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A Quilt Made From Patches – Help a brother out.

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An old ambulance partner of mine called me up the other day with a favor to ask.

He and I haven’t been on a truck together in a few years, but this guy’s one of the best I’ve ever had the privilege of working with. If Bill asks me a favor, it gets done. He’s good people.

It seems there’s bad news. Bill’s new partner, Noah Filer, an almost-done paramedic student and firefighter with the Durand Fire Department was involved in a terrible motorcycle accident a while back. Unfortunately the news isn’t good. While Noah’s fighting on, he sustained serious, possibly life-altering injuries and will have an exceptionally hard road to recovery in front of him. He’s a young guy, and from all accounts I’ve heard a stand-up guy and a good person with a lot of potential in front of him. I don’t know Noah personally, but a good many of my friends do and if Bill vouches for him, he’s a friend of mine as well.

Noah’s friends and family are making him a quilt made of fire patches and have been asking departments to send patches to his fire department for this purpose. Bill has asked me to help spread the word and ask you to send in your patch and patches from your area so they can be incorporated into the quilt. I’m happy to ask you to do so. Noah’s family loves the idea and his fire/EMS friends are stepping in to make this a reality. I’m asking you to do the same.

Here’s what I’d like you to do:

  1. Get an extra patch from your Fire Department, Police Department, EMS agency, or any public-safety entity that you are a member of or can get your hands on. Send one of your patches and grab a few from your surrounding agencies. Anything will help.
  2. Send the patches to the following address BEFORE MAY 12th, 2012.

Durand Fire Department

P.O. Box 185

Durand, IL 61024

  1. Help us spread the word. If you’re an EMS blogger, would you mind posting up a link to this post or making a post of your own asking your readers to do the same? Would you mind posting this link on your Facebook or Twitter accounts? Would you ask your other Fire/EMS friends to send in a patch or to give you one that you could send in?

I’d really appreciate it. You’re helping out a good cause for a good guy. Trust me, if Bill vouches for him, I do too. I’m sending in all the patches I can grab for the guy and you should to. Please. Both he and his family and friends will really appreciate it.

Thank you.

You can read more about Noah’s story on his CaringBridge web site. It would be nice for his family if you’d send some well-wishes in the form of writing a short note in his guestbook as well.

Bill wrote about his feelings in the guestbook. If you don’t believe that you should send in a patch… read this, you will:

“Dear Noah,

Well it has taken me a week to find the words to write you. You have been my partner on the ambulance since September 2008. Since that time we have spent a third of our lives together. Sometimes you are like a brother to me and other times you are like a son to me but you have always been family to me. Coming to work since your accident is challenging. All of us come in and do our jobs, but there is no laughter, no fun anymore. We all ask each other "how are you" and we all answer each other "I'm ok". But, we're not. This station is empty without you. I worked up the courage to peek inside your locker today to see if there was anything your folks or Jenny would want. I burst into tears and closed the door. I swear kid I've never cried so much in my life as I have in this last week. You have touched so many lives and I know for a fact that there is people walking the Earth today due to some of your actions. You are a hero. Maybe I didn't tell you that very much before, but you need to know that. I had a new fella come and work with me today. He is a great guy, and like you, one with a promising future. But, HE IS NOT YOU. Some days I can eat, some days I can't. Sometimes I can sleep, other times I can't. I just want you to wake up and say Hi, that would make things so much better. I have visited with your Jenny and your Folks several times this week, and I hope they know they can count on me if they need anything. We are all hurting and only you can make us feel better. So keep fighting my friend! I know you can beat this.

I will be waiting as long as it takes for you to get better.

 

Your friend,
Bill Scheider
Paramedic”

Come on y’all, help a brother out.

Posted by on April 29, 2012 • Filed under: EMS Topics, Fire Rescue Topics, Uncategorized

EMS 12-Leads – The Standard of Care

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I’m going to make a statement:

Every ambulance in the United States should have the capability to obtain a 12-lead EKG. Regardless of the service’s level of care, be it Basic, Intermediate, or Advanced Life Support, every ambulance should have the ability to get a 12-lead. There are no exceptions in my opinion. It is the standard of care and every ambulance should be able to do it.

In the last few years, the 12-lead EKG has not only revolutionized EMS care, it has influenced the care given throughout the entire healthcare system. Bringing it to the forefront of urgent and emergency care has helped not only save countless lives but also has improved the ongoing quality of life for countless patients. The 12-lead EKG provides invaluable insight into a patient’s true underlying medical complaint and is useful in diagnosing a whole host of potential medical conditions. If you are an EMT or paramedic, you should be able to obtain a 12-lead.

