textbook and she’s asking me ethical questions as she’s studying medical legal aspects of paramedicine. Tonight, she asked me this question:

Imagine you’re in the back of an ambulance with a patient on a long-distance transfer. During the transfer, the patient states to you: “I think that I’m ready for my life to end. I’ve had a good run and I’m just comfortable with the idea of the end of my life. If I die, don’t do anything to bring me back. I’m ready to go”.

 I said, “Well… it depends. Is the patient in his right mind?”, “How old is the patient?”, “is this a suicidal ideation? Or is this someone who might be getting ready to sign a DNR but hasn’t yet?”. She indicated that in her mind, it was an elderly person with a long medical history. If it was someone that was possibly mentally ill… the likelihood of which increases with decreasing age and better long-term prognosis, then I wouldn’t honor it just the same as you wouldn’t kill someone who asked you to kill them because they wanted to commit suicide. However, if it was, say, a long term brain cancer patient that had metastasized and was causing great pain… then it’s a different question. Ultimately, if I was the only person that the patient said it to, I would try to get them to say it in front of other witnesses. If that couldn’t happen, and the patient did in fact go into cardiac arrest… well then I would probably resuscitate them because I would never be able to prove that I acted in accordance with the patient’s wishes. But I wouldn’t like it. Please tell me what you would do, because heck, I don’t know…

The other thing she brought up was if I knew about the “Oath of Geneva” and um… I didn’t know about it.
A quick Google search brought it right up for me, so here it is:

Physician’s Oath

At the time of being admitted as a member of the medical profession:
  • I solemnly pledge myself to consecrate my life to the service of humanity;

  • I will give to my teachers the respect and gratitude which is their due;

  • I will practice my profession with conscience and dignity; the health of my patient will be my first consideration;

  • I will maintain by all the means in my power, the honor and the noble traditions of the medical profession; my colleagues will be my brothers;

  • I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;

  • I will maintain the utmost respect for human life from the time of conception, even under threat, I will not use my medical knowledge contrary to the laws of humanity;

  • I make these promises solemnly, freely and upon my honor.
According to the article I read on it, which surprisingly wasn’t from Wikipedia this time, and is located at (http://www.cirp.org/library/ethics/geneva/) this oath was adopted by the World Medical Association (A group made up of National Medical Associations… well, read it yourself:

The World Medical Association is an association of national medical associations. This oath seems to be a response to the atrocities committed by doctors in Nazi Germany. Notably, this oath requires the physician to “not use [his] medical knowledge contrary to the laws of humanity.” This document was adopted by the World Medical Association only three months before the United Nations General Assembly adopted the Universal Declaration of Human Rights (1948) which provides for the security of the person.

Paramedics come from physicians. Therefore, I believe that we are to honor much of the same ethical standards as they are. Healthcare is an honorable profession. We have the obligation to carry it on that way.

Sorry about the serious posts lately guys J I’ll go back to posting about driving fast and kneeling in poo soon.


 
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Everyday Ethics for EMS Providers

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Mike left a comment on the last post I wrote “EMS Politics, Medical Ethics, and… What would you do?” with a good quote that I’d like to bring the forefront of discussion: “Your next call could be your last call”.

That sentence sums up something that I’ve always said about EMS quite nicely. Bravo to you and your old partner, Mike.

I firmly believe that EMS professionals face “No Win” scenarios several times in their careers. There are things that come up and situations we face that would test the most knowledgeable medical ethicist. Often times we have to make terrifyingly difficult split second decisions using woefully inadequate information that will not only affect the very life of a patient but also our careers and our livelihoods. It’s not fair, and it’s not fun. Paramedics are entrusted with huge responsibility for clinical judgment but can be quickly chastised and sanctioned for even stepping a little bit outside of the box. No, we’re not physicians and No, we’re not licensed to perform everything that a patient may need. I understand that there are some things that are just too dangerous to do in the field, and that yes, patients sometimes die in front of us and we are powerless to stop it.

However, in the scenario presented in the abovementioned post, that was not the case. In the case presented, the patient needed a surgical cricothyrotomy and needed it NOW. The paramedic described in the scenario had been trained in the procedure, had the tools available to him to perform the procedure, and the patient was going to die quickly without the procedure. The catch was that the protocol system he was working in did not allow him to perform the procedure.

The scenario gives two choices:

  1. Don’t perform the cric. Use your full airway bag o’ tricks such as first trying BLS techniques (Heimlich Maneuver, abdominal thrusts) attempting to remove the object with Magill forceps under direct laryngoscopy, attempting to intubate the patient with an ET tube and push the blockage into the right main stem bronchus with the tube allowing the left lung to be ventilated (It’s better than nothing), and scooping the patient up and running really fast to the hospital. If all that takes more than 5 minutes from the time the airway got blocked, including the time from incident to the 911 call, the dispatch time, and your travel time, expect brain damage at the very least. If it’s much longer than that, expect the patient to die.

     

  2. Perform the cric. You’ve got the knowledge, you’ve been trained on the procedure, and you have the equipment available to perform the procedure. The procedure is in the standard scope of practice for paramedics all across the country. Unfortunately, even if the patient makes a full recovery, you’re in deep trouble. The Medical Director in the scenario has not authorized the procedure for paramedics under his/her direction and therefore you’re practicing medicine without a license which is a violation of the letter of the law. It may very well be the only thing that will save the patient’s life, but you’re likely to face severe penalties for violating your protocols.

So what do you do?

I firmly believe that medical direction should not hold paramedics back and that there has to be some leeway in the standard operating procedures that paramedics function under to allow for these situations. Every protocol system and EMS service that disallows such procedures that are allowed under national accepted scope of practice can have situations where patients have poor outcomes up to and including death. In these systems, the EMS provider bears the brunt of the negative result. If he allows the patient to die, it could be argued that he withheld lifesaving care and violated a duty to act. If he was protected legally by the letter of his protocols and the fact that he followed them, he at least could be committing a moral and ethical violation that will haunt him for the rest of his life. I would suspect that the medical director and/or the authorizing body would not be sanctioned in this case… if they were even aware of it. By performing the procedure and saving the patient, the paramedic will be punished quite severely. Even if the patient survives but has residual morbidity resulting from the prolonged anoxia, the medic could be sued for and be held liable for the damages.

In any case, the paramedic carries the burden. It’s a no-win situation.

For the record, I didn’t actually have this happen to me, but I have worked in two systems simultaneously where one is more progressive than the other. In fact, I do right now. Fortunately, both of these systems allow surgical cricothyrotomies, but they carry different medications and have different dosages. One of my services uses CCR (Cardiocerebral Resuscitation – http://www.callandpump.org/) and the other follows an older version of the AHA guidelines. While both are acceptable and I follow the protocols for the system that I am working at when I am working there, I can see the potential for ethical conflict. I’ve been a full-time paramedic for a long time and I’ve flexed the rules occasionally when it was in the best interest of the patient. Luckily (and yes, I know I’ve been lucky) the patient has always had a good outcome when I’ve had to do this.

