Archives for

See all posts in the network tagged with

Blood Pressure – Vital Knowledge for EMS

The blood pressure is one of the most ubiquitous diagnostic tools used in medicine and has a sacred role in EMS. Every EMT and Paramedic needs to be able to get an accurate blood pressure from every patient, every time. It is so widely regarded throughout medicine as a useful diagnostic tool that it’s considered to be one of the “Vital Signs” and pretty much everyone reading this has either taken someone’s blood pressure, and/or has had theirs taken many times.

Of course we know that the blood pressure is the measure of the heart’s ability to pump blood throughout the body. It’s simple, right: Cardiac Output – Vascular resistance = BP. The blood pressure is represented as a number *slash* number, or “Something *over* something” measured in “mmHg” (millimeters of mercury). These numbers represent the “Systolic” and the “Diastolic” pressures, with the Systolic blood pressure meaning the peak fluid pressure of blood flowing through the arteries at “systole”, or the heart’s peak contractile force; and the Diastolic blood pressure measuring the pressure of blood in the arteries when the heart is at “diastole”, or at rest. EMS people use the blood pressure to see how well the patient is “Perfusing” or circulating blood and the oxygen and nutrients it carries to the end tissues it supplies. “Hypotension” is too low of a blood pressure and can result in tissue damage, tissue death, and/or Shock; and “Hypertension” is too high of a blood pressure and can result in all kinds of short and long-term damage to the body, including heart disease, kidney disease, stroke, and many other chronic conditions. In EMS, we use the blood pressure as an important diagnostic tool in such things as trauma to measure blood loss, and also in medical care to determine shock or cardiac compromise.

But we all know the basics, right? Good, if you’re an EMT, you probably should know all that. However, you may not have heard these terms:

Pulse Pressure: The difference between the Systolic Blood Pressure and the Diastolic blood pressure. For example, a patient with a BP of 120/80 has a Pulse Pressure of 40mmhg.
Stroke Volume: A measure of the volume of blood ejected with each beat. (Stroke volume + Pulse rate = Cardiac Output)
Preload: A measurement of the pressure left in the vascular system during Diastole (Or “Left Ventricular End Diastolic Pressure” I’m just going to call it preload)
Afterload: The pressure that chambers of the heart must generate in order to pump blood. In the case of the Left Ventricle, it’s the pressure it must create through contraction in order to pump blood into the aorta.

(For everything else you’ve ever wanted to know about blood pressure, read this: “Overview of Blood Pressure” by John Ross)

What if there were more things that taking a patient’s blood pressure could tell you about them?

There are, of course. The blood pressure is way more useful as a diagnostic tool than most EMTs and Paramedics realize. Here are some of the things that the simple blood pressure can help you learn about your patients and the care they need:

———————————————————————————

It can diagnose Orthostatic Hypotension

Have you ever seen a medical provider take “Orthostatic Blood Pressures?” These are taken as three consecutive blood pressure measurements taken with the patient in the Supine (laying down), Sitting upright, and Standing position. To properly perform this, have the patient lay supine for five minutes and take a baseline blood pressure measurement. Then have the patient sit upright, wait two minutes then take their blood pressure. Repeat with the patient in a standing position. If the patient gets dizzy for more than a minute with positional changes, that’s a positive sign for orthostatic hypotension, as is a drop in systolic blood pressure by 20mmhg between readings.

What does this mean?

Well, it can mean that the patient is dehydrated, is experiencing hypovolemic shock, has some type of cardiac compromise or an arrythmia, is anemic, has a problem regulating their blood pressure, has an electrolyte imbalance, and a few other conditions. It can also be caused by medications such as Beta Blockers or even Viagra. Orthostatic Hypotension is also a common cause of Syncope, or fainting. It’s an important assessment finding to record in your patient care report and to pass on to the receiving facility.

———————————————————————————

It can help diagnose a Thoracic Aneurism

The arms are the most common places where the blood pressure is measured. The blood pressure cuff aka a “Sphygmomanometer” is wrapped around the arm at the bicep and applies pressure to occlude the brachial artery. The brachial artery is supplied by the subclavian artery, of which there are the Right and the Left subclavian arteries respectively. It has been shown that there may be a normal 10 to 20mmHg difference in blood pressure between the arms in a small minority of patients. Therefore it is important to take blood pressure readings from both arms when diagnosing hypertension. It is also useful to note when there is a difference in readings above 20mmHg from one arm to another. This can be a sign of Increased intra-thoracic pressure, a Thoracic Aneurism, or something called “Subclavian Steal Syndrome”.

In a thoracic aneurism, a condition with a mortality rate reaching up to 80%, the aortic arch in the chest is compromised. This results in severe pain (usually described as “ripping” or “tearing”), hypotension, and usually death if it ruptures. As the aneurism tears, it compromises the entrance to the right subclavian artery before the left, causing the blood pressure in the right arm to drop. This is an important diagnostic tool to use in diagnosing chest pain and should be documented.

———————————————————————————

It can help detect increased intrathoacic pressure and other conditions

The thoracic cavity is the area commonly called the chest and is the area above the diaphragm protected by and enclosed in the rib cage. As we know, there are a lot of important things in there that humans need functioning properly in order to, you know, live. Pulsus Paradoxus is a condition where the heart’s pumping capacity is compromised by the thoracic pressure and the blood pressure rises and falls with inspiration and exhalation. The blood pressure drops (and sometimes even the radial pulse disappears) with inspiration and rises again with exhalation based upon the volume/pressure of air in the chest. The “paradox” results from the fact that you can hear cardiac beats on auscultation of (listening to) the chest, but cannot detect them with the blood pressure and/or pulse.

What does this mean?

Lots of conditions can cause Pulsus Paradoxus and roughly they can be broken down into three groups: Cardiac causes, Pulmonary Causes, and Other causes.

First, let’s give a nod to the other causes, the non-cardiac and non-pulmonary causes, which are Anaphylaptic Shock and an obstruction of the superior vena cava.