I’m saying this because right now in communities both urban and rural there are ambulances that still do not have this essentially lifesaving capability. The problem crosses all divisions in the level of care and there is no excuse for this fact. Obtaining a 12-lead is an essential piece of the diagnostic puzzle for many patients. It can make the difference between a proper diagnosis and misdiagnosis that can have a lasting detrimental effect on a person’s entire life. There are many solid positive reasons that support EMS agencies expending their critical resources to obtain this capability and few, if any reasons for them not to.

If your agency does not currently have the ability to acquire a 12-lead EKG, here are some reasons that you can take to the powers that be for your service or use as information to show your community for fundraising activities. In my opinion, these things help show the solid reasons why you should begin offering the service as soon as possible.

  1. Better knowledge drives better medical care – The most common EMS treatments for chest pain can mask essential diagnostic signs and symptoms that help pinpoint cardiac causes of the complaint. Things like Nitroglycerine, Oxygen, narcotic analgesics, and aspirin can normalize the waveform complexes on an EKG tracing after only a few minutes. EMS providers used to begin treating the symptoms of chest pain before acquiring a 12-lead when the technology was not widely available. This caused a broad cross section of patients who were truly experiencing a heart attack that needed to be treated emergently to have 12-lead tracings that were normal upon their acquisition in the ER. The ERs then needed to rely on the laboratory values of the patient’s cardiac enzyme markers to make a diagnosis. This often times added 12 to 24 hours to a patient’s time to proper diagnosis and sometimes resulted in a heart attack that was missed entirely. EMS 12-lead EKG acquisition helps change that. EMS providers can obtain a symptomatic 12-lead EKG at a patient’s first point of entry to the healthcare system when their symptoms are at their worst which will oftentimes show diagnostic information that 12-leads obtained later in their care will not. This exponentially increases the diagnostic sensitivity of the overall assessment of a patient and can change their entire path of care, resulting in more appropriate treatment being given sooner. This can save more of the patient’s heart tissue and increase their quality of life for the rest of their life. In addition, proper care can decrease a patient’s length of hospital stay, saving millions in healthcare costs when viewed as a sum total.

 

  1. 12-lead EKGs increase the safety of EMS care – Certain types of heart attacks such as ones occurring on the front, underside, and the right side of the heart can cause nitroglycerine administration to be dangerous. EMS providers of all levels give nitroglycerine for chest pain. However, when given to a patient experiencing a right-sided, inferior, or anterior heart attack that affects the right ventricle of the heart, nitroglycerine can cause a severe drop in a patient’s blood pressure that can prove detrimental or even fatal for some patients. A 12-lead EKG can pinpoint these types of heart attacks with a fairly high degree of sensitivity and can help prevent the harmful drop in blood pressure. Heart attack victims need nitroglycerine and like all medicines that can be harmful when not properly used, EMS providers need to be able to see the 12-lead and share it with physicians at the receiving hospital to increase patient safety. Increased safety equals better patient care, decreased liability, and better patient outcomes overall.

 

  1. If you can provide oxygen, you can take a 12-lead – All paramedic ambulances should be able to obtain a 12-lead EKG with no exceptions, however so should all ambulances of any level. EMT-Basics and EMT intermediates functioning on an ambulance service of any level should be able to get a 12-lead. The first arriving care providers who will be beginning treatment on a potential heart attack victim need to be able to obtain a symptomatic 12-lead. While BLS and ILS providers cannot and should not interpret the 12-lead EKG and should not change their care based upon it (unless ILS protocols allow), they may transmit the information to the receiving hospital and/or responding ALS intercept and may act upon the orders they receive from their medical control. Obtaining the symptomatic 12-lead is essential for proper diagnosis of heart attacks. The first arriving care provider needs to get one, regardless of their level of care.

 

  1. It can determine the proper hospital to take a patient – Patients having heart attacks need hospitals that can take care of them. The current gold standard of heart attack care is generally agreed upon by physicians to be “Percutaneous Coronary Intervention” (PCI), also known as a “Cardiac Cath.” This is a surgical procedure where an interventional cardiologist threads a tool into the arteries that feed a patient’s heart through the vessels in their leg. The cardiologist can then open a blocked coronary artery and allow the area of the heart being damaged by the heart attack to receive blood flow again. The sooner this is done, the better. A symptomatic 12-lead EKG obtained by EMS can make the difference between a patient being transported to a patient where this surgery can be immediately performed rather than to a hospital that may not have this capability or does not have it immediately available. This makes the difference between immediately appropriate treatment that saves both lives and heart tissue and treatment that may not be the best for the patient. Inappropriate treatment costs a lot more money when it results in a patient needing transport from a facility that cannot properly care for them to one that does.

These are just some of the reasons that all ambulance services of any level should be able to obtain 12-lead EKGs in the field. It is an essentially lifesaving tool and is the standard of care. There are few, if any dangers or drawbacks to using the tool and multiple strongly supported reasons to do so. EMTs and Paramedics that do not currently have the capability should get it as soon as possible, and the communities that they serve should support them with the funding and resources to do so. The medical directors of communities where EMS 12-lead acquisition is not currently possible should write protocols for the practice and should support development of a system of care that properly uses the critical information obtained to make the most positive impact in patient care.