Here are my rules for “bending” the rules:

  • Above all, always act in the best interest of the patient – If you can show that you acted in the best interest of the patient, disregarding any other potential motives, you’re well on your way to vindication. However, remember that ‘rule bending’ must be for the patient’s best interest, not your own. Something like not placing the shoulder straps on the patient during transport because it makes it more comfortable to care for them is in your own best interest, not necessarily in the best interest of the patient. Taking a patient to a hospital closest to your next errand and not to the most medically appropriate is also in your best interest and not in the patient’s. The cric scenario regards whether the patient will live or die at great peril to the paramedic.
  • Know what your protocols are and why they are the way they are – Knowing your protocols inside and out is essential to being a good professional provider. Knowing WHY they are the way they are, i.e. the reasoning behind them is essential as well. Be able to show that you know them inside out when you’re questioned, to show that you’re not negligently ignorant of the rules you have to function under.
  • Be able to prove what information you had available for you to consider – In these situations, you’re working with incomplete information. However it is your professional obligation to gather as much information as possible as quickly as you can gather it. Do a thorough assessment, and talk to the patient and any bystanders, if possible. When questioned about the incident later, you need to be able to present the information that you were presented with to the people who are going to play armchair quarterback. Be able to put them inside of your shoes.
  • Be able to prove what options you had available to you, how you considered them, and why they did not or would not have
    worked – In the previous airway control scenario, I laid out possible options that the paramedic in the scenario considered. I also laid out why they would not work as the situation unfolded. Be able to show your thought process and how you ruled out options that were within the letter of the rule book.
  • Be able to prove why you thought that the option you chose was absolutely necessary – If it was a “do or die” call, be able to prove it as best you can. You should be
    able to show why it was necessary that you chose the option you did. In the cric scenario, transporting the patient to the hospital so that a physician could perform the procedure would most likely have resulted in the death of the patient. In that case, the best interest of the patient, obviously, would be to continue living… which he would not have done without the paramedic violating the rules. BE THAT SURE of yourself.

I would love for people to jump in and offer their takes on this topic. Please comment away. If you haven’t read the great comments on the previous post, left by such people as Medic999, HappyMedic, and TOTWTYTR you can find it here.

I use scenarios like the one that I wrote out in the previous post as a teaching tool for new EMS people and students that I precept. I think that scenario-based teaching is a great way to promote critical thinking skills and to evaluate what a person would do when faced with the situation presented. In the future, I’m going to be featuring scenarios that challenge ethical standards as a way to educate ‘Everyday EMS Ethics’. Look for the “Featured Areas” to showcase these and other interesting articles.
And thank you for reading.

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"The Handover" is Coming!! Oh, and some changes to the blog.

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This is just a reminder for everyone that the new edition of “The Handover” Blog Carnival, the Finest EMS Blog Carnival, is coming up soon! It is being hosted by Medic999 who is saying that this is the biggest blog carnival yet! The theme for this month is “First Call” and is featuring EMS Bloggers from around the world talking about a sentinel event in their life, their first EMS call.
Be sure to visit! Next month, “The Handover” will be hosted right here by your’s truly. I’m working on some things and I know that Medic999’s will be a tough act to follow.
Oh, and over on the left side of your screen there’s a new navigation area. I’m putting “Featured Areas” for related content. Check it out as it grows. Also, has anyone tried the “Click here for a random post” link over on the top left? Try it out.
If anyone has any questions they’d like me to try and answer, shoot em’ to me. My e-mail address is right over there on the left as well. Please feel free to shoot me an e-mail. The more suggestions you send me to write about, the less I have to think up new ideas!
Thanks for reading, everyone.
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EMS Politics, Medical Ethics, and… What would you do?

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You’re sitting in your station playing one of your coworker’s new High-Tech Advanced Video Game System on shift one day. It’s so freaking cool you think. Man, I gotta get me one of these. You’re just getting the hang of really splattering those aliens on the walls of the rogue spaceship when:

“Doooo DOOOOOO!!” go your tones over the radio.

“Attention Medic 39, Medic THIRTY nine! You have a medical call for a 37 year old man choking, not breathing, at 1236 Kicking Turd lane. Caller reports that the person is losing consciousness and that the Heimlich Maneuver is not effective”

So, being that this is one of those “low priority nuisance calls” that some grumblemedics complain about, you get up and begin to saunter slowly to your truck.

Wait, no you didn’t. You run out there like a man on fire with your gut hanging up in a knot. Airway calls suck. They’re hard, and the stakes are high as heck. You’ve got to know your crap and you’ve got to do it well. Because, as we all know, without the “A” for “Airway”, the “B” for “Breathing” and the “C” for “Circulation” tend to go buh-bye rather quickly. You hit the lights as your partner brings up the address on the GPS Computer. It’s about a 3 minute ride normally, but today the Gods of Roadway Construction are not playing nicely in the sandbox and it takes a minute or two longer. Along the way you get so many “Construction Worker Manly-Waves” that you think you might go apply for a job as one of them guys that hold the “Slow/Stop” signs. I’ve heard they get paid well. Probably better than we do and they don’t have to go unplug some guys airway before he dies. Man oh man, I can’t believe that we get paid so low… I mean

“Dude! We’re here!” Your partner yells incredulously. “You gonna get out of the truck or keep day dreaming?!”

Oh, yea, the call…

You hop out and grab the front of the cot that your partner has loaded with your full complement of bags and the suction device (bless her heart – cuz in this scenario it’s me working with Gkemtb). She’s so thoughtful and cute (My brain needs to get back on the scenario here) and you wheel it into the supper club where people are frantically waving you inside. Hurrying now, you arrive at the side of a 38yo male laying supine with vomit coming down the sides of his face. His skin is turning a nice shade of pale blue and he doesn’t appear to be breathing.

“I’m a nuse” says a lady doing the floor version of the Heimlich, or abdominal thrusts as AHA calls them. “Nothing is working. I think that he’s choking on a big piece of steak but I can’t get it out!”

No time to lose here, the guy’s still got a pulse but he’s been apneic for quite some time now and that pulse isn’t going to be lasting very long. You quickly dig out your airway tool kit and get out an appropriately sized laryngoscope and Macintosh blade. Grabbing for the Magill forceps with your free hand, you peer into this guy’s airway.

“Crap” you think. The guy’s got a piece of steak in his trachea deeper than you can grab with the Magills and it’s huge. How’d this guy get that down there? Wow. Thinking further down into your bag o’ tricks, you grab a 7.0 ET Tube and try to intubate the guy to push the steak down into the Right mainstem. It doesn’t work because the steak won’t move and you don’t want to negate your next and only option.

“Get me the cric kit” you say confidently to your partner, the “nurse” and the crowd of certified bystanders. Even though you’re scared as all heck because this will be your first one that isn’t on a silicone dummy that’s been cut on more than a Goth… (nope, too mean) a cadaver in a Central American Medical school.

“I’ve got a pocket knife, a lighter, some vodka, and a pen” says a drunk guy standing next to you. “I can do it, MacGyver showed me how!”

You thank him for his ingenuity but decline his offer. Working quickly, you assemble the shortened ET Tube, the scalpel, the skin retractors, and the syringe. Remembering to prep the anterior neck with the povodine/iodine swab, you find the cricothyroid membrane by feeling approximately 2 fingers down from the thyroid notch. You slit the skin vertically down the mid-line of the next above the area and spread it apart with your fingers, and then the skin retractors.

“Bleeaaarggrgeh” Throws up the “nurse” (who works on the Chronic Podiatry Unit at St. Crappy’s) along with several members of the Certified Bystander Brigade.

“Wow, there’s more blood than I thought there’d be” You think… but you say “Hand me some 4 by 4’s”. You swab the area, see the membrane and open it up by stabbing it with the scalpel and twisting it in the new hole. After it’s opened, you insert the shortened ET Tube, inflate the seal bag, and ventilate.

