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Dirty Wet Wipes, Millions of Dollars, and the Coming Changes to EMS

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It was quickly turning out to be one of those mornings. The ER was hopping and everyone was busy. We had been taking in a lot of ambulances since the start of the day shift and everyone was trying to muddle through the increasing patient load. While I was in-between tasks, I noticed that one of the nurses had left a backboard in the hallway outside of a patient room. I figured that I had a few spare moments and took it out to the ambulance garage to clean it and throw it in the cabinet. A mundane task wrapped up into a hectic day.

I have to tell you that I wrote and rewrote that first paragraph four times because I couldn’t seem to write it in a way where it sounds interesting. Cleaning a backboard in an ER isn’t all that exciting, right? Why would I write about something like that?

Because after I wiped the board down with the disinfectant towelettes, I was absolutely horrified with what I found.

The handful of disinfectant wipes I used to wipe the thing off with came out filthy. They were mostly black but were speckled with orange-ish brown spots that come from wiping up drops of blood. The board looked a tad dirty when I started and even smelled faintly of pee but I never expected it to be as dirty as it was. It was absolutely disgusting. What makes it all the worse is that there was no way the blood, dirt, and pee came from the patient who was most recently put on the board. That patient wasn’t bleeding, hadn’t peed, and was well dressed from a clean environment. The patient had been placed on this festering petri-dish of a medical tool by the (hopefully) well-meaning ambulance crew who had responded to the call for help. They had put her on this thing and happily whisked her off to the ER for treatment.

So why, you ask, is this important enough for me to write about. Why would I write about one single backboard carrying one single patient brought in by a small ambulance service to a small hospital? Why is that worthy of wider attention?

I’ll tell you why:  This one incident epitomizes a coming tsunami of liability, headaches, and hardship for EMS providers around the US that is going to completely blind-side EMS. A few years back the Centers for Medicare and Medicaid (CMS) quietly stopped paying for things considered to be “preventable medical errors” including hospital acquired infections. They believed that they could save substantial amounts of money by not paying for injuries and illness caused by the hospitals that were treating the patients they were financially responsible for. You might have guessed that Healthcare Acquired Infections (HAIs) happen to be the largest group of these preventable medical errors and hospitals have gone in to full battle mode to combat them.

It is estimated that one in twenty patients will contract a HAI during their hospital stay. It is also estimated that around 98,000 patients die each year from them. HAIs are the most common complication in hospital care of patients costing the US healthcare system around $45 Billion annually.

Hospitals have to take care of patients who contract HAIs in their facility; they’re just not paid to do it. There are estimates out there that say it costs an individual hospital between $10,000 and $25,000 (or more) for every instance of an individual patient contracting a HAI while in their facility. That’s not small change and hospitals are spending money like crazy to fight germs. Infection control departments are being fully staffed and well-funded, housekeeping and environmental services workers are sitting through hours upon hours of training, policies and procedures for cleaning and disposing of potentially contaminated items are being written and enforced by the truckload and they’re just getting started.

And we in EMS are largely oblivious to this fact.

Think of this. If this patient would have been admitted and found to have a HAI, who would have been at fault? Think hard, because tens of thousands of dollars are on the line per each individual patient. Is it the hospital, which has an army of environmental services staff, a battalion of infection control nurses roaming the hallways, and a forest of policies and procedures in place regarding meticulous cleaning practices? Or the EMS agency that brought in a patient on the backboard that was as clean as those wet wipes showed us it was?

To my knowledge, no hospital in the United States has ever sued an ambulance service or otherwise attempted to collect from one due to non-payment related to a HAI. But it’s coming. It’s coming sooner than you think it will come and if you’re not ready it will blind-side you and potentially bankrupt your service. If you think that I’m mistaken, fine… however when Millions of dollars are on the table locally and Billions are on the table nationally… I don’t think that I am.

Clean your stuff. Wash your hands. Write policies regarding cleaning and infection control, enforce them, and document their continuous use. It’s not a small issue. This is one of those things where EMS must act now or someone will act for us.