This is an area where EMS truly makes a documented, lasting impact in quality care and where EMS development is driving the healthcare system as a whole. Make sure your service and your practice is a part of it. Do the best by your patients and communities. Save more lives. Help more people get better.

If you have questions, I offer myself for any information you may need. My e-mail is proems1(at)yahoo(dot)com.

Posted by on April 23, 2012 • Filed under: Administration & Leadership, change, Command & Leadership, EKG, Emergency Medical Services, EMS, ems 2.0, EMS system, EMS Topics, new perspective, Paramedic, Patient Assessment, patient care, Patient Management, Scope of Practice, STEMI, Technology & Communications, Uncategorized

An article on EMS that may actually “get” it

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I don’t usually like things in the media portraying what we do in EMS. Usually they’re too full of melodramatics, misinformation, or just plain callous misunderstanding of what we actually do in the field for my taste. Most of them play out like fantasy, showing EMTs and paramedics as the bumbling idiot “ambulance drivers” they think we are on old TV shows like “ER,” or the junkie borderline monsters like in the movie ”Bringing out the Dead,” or even like the camera-friendly vapid idiots on NBC’s (thankfully) ill-fated show “Trauma.” I just can’t bring myself to watch any of those shows, or even to read most articles printed in the mainstream media covering EMS. They just seem to make me mad as I read them because they don’t get it… and they don’t try to.

Most of them don’t try to get it I should say, because today I came across a piece in Esquire magazine that actually seems to try. Chris Jones, the author does a pretty good job of representing EMS and EMS people though an article he wrote after a series of ride-along shifts he did with paramedics in Canada.

Nice job, Sir. The article isn’t a perfect representation of everything we do out here on the streets, but it’s probably the closest I’ve ever read. You have done our profession a service and I appreciate you for it.

Here it is, you should read it too: “The Strange Happiness of the Emergency Medic” – Esquire Magazine

Posted by on April 20, 2012 • Filed under: Emergency Medical Services, EMS

Vive la solidarité! Something we have in common with our French friends

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Spoiler alert: There are a LOT of French jokes in this one. A LOT of them. You’ve been warned.

This should come as relief to those of you that are tired of measuring your suction catheters in “freedoms” instead of in French. While I was researching the French model of EMS delivery for the post I wrote last week (Hypocritically Speaking – My opinions about EMS models and philosophies) I stumbled across something in the Wikipedia article that made me want to raise a baguette in solidarity to our cheese-eating friends. You might just agree.

It is of note that the French model of EMS delivery involves physicians in all levels of the system. Unlike the American model, where physicians provide

oversight and only rarely respond to scenes, in France physicians are included everywhere from taking calls in the dispatch center to actively responding to scenes and taking care of patients. Their system is different than ours in many ways other than this, but the physician thing is pretty big. I’d always guessed that a system like that could only exist in the realm of near-total government funding, considering they’ve surrendered to the idea of socialized medicine over there. (Hey now, that was a French joke, not an American political statement. Cool your fondue)

But then, in the Wikipedia article, I read this:

“The situation is further complicated by the fact that the physicians staffing the SMUR units are among the lowest-paid in Europe. Although salaries have recently improved somewhat, in 2002 it was reported that these physicians, who are, for the most part, full-time employees of public hospitals, had a starting salary of only €1300 (£833; $1278) per month.[14] This economic reality has resulted in understandably high turnover and some difficulty in staffing positions. It has been suggested, however, that the recognition of emergency medicine as an in-hospital specialty in France and elsewhere in Europe is likely to result in the evolution of that system towards more comprehensive in-hospital emergency services.”

Garcon! Bring me my beret and your finest, cheapest cabernet sauvignon! It turns out that the low pay, little respect, and feeling that “once we’re viewed as a specialty the conditions will improve” isn’t limited to just this side of the Atlantic. Maybe if we’re both underpaid for taking care of sick people we might have other things in common. Maybe they can learn to like our cheap, watered-down beer and we can learn to like their stinky cheeses. Maybe there’s a common theme to EMS around the world that binds us all together. Maybe, just maybe, I can start calling my burn patients “French toast” and they can call their obese heart attack victims an “American Special”.

 

Or maybe not…

C’est la Vie, eh?

Posted by on April 18, 2012 • Filed under: appreciation, Economics, Emergency Medical Services, EMS, ems 2.0, EMS Management, EMS pay sucks, EMS Topics, humor, Paramedic, paramedic salary

Heat Emergencies for EMS – The Summer Time Blues

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It’s just about here! Summer time is awesome in where I live. It almost makes those long winter months seem worth it. Almost. With the warm weather close upon us it’s time to review some of the common complaints that EMS providers seem to see more of in the summer time. Gone are the days of frostbite and hypothermia and here are the days of heat stroke and bee stings. It pays to brush up on these complaints because we’ll be seeing them before we know it.