The cardiac causes can be: (and THANK YOU Wikipedia for being smarter than me and very accessible)

cardiac tamponade – A “bruise” of the heart resulting in the pericardial sac filling with blood that cannot escape and compromises cardiac function. (Treated with a pericardiocentesis, which some EMS providers can do in the field. I can).
constrictive pericarditis – Inflammation or purulent (puss-filled) infection of the heart which compromises pumping ability.
pericardial effusion – Fluid around the heart
pulmonary embolism – A blockage in the pulmonary artery or vein
cardiogenic shock – Impaired pumping ability of the heart due to cardiac damage or other compromise. Commonly seen in severe myocardial infarctions. (Heart attacks)

It can also be caused by pulmonary (lung) conditions, such as a tension pnuemothorax, COPD, and sometimes in severe and acute asthma, where the patient traps so much inhaled air in the lungs that they cannot exhale the excess pressure due to the inflammation of the air passages.

When you see these signs, make sure to take multiple blood pressure measurements to trend the patient’s progression. Calculate their Pulse Pressures, as cardiac tamponade, tension pneumothorax, and other conditions are characterized by narrowing of pulse pressure and compromised cardiac output also resulting in hypotension.

—————————————————————-

It can help detect a closed head injury, stroke, or Intracranial Hemorrhage (<– that’s an excellent link)

Cushing’s Triad, aka Cushing’s reflex, is a group of symptoms that has been shown to reveal increased intracranial pressure (ICP), the pressure within the cranial vault around the brain. This reflex shows three distinct signs which are predictive of Stroke (both ischemic and hemorrhagic), intracranial bleeding, head trauma, and some other conditions that raise ICP. These signs are:

Slowed pulse rate
Markedly increased systolic pressure (high BP) with widened pulse pressure, as the diastolic pressure usually stays normal, and:
Irregular breathing (Cheyne-Stokes pattern respirations)

Any time you suspect an injury or condition that may raise ICP, check the blood pressure and look for Cushing’s Reflex. It can help you zero in on the patient’s condition.

———————————————————————

Here are some tips for making sure your blood pressures count:

Automatic BP cuffs do an ok job of measuring the blood pressure in a routine setting, but they have weaknesses. They cannot detect pulsus paradoxus, they give wildly inaccurate readings in bradycardia (slow heart rate), and they’re very much affected by the bumps in the road felt in the back of an ambulance. TAKE AT LEAST ONE OR TWO MANUAL BLOOD PRESSURES.

Can’t hear the systolic pressure? Take a palpated blood pressure by feeling the radial pulse while you deflate the cuff. The first pulse you feel = a reasonably accurate systolic pressure.

As with a lot of diagnostic tools, the first blood pressure measurement is a spot-check. The second reading creates a trend and reveals a lot more information. Take them every 5-10 minutes on critical patients, and every 10-15 on stable ones, keep mindful of the pattern.

This is by no means an exhaustive list, but it should give you some more respect for the humble blood pressure. As always, follow your local protocols and medical orders and this article isn’t meant as medical advice. Keep learning out there.

Also, feel free to add things in the comments section. I’d love to see what I missed.

——————————————————————-

Want to learn more stuff about stuff? Check out:

Links to my articles on everything you’ve ever wanted to know about writing the perfect EMS Narrative Report.

EMS Practice – Practice makes perfect – Comparing High School football to EMS skills

Assessing Greatness: Catching the stuff you’re supposed to

Posted by Ckemtp on June 20, 2011 • Filed under: Ambulance, Emergency Medical Services, ems education, ems narrative, ems patient care report, EMS Topics, EMS training, Fire Rescue Topics, Paramedic, paramedic education, Patient Assessment, patient care, Patient Management, Training & Development, training-fire-rescue-topics

Perils of Paramedics Pursing imProper Patient Refusals

7 comments

Inspector General Faults DC Paramedic’s Response to ‘Acid Reflux’ Case

This article comes to us from JEMS.com which has a link to the full article over at The Washington Times. It’s not necessary to read both articles, but since JEMS originally called it to my attention it’s only fair to link the boys over there first. Read the full article, please… I want to see if you feel the same way about it that I do.

Ok, ya back? Good.

In this case that is very reminiscent of the case law I wrote about last year in “EMS Case Law – AMA Refusals, Death, and Documentation” – A DCFD EMS paramedic obtained a signed refusal from a patient who called 911 for chest pain. According to the < sarcasm> stellar, just friggin’ stellar < /sarcasm> journalism employed in the story by the reporter (I mean seriously, can any reporter anywhere ever write a story about EMS that doesn’t sound like a 5 year old’s understanding of Mozart?) the Evil paramedic did bad things that caused someone to die.

And, well… Here are some quotes from the piece, although I still think you should read the whole thing:

“The crew found Givens, 39, on the floor of his home after his mother called 911 — “an indication that he may have experienced something more serious than what was later described as simple acid reflux,” the report says.

Although they asked Givens multiple times whether he wanted to be taken to a hospital and he declined, the report suggests responders should have done more to persuade him to go.”

So they find some guy, a 38yo guy, a young guy who lives with his mother (maybe) laying on the floor probably being all dramatic and stuff… I’m sure he was all like “Ow. My chest hurts” and the medics were all like “Dude, we have a low index of suspicion for your condition being cardiac related due to the fact that you’re young and don’t appear to have many risk factors” n’ stuff.

Or something like that. At any rate, I’m sure they were less concerned about this guy than they would have been with say, a middle-aged male with classic STEMI (heart attack) symptoms. Yes, they signed him off AMA while telling him to take Pepto-Bismol, and yes… the article does indeed say this:

“The inspector general’s report also faults emergency workers for not recording fundamental information, such as Givens’ first name, age and medical history and interactions with his family members on a patient care report. The reports are typically passed on to hospital personnel when a patient is taken to a hospital but are considered necessary even in cases in which a patient is not taken to a hospital to provide medical and legal documentation of responder’s actions.”

But that doesn’t mean that they just plain didn’t care about the guy and were encouraging the refusal, right?

“When Givens asked one of the four emergency workers who responded if he needed to go to the hospital, the responder replied, “That’s up to you; if you want to go we will take you,” according to the report.”

Yea… I’m just going to come out and say that the only time I ever use that line is at 0330hrs when I’ve been called out for a stubbed toe in the winter time and I am actively encouraging the AMA.