Oh, and on that note, have you heard about Medicare’s new concept of paying for patient outcomes? This is where hospitals that have better results for their patient care will get more money than hospitals that have poorer results for their patient care? That’s coming too. What do you think it will do to ambulance services when the hospitals start to identify services that consistently bring in patients who do poorly as opposed to services who consistently bring in patients who do better? Right now, nobody knows… but that issue is coming too. Believe me, the hospitals are tracking it. It’s time to get to work.

Here’s some light reading for you as well as my references.

http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf – CDC analysis paper on cost of HAIs and benefits of prevention.

http://www.huffingtonpost.com/glenn-d-braunstein-md/hospital-acquired-infections_b_1422371.html – Good article with statistics from about hand-hygiene

http://www.medicalnewstoday.com/articles/80074.php – Medicare to stop paying for HAIs

http://www.hfma.org/Templates/InteriorMaster.aspx?id=22142 – Article about pay-for-performance and pay for patient outcomes

Posted by on September 27, 2012 • Filed under: Administration & Leadership, ckemtp rants, Command & Leadership, disinfection, Emergency Medical Services, EMS Health & Safety, EMS Topics, Fire Rescue Topics, Funding & Staffing, infection control, Patient Management, Training, Training & Development

Tracking Traction – When Traction Splints Should Pull Their Weight

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“What’s that mailbox say?” You ask your partner, “14338 Hansen Road? Good, we’re here. Your partner calls “on scene” to dispatch as you pull into the gravel driveway of the farmhouse you’re responding to. It’s set some distance from the road, but as you pull up you’re met by two teenagers who are waving you towards the gate to a field. You stop and ask them where they’re directing you.

“He’s out in the field!” They both exclaim at once. You ask the older of the two what’s going on. “Our dad was trying out our new dirt bike and he fell! He’s about a quarter of a mile out in the pasture! He’s hurt real bad! We think his leg’s broke! He’s yelling a lot. You’ve got to go help him!”

Judging by the amount of rain your area has had in the last few weeks, the dirt lane out into the pasture doesn’t look all that friendly for your ambulance to travel down. Luckily, the guys from the station are following you in Utility 984 which is a 4-wheel-drive pickup truck. They arrive shortly after you get out of the ambulance and pull out the gear you need. You take a backboard, the c-collar bag, your trauma kit, the drug box, and on a whim you dust off the traction splint and take it with you. As the utility unit pulls up, you throw all of your gear in the back and ask them to give you a lift down to the patient.

After about a 3 minute ride you find the patient, an adult male in his late 40s. He’s lying in a kind of fetal position on his left side holding onto his right thigh very tightly with both hands. He’s pale, cool, and diaphoretic and even though he’s trying to be brave for his sons, you can tell that he is in extreme amounts of pain. You introduce yourself to the patient and ask him what happened while your partner attempts to protect his c-spine. He seems to be conscious and alert but has trouble getting the words out. Through the story told by him and his sons, you find that he was turning sharply on the new dirt bike and had stuck out his leg to help him keep his balance. Apparently he must have caught something with his foot because he felt a terrible pain in his thigh and flew off of the bike at a fairly high rate of speed. On assessment, you find a few superficial abrasions to the patient’s arms and one on his forehead, but no other injury other than to his obviously deformed leg. You ease the patient to a supine position and can see that the leg is shortened and rotated. Then you expose the patient and see that his right thigh is swollen to about twice the size of the left one. He has no pain to palpation to his head, neck, back, chest, abdomen, pelvis, arms, left leg, or right ankle… but that deformed, shortened, rotated, and swollen left thigh suggests a mid-shaft femur fracture, and a painful looking one at that.

Since you’re working a paramedic truck, you have your partner pop in a large bore IV line while you get out the drug box. The patient’s going to need a line anyway as people can lose a huge amount of their total blood volume into their thigh without spilling a drop externally and he could probably use some pain control before you move him. You choose to give him 50mcg of Fentanyl and have the rest drawn up to give him after you see his tolerance to the medication. While you’re doing this, you‘re thinking about how lucky you are that you remembered to grab the traction splint. You’re also desperately hoping that you remember how to put it on. It’s been… a while since you put one on a patient last and you think you were sick that last skills review day where you were supposed to practice it. Your partner wasn’t however and you put the patient on the traction splint together. Once you pull the traction, you see the relief spread over your patient’s face as the bone is pulled back into alignment and his muscles stop spasming. His pain drops markedly and his blood pressure is actually up a bit since you last took it. You give him a repeat dose of Fentanyl to prepare him for the bumpy ride back in the pickup truck and package him the rest of the way on the long-board for spinal precautions.