Heat Emergencies

We humans are a fickle bunch. Get us too cold or too hot and we tend to get sick as the dog days of summer. Since there’s little chance of hypothermia coming in the summer, a review of the hotter side of environmental emergencies couldn’t hurt. In emergency care, heat emergencies are generally classified into three levels in terms of severity. These are:

  • Heat Cramps
  • Heat Exhaustion
  • Heat Stoke

It’s important to remember that these classifications aren’t absolute and are harder to pin down when combined with concurrent medical conditions and other factors such as age, gender, and physical health. It’s also important to realize that some physical conditions, caffeine and alcohol consumption, and prescription medications can diminish a patient’s capacity for thermoregulation and precipitate heat injury.

Heat Cramps – Generally occurring in athletes or those undergoing physical exertion in a hot environment, heat cramps are muscle spasms that mostly occur in the abdomen or extremities. (Core temp 99.1-101.3)

Treatment for Heat Cramps includes general medical care, removing the person from the hot environment, providing oral fluid replacement, and cooling them gently.

Heat Exhaustion – Characterized by Fatigue, weakness, anxiety, intense headaches, profuse sweating, nausea/vomiting, and decreased urine output, heat exhaustion is caused by inadequate fluid intake and excessive fluid loss through sweating. It is essentially hypovolemia caused by hyperthermia and may be the result of several days of inadequate fluid replacement and dehydration. (Core temp 99-104)

Treatment includes much the same as the treatment for heat cramps. Do not give oral fluids to patients with a decreased level of consciousness. If your level allows, start an IV and consider a fluid bolus. Begin active cooling with ice packs to the axilla and groin. Monitor the patient’s vitals closely and watch for cardiac arrhythmias. BLS providers should consider an ALS intercept for fluid replacement.

Heat Stroke – This is a true medical emergency and aggressive treatment is warranted. It is characterized by a decreased level of consciousness, increased pulse and respiratory rates, and hypotension. Skin color, temperature, and moisture findings are not reliable but are generally hot and dry. It is becoming shown that patients that suffer near-fatal cases of heat stroke have a strikingly high 1 year mortality rate. (Core temp >105)

 

Treatment for Heat Stroke includes aggressive cooling with ice packs, evaporative cooling, and IV fluids. BLS providers should request an ALS intercept. Rapid transport is warranted. Manage the airway and other complaints such as arrhythmias as per protocol.

Watch your coworkers too. Make sure that your fellow EMS people are staying cool on incident scenes, especially when they may be wearing turnouts or other protective gear. When you're not actively performing tasks that require protective gear, strip it off to allow yourself to adequately cool. Push them to drink plenty of fluids and go to rehab when they need to. Be safe out there and watch each other’s backs. We need you out there.

Posted by on April 16, 2012 • Filed under: ALS Intercept, Emergency Medical Services, EMS, ems education, EMS Health & Safety, EMS Topics, EMS training, Firefighter Safety & Health, Paramedic, paramedic education, Patient Management, Training, Training & Development

Hangover Heaven? WHY ARE WE NOT DOING THIS!?!?

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I came across a new business today while I was casually wandering around the Internet and I just absolutely had to share it with the EMS crowd. The company, called "Hangover Heaven" (www.HangoverHeaven.com) is set to open April 14th, 2011 in Las Vegas, NV. (Where else?)

If you haven't already clicked the link their business model is that they have a bus that drives around the strip, picking up the hungover masses, and providing "a small IV in your arm that provides the necessary treatment to continue the party or just get back to your normal self." They have two packages, the "Redemption" package for $90 that provides IV hydration only, and the "Salvation" Package for $150 that provides relief through their "Proprietary treatment" which they say contains intravenous hydration, an anti-emetic, an anti-inflammatory medication, and a "Vitamin supplement" package.

You should really read their website yourself. Some copywriter did a great job of selling what I can only surmise to be a banana bag, ondansetron, and toradol. Those meds and the IV fluid will most probably cure any hangover quite handily. While I think this is a bit cheesy… I've got nothing but respect for their plan. Heck, if anything I'm jealous that I hadn't thought about it first. While I'm not licensed to practice EMS in Nevada, I could easily cruise around the streets of Milwaukee, Madison, or Chicago in my ambulance providing the same services to the over-imbibed folks in those fair cities. If we could ask for cash up front, like I'm sure they are, we could probably pull in a few thousand a week doing this. For that kind of coin any city could afford to fund the pension plan and give the nice EMS folks a hefty raise.

What I'm saying is, come on cash-strapped municipalities, belly up to the bedside and get your medical directors to authorize this service. Your budget woes are a thing of the past!

I do have a few questions though:

  • Is this legal? The owner is an anesthesiologist, but there is no mention of who is actually providing the service.