But this can’t be a systemic problem with the whole administration of the DC Fire Department EMS division, can it? I mean… that’s one of the nation’s busiest fire-based EMS providers and I’m sure they care a great deal about EMS and give it the full attention it deserves.

“A 2009 investigation by The Washington Times into the training and education of the District’s paramedics found many could not pass basic written exams testing their medical knowledge or that they mishandled basic life-saving procedures during videotaped assessments.

The test results of the paramedic who treated Givens were among those criticized by experts in the report by The Times, and the lawsuit filed by the Givens family accuses the fire department of being aware of the paramedic’s “poor performance” but leaving him in the field.”

Um… but that was in 2009! And I’m sure that the DC Fire Department EMS Division has progressed greatly in improving their EMS care and service delivery, right?

DC BLS Ambulances out of service as Hot Weather Arrives

<sigh>

I will admit, there isn't enough information or proof here to make a decision on due to the *amazing* clarity of the reporting here. I'll admit that I read between the lines when I made my judgement and then pulled back from my original thoughts. Then again, it does seem like my worries about this case are correct… I don't know exactly what the truth is, but I'm guessing it's not favorable for DC Fire EMS.

Excuse me, I mean "FEMS."

<sigh>

—————————————————————————–

Have you ever read my post on the ultimate, most off-limits “no go” topic in EMS blogging? It might tick you off as well.

My Thoughts on Fire-Based EMS

Posted by Ckemtp on June 17, 2011 • Filed under: Administration & Leadership, Case law, Command & Leadership, Emergency Medical Services, EMS, EMS Management, EMS rant, ems report, EMS Topics, everyday ems ethics, Fire Rescue Topics, Paramedic, training-fire-rescue-topics

Death Rate to Increase in London – and – The Medicare Tomato

4 comments

Howdy everyone!

I’ve read some things out there on the interwebs lately that I’d like to share with y’all. These are articles that made me think. They also made me feel a certain way after I read them. Individually, they would have been interesting on their own merits. However, when read together one after another, I think they do something to your brain that you should experience.

And let me just say, good luck with this.

First off, I read this post by Rogue Medic that linked to this post by BryanKellet.net entitled “Death Rate in London to Increase”.

As always, Rogue Medic has provided his genuinely valuable insight to the article and I am very much glad he called it to our collective attention. I suggest you read the original post first and then read the Rogue’s interpretation on it. While you’re at it, be SURE to read each and every one of the comments on Mr. Kellet’s article. Read them all, it’s very telling.

Including this one:

"560 frontline cuts is a huge number and your comments with regards to little yellow cars is spot on. Time to start investing in private healthcare company shares perhaps."

Uh huh.

It looks like the London Ambulance service is cutting 560 paramedics from their staff, decreasing available ambulances, and is shifting the focus to Rapid Response cars with a single-medic. While these cuts would be common-place in American cities these days (except of course, for the Rapid Response Cars); doesn’t the NHS support the LAS? Wouldn’t they be fully reimbursed for their care? I thought they had a well-funded healthcare system over there across the pond.

Then read this fascinating look at universal healthcare written by The Happy Hospitalist and posted on his site about a year ago: The Medicare Tomato – It is just an absolutely fantastic article that you need to read, now. If you’re not convinced, read this quote from the piece:

“A consumer came in today at 12:04 pm on March 7th, 2008. He did not complain of any tomato headache. He had no gas pains. He appeared to be in good spirits. He was not orange. His lips were drooling for a chance at free tomatoes. He appeared angered at the lack of options and declining quality. He was at one point found to be pointing and yelling profanities. He took 7.4 pounds of the super duper genetically altered tomatoes (verified by government scales) with a big fat giant grin on his face, yelling, "I ain't paying for it", all the way out the door.”

This guy’s one of us.

I’m withholding comments of a political nature right now. While I have strong feelings on the looming changes in US healthcare and the economy in general, I want to foster the discussion and see a broad cross-section of opinions in the comments section. I want to know what y’all think.

However, if you would like to read some of my articles on what my opinion is, feel free:

The Current US Economy and EMS: An In-depth look at how this mess will affect 911 in your community

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

I’m not picking on my British EMS brethren here. I like the boys in green quite a bit, like my friend Insomniac Medic and @ukmedic999. To prove it, here’s some of my writing on the whole UK thing and how it’s good, too.

A Shoutout Across the Pond to our British EMS Brethren

Posted by Ckemtp on June 15, 2011 • Filed under: 911 fail, Administration & Leadership, Emergency Medical Services, EMS, EMS Health & Safety, EMS Topics, Paramedic, UK paramedics, united kingdom, universal healthcare, US economy

EMS Narrative Report – Ckemtp on the MedicCast EMS Podcast

No comments

EMS Narrative Report writing is one of the most important skills an EMT or Paramedic should hone in order to make themselves a better provider. They can improve their long-term patient care, and improve the image of the profession in other healthcare providers' eyes through a well-written, informative narrative report. Not only is a properly documented EMS narrative report critical for communicating vital information about the events of an ambulance call, it also helps shape a patient's overall progression through the healthcare system. Last but definitely not least, a well-written EMS narrative report can keep your butt out of legal hot water and may just save your career.

Recently, Jamie Davis invited me to speak on the MedicCast EMS podcast, his ever popular educational EMS show that comes out every Monday. In this two-part series, we discuss my piece: "Six Tricks You Can Use Today to Improve Your EMS Narrative Report." and various other ways an EMT can improve their narrative report-writing skills. As always, Jamie offers excellent guidance on the topic which helps drown out my babbling.

If you'd like to download it, head to the post page by clicking HERE or clicking on the logo on the Right.

Otherwise, you can view it here.

Part two will be posted here when it comes up. Look for it next week!

Also, look for all of my stuff on EMS Narrative Reporting, click here.