“Holy Crap it worked!” you say, when you were trying to only think it. The patient still has a pulse and everything. The time felt like hours, but all of the above happened in only a few minutes. After some bagging with high flow oxygen, the patient’s vital signs begin to normalize and his ETCO2 begins stabilizing. You leave the fire crews to clean up the bloody mess you’ve left on the floor (after all, following that dazzling display of paramedical magic, should they not be left to clean your leavings?) During the transport you start an IV, and drive lights and sirens to the closest ER. The patient begins to wake up, and you sedate him a bit with Versed to take the edge off of his consciousness.

After the call, you run all freaking night and don’t get hardly any sleep, let alone a chance to speak about the call with your partner. When you finally get to sleep it comes hard and fast. You awake to your cell phone playing the tune that you thought would be peppy and fun to wake up to and set as your alarm but now makes your skin crawl when you hear it. You’ve got to get up, fill out your end-of-shift paperwork, shower, change, and get to your other medic job.

That sign-holding gig is starting to look better and better these days.

Your other medic job is for another city in an area with some stricter “Mother-May-I?” protocols that don’t hardly let you do anything without calling first, and then they deny pretty much anything when you do. It’s annoying, but it pays well and your kid’s looking like he might need braces soon. I heard they gave out an award to the dentist who devised the procedure for emptying an entire savings account through a child’s mouth. Maybe that’s a good gig… I wonder how long I’d have to go to school….

Anyway, while you’re sipping coffee and checking in your truck at the other job the tones go out for a male subject choking. You get there and are faced, unbelievably, with the same exact patient presentation you had the day before.

Only this time, your stupid medical direction WON’T ALLOW YOU to perform any type of airway adjunct past intubation or the combi-tube. You try all of your other airway tricks and realize that your patient NEEDS his neck cut or HE IS GOING TO DIE.

You’ve got the skills and the knowledge, and you can improvise the tools to cut the neck with the scalpel from the OB kit and by shortening the ET tube with your trauma shears.

Do you do it and get in Really Big Trouble and harm your career?

Or…

Do you let the patient die because of EMS politics and the stupid protocol system?

I know what I’d do, but I’d like to get your opinion.

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Treat Here? Treat There?

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Walking through the door of the well kept home you can hear the patient gurgling every time they suck air into their lungs. He’s breathing fast and those lungs sound wet. When you round the corner, you see the man sitting in the tripod position working, really working hard, to breathe in and out. He’s sweaty, his legs are swollen as big as an elephant’s, and he tells you “I’m… tired…” when you ask him what is wrong.

Obviously a sick one, right?

Definitely in need of some immediate intervention, I’d say.

But here’s the question: Do you treat him here in the house? Or do you scoop him up onto the cot and haul him right out to the rig to begin the care? Treat in the house? Or Treat on the street?

I firmly believe that the days of Hearse/Ambulances driving patients to the hospital really fast are over and that the point of an Advanced Life Support ambulance is to bring advanced level care to the patient. When done right, in my opinion, there are very few things that cannot be given immediate stabilizing care in the back of the truck. If it needs surgery right now, drive fast. If it’s just well beyond your capability, by all means treat them with diesel. However, the above patient is well cared for within the scope of my protocol system where I work and I can make this patient feel better right here and now with the tools that I carry with me.

So I “stay and play” a lot, and only beat feet to the ER when there is clearly more benefit to the patient to do that than there is to working on them for a while to stabilize them in the truck and then giving them a smooth, safe ride to the hospital.

But generally, I do most of my stuff in the back of an ambulance and provide only minimal treatment inside of the location where I find the patient. Even though I may start an IV, give o2, and maybe even give a medication or two to the patient, I like the more controlled and more sanitary environment that I provide in the back of my truck. It’s definitely more comfortable to me and all of my equipment is within easy reach. It’s safer for me and the patient, in my opinion.

However, there are a few things that will make me drag my stuff into the house, kneel down, and treat the patient where I find them.

The first would be something like this patient. I’d most probably throw him on a non-rebreather at 15 Litres for high flow oxygen, listen to his lungs to confirm the rales throughout, send my partner out to the truck to get the CPAP machine, and pop in a line while someone was getting vital signs. If there were just the two of us I’d make sure he had a strong radial pulse (and it’s my scenario, so he does) and then start the IV. If the blood pressure’s good and the pulse rate’s good I’d then push 40-80mg of Lasix (furosemide), pop in a sublingual nitro tab, and then slap him onto the CPAP machine as soon as it became available. After that, comes the cot and the move to the truck. Probably this would result in a lights-and-sirens transport, but it wouldn’t be at breakneck speeds.

Other than someone who is going to die without immediate treatment, or who is currently in cardiac arrest, the other things I treat in the house for is an orthopedic injury in need of splinting (a lost art), someone who is very nauseated and is going to throw up on me (I love Zofran so much!!!), or who is in real pain that would be aggravated by movement.

So when I find an elderly person down with a hip fracture, I pop in a line and give a few mg of Morphine (or a few mcg of Fentanyl) to take the edge off of the patient’s searing pain before I splint them. I think that it’s inhumane not to.

What do you all do?

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New Adventures

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This morning was a momentous event in the lives of my family.

Gkemtb (my wife) was a little teary-eyed, but there’s no photographic evidence that I was.

Today was our little boy’s first day of Kindergarten! (Which is the first year of school here in the states, for my international friends)

I don’t usually put up personal posts here, unless I’m ranting about something EMS related, but this was just too cute not to put up here. What a good kid I got. I’m so proud of the lil’ guy. He was all dressed up in his new school clothes, clutching his “Emergency!” backpack and lunchbox (no, not really, it was something else from the Land of Licensed Characters – *my* Johnny and Roy lunchbox is sitting up on my china cabinet in a place of honor) and he’s little enough that he darn near fell over backwards trying to take the big steps up onto the Big Yellow School Bus while carrying the backpack all stuffed with brand new school supplies.

Big steps indeed.

In related news, Gkemtb is starting Paramedic school on Thursday 8/27. So for the next year, I might refer to her as Gkemtp-it (GK-EMT-Paramedic in training). Last night she came up and had me compare her paramedic textbook to my old paramedic textbook. Hers is almost two inches thicker than mine was! It’s also inordinately heavy… I wonder if that’s because they packed more knowledge into it?

I’m going to be auditing the class and posting up my thoughts as a “seasoned” (read: old) paramedic looking at contemporary new paramedic training. It will be hard to keep my mouth shut, however Gina says that she has duct tape. (so did her instructors, oddly enough… I guess the fact that I’ve known them for years plays into this)

And no, she doesn’t get to bring Johnny and Roy for lunch either.

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A new blog I just found with a great post

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http://anarchangel.blogspot.com/2009/08/leave-us-hell-alone.html

Mine isn’t a political blog unless the issue is directly related to EMS politics. If I do get political, I usually do it elsewhere.

However, I just found this blog and this posting. It’s very, very good. I haven’t read anything else of her stuff, just this was enough to deserve a front-page-link.

You might like it too, or it might tick you off. Heck, you’ll probably like it AND be ticked off by it.

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Saturday Fun and Funnies

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Good Morning Everyone!

You may have noticed that I broke my unspoken promise to myself that I would be trying to get a post up every day. I made that promise to myself four days ago, posted once, and then didn’t post anything for three days. (Unlike Medic999 – Say it ain’t so Buddy!)

That’s why I never went to med school.