 

  • I'm a Nationally Registered Paramedic… are you hiring? Please?

 

  • Are you selling franchises? Cuz I could use one here in Wisconsin and Illinois real bad. I'd start my own but I'd need a medical director who would be willing… and the ones around here are probably spoil sports

 

  • Although… I haven't yet asked them if they  are ok with this. They could be. Perhaps it's better that you just sell me a franchise real quick and real cheap-like and we can just keep the brand-name going strong.

In all seriousness. Think of what effect this could have on the already overused emergency healthcare system in the city. I mean, if even 10% of the people who are going to be seen by this bus would have otherwise ended up in the emergency rooms getting largely the same treatment, this company could sincerely ease some of the burden on the healthcare system. It's definitely a cheaper alternative. Even their $150 treatment is way cheaper than a trip to the ER. This bus could immediately benefit the entire system by giving patients an alternative to the traditional, significantly costlier, methods. It will save insurance companies and governmental healthcare payors thousands and free up the ERs from taking care of this patient demographic.

I really do think they're on to something. Wish I'd have thought of it first.The success of this business will go to prove something. If it survives and thrives, then EMS can also find free-market alternatives that will help save our profession and the communities we serve. Obviously it can be done.

In other news, kudos to the State of Maine, who authorized funding for Community Paramedicine. Bravo guys, way to intellegently look for real solutions to your healthcare budget woes. I tip my hat to you. – http://www.jems.com/article/news/new-community-paramedicine-law-maine-loo

Notice anything similar?

Posted by on April 13, 2012 • Filed under: Als, ambulance humor, ckemtp rants, Economics, Emergency Medical Services, EMS, ems 2.0, EMS Humor, EMS Management, EMS rant, EMS Topics, Fire Rescue Topics, Funding & Staffing, humor, IV, odansetron, Paramedic, Patient Management

Hypocritically Speaking – My opinions about EMS models and philosophies

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I hate when this happens.

I recently had two separate conversations with people that made me think some of my opinions may be in conflict with each other. In fact, the outcome of these conversations made me realize that I may be a tad bit of a hypocrite when it comes to some of my long held beliefs. I hate when that happens. While I freely admit I will happily change any of my opinions in response to new and/or better information, I can’t seem to change my opinion on either one of these beliefs and it’s making me feel… well… like a hypocrite.

Let’s see if you can help me out.

Opinion #1: Modern EMS exists to bring care to the patient.

That’s an important sentence up there if you didn’t realize, because it represents two monumentally different schools of thought. I believe that the primary purpose of modern EMS is to bring care to the patient, not the other way around. That statement may not sound like much, but it is hugely important for the development of our profession. In the very beginning of what evolved to be EMS, back even before the Cadillac ambulances and hearses, EMS existed to bring the patient to care. Everything was based upon that fact. From the “Flying Ambulances” invented by Napoleon’s surgeons to bring injured soldiers to the surgeons away from the battlefield to the ambulances used in the US in the 60s and 70s, most everything that existed before the advent of paramedics and EMTs existed for the purpose of bringing the patient to the care that could only be provided for them in a hospital. That’s why the Cadillac ambulances had those big engines that could drive so fast and the qualifications for being an “Ambulance Attendant” involved mostly being able to burn exceptional amounts of rubber without killing the majority of the motoring public.

The conversation that brought this up was one I had recently with a Wisconsin EMT-IV Tech (think: NREMT-I 85 level) about a community of 15,000 people nearby that I think should upgrade their EMS to the paramedic level. Their ambulance service is operated by their local fire department and runs an excess 1000 calls for service per year. They have a fairly large state college in their jurisdiction that pumps up their population during the school year and increases the diversity of their response area. I believe that they should upgrade to provide their citizens better care. She believes differently. Her thoughts were that even though there is no hospital in the town, they have three within the area that they transport to. The closest is 10 miles away from their city limits in another town and the other two are both +/- 20miles away. She believes that they don’t need to offer their citizens paramedic service because they’re so close to the hospital. (This is Wisconsin, 20 miles is a run to the corner store ‘round these parts)

I trotted out my old standby, the one I wrote about above that says that EMS is about bringing care to the patient. I explained the two schools of thought and stated that they would be saving more lives and caring for their patients better by offering paramedic care immediately at the patient’s side, rather than withholding advanced care until they had driven a minimum of ten miles. While they provide good service at their current level, I believe that paramedic ambulances in our area bring with them the majority of the care a patient would receive in an emergency room for the first hour or so of their care sans most of the lab work and x-rays. Why wait to stabilize any patient’s condition? Why let someone deteriorate when there are tools out there that can help them?

She seemed to agree with me after I explained it using the “Bring to care Vs. Care brought out” analogy and I, for lack of a better term thought that I had “won” the conversation. (I like winning things) The next week, however, I had a conversation that completely challenged my original argument and made me resort to saying “Because I like it that way” when being asked my opinion about something somewhat similar.