Posted by Ckemtp on June 14, 2011 • Filed under: Emergency Medical Services, EMS, ems education, ems narrative, EMS narrative report, EMS Topics, EMS training, emt narrative, Paramedic, paramedic education, paramedic narrative, Patient Management, soap, soap charting, Technology & Communications, Training & Development, training-fire-rescue-topics, Uncategorized

Eight Ways you can Ace your Patient Assessment – EMS

3 comments

The patient assessment is probably the most important skill every EMS person should master in order to be a truly exceptional EMT. No matter the call, no matter the patient, the EMS provider needs to be able to rapidly zero in on a complaint, make a working diagnosis, and provide adequate treatment for the patient’s condition. This skill is more important than any other simply because if you don’t know what is going on with the patient, you can’t know how to treat them.

Patient assessment has been taught many ways over the years by different versions of the EMT curriculum. I was taught that each patient gets three different types of assessment during the course of an encounter with EMS. These are: The Primary Assessment, the Secondary Assessment, and the Ongoing Assessment. Each of these three types of assessments is valuable to the EMT or Paramedic in determining what is really wrong with the patient. They’re designed to function in concert, each giving more information to the EMS provider that they can use in formulating an effective treatment plan. The more detailed they are, the better treatment decisions they allow and the better the patient’s overall progression through the healthcare system will be. Every patient should get all three of these assessments. EVERY PATIENT, EVERY CALL, EVERY TIME. Whether the call is a 911 emergency fall off of a cliff or a simple discharge back to a nursing home, every patient you come into contact with in your entire career should get your best assessment. It’s something you just can’t skip.

Take a look at the three general types of assessments:

The PRIMARY ASSESSMENT: The quickest assessment in the EMS toolkit, it is the first impression you make of your patient. It is intended to rapidly identify life-threatening conditions and facilitate immediate stabilizing treatment. In this assessment you should check for Airway Patency (openness), Breathing (Rate, quality, presence), and Circulation (Pulse, blood pressure, and Skin perfusion – Color, temperature, and moisture). You should also check for gross deformity, major trauma and/or blood loss, or anything else that may cause the patient to crash. If found, you should act immediately to provide stabilizing treatment. This is also where you should determine the chief complaint, the need for spinal immobilization, and form your general impression of the overall patient condition.

The SECONDARY ASSESSMENT: Also known as the “Head to Toe Assessment”, this is a detailed physical examination of the patient, literally from head to toe. A secondary assessment should check a minimum of the following: Skin perfusion (again), Pupil and eye condition (using the acronym PERRL “Pupils Equal, Round, and Reactive to Light), Jugular Venous Distention (JVD), condition of the Trachea/neck (is it Midline? Is it mobile? Tugging to one side? Trauma?), Chest Rise and Fall/condition (Equal bilaterally? Normal?) Lung sounds? Abdomen (Pain? Tenderness? Soft, Firm, or Rigid? What quadrant? Any Pulsatile Mass? Any Rebound Tenderness?) Extremities (distal pulse/perfusion, deformity, Motor/Sensory/neurological function? Pitting Edema?). You should also look the patient over from head to toe to check for any hidden injuries and for anything that doesn’t appear normal. During the secondary assessment, you should remember the acronym “DCAP-BLS-TIC” (pronounced “Dee CAP-B-L-S Tick”) that reminds you to check for the following: “Deformity, Contusions, Abrasions, Penetrations, Burns, Lacerations, Swelling, Tenderness, Inflammation, Crepitus” (The links are to the Wikipedia definition of the words, also TheEMTspot.com has a great post on this topic)

The Ongoing Assessment: The previous two assessments are useful in determining your patient’s baseline presentation and making your working field diagnosis. However, your assessment doesn’t stop there. The Ongoing Assessment is used to monitor changes in the patient’s condition and to get a trend of their progression, good or bad. You can measure the effectiveness of your treatments and see how their condition is progressing. This could be as simple as asking a patient “Do you feel any better or worse?” and rechecking their vital signs, or as in-depth as redoing your entire secondary assessment. Monitor every patient closely for changes. Recheck vitals every 5-10 minutes for compromised patients, and every 10-15 for stable ones.

Here are some tricks you can use to nail your assessment:

Just Do It! – Remember, you can’t over-assess your patient. The more information you get the better. Every patient gets a full assessment, every time. Even if you can’t act on the information you gather, the information could prove invaluable to healthcare providers further down the road. They need good information on the acute phase of the patient’s illness. Remember, the EMT is “the eyes and ears of the physician in the field.” You’d never see a physician diagnose a patient without a thorough exam, don’t skip it either.

Standardize! – Develop a standard assessment that covers at least all of the stuff I talked about above, and do it every time. Start at the head and work your way down. Think up a set of questions you want to know the answers to about your patient, and answer them every time. Not only will practicing the assessment get it down to a science, you’ll also get very quick at it. This also can help you with your narrative report writing. You can put the answers to all of your questions in your patient care report, and that’s a great way to write a narrative.

Start your assessment the second you arrive on scene – Start gathering information about the patient immediately. Note the ambient temperature. Note the condition of the patient’s living space and where you found them. If the patient is at home, look for adequate food and water. Check for disease vectors such as filth. You may want to ask the patient about their living conditions later, such as asking them if they’ve been sleeping upright in a chair when checking for CHF. Any information you gather is useful.

Check THESE THREE THINGS when you first encounter the patient – Always introduce yourself to the patient using your name and while you’re doing this, feel their radial pulse with your fingers. This tells you three immediately important things that will drive the rest of your care: The status of their Airway, Breathing, and Circulation. You’ll feel the rate and quality of their pulse; feel their skin temperature, moisture, and condition; and be able to assess their work of breathing when they answer you back from your introduction. If any of these things are compromised… the patient is probably sick and in need of intervention.

Try to determine the patient’s ultimate diagnosis – What, you’re scared of making a diagnosis because you’ve heard that medics don’t diagnose? That’s BS. We diagnose all the time, we just don’t make the final diagnosis. Call it a “Field Diagnosis” if you want, but I say you should try to piece together the symptoms your patient is having and try to diagnose the cause. If you don’t know the answer, fire up the Google and do some research. You’ll be surprised at what you can learn that way. Also, talk to the receiving physicians and nurses at the ER. You’ll learn a vast amount of information that will make you a better provider overall.