The femur is one of the strongest bones in the body and is said to be able to withstand forces of up to 15-30 times a person’s body weight before breaking. It does this because it is surrounded and supported by the powerful muscles within the thigh that contract around it to provide reinforcement. Femurs are connected proximally to the pelvis through the femoral neck or acetabulum, and are connected distally at the knee joint. When the femur is fractured, the muscles of the thigh spasm and contract, pulling the jagged ends of the newly fractured femur past each other, shortening the leg and causing great pain and damage to the internal tissue as the bones lacerate and damage the structures around it. The damage from an improperly splinted femur fracture can be worse than the injury from the trauma taken to break the bone in the initial injury. In fact, due to its proximity to the femoral artery and vein, a patient can completely exsanguinate from an isolated femur fracture. It is of vital importance to stabilize and realign a femur fracture as soon as possible after an injury in order to prevent further damage and potential other complications.

Traction splints are required by law to be carried in most ambulances in the United States. They come in three popular varieties, the Kendrick Traction Device, The Hare Traction Splint, and the Sager Splint. All of them are designed to perform the same function for a wide cross section of patients however their design and application vary greatly. They serve to pull distal force along the leg to lengthen it back to its normal length. The traction applied by the splint pulls the femur back into normal alignment and the splint then serves to immobilize the leg. The traction and immobilization stop the muscle spasms and realign the bone, preventing further injury and greatly reducing pain. It is amazing the first time a provider sees a traction splint being properly applied to a femur fracture and realizes the amount of immediate pain relief the splint provides. While EMS providers don’t tend to use traction splints very often, once they do they consider them to be extremely valuable pieces of equipment.

A traction splint is indicated for a mid-shaft femur fracture with no pelvic involvement and no injury distal to the femur on the involved leg. Mid-shaft femur fractures present with a history of an injury from a specific force, such as the story above or from a front-end vehicle accident, but can also occur from incidents of lower energy transfer. Femur fractures will be present with shortened, rotated extremities with swollen, painful thighs in the affected leg. Be sure to check distal pulses before and after application of the splint.

Get to know your traction splint and pull it out to play with it every so often. When you need it, you’ll *really* need it and it’s good to know how to use it. Your patients will thank you.

Posted by on September 25, 2012 • Filed under: Emergency Medical Services, EMS, ems education, EMS Topics, EMS training, Paramedic, paramedic education, Patient Management, scenario, scenario based training, Training, Training & Development

EMS Providers Carrying Guns – A terrible idea

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Have you ever tried to kill a noxious, invasive weed in your yard? Think of something like bamboo or creeping charlie… something that isn’t serving any purpose and is hurting the growth of the good grass that you want to be in your lawn, something that just keeps popping up no matter what you seem to do.

That, my friends, is how I feel about the recent eruption of posts on Facebook and the blogs lately about how EMS providers should be allowed to carry guns. It’s an annoyance and hurts any constructive growth for our profession.

I’m going to come out right now and say that it is a terrible, awful, no good, very bad idea that needs to be put down the sewer like the turd of an idea it is. EMS providers should not carry guns. Not now, not ever. Never ever never never never. It is a terrible idea fraught with so many perils and pitfalls that it is more than just a slippery slope; it is a death trap that stands to hurt everyone should it come to fruition anywhere.

I didn’t form this opinion lightly. In fact, I strongly support our right as Americans to keep and bear arms. I generally support concealed carry. I don’t take disagreeing with the likes of the venerable Kelly Grayson as anything other than something very serious. I respectfully, yet strenuously, disagree with his opinion and while I know he has reasons for what he believes; I just can’t support his position on this issue.