Opinion #2: The US model of EMS is better than the French model.

There are a few competing models of EMS in the world, but two of the starkest contrasts are the French Model of EMS and the US model. In a nutshell, the US model employs paramedics and EMTs who provide limited stabilizing care on site and remove the patient to an emergency room to be attended to by a physician for definitive treatment. The French model relies on physician triage of emergency calls and then sends either a physician to the scene or an “ambulance” with the basic capabilities of a taxi. It’s more complicated than that, and you can read more on the French system on this well-written Wikipedia entry: Emergency Medical Services in France

My thoughts are that the French Model provides too in-depth of care on scene of an incident for severe complaints. For example, while most US paramedics can diagnose and begin treatment on most STEMIs (severe heart attacks) immediately and have the patient undergoing a cardiac cath by a cardiologist in under 30-40 minutes, I challenge the French system to do similarly. I believe that putting physicians on the ambulance limits the availability of EMS care and causes rationing due to the immense costs of having a physician attend to the patient. I also think that the economy lies in having a physician present in the ER where they have the best availability of their necessary tools and the ability to treat many patients at once.  However in truth, most my belief comes from little personal experience and more from media reports of incidents like the death of Princess Diana where the doctors sat on scene for two hours trying to treat her injuries rather than bringing her to a hospital with full capabilities.

The conversation I had that made me question this is one I had about a local helicopter ambulance service that provides either a physician/nurse or physician/physician flight crew. I remarked that I didn’t know how an on-scene interface with a physician would be and that I would be worried that they would over-treat a patient that needed to be swiftly removed to a trauma center instead. Of course, I’ve never seen nor heard of an experience like that with this service, I just was airing my biases. That fact was swiftly, and correctly, pointed out to me and I resorted to the shallow argument that I simply thought that EMS was “Our place” and that other professions needed to butt out…

And I was wrong, and admitted that I was. Then we all laughed heartily.

My potential hypocrisy lies in the fact that I want to support the neighboring community to pursue the paramedic level for their service but cannot seem to extend the same argument to support physician/physician crews on the helicopter. Isn’t it the same argument?

In addition… why don’t I support the French model of providing EMS over the US model for the exact same reason? Aren’t I the guy who thinks it’s time for Primary Care Paramedics in the US?

I’d like you to poke holes in all my arguments and call me out in the comments section, but before you do that, in my pre-defense I like parts of the French system and want to adopt them here. I like that they provide physician-level triage for 911 (or 112) calls and send out appropriate resources, provide instructions for self-care, and/or direct people to primary care by alternate transport. I like that they can treat-and-release on scene for appropriate complaints. I think that they have a lot aspects of their service I like, the same things I like about the British EMS model that are provided by paramedics. I also think that Paramedics are the experts in field care. We exist for the purposes of being the masters of the acute, the experts in the expedient, and the… somethings of the… people who need immediate stabilizing care. (Hey, you try thinking up a third thing). I like the US model because I think that it provides appropriately advanced care and proper specialized focus of training while allowing for cost-effective deployment, availability, and access across the broad spectrum.

But nobody’s perfect.

Your thoughts?

Posted by on April 11, 2012 • Filed under: Emergency Medical Services, EMS, ems 2.0, EMS ethics, EMS rant, EMS Topics, Paramedic, politics

12-lead EKG tips for EMS – Making the most of the squiggly lines

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The 12-lead EKG is one of the most fantastic advances in EMS treatment since the invention of the bandage. The movement of this powerful diagnostic tool from the confines of the hospital to the streets has been nothing short of revolutionary. It has given EMS professionals a wealth of information on how to best care for our patients and has driven hospital care and the development of medical care practices by providing clear and critical data that physicians had rarely before seen.

Did you realize that by moving this tool to the field, EMS has almost made heart attacks into a minor medical complaint that can be effectively treated if caught early? EMS has changed healthcare with that. We’re catching things that used to go uncaught and have vastly improved the lives and qualities of life for countless patients who pass through our care. Kudos to the visionaries that helped drive this change. No matter the level of the service, be it ALS, ILS, or BLS, a 12-lead EKG is an essential EMS tool and should be the standard of care.

Proper acquisition of the 12-lead EKG is paramount to getting the most out of this tool. An improperly acquired 12-lead does not provide diagnostic quality information and can render the tracing mostly useless. Here are a few tips to making sure that you get it done right:

Lead Placement

Traditionally, the limb leads go on the limbs, and while it’s acceptable to move them closer if you have to, try to avoid placing the leads over bony prominences or overly fatty areas. Look for a generally flat, clean, intact area of skin with muscle generally underneath.