Be as thorough as time will allow – Certainly, there are times where an EMT will be focused on immediately stabilizing treatment, such as airway management or hemorrhage control and won’t be able to hit all of the possible nooks and crannies of a patient assessment. However, most patients aren’t that severe and you’ll have time to gather all of the information you can. The more you assess the better information you can collect and pass on. Check for such things as: Pulsus paradoxus; a difference in blood pressure between the arms; the Babinski Sign; hidden trauma; Cushing’s Triad; and many other interesting things. You’ll learn a lot, and might just catch a few zebras.

Don’t afraid to touch the patient – You’re a medical person. Medical people touch other people. Sometimes they see them naked. Sometimes it’s uncomfortable and sometimes you have to touch them in a way that wouldn’t otherwise be socially acceptable. Of course, don’t do anything wrong, illegal, or immoral… but when you’re checking for a broken leg you have to touch the leg. Actually Look at, Listen to, and Feel your patients. Be a professional.

Know what “normal” is, and look for things that aren’t – Eventually, once you master the art of determining what a normal presentation is, the things that are abnormal will jump out at you. Once you’ve practiced and honed your assessment skills, you’ll be able to see any abnormalities with relative ease. It takes practice, but developing the skill is well worth the effort.

Employ these tricks and you’ll be well on your way to mastering the art of the assessment. Always learn and strive to improve your craft. Keep your eyes open and absorb new information. Pretty soon you’ll be amazing your colleagues with what you know and what you can tell them about your patients.

——————————–

Want more information on the patient assessment?

Read – Assessing Greatness: Catching the stuff you’re supposed to

Or – Ten (or so) Things You Should Try to do with Every Patient

Also, Check out TheEMTspot.com’s “Mastering the Head to Toe Assessment”

Posted by Ckemtp on June 13, 2011 • Filed under: Ambulance, Emergency Medical Services, EMS, EMS practice, EMS Topics, EMS training, paramedic education, Patient Assessment, patient care, Patient Management, Training & Development, training-fire-rescue-topics

Keeping an Eye on the Sky

No comments

If some of you out there don’t know it yet, I’m away from my home area working one of my jobs in another state. I’ve been gone for just over a month at the time I write this and I haven’t gotten my end date quite yet. I may be here a while longer.

Last night I came back into my hotel room and turned on the TV to find none other than Jim Cantore on the screen talking about my home area. Apparently, the wrath of Mother Nature isn’t limited just to other areas of the country. My area took it pretty hard last night and thank goodness there weren’t any injuries.

My girlfriend (Oh yea, I have one of those now by the way, which you would know if you followed me on Facebook or Twitter) was driving my car during the storm and just happened to drive right into the heart of the gust line, the leading edge of this monster storm. She ended up taking the brunt of it and had to leave the car and take cover in a ditch (Which by the way, is the smart thing to do) she got scraped up a little bit by flying debris and all; but thank goodness… the car is fine. (Love ya honey!)

This storm blew up quickly and just exploded out there. To my knowledge, there wasn’t a tornado formed, but the wind gusts were reported at upwards of 80mph and were forecast to hit over 100mph. The rain was torrential and the storm lasted a long time, lashing the area with high winds for quite a while. It was a bad one, but thankfully not as bad as other areas of the country have been getting. There was some damage, and my local Facebook buddies have been posting pictures of it on their accounts all morning. It could have been much worse, but it was pretty bad by itself. It certainly was a wake-up call.

Talking to my girlfriend on the phone last night after her scary ordeal she told me how she figures she was able to be caught off-guard by the storm. While she drives, she listens to MP3s rather than listening to the radio and therefore did not hear any severe weather warnings. She said that as soon as she saw how bad the storm was getting that she turned on the local radio, but by then it was too late… she had driven right into the path of the oncoming fury. A few days prior to this, I had discussed with her the possibility of employing underground storm shelters in our area and she said how she thought it was overkill. She didn’t think that we had bad enough weather in our area. I assured her we do get bad enough storms often enough, but the conversation didn’t go much further. Storm preparedness, like fire safety, is not a flashy topic. It doesn’t seem to be taken seriously until after something happens. However, as Mother Nature has proven to us this season, we need to be prepared.

The girlfriend is a smart lady, very smart actually. She’s not one to be taken off-guard by anything and can handle most anything that comes. This, however, was a surprise to her and I’m sure it surprised a lot of other people as well. It’s not that we don’t get storms like that in my area, in fact they come quite frequently, but people are still complacent about them. They just don’t think that it could ever get that bad, no matter what they see on the news happening in other areas. There are a lot of things in our society that are affected by our natural tendency to become complacent in our contemporary lifestyles. There are lots of things we just seem to forget can happen to us when we’re caught unaware by the realities of our world. Everything from storm preparedness, to fire safety, to cardiovascular health, to crime prevention, to drinking and driving, to most of the behaviors that keep EMS in business can be attributed to this fact. It’s just how we’re wired, I think.

If I can offer you all out there any advice, it would be to consistently remind yourself of the need to be aware of your surroundings. Maybe it’s the fact that as a paramedic my life is spent cleaning up the messes of the more unwary of those among us, but I tend to believe that most “accidents” can be attributed in most part to a lack of planning and situational awareness. I don’t want anyone to be afraid of living their lives, but keeping an eye on the horizon seems prudent these days. Don’t be caught off guard. I need all of my readers out there and want you to be safe.

Also, if you’re driving and you see or suspect severe weather, turn on the radio and turn off the CD or the MP3 so you can hear emergency broadcasts. It might just save your life.

Have you been to these websites yet?

www.Ready.gov
www.FEMA.gov
www.NHC.NOAA.GOV ß I love this site
http://www.fema.gov/emergency/reports/index.shtm <– A daily read for me, every day FEMA puts out the “National Situation Update (SitRep). It is a wealth of information and I strongly suggest you start reading it too.
www.IcanHasCheezburger.com ß Funny pictures of cats… because this disaster stuff gets depressing some times.

As always folks, stay safe out there.

Posted by Ckemtp on June 9, 2011 • Filed under: Ambulance, ckemtp, Emergency Medical Services, EMS, EMS Health & Safety, EMS safety, EMS Topics, FEMA, Fire Rescue Topics, first responder, Paramedic, severe storm pictures, Training & Development, Uncategorized

From the #WTF files – AL Fire Chief Flushes Twins down the Toilet?