I’ve been busy, you see. Lots and lots of work with a smattering of cool calls thrown in. Yesterday both my wife, Gkemtb and I had a day off together. We actually had a willing babysitter for the boy as well! It was great. We went out and engaged in one of my favorite activities, bar hopping in an unfamiliar town while walking up to random strangers and saying “Hi, my name is Ckemtp and I’m harmless and friendly. Would you tell me a story about yourself?”

Hilarity ensued and a good time was had by all. We met people that had good stories to tell. We even met someone that lives up in Happy’s neck of the woods that seemed really interested about my plan to save healthcare using paramedics. If you visit, like you said you would (I think… they had draft Newcastle) I put the link right there for you. I had to cut it off early though. I was drinking water by 8pm and sober as a church by the end of the night because I had to work today. I have an “8 hours from bottle-to-throttle” rule for alcohol and EMS. Today, Gkemtb and I actually get to work together on a 24 at the fire department. So we were good little EMS people and stayed responsible.

Heard an awesome joke too:

“A man comes home from a long, hard day of work one evening. He’s tired. He drops his stuff down in the middle of the living room floor, plops down on the couch and turns on the TV. He looks at his wife and says “Hey, get me a beer. It’s going to start in a little while”. His wife’s a little annoyed, but she goes to the fridge and gets him a beer anyway. He drinks it as he’s flipping through the channels. When he finishes, he looks at her and says “Hey, it’s going to get started any minute now, go get me another beer”. Starting to get mad, his wife goes and gets him a beer and slams it down on the table in front of him. He drinks it in silence, still flipping the channels. When he finishes it he looks as her and says “Go and get me another one! It’s going to start any second now!”. The wife’s pissed at this point and starts yelling “Is this all you’re going to do tonight!? I can’t believe you!” She continues. The man sighs and says “Dang… It started….”

So my wife and I are 1/2 of the engine company today. We’re also the 2nd out ambulance with the way our department works. I really like working with her and we used to work together a lot more before we got married. There’s some rule about not working together on the same days… but what are you going to do. I have no problem with it. She’s a heckova firefighter and a good EMT. We also get to do the regular firehouse ball-breaking and she’s always been able to put the guys (and me) in their place and keep up better than most.

I wonder. Why is it acceptable to put a policy in place banning public displays of affection, but it isn’t acceptable to put in place a policy banning pubic displays of contempt?

I’m trying to take a light view of blog posts today. When something happens that’s funny, you’ll be the (insert number here) to know.

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Things That Can Only Happen to EMS’rs

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My wife caught me in bed with a strange woman who was in a state of undress.

And no, Gkemtb wasn’t mad at me at all, in fact, she was pretty happy to see me there.

You’ve probably guessed by now, but I was on the first responding ALS ambulance and she was the second unit in to back us up. Our patient was simply hypoglycemic and was pretty unresponsive because of it. It’s a common complaint we get as EMS people in my area. It seems that there’s a somewhat regular percentage of our citizenry that just aren’t sweet enough and need us to come and sweeten up their dispositions.

“What’s wrong?” We ask. “Can’t wake em up” Generic Family Member Says

Check ABCs: Good. Check Pupils: Equal. Check SAMPLE: Known type 1 (insulin dependent) diabetic mostly unresponsive with good pulse and respirations, no known allergies, Meds are insulin and one or two others, Last oral intake was thrown up after taking insulin, events were throwing up after taking insulin and then going to bed. No trauma? Check. Glucose check: 38mg/dl (that’s milligrams per deciliter for those who never knew what they were writing)

Simple matter then, if they can protect their airway we try to get them to drink some orange juice with some added sweets mixed in. It’s like Christmas for these diabetics who never get to eat sugar. Sometimes we mix in some pancake syrup, sometimes grape jelly. I heard once somewhere that the “home remedy” if you will for hypoglycemia is granulated sugar. I can’t advocate for this on the blog officially, but a small amount of granulated sugar pinched between the fingers and sprinkled under the tongue seems to be a fine idea. The problem with giving anything orally to someone with an altered level of consciousness is that they can choke on it or suck it into their lungs and give themselves pneumonia. If the patient is unconscious then we have to pop in an IV line, the bigger the better, give a little fluid, and inject some IV 50% Dextrose (D-50) into the vein to sweeten them up.

And the effect of the IV sugar is nothing short of miraculous. People go from unconscious to fully alert in a matter of a few minutes. The family goes from thinking that their loved one is dying to knowing that they’re going to be ok. It’s one of the coolest things to do in EMS, and since we do it a (freakin’) lot, um… we get to do it a freakin lot.

So on this call, Gkemtb found me lying in this woman’s bed starting an IV line. The family was there, my partner and I were there, and there was a cute little kid as well. We were all standing in the room very concerned about Mommy. I said “Oh great! Now my wife comes in and finds me in bed with another woman!” Everybody laughed… except for the patient who was currently unconscious. (She would’ve laughed though. My humor is crackerjack with the unresponsive)

We popped in the line, pushed the D-50, and lo and behold Mommy woke up. Everyone was happy and the day was saved. Yes, a follow up with a physician is in order for the patient, but not a trip to the ER. She signed off and we were off to breakfast.

Oh, and for the record, the patient (once conscious) thought my joke was funny too.

 

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UK Woman "Refused Ambulance"? Hey UK peeps, question for ya

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This was the headline on the Drudge Report: “UK System: Woman gives birth on pavement ‘after being refused ambulance’” It was immediately preceeded by a comment on the Canadian healthcare system.

Scary stuff there, those UK and Canadian socialized medicine systems. Right?

Drudge, who’s site I go to like 17times a day if I’m bored (or if I can’t find something to blog about and want to do something else) wants to report on the coming healthcare mess that’s being um… (oh what’s the word) “Fixed” by our politicians.

But this story… Um, guys? This isn’t about the ambulance system refusing ambulance care to an expectant mother… I would think that this is about a system abuser who couldn’t bear to plan her arrival at the hospital so that she could deliver her baby in the manner she planned.

First of all, I’m not for socialized medicine and I don’t think that the UK system is perfect in any stretch of the imagination. I’m also terrified of Obamacare and/or whatever the US politicians do to try to “fix” our healthcare.

However, the fact remains that this headline looked to me like it was bringing shame upon the UK ambulance service, or should I say now that I’ve made so many UK Medic friends: Looked like it was bringing shame upon Our Brothers in the UK Ambulance Service.

So let’s dissect the article, shall we?

A young mother gave birth on a pavement outside a hospital after she was told to
make her own way there.
Mother-of-three Carmen Blake called her midwife
to
ask for an ambulance when she went into labour unexpectedly with her
fourth
child.
But the 27-year-old claims she was refused an ambulance and
told to
walk the 100m from her house in Leicester to the city’s nearby Royal
Infirmary.

Cue the picture of the loving mother with the cute baby.

So the mother goes into labor unexpectedly? Ok, quite possible and plausible.

She calls “her midwife” to get a ambulance called to her house to help her? Well, I don’t know how that system works over there, but I guess that some people here call their doctor’s office when they feel sick and want an ambulance. It’s not the right thing to do and it’s not smart, but people still do it when they’re scared and they want someone they’re familiar with to help them. I can understand it. It may be reasonable and proper for this to happen in the UK. At least she didn’t want to be a 999 abuser, I guess.

She um, what?

She couldn’t make it the 100m (That’s 300 feet for us US types who use the “real” or “correct” system)

Ok, well maybe she had kids to take care of, or something. I don’t know.