EMS providers should not carry guns. They should not be issued guns to carry by their agencies; they should not be allowed to carry on-duty even if they have a permit to carry off-duty; they should not be allowed to carry even if they are sworn law enforcement officers working EMS part-time or as a volunteer. I do not say this because I am a bleeding-heart liberal because I am not. I say this, because it is a terrible idea.

Here are some of the reasons why:

1. Using a weapon for defense or as a tool for any other kind of task takes training, experience, and practice. Not only that, it takes lots of training, lots of experience, and lots of practice. Police officers, military heroes, and other professionals who are armed for their occupations receive lots of training, experience, and (hopefully) practice. Without it, any weapon becomes less of a tool and more of a liability. Remember folks, EMS is a profession where members furiously struggle against adding even tiny amounts of time to their initial training classes and can barely be forced to sit through, let alone actively participate in required continuing education classes. Can we ever hope to get them to train, practice, and gain experience in the safe handling and use of a weapon? It’s not possible and won’t happen.

2. Has gun violence against EMS providers spiked recently? Is it really bad out there? I personally know police officers who have been fired upon and hear regularly about police officers who have been shot. It’s terrible for them and I respect the courage they display by simply doing their jobs. While I hear about and have personally experienced physical attacks on EMS providers, the vast majority of them are closed hand attacks perpetrated by mentally impaired, intoxicated, or otherwise disturbed individuals, I rarely if ever have heard of an EMS provider being shot with a gun or stabbed. While I could believe that EMS providers have a higher risk of being shot or stabbed while performing their duties than does the general public, I have never seen data to prove that. I’ll concede though, that it passes the smell test and could be true. However… do you want to know why EMS providers aren’t being shot, stabbed, or assaulted to the extent that police officers are? It’s because we’re not cops. It should never be taken lightly that we are, if not considered neutral in street culture as we are targeted on occasion, largely considered to be non-combatants. We’re not cops. We’re out there to make everyone feel better and are largely being left alone. It’s a finite balance that will be upset the first time that Clint EMStwood pulls out his shootin’ iron and points it at a gang-banger. Once that happens, we lose our neutrality and will be targeted much more often than the comparatively rare times we are now. People will die because of it.

3. More lives have been saved by EMS’s policy of withdrawal from violent situations than could ever be saved by EMS carrying guns. It isn’t cowardly for us to withdraw, it is lifesaving. We do not enter dangerous situations and we do whatever we can to run from them when we find them. Bravado doesn’t figure in to this. We don’t do it because we are cowardly; we do it because it is not our role to face violence. Eventually, people who skirt this rule and do not withdraw run into situations where they must act in a hostile nature to defend themselves or someone else. Eventually, people who do not withdraw injure or kill someone; perhaps they are injured or killed themselves. EMS providers do not have the legal protection, authority, or ability to act in hostile situations. It isn’t our job and it isn’t our job for a reason. That’s what cops do and EMS providers aren’t cops. If you personally want to be a cop, go be a cop. If you wanted to be a cop but found out that it was easier to get a job as an EMT and now hope to bridge the jobs to realize your dreams, then please leave EMS. You’re not helping as much as you think you are. If you just want to strap a gun on your uniform because you think it looks cool, you’re probably not the type of person who reads EMS blogs because of all of the fancy words we tend to use. You may say that we can still withdraw at the same rates that we do now, but I’ll quote my father, who told me that “When you have a gun, every fight is a gun fight.”

You may disagree with me and that’s fine. Please leave your reasoned, courteous debate in the comments section. However I will state that all of the debates on this topic tend to degenerate into shouting matches where the supporters of EMS providers carrying guns prove to me that the state of this country’s educational system could stand to be improved. Do not do that here.

Stay safe out there. If you'd like to read another opinion I agree with, our friend Greg Friese posted this on the same topic.

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Posted by on September 20, 2012 • Filed under: Administration & Leadership, ckemtp rants, Command & Leadership, Emergency Medical Services, EMS, EMS Health & Safety, EMS Management, EMS Topics, Fire Rescue Topics, News, safety, Uncategorized
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