7 comments

Holy crap! Read this: Odenville, AL Fire Chief Terminated FireLawBlog.com

Did I read that correctly? Did a Fire Chief really FLUSH TWO STILLBORN TWINS DOWN A TOILET!?

No way, that's gotta be a hoax… I mean, that can't happen, right? Please tell me that nobody is that stupid. Please restore at least a little of my faith in humanity…

Nobody? <sigh>

FireLawBlog.com's story on this has a link to the St. Clair Times article on the subject, and it looks like there's a lot more to this story than has been reported. The comments on the article are pretty telling… although I still have very little idea on what actually went on here. At face value, I can't see any possible reason that this would have happened. I just don't understand. Maybe if she miscarried into the commode maybe? I suppose they *could* have missed them… right?

Eww.

Also, the former chief defended himself with this cryptic statement, which I've seen repeated three times in various articles on the story:

"There were two of us there, and we followed protocol,” Davis said. “We followed the state protocol issued by the medic who was in charge at the scene.”

Soooo… Um… The medic… issues state protocol? and he/she ordered this? Aaaannnd… I'm sorry I just don't understand the statement. Maybe it's a bad quote, I don't know.

Anyway, here's the followup story. I just thought I'd call it to your attention.

http://firelawblog.com/2011/06/alabama-fire-chief-sued-over-disposal-of-stillborn-twins/

Posted by Ckemtp on June 8, 2011 • Filed under: Administration & Leadership, Command & Leadership, Emergency Medical Services, EMS Management, EMS Topics, Fire Rescue Topics, News, Paramedic

We Oughta Look In to This – EMS 2.0

3 comments

It looks like something has been right under our noses all this time, and I think that it just might be looking into.

Mobile Doctors: Http://www.MobileDoctors.com

Yep, you read that website address correctly, and yes, it really is a group of Primary Care and other physicians that make house calls their business. In fact, according to their website, they make around 5000 house calls PER MONTH in the Chicago, Detroit, Indianapolis, and Phoenix areas. The website also says they’ve been around since 1996.

I came across this ad today as I was surfing around and I was curious enough to click on it. I read their website with some interest, and their claims started sounding awful familiar to me. If you’ve been following the EMS 2.0 and Community Paramedicine movements, you’re probably familiar with what they say as well. It’s pretty much what we’ve been talking about. Read this:

“Our team of healthcare professionals specializes in chronic disease management and care plan development. This results in a significant reduction of emergency room, hospital and nursing home admissions for our patients.”

Also, this:

“Our practice focuses on primary care/internal medicine, podiatry, and diagnostic testing. Our goal is to provide high quality, responsive in-home health care to stabilize patients, improve their health, manage their medications, and reduce hospitalizations and ER visits. We also coordinate patient care with home health agencies, durable medical equipment providers, hospitals, and other medical professionals.”

Huh.

Those two short paragraphs in their static, online brochure of a website are quite obviously advertisements for the services they provide… but aren’t those the things we’ve been saying with the whole EMS 2.0 thing? Isn’t that what we want to do? To expand our service offerings and reduce inappropriate use of emergency healthcare while increasing overall wellness through primary care, that’s the point of it all, right?

Well here’s a company, albeit very much a physician driven company, that’s been making their living off of doing just that since 1996. In addition, they take Medicare.

I think that there’s something we can learn from this company and their business model. It’s worth a look at their website: Http://www.MobileDoctors.com. Sometime in the near future I plan on contacting them and asking them about how their company can interface with EMS.

Till then, take a look at these two posts and see what you think:

Primary Care Paramedics? I think it’s time

Are We the Gatekeepers to the Emergency Healthcare System? EMS 2.0

Posted by Ckemtp on June 8, 2011 • Filed under: Ambulance, Emergency Medical Services, EMS, ems 2.0, EMS Management, EMS Topics, Paramedic, physician, politics, Uncategorized

Remembering the True Heroes – D-Day, June 6th 1944

2 comments

I plopped down on the bench seat next to the patient we had just picked up as my partner closed the door of the ambulance behind us. I’d already gone through the usual pleasantries and introductions with the guy and was making him comfortable for the trip from a small ER for to a slightly larger hospital with an ICU. The patient was sick and advanced in years. I suppose you could say that he was elderly and infirm. The years he had seen were catching up with him and he didn’t seem to think too much of it. He wasn’t very talkative to this ambulance guy who was loading him up and trying to make conversation and I tried to find something to spark it, else I respect his wishes and let him be.

I hooked his nasal cannula up to the main oxygen tank and slipped on the automatic blood pressure cuff. While doing so, I noticed an old, faded tattoo on his arm and figured out what we could talk about for the 30 minute trip to the next hospital. As I was hooking up the patches for his EKG I asked him, “So, you’re a Navy man, eh?”

He looked at me like I wasn’t worth spit and said “Naw, I wasn’t ever one of those bastards.”

I have the utmost respect for the Navy. My grandfather served aboard ship in the Pacific Theatre in WW2 and was one of the lucky and skillful ones who lived to tell about it. I still remember the stories he told, at least the ones he would talk about, and I have always held the service of He and others like him in the highest reverence. So I was taken aback by the patient who’d just derided something I happen to hold so dear.

“Really?” I asked. “I saw that tattoo on your arm and figured you might have been”.

“Son, ain’t you ever seen a Coast Guard tattoo before?” he snapped back.

Honestly, I never had. I live in the Midwest where Coasties are pretty scarce. I’ve only rarely chanced to meet someone who is actually in, or had been in the Coast Guard. His tattoo was pretty new to me and I explained my ignorance to him. He wasn’t offended. He began to open up and we talked the whole rest of the trip to the ICU. He explained his aversion to the Navy by telling me this:

“I was there when they stormed the beach at Normandy and I tried my damndest to rescue the men those Navy guys were dropping in the water. The guys drivin’ the landing craft were opening the gates too far away from shore and making those poor soldiers drop into water too deep for them to swim. Lots of men drowned under the weight of the packs they were wearing without firing a shot. We tried to rescue them, pulled as many as we could into our boats as they were shooting at us. I couldn’t believe that the Navy would do that. I just can’t believe it.”