‘They said they were not sending an ambulance and told me I had had nine months to sort out a lift.

This sentence made me laugh. Oh my. Delivering a baby isn’t something we do often here in the US because, well, people tend to make their own way to the hospital. I’ve delivered 5 and a half babies in my career. 3 in the hospital, one on someone’s living room floor, one in the back of an ambulance in Costa Rica, and a placenta in the ghetto somewhere – hence the half. The fact that I have only had two and a half field deliveries in the ten years that I’ve been in this game full time means that lots and lots of women find time to “sort out a lift” in the 9 months they’re preggers.

It turns out that the woman tried to make the walk and that she went into really active labor. A passerby happened to be a “physiotherapist” (I assume that’s a physical therapist) and the passerby called 999 and delivered the baby on the concrete. Shortly thereafter, 999 arrived and, I assume walked the patients the remaining 100 feet to the hospital.

I think that if the woman called 999 in the first place she would have gotten the ambulance right away, right?

I also think that if she had planned a bit, or honestly if she had time to, that she could have gotten another ride.

I don’t think that this would be the fault of the ambulance folks. And as scared as I am about socialized medicine: Drudge, leave the paramedics alone.

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My Thoughts on Fire Based EMS

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I’ve been avoiding this.

Medic999 and HappyMedic have been playing with fire lately. They’ve gone on to speak about one of the hottest issues facing US EMS today. That is, (and please pardon the puns) the issue of Fire-Based EMS.

Now, I’m probably remiss for not jumping in to the fray on this because I hold very strong opinions on the matter. In fact, if you were to catch me in person at the firehouse or the ambulance base I’d be happy to talk your ear off expounding upon the issue. I’m never one to hold back my opinion when I think that I’m right or when I think that my opinion will add value to the discussion. I’m not afraid of my opinions on the matter and I’m happy to speak about them.

But honestly, I’ve been afraid to write about them here. That’s why my posting has been pretty infrequent in the last couple of days. You see, I know what a tinderbox issue this is and I know the flames that can result. I try to speak to my (small, but growing) audience of professional EMS people as equals, because you are. I’m no expert on anything just because I decided to start a blog, but I do care deeply about EMS and the Profession of Paramedicine. I care about the future of EMS. I care how EMS is provided and I want to see it grow and flourish.

And if you’re here reading EMS blogs you’re probably of a like mind. I respect and applaud that and I appreciate that you’ve given me a tidbit of your time to read my ramblings.

But I don’t like Fire-Based EMS. There, I said it. I am a state certified FF II (FF III is pending). I’ve got a bunch of fire credentials. I love the fire service. I love the brotherhood, the tradition, the adrenaline, and the work. I love fighting fire and being an active part of my fire department. My father was a fire chief. The fire service is in my blood.

But as a professional Paramedic looking to advance my profession into the future, I have to put my personal feelings aside and say that I disagree with how the US Fire Service has treated the profession that I love. I disagree with the way they have steered my profession into technician status and fight to hold down true educational standards. I hate that they pigeonhole paramedics into one role that cannot be expanded upon. I hate that the majority of paramedics I see are just “doing this ambulance thing” until they get a “real job” on a fire department. I hate that fire blogs advise young, impressionable kids to “Go get their medic” so they can be marketable to a fire department.

I think that it takes a different (read: “not better”) set of intellectual and ethical reasoning skills to be an awesome paramedic than it does to be an awesome firefighter. The gung-ho pro-fire folks will tell you that because of the rescue component of the fire service and EMS that they’re inseparably intertwined. I disagree inasmuch as the same fact holds true with bus drivers having a “transportation” aspect that they share with EMS. I read paperwork about patients, does that make paramedics one-in-the-same with librarians?

Let me tell you a story about way back when I took my Paramedic class. I went through all of my EMS education at a local community college instead of one of the hospital classes that were offered where I lived because I wanted the college credits. I still think that it’s a great idea to get college credit for EMS classes, because EMS classes should be “Education” and not “training”. In my class there were 23 students. Of the 23, there were 3 of us that actually wanted to be a paramedic. Everyone else was taking the class because in order to get on any full-time fire department in Northern Illinois, you have to be a paramedic AT THE TIME OF APPLICATION. (There are a handful of exceptions, but just a handful) This was a decade (or so) ago, and some of the guys had been told that in order to keep their long-held positions as a firefighter, they had to “get their medic” as well.

How many of those 20 do you think were *really* motivated to be an excellent paramedic and a true healthcare professional? If you guessed a low percentage, you were right. While I’m not necessarily questioning any individual’s motives for becoming a paramedic I do think that it does not say much for any profession when a good percentage of their new members do not actually want to become a professional.

Does it make sense to keep a physician who really desires to be a concert pianist but can’t make it on the ivories so he’s a doc just to pay the bills? Sure, there’s adequate paramedics out there who didn’t really *want* to become medics… but they’re not the ones trying to excel in and advance the profession. They may care about their individual patients to the best that they are able, but are they out there pushing their medical direction to give them the latest tools to better treat their patients? Do they study the latest research so that they can discern the best possible chance of a positive outcome for their complicated patients? Or are they just doing enough to get by, putting their time in “on the bone box” and bitching about being called out for calls that they feel are beneath them while they wait to get back on the engine?

Let me say this. I’ve worked in Hospital Based systems, high-performance private 911 systems, private transport systems, private rural 911 systems, and fire-based systems. I’ve found faults in them all. I’m for EMS based EMS, or “Patient Focused EMS”. If tomorrow, the fire service as a whole decided to change a few things, I would sing their praises and change my tune. If there were such things as “Public Works-based EMS”, or “Parks Department-based EMS” or “Any-other-non-healthcare-based EMS” and I saw the same things with their organization as I do with the fire service, I would disagree with them too.

So here, fire service, do these things and you’ll convert me to your side:

  • Stop making everyone in your agency “get their medic” so that they can get a job – Not everyone can be a great healthcare provider and especially not everyone can be a great paramedic. Stop pretending they can be. Fire Department entry tests like the CPAT test things like physical agility and basic mathematical computation. Yes, they’re important for firefighters and for EMS as well… but what the heck does a hose drag have to do with patient care?
  • Stop making every position on every piece of apparatus an ALS position. I’m diverging with Happy here and saying that a BLS engine response is great, as long as there are enough ambulances out there to guarantee a response and you have well educated and motivated BLS providers. Skill degradation due to too many paramedics attending a patient is a real phenomenon. There’s emerging research (and I can’t find it but it was done out of Kenosha, WI and listed somewhere in JEMS) that states that having over 3 paramedics to any patient actually harms patient outcomes. The “engineer” position and the officer position on a fire apparatus is an earned place of honor. So should be the ONE PARAMEDIC (if any) on a fire apparatus. Right now it’s not and you don’t treat it as such.
  • To use a local FD as an example, they have a population between 125k and 175k. They have around 15 staffed pieces of fire apparatus staffed every day… and 5 ambulances. 80% to 90% of their calls are EMS related… why are 20% of their staff running 80% – 90% of their calls? Where are their priorities? Firmly on the “fun” stuff… and not on the “boring bone box”. Change that.
  • You’ve pigeonholed my profession into a “you fall, you call, we haul, that’s all” system that only values true emergent response. Patients are using our service for all kinds of things and you complain. No other business (and EMS is a business as in we need revenue to survive) relegates customers to second class status because they choose to use us in a way that we don’t want to be u
    sed. Paramedics are capable of all kinds of fantastic things. Allow us to branch out.
  • Fight for more knowledge, more education, and higher standards. Don’t hold us back. To the IAFF and IAFC: Why is the “National Scope of Practice” the way it is? Why aren’t we using something closer to the “Dr. Bledsoe Scope of Practice”? Because fire departments and the IAFF don’t want to do that stuff, that’s why. Yes, you pay well and treat your employees better than I get treated by my employer… but don’t hurt patient care because there are classes you don’t want to sit through and responsibilities you don’t want to have. A Union contract is a terrible way to design a healthcare system.
  • In my area of the country, and in EMS systems that I’ve researched through my travels, I’ve noticed a phenomenon (and it may not be this way in your area): Shared Protocol Systems that include a large (or a large number of) traditional full-time FD ALS providers have less advanced protocols and procedures than do Shared Protocol Systems that do not include the above. The state line between IL and WI is a great example of this. Fix that.