The V-Leads go on the chest in a specific pattern. Leads V1 and V2 go in the 4th intercostal spaces (between the ribs) on either side of the sternum. To find these, go about 3 finger widths up from the xyphoid process, or bottom of the sternum. V1 is on the patient’s right, V2 is on the left.

V4 should be placed next, it goes one rib down in the 5th intercostal space, on the mid clavicular line. Place V3 in between V2 and V4.

V5 goes in the anterior axillary line (front of the arm pit) and V6 goes in the mid-axillary line. They go in the same horizontal line as V4.

Skin preparation

It is important to prepare the skin by cleaning it with an alcohol prep and by abrading it with a cloth towel to remove dead skin cells. You may need to wash the area with saline and dry it. Remove excess body hair by shaving. For females, place the leads under the breast tissue. You may need to lift and clean the skin underneath the breast to get a clear tracing.

Baseline

A quality 12-lead EKG has a smooth, flat baseline (called the isoelectric line). Baseline wander, or the vertical motion of the EKG line can mask important findings in the EKG tracing and result in a non-diagnostic EKG. The patient should remain motionless and lay as close to supine as possible for the acquisition of the tracing and the ambulance should be stopped and not moving during the process. It sometimes takes a few minutes for the EKG tracing to normalize and you should wait for it to do so. The goal is to be able to see the entire cardiac waveform clearly and be able to measure accurate ST segment levels. Skin prep is important to reduce artifact. A tracing with artifact or baseline wander can mask serious EKG findings and may cause a patient to be misdiagnosed.

Multiple EKGs

One EKG is a spot-check of the patient’s heart. Two EKGs are a trend of their condition. Try to obtain a symptomatic tracing of the patient before treatments like oxygen, nitroglycerine, or aspirin are given. While you shouldn’t  delay treatment, it has been shown that ST segment elevation can normalize quickly with EMS treatment and an EKG obtained afterwards that does not show ST segment changes can mask a STEMI that should be emergently treated by a cath lab. The 2 or 3 minutes you spend taking the symptomatic EKG can save the patient hours or days going without definitive treatment for their underlying condition.

A good rule of thumb is to capture a 12-lead EKG tracing at the patient’s side where you find them symptomatic, then again when you load them in the truck, and then before you arrive at the ER.

Conditions Requiring an EKG

A 12-lead isn’t just for chest pain.Acquiring one never hurts any patient and may help catch the odd presentation of a serious but vague condition. Obtain a 12-lead for possible strokes, altered levels of consciousness, weakness, dizziness, fatigue, palpitations, and otherwise vague medical complaints. Remember that diabetic patients, younger women, and various ethnicities often have atypical presnetations and may have “Silent MIs.” Be vigilant. You may just save a life.

Posted by on April 9, 2012 • Filed under: Emergency Medical Services, EMS, ems education, EMS Topics, EMS training, Paramedic, paramedic education, Patient Assessment, patient care, Patient Management, STEMI, Technology & Communications, Training, Training & Development, Uncategorized

In Honor of National 911 Education Month – Help Spread the Word

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Here is an article that I'd love for you to steal. Feel free to print this out and send it to your local newspaper in your (or your agency's) name. Help spread the message of the proper use of the 911 system and show your dispatchers some love. Remember, "National Public Safety Telecommunicators Week" is April 8th – 14th, 2012.

Here again, is the National Emergency Number Association's resource and education page

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It’s a crazy world out there.

Mayhem happens. Cars crash, buildings burn, people get sick and injured. We’re all guilty of doing some not-so-smart things every now and then. Usually we’re lucky and nothing happens, we skate by with hardly a thought to the consequences that might have been. However, sometimes it catches up with us. Sometimes those last second chances in traffic cause metal to crunch upon other metal; Sometimes we find out just how well the batteries in our smoke detectors still work; and sometimes we are shown just how fragile life really is. The human body is a masterfully crafted machine capable of doing everything we really need it to, but sometimes it stops working. Sometimes tires on semi-trailers blow while you’re passing them on the interstate. Sometimes your new baby has a seizure. Sometimes your spouse won’t wake up.

As I said: Mayhem, it happens.

While there isn’t anyone out there who would want to dwell on the unthinkable we all know exactly what we’re going to do when we’re faced with it. It’s ingrained into the fabric of American culture and is mostly the same anywhere you go. Everyone knows that when there is a serious risk to life, limb, sight, property, or safety you simply call 911.

“Nine-One-One.” It’s always pronounced that way. Those three numbers are said individually because people who panic over the situation they are calling about used to fumble in vain looking for an eleven key. Nine-One-One. We all remember it and reflexively know that it’s there. We know that someone will answer it and that they will help us when we need it. We know that help is just a phone call away. We know if we call and we really need them that police officers, firefighters, and paramedics will come and help us. We know it to be true and it provides a subconscious level of security for our entire lives. We don’t know what we’d do differently if it wasn’t there, but luckily we know that it is. It affects the American psyche in many ways and probably affects our culture in ways we’ve never studied. Nine-One-One. When we need it to be there, we really *need* it to be there.