He continued telling me about his service in WW2 and at D-Day as I sat there, spellbound by his stories. I was in awe of him and what he had done. I was humbled to be in his presence and was enthralled by what he was telling me. He told me stories of the invasion the likes of which I’ve never read about nor heard. I learned more history of our country and the service of the men who defended it in those thirty minutes than I ever could in a history book.

I was humbled. I was honored to be in this man’s presence. I couldn’t believe my luck to get a chance to sit and talk one on one with a living piece of history. What a man he was. I had never heard WW2 stories from the perspective of the Coast Guard and I am so thankful I had the opportunity to hear his stories.

Before I knew it, we had arrived at the destination hospital and I realized I hadn’t done any of the normal things I do on transfers. I hadn’t gotten signatures, I hadn’t written down the vitals more than once, and I was way behind on paperwork as it was. I didn’t care. I had listened to the patient’s stories the whole time and I figure he would have told me had something been wrong. I got the signature and my partner and I unloaded him from the ambulance. We continued talking as we wheeled him up to the floor. He was friendly now and very talkative and I was sad that the transport hadn’t taken longer. When we got him to his room and transferred him to his new bed, the ICU nurse came in to take report. I gave it, there had been no change in his condition from one place to the other and the only thing I did was tell the nurse that the patient was a national hero. It’s not every day that someone from my generation gets to meet and talk to a living part of history, a true national hero the likes of which I could never be.

I never got a chance to talk to the patient again, but I know he’s going to be just fine, regardless of what happens. Men like him take their challenges in stride and overcome them. That’s what being a hero means.

I wrote this on the anniversary of the D-Day invasion June 6^th 2011. On that day, 67 years ago, our nation proved we had what it took to overcome the looming darkness and fight the good fight. We still have that resolve within our nation and the men and women of our military are out there proving it every day. Thank you, all.

Here’s an Excerpt from Ronald Regan’s speech given on the 40^th Anniversary of the invasion:

"Forty summers have passed since the battle that you fought here. You were young the day you took these cliffs; some of you were hardly more than boys, with the deepest joys of life before you. Yet, you risked everything here. Why? Why did you do it? What impelled you to put aside the instinct for self-preservation and risk your lives to take these cliffs? What inspired all the men of the armies that met here? We look at you, and somehow we know the answer. It was faith and belief; it was loyalty and love.

The men of Normandy had faith that what they were doing was right, faith that they fought for all humanity, faith that a just God would grant them mercy on this beachhead or on the next. It was the deep knowledge–and pray God we have not lost it–that there is a profound, moral difference between the use of force for liberation and the use of force for conquest. You were here to liberate, not to conquer, and so you and those others did not doubt your cause. And you were right not to doubt.

You all knew that some things are worth dying for. One's country is worth dying for, and democracy is worth dying for, because it's the most deeply honorable form of government ever devised by man. All of you loved liberty. All of you were willing to fight tyranny, and you knew the people of your countries were behind you."
"Today, as 40 years ago, our armies are here for only one purpose–to protect and defend democracy. The only territories we hold are memorials like this one and graveyards where our heroes rest."

(Posted from: http://chatterboxchronicles.blogspot.com/2008/06/ronald-reagans-speech-at-normandy.html)

Well said, Mr. President.

Posted by Ckemtp on June 7, 2011 • Filed under: appreciation, Emergency Medical Services, EMS, EMS Topics, Fire Rescue Topics, In the Line of Duty, Paramedic, Patient Management, pride, professionalism, thank you

Announcing the EMS All-Call

1 comment

I’d like to announce some new features here on LUTL that you may be interested in:

First, I’m playing around with the design of the place, trying to make it look more hip and trendy. Unfortunately, since I’m basically akin to a monkey holding a rock when it comes to this whole blog design thing, it’s going slow and may have some kinks to it. Feel free to drop me a comment or a critique on the changes. I appreciate it.

Second, I’ve decided to add a new Saturday feature that I’m calling the “EMS All-Call” it will be a post featuring links from around the EMS blogosphere. Shoot me a link and if I feel like it (My post, my decision) I will aggregate the links to your stuff in a post that comes out every Saturday. Submissions are due by Thursday of every week. Send all submissions to EMSallcall-at-Yahoo.com. This is open to any EMS blogger out there. Feel free to, and please submit. I'd love to help showcase your stuff.

Happy EMS’ing out there. Oh, and also… if someone could slip Mother Nature some Midol, I’m sure we’d all appreciate it.

Posted by Ckemtp on June 6, 2011 • Filed under: EMS, EMS Topics

Wake Up! You may have a call…

2 comments

Every so often the discussion of the most healthy and appropriate way to wake a sleeping firefighter or EMS person from their slumber in order to alert them to the presence of a call for service crops up in the national discourse. Some believe that soft, gradiated lighting combined with a soothing tone and soft-voices is best for the long-term cardiovascular health of EMTs, Firefighters, and Paramedics. They say that a quick wake up to a jarring alarm tone is unhealthy and can cause long-term damage through a rapid increase in heart-rate and blood pressure.

I think it's BS, actually. I can't seem to get up without the assistance of Gabrial's trumpet, a car battery, and some alligator clips… and even then, I have woken up more than once in the middle of a call, coming to fully-realized alertness in the act of performing CPR or decompressing someone's chest. I think that that's way more startling. Also, our night dispatcher has a voice that would be very well suited to that of a 900-number call-taker and isn't the kind of voice that tends to make a guy want to get *out* of bed. ("Tell me more about the fire, Dave!")

While searching the world's most accurate source of information, the internet, I came across this invention. I love it. I may try and buy the rights to it and sell it to ambulance agencies such as mine.

Here, see for yourself!

In addition, I think this would be an awesome way to get the crews to do their shift chores. The supervisor of the day would keep the machines on until the garbage cans were emptied, the floors were mopped, the toilets were clean, and the training was trained.

I think it's a potential gold mine.

Posted by Ckemtp on May 23, 2011 • Filed under: Administration & Leadership, Emergency Medical Services, EMS, EMS Health & Safety, EMS Humor, EMS Management, EMS Motivation, EMS safety, EMS Topics, Fire department, Fire Rescue Topics, Firefighter Safety & Health, funny, Paramedic, Videos

EMS Week 2011 – WANTYNU

7 comments

We’re going to do a little thought exercise here, Folks.