Yes, I’ve ranted… and there, I said it. I’m going to continue this conversation in the comments section of this and many other of the blogs out there. The discussion is alive and it’s burning. The profession is changing and people are starting to wake up to the fact that “EMS-based EMS” is the proper way to go. If your (insert service model here) EMS agency truly strives to provide the best quality patient care and the best possible future for the profession, then I’m in your corner. No matter what it says on the patch on your sleeve.

 

 

 

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Someone is stealing my stuff… Ckemtp is not pleased

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So tonight I typed in one of my post titles “Operation FEE Line” into my friend Google checking for links back to the blog. I found the usual stuff, all of the blogrolls that I’m on, and then this:

http://leathergloves.start4all.com/2009/08/08/life-under-the-lights-operation-fee-line-exposing-the-deadly-side-of-kittens-on-emergency-scenes/

Wtf!?

Obviously it ran through some wicked bad translation software because, while it’s quite obviously my piece… I dunno what they did to it. It’s um, funny in an Engrish sort of way.

Here’s an excerpt:

We had been requested accessible the county uncultured manage officers to freeing a cat stuck in a gutter on a exorbitant roof with 14 feet of the acquaint with. At least it wasn’t in a tree, that would own been too clichй. We brought the rise ladder far-off of our place with a six bracelets company allowing for in the matter of this irascible freeing and met with the Animal Control Officer on Scene. The roof was moderately exorbitant, and covered with asphalt shingles. “There’s the cat” He said. With the extravagantly one just starting to clear assemble loose with a one only just sprinkles of come down, the 20 foot bead eccentric the side into a disconcert garden was starting to be distressed me. Yes.”

Well, I guess I’m flattered or something like that. I think.

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A Major Breakthrough in the Treatment of Swine Flu!

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[youtube=http://www.youtube.com/watch?v=EFebGZ7FJQQ&hl=en&fs=1&color1=0x006699&color2=0x54abd6]

Announced today from Muppet Laboratories, a major breakthrough in the study and treatment of the dreaded swine flu. EMS providers, take heart!

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Fire Based EMS? Ouch, hot issue

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HappyMedic and Medic999 just took on one of the most contentious issues in US EMS today: The issue of just what the heck the fire department is doing running EMS.

I just haven’t had time in between calls in order to jump in yet… but trust me, I will.

Meanwhile, head on over to Happy’s and Medic999’s places to read their takes on the issue.

Dang, more tones…

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A Little Quantum Physics for EMS

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I’d like to get a little, well, theoretical on you for a second. Humor me here if you would.

You know that we all live on a big, mostly spherical ball of dirt and rock that spins wildly through space. We’re always moving on this planet. The Earth spins on its Y axis while moving incredibly fast in an orbit around the sun. It’s this very motion that gives us one of our most important inventions, our perception of time.

The thing that we perceive and know as linear “time” is a human invention. It stands to reason that animals and non-sentient beings perceive time as only an indication of how hungry they are, when they think that they should mate, or how they should behave with the change of the seasons. What we humans call time is our reasoned perception of the past, present, and future. We observed that the sun and moon move across the sky in a repetitive pattern and that the transition from sunlight to darkness gives us what we call a “day” and a “night”. This, we reasoned, is due to the Earth’s rotation on the Y axis. We observed that the sun is directly overhead at roughly the same “time” each “day” and we devised a scheme to measure that using hours, minutes, and seconds. We observed that the sun, moon, and our “seasons” follow a pattern and that the same type of weather pattern and length of the day will follow exactly 365.25 days from this day. Our “year” we devised, follows the rotational orbit of the earth around the sun.

Our sense of “time” has developed over the years and there are still differing methods of keeping it. There are various calendars available for different cultures. There’s disagreement even to what year it is as determined by different date-keeping systems. While everyone pretty much agrees on Greenwich Mean Time, there is some variation. The forward-motion of hours, minutes, and seconds are roughly kept on clocks by the motion of springs, the pulsations of quartz crystals, and even by atomic energy. These clocks, however, are only good for a longitudinal standard. Our “Time Zones” are based upon the rotation of the Earth creating a “sun rise” on different parts of the earth at different times. We have adjusted the clocks accordingly, but it is only a rough measurement based upon political agreements. If one were to move across latitudes, meaning East and West, the time would be different using the time zone theory, with it being later towards the East and earlier to the West. We have solved this problem by drawing lines on a map and changing only the hour when you cross those lines, but like our perception of “time” the time zones are a human design.

To further confuse the issue, we really wouldn’t know if our “time” was affected by any speeding up and/or slowing down of the orbital or rotational motion of the planet. Theoretically, the Earth could be speeding up and slowing down wildly and at random… and if that motion were to affect our perception of time as well at the motion of springs and the pulsation of quartz crystals and atomic materials… then we could all be experiencing different ebbs and flows of time without knowing it. There isn’t a way to prove or disprove that from the ground. If these ebbs and flows of time were to affect some clocks and people differently, as it could be due to the fact that clocks are can lose their accuracy over time (as measured by other clocks), then our timekeeping system is way off. I do understand, however that it is probably the best we can do.

So with all this going on Chief… It’s a wonder that I make it to work on time EVER. How can you be mad that I was “late” today?

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Some awesome stuff – with pictures

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First of all, a person named Jak B left a comment on my post “EMS 2.0 – A paramedic Dreams of Changing EMS”

In it, he explains some parts of the Irish EMS system, their levels of practitioner, and some of their educational levels. He also put up a link to the Irish “PreHospital Emergency Care Council” which has a lot of information about the Irish EMS system. Great information for a curious US Paramedic. I liked it. Here’s the link: Http://phecit.ie

Thanks Jak B, come back soon.

In addition to that, Gkemtb, my boy and I were driving today and saw an absolutely breathtaking wall cloud from a line of severe thunderstorms that rolled through our area. Sorry about the poor quality of the pics… I took them from my cell phone, but despite the resolution they’re still cool. There was a local police officer stopped taking pictures out there too and he told me he’d send me some of the pics that he took. I’ll post those if I get them.

Enjoy.



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Operation FEE Line: Exposing the Deadly Side of Kittens on Emergency Scenes

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Kittens: Deadly minions of the Dark Side, or Cuddly Agents of Evil… You decide.

Today, I faced my own mortality in a daring, high-stakes, high-angle rescue. A life was on the line and my truck company was assigned to respond and snatch it from the jaws of death. We had been requested by the local animal control officers to rescue a cat stuck in a gutter on a steep roof about 14 feet of the ground.