April 8th through the 14th is “National Public Safety Telecommunicators Week” as part of the larger “National 911 Education Month.” Sponsored and celebrated by various groups as well as the National Emergency Number Association (www.NENA.org), the events help bring awareness to those who answer our pleas for help. They’re always there around the clock but most people hardly give these trained professionals a second thought. They toil in relative obscurity until we need them. We don’t think about them or the system they command until they’re the calm voice on the other end of the phone helping you deal with the unthinkable. When that happens they’re the most important persons in the world. We need them. They’re the lifeblood of public safety and the life line for everyone from the police officer in a shootout to the firefighter in a burning building to the husband doing CPR on his wife. They deserve our respect and there are a lot of us that quite literally owe them our lives.

There are some ways that you can help your local 911 system:

First: Learn how to dial 911. It sounds silly when you say it, but do you really know how to call it from every device you own? Can you call it from your Voice-Over-IP (Internet) phone? What about your iPhone or Droid? Do you know how to call it from home? From work? What about your kids? If you were unconscious could they figure out how to call 911 from your cell phone? Could they call it from school?

Second: Know how to give a correct location to the 911 operator. Even with the “Enhanced 911 system” that is supposed to provide location information to the dispatcher, your phone may not do it. Think about providing a clear location to 911. Teach your kids their address and their full names.

Third: Stay on the line. When you call 911 do not hang up first. Let the dispatcher end the call. There may be more information the dispatcher has to get from you. Responding emergency units may get lost and need directions on where to go. Every emergency dispatch is a carefully orchestrated series of events between various systems and groups. The fire department coordinates with the ambulance which coordinates with law enforcement and vice versa. The 911 dispatcher is the person who makes a lot of these decisions and has a lot to do in order to get things rolling. If they need information from you they will ask. If they don’t, they’ll end the call first. Please stay on the line and help give them all of the information they need.

Finally, learn CPR. Everyone should know it. 911 dispatchers are trained to give instructions over the phone to you on how to help in a medical emergency, but this is not a substitute for training on what to do. Learning CPR saves lives. Know it and be ready to perform it.

Think about the system and find ways to support the local 911 dispatchers. They don’t get hardly any credit for being the absolute lifesavers that they truly are.

Posted by on April 4, 2012 • Filed under: 911, Administration & Leadership, appreciation, Command & Leadership, Dispatch & Communications, Emergency Communications, EMS, EMS Dispatch, EMS Topics, Fire Dispatch, Fire Rescue Topics, Uncategorized

National 911 Education Month – What EMS can do

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If you're an EMS person, you should probably know that April is designated as "National 911 Education Month." It is sponsored by the National Emergency Number Association (NENA) and is dedicated to educating people about the proper care and feeding of the 911 system and the dedicated emergency telecommunicators that make the system run. The month spreads awareness of how to use the 911 system properly and culminates with "National Public Safety Telecommunicators Week." NENA has some great resources, including pre-made radio, web, print, and video PSAs, on their website: here.

I've always said that I am NOT cut out to be a dispatcher. I just don't think that I personally have the mental quickness, ability to multitask, or organizational skills it would take to be good at the job. As an EMS professional, I revere my dispatchers and show them as much love as I can. Dispatchers are the omnipresent bits of sanity in our daily schedules. We need to treat them well and give them equal respect. They do a terribly hard job and I salute them for it. You should too.

EMS professionals should celebrate National 911 Education Month as well as National Public Safety Telecommunicators Week just as much as we celebrate EMS week. We need to do this because well, can you imagine any potential benefits to educating the public about proper use of the 911 system? I think I can. Remember, it's not just about reducing nuisance calls that bog down the system; it's also about educating people when they absolutely need to call 911 because it's better medicine for them or better for society in general. I cringe when I see people who have legitimate medical problems that would benefit from EMS care drive themselves into the ER or even go untreated. It's our mission to help them and the first step is to spend time educating people when it is appropriate to call, without being condescending to those that call inappropriately.

Let's make the message as positive as we can people. We're professionals who care for others. Working EMS is a privilege and we need to remember that. I would rather go to 100 inappropriate calls than miss one single call where we could make a lifesaving difference.

In celebration of the month, I'm going to write a few pieces in honor of those that tell us where to go. I'm going to show some love to the voices in our radios and give you some tools to help spread the message at your own agencies. Tomorrow, look for a piece I've written that you can cut, paste, and send in to your local newspaper as a letter to the editor. Every little bit helps.

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Posted by on April 2, 2012 • Filed under: 911, Administration & Leadership, Command & Leadership, Dispatch & Communications, Emergency Communications, Emergency Medical Services, EMS, EMS Dispatch, ems education, EMS Topics, Fire Rescue Topics, News, Technology & Communications
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