If you’re in a place where you’re around people, pick out five people at random. If not, think of five friends or family members. Look at their faces and get a good mental picture of them as the people you know or can assume them to be. Take a minute or two, I’ll wait.

Now assign one of the following emergency medical conditions to them. One of them should have a seizure, one of them should have a stroke, one should have a heart attack, one should get into a car accident, and one should stop breathing. Remember, this is a thought exercise, so don’t actually do anything to harm anyone. Just imagine that these things have happened to the people you know and care about. Pretend they happen to them right in front of you.

Really, do it.

Scary, isn’t it? It’s terrifying really, if you stop to think about it. I can imagine you’re thinking that this is overly dramatic and maybe even a little silly. Perhaps you’re wondering why I would ask you to think about terrible things happening to people that you know and or love. Why would I make you do such a thing? It’s awful, isn’t it?

Yeah, it is. Just trust me on this; it’s necessary for this one.

Now think of exactly what you would do in each and every one of the above situations. Think of the very next people you would want to see. Chances are you know exactly what you would do and who you would want to see. You’d call 911 and hope that the ambulance would show up to take care of the situation. You’d pray that they got their quickly and then you’d pray that they knew what they were doing and were good at doing it. You’d pray for your loved one and you’d be scared. You’d want them to get better and you’d want the people in the ambulance that came to help them to make them get better. I can guarantee that this would be an intense experience that you would remember clearly for a very long time. It would probably be a life-changing event for you… and maybe for them as well.

As a paramedic, I cover a 911 response territory that contains anywhere between 20,000 to 30,000 souls. It’s not the biggest jurisdiction out there, nor is it the smallest, but it generates enough calls to keep me busy. My service responds to around 3000 requests for ambulance service every year and the number keeps rising. Every one of these calls for help come from people that somebody, somewhere cares about. Every one of these people is a friend and family member to someone in and around our community and every one of them are important. Every one of these people instinctively knows exactly who they will call and come to depend upon when the unthinkable happens to their loved ones or to someone around them. They’ll call me or one of my coworkers and just like you in the thought exercise above, they’ll pray that the same things happen for them. They’ll want us to come right away, they’ll want us to be exceptionally good at what we do, and they’ll want us to make them or the person they called for be better. They’ll want our service right then and there and they’ll demand these things of us at that time. They’ll think nothing of the system that’s in place to come to help them, they’ll just demand that it be there and that it be excellent.

Luckily for the people in my jurisdiction, I work with some exceptional individuals. I take pride in the Paramedics and Emergency Medical Technicians who I work with at my ambulance service. I know that each and every one of them is a competent, caring professional who is very much up to the task of caring for our community. I know that they all take their high level of responsibility very seriously and I know that every time they roll out they will do a fantastic job. I know their strengths and their weaknesses. I know how they’ll react to most situations and I know the tools they’ll use to do it. I know the system intimately, its strengths and weaknesses and where it could use improvement. I know where we need to strengthen our service level and where we could stand to apply more resources. I know this because I’m involved in the system, and also because I care about it. I do my part both as a citizen and as an EMS professional to ensure that my community’s EMS system is in-shape and second to none.

I care about EMS before I need it.

Today is Wednesday, May 18, 2011 and we’re smack-dab in the middle of EMS week 2011. EMS Week is a week where EMS people are generally ignored a little less than we usually are during the other 51 weeks of the year. Sometimes we get little trinkets from our employers and sometimes we get free food from the hospitals we transport patients to. It’s nice. Unfortunately, it’s mostly EMS people who celebrate it, and we generally do a poor job of getting the word out.

There’s a product I use called the WANTYNU oxygen wrench that an EMS person designs and sells, and no, this isn’t a paid ad for the product. However, I have always loved the name. It’s an acronym that stands for “We Ain’t Nothing Till You Need Us” which is unfortunately is how a lot of EMS people think the public sees them. I’ll admit that there are days where I feel the same way. I try to remain positive about our public image but I see examples of the public not knowing, nor caring about what we do until the moment they need us. I can only imagine what we could accomplish if the public would care about their EMS service all 52 weeks of the year. Maybe all of our problems would disappear if the public cared about how much they supported us. Maybe we could finally give them the true level of service they deserve if we had the resources to give it.

Maybe so.

_______________________________

Happy EMS Week. For some things that I’ve written in past years, check out the links below.

http://lifeunderthelights.com/2010/09/1242/ – What difference does EMS make?

http://lifeunderthelights.com/2010/05/ems-week-2010-all-respect-is-earned/ – Earning Respect

http://lifeunderthelights.com/2010/05/ems-week-2010-sent-to-the-newspaper/ – A letter to the editor that you can send to your local paper.

Posted by Ckemtp on May 19, 2011 • Filed under: appreciation, Emergency Medical Services, EMS, EMS Topics, EMS week, letter to the editor, Paramedic, Uncategorized

Dreamland Paramedics…

8 comments

So there I was, on shift and driving around in what we call our Interceptor vehicle. It’s a marked SUV outfitted with lights and sirens that carries a full compliment of ALS gear. We use it to quick-respond to 911 calls in our own jurisdiction and to intercept BLS ambulances with a single paramedic. It’s a cool ride and I was driving it around what looked like our town when a very cool lightening storm rolled in. Then a blizzard started up, and then it was sunny when I pulled into a parking lot of… a building I didn’t recognize. I think it was another ambulance station whose members were working on a male patient who was lying unresponsive in front of their front door… I parked, got out, and walked up to them. Their uniforms were white shirts, badges, with navy-style epaulets on their shoulders. They looked nice.

This alien ambulance crew said they had the situation under control, and even though I thought this was odd… since I was in our 911 territory, I didn’t argue… I did, however go in the building to find their commanding officer, whom they had said was inside. Turns out, their ambulance station was this awesome night club complete with a stage, people dancing, and a good-looking crowd. I found the ambulance manager at the bar and asked him what was going on… He started to run away but motioned for me to follow. I ran after him, chasing him