Yea, a freakin cat. At least it wasn’t in a tree, that would have been too cliché.

We brought the tower ladder out of our station with a six man crew for this dangerous rescue and met with the Animal Control Officer on Scene.

“There’s the cat” He said.

The roof was pretty steep, and covered with asphalt shingles. With the sky just starting to let loose with a few sprinkles of rain, the 20 foot drop off the side into a rock garden was starting to concern me. Yes… I know that us firefighters are supposed to be good at working on roofs, but when a building’s on fire we don’t have to care how we may harm the roof by gaining traction. I really didn’t want to harm this nice lady’s roof, so sticking an axe in it to get a foothold was going to be a no-no. We pulled out a 24 foot extension ladder to reach the roof and a roof ladder to keep from falling to our deaths.

Or I should say, my death… because Captain Mike looked at me and said “Since you like cats so much CK, you go up there and get it”.

At this point, you might wonder why I’m being so dramatic about this.

Because cats on emergency scenes are evil death killers of doom and are more dangerous than ninja bunnies carrying lasers.

That, and well… I’ve never had good experiences when there have been so-called “cute little kitties” on my emergency scenes. I always end up flat out on my back. Literally.

You should know that I like cats. Really, (thanks to Gkemtb –my wife for my new readers) I’ve got three of them. However, when there’s a cuddly kitty on one of my scenes, ominous music starts to play and shenanigans ensue.

I learned the horrible truth about cats some years ago. My Paramedic/EMT-Basic ambulance had been called out to a “sick woman” at a local residence. When we arrived on scene shortly after fire and police we found an obviously grieving family huddled around a hospital bed where a frail elderly woman was laying. She was crying as forcefully as her frail body would let her. We learned the sad truth soon enough. The patient had been referred to hospice care a few weeks prior to this when the cancer that she had was deemed to be beyond hope. Her last wishes were to convalesce at home with her beloved husband and her beloved cat by her side. Unfortunately, her husband had passed away suddenly a few days before and she was at home, in her bed, too sick to attend the funeral which was in progress. Her family had become concerned and had decided that a trip to the hospital was necessary. I agreed, even though there was nothing that any paramedic or hospital could do to alleviate this poor woman’s suffering.

So it was a sad scene all around. We loaded her up on our cot and wheeled her into her living room when she became concerned and would not let us leave the house until we locked her beloved cat in the bathroom to keep it from, I don’t know, shredding the curtains or something. I was picked, because as is well known in my region, “CK likes cats”.

I found fluffy hiding behind a couch, pretending to be scared from all of the bodies in the room. Little did I know she was just pretending to be scared, and was really plotting our ultimate destruction. She came to me after a little bit of coaxing, and I picked her up and carried her from the living room, down the short hallway, and entered the bathroom.

The cat, who had been waiting for his minute to strike once I had been thinned from the herd, realized that I was planning to lock him in the bathroom and deployed his needle-sharp, slashing claws of doom and wrestled himself from my hold. I tried to grab him as he got to the floor and began running towards the bathroom door which was towards my back. I reached down and backwards for him, catching hold of him on his back. He slashed and squirmed towards the door, pulling me down and backwards with every razor sharp undulation.

So here’s the scene, I’m bending over backwards for this cat and was falling for his evil plot. Finally I lost my balance and fell. I rolled out of the bathroom backwards, head over heels into a perfect back flip. The fire crew, my partner, the police officer, and the family heard the commotion and witnessed my epic fail which I punctuated by crashing forcefully into the wall of the hallway. For his part, the cat sauntered back into the living room, sat down, looked at the rest of the people there, and licked his chops in a dare to any other would-be hero that would dare to try and cage him again.

No one dared. He stayed out and the patient went to the hospital.

So back to my daring rescue, this call was in the forefront of my mind as I climbed the 24 foot ladder and hoisted the roof ladder onto the small roof. It only fit about halfway on, so I made sure that the hooks were firmly set in the shingles. I knew what cats were capable of. I eased myself onto the ladder and crawled up to the peak of the roof. The cat was on the other side, away from the protection of my roof ladder. I slowly eased myself down the slick, steep, rain-soaked roof towards the cat who was patiently waiting in the gutter at the edge of the roof. I wasn’t as concerned as I should have been, because there was only a 14 foot drop at this side of the roof. I eased towards the cat saying “here kitty” and “I’ve got cheezburgers in my truck and yes you can has one” to her as I got to the edge. I was just able to get my hand on the nape of her neck and was able to grab the scruff. I picked her up out of the gutter and…

No I didn’t fall off, but the cat wrested herself from my grasp and while I was grabbing for my balance she walked up the roof and down to the other side. She sat right down in the gutter on the edge in the furthest possible spot from my roof ladder. At this point of the roof, due to the slope of the yard, there was a sheer 25 foot drop onto a rock garden.

Crap.

Because then I remembered another call, a fire this time. I responded 3rd engine in fresh from the scene of a mutual-aid brush fire. When we got there, we found the other two engines and a truck company had knocked most of the fire down on a single-story ranch type home. They had found a fully-involved attached garage when they arrived on scene and had made a good stop. Now, it was mostly overhaul that needed to be done. The homeowner however, was standing in the driveway begging the IC to rescue his cat that was still inside.

Cue the ominous music when the IC looked at me and remembered “CK likes cats”.

I went in the smoke-filled house with Lt. Tuna in full-gear and SCBA. We searched three rooms and located the cat in the far bedroom of the house. Lt. Tuna secured the doorway to the room to prevent the cat from escaping and I was tapped to go get the cat.

“Nice Kitty” did not like his house being on fire. He especially did not like alien-looking firefighters in full gear trying to grab him. I struggled and flopped around the bedroom chasing the cat. He finally made it to the headboard of the bed. I launched myself prone onto the bed and got a thick-gloved hand on him. He ran to the side, I rolled long ways on the bed onto my back and got another hand on him.

I had
him! Then I realized that I was on a… a waterbed with my hands stretched out over my head onto the headboard holding a sharp kitty who was rapidly finding out new ways to penetrate my leather firefighting gloves with his sharp teeth.

I think that this would be a good firefighting drill. Wear your 70 pounds of firefighting gear and an air pack, sprawl out supine on a water bed, and try to self rescue while holding a cat. I call it the “Ckemtp” drill.

I was stuck, much to the amusement of Lt. Tuna who entered the room, wrapped the cat in a towel, and carried him out of the residence. He left me there to flop around on the waterbed for a while until I was able to roll off of it, hit the floor, and crawl out a broken man.

When I got out of the house, the owner was petting the *really pissed* kitty and was trying to stuff him into a waiting kennel. I did not intervene, I had had enough.

So now this call was knocking around in my brain as I edged ever closer to the sheer drop to rescue gutter-kitty. Joe, another firefighter, had climbed the ladder by this point and handed me a net that had been given to him by the animal control officer.

“The cat’s over there” the animal control expert called up from the ground.

“Thanks” I said.

Joe climbed onto the roof and Capt. Mike moved the ladder closer to the cat and then climbed up to help. The three of us edged closer to the kitty. I nudged him with the net, Joe prevented escape, and Capt. Mike reached over from the safety of the ladder, grabbed the cat by the scruff of the neck, and placed him in the net.

Mission accomplished. I think that the cat let himself get caught though. Probably because my promise of a cheezburger in the truck had sounded better to him than did lapping up freshly splatted firefighters. Man was he ticked when he got placed in the Animal Control Officer’s van and found out I didn’t have one. I could hear him squalling as the guy walked back up to us.

“Thanks for getting the cat” He said.

“Just doin’ My Job Sir. Just Doin My Job.”

But I know that the cat’s out there. He’s plotting his revenge. He doesn’t sleep… he waits.

 

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Wildfire Awareness

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A Shrine to Zofran

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I’ll get back to my more serious things probably with the next post, but I wanted to get this out there.

When I got in to work today, I found out that the guys had been commenting on my love for Zofran (odansetron – an anti-emetic or anti-throw up med). The guy who orders the medications said that he has to order the stuff by the crate now at the rate I’m giving it.

I’ll admit I do give the stuff out like water. I love it. I have a shrine to it in my bathroom made out of porcelain.

Think of it this way: It’s easier to replace a vial of zofran, an alchohol prep, and a 3cc syringe than it is to replace an emesis basin, 3 towels, and a duty uniform.

That is all.

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EMS 2.0 – A Paramedics First Step in the plan to Revolutionize Healthcare

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EMS Can “fix” the US healthcare system.

Let me repeat that above statement.

I believe that the Emergency Medical Services and the Profession of Paramedicine can offer a private sector solution to save the healthcare system billions of dollars in the short and medium term.

Until now, the EMS people haven’t been able to recognize or work towards their full potential due to a wide variety of competing interests, outside influences, and well… just a “difficult” perception out there of exactly who we are and what exactly it is we do.

Really, is EMS a public safety discipline? Are we allied health? Are we public health?

We’re none of those things because we’re all of those things. We are a profession that encompasses all of the above into our fold, has made all of those things our own, and has mastered our competing interests. We are professionals working in a dynamic field. We are adaptable and are able to work miracles with no support. We are the Professional Paramedics (and EMTs) working to advance our profession.

In the last post I said that it was time to end the talk about problems and instead to talk about solutions. This post is the first step in my solution to the problems facing EMS and the greater problems facing the US Healthcare system. I’m asking everyone who reads this to participate in the plan. Please get energized. Please pitch in and help. We’ll save countless lives, alleviate unimaginable suffering, and can have a huge impact on the US economy.

Here’s my hypotheses:

Paramedics are currently underutilized and have a much greater potential in the greater healthcare system. If we change the role of paramedics to include higher education and give them greater legal responsibility for healthcare decisions including the ability to make diagnoses and devise treatment plans for patients, we can have a huge number of additional primary healthcare providers on the street providing healthcare to the entire patient population. Paramedics and EMTs already work with the entire population of those seeking healthcare and have already proven to be masters of acute emergent healthcare. However as the laws are written at this time they cannot “treat and release” or make a decision to downgrade a patient’s treatment path to less acute and less expensive healthcare delivery points other than the Emergency Room, such as to an Urgent Care Center or Primary Physician. An Ambulance to Emergency room is life saving in cases of massive trauma, stroke, or heart attack. It is woefully too expensive in less acute conditions. By allowing Paramedics to treat and release minor complaints in the field, to divert moderate complaints to physicians in urgent care centers or to the “front-of-the-line” in their personal physician’s waiting line, and to provide community health services and help at-risk patients manage their chronic diseases, we can save billions of dollars in the overall healthcare system. Remember, the cost of an ambulance transporting a patient with a case of the sniffles to the ER is upwards of $7000.00 the cost under this plan, of the paramedic being educated and empowered to prescribe a decongestant and leave the patient at home is around $150.00. Which would you rather have your money pay for?

Here’s what I want to do to test this hypotheses:

    I would like to conduct a research project to test this. This research project will need participation from a number of players from different disciplines and, since this blog is read by an international audience, I would like participation from EMS people in other countries, especially the United Kingdom (Medic999, got any ideas?). This will be an on-paper test of the system with comparisons being drawn from the results of the current system and the proposed system.

Here are the steps:

  1. Currently practicing, experienced field paramedics will be trained to complete a detailed physical exam and proposed treatment plan on non-emergent patients presenting with complaints that are not generally life threatening and do not require emergent admission to the ER. The diagnosis and treatment plan will be documented and saved for review. No actual field care will be changed. The paramedics will recommend the following:
    1. Examination and Release of the patient with field-performed and field-prescribed care only. (Treat and Release)
    2. Examination of the patient, some field care, and transport and/or referral of the patient to an urgent care center or primary care physician’s office (ER Diversion)
    3. Transport of the patient to the ER (traditional)

     

  2. The documentation on these charts will be reviewed by a group of physicians, physicians’ assistants (PA-Cs), (and by UK paramedics) to determine the accuracy of the exam, the accuracy of the proposed diagnosis, and the appropriateness of the proposed treatment. They will adjust the training program to improve accuracy and record their opinions on the results of the treatment plans.

     

  3. The results will be reviewed and we will share what we learn with the results.

The Training Program: With the aid of a group of physicians I would like to devise a training program for currently practicing, experienced field paramedics focusing on the following topics.

  • Physical Examinations – There is an obvious difference in the ALS Patient Assessment provided by a paramedic in the field and the Physical Exam conducted by a physician in a clinic. These would need to be brought closer together with the Paramedics learning from the Physicians a more in-depth patient exam.
  • Documentation – There is a difference between the EMS patient report and the charting performed by a physician. The Paramedics will need to learn how to document a detailed physical examination and proposed treatment plan so that a physician can adequately understand the patient’s presentation and prognosis with a chart review.
  • Common treatment modalities – For commonly diagnosed conditions, there are commonly prescribed treatments. These would be the most commonly prescribed treatments prescribed for the most common conditions diagnosed in an urgent care setting. For example, a patient who comes in with burning upon urination, lower abdominal pain, and has leukocytes in their urine upon mechanical urinalysis is prescribed a 3 day treatment of Bactrim and pyridine tablets for symptom relief. They’re also advised to void frequently, and drink cranberry juice and water. There are other common complaints and common treatments that can be included.

It is important to note that the above is not a plan to educate paramedics for the change in their roles, just to train them for their roles in the research project. I am not a physician, I am a paramedic and I expect that the above will be modified by the physicians involved in developing the training program.

The Expanded EMS Documentation: I would like paramedics to compete expanded documentation on non-emergent patients presenting for EMS treatment. These patients would be from the current EMS patient population and would not include patients with acutely-emergent medical conditions such as a heart-attack or stroke. The documentation completed will include the following topics:

  • Detailed History and Physical Exam – More in-depth and detailed than the EMS assessment, these would be closer to the examination provided by a physician.
  • Proposed Diagnosis – While Paramedics will not be expected to know what the true, 100% acc
    urate diagnosis would be, they can be assumed to be able to make a close guess. This will be documented in addition to differential diagnoses and conditions that they ruled out.
  • Proposed treatment plans: These fall into the category of: 1. Treat and release 2. ER diversion and 3. Traditional.

The Review Process: The data collected from the field providers will be analyzed and reviewed by physicians, physician assistants, and other entities and the results will be learned. I would also like to see if there are cost savings realized with the treat-and-release and ER diversion pathways.

—————————————————–

This was a long post! Please participate and forward this along to your peers. This can be a private solution to healthcare in the United States and the world. With your active participation we can make the overall plan a reality by taking baby steps towards our goal. It is possible, it is practical. With your help, it is near.

For more information:

The previous post: “EMS 2.0: A Paramedic Dreams of Changing EMS”

 

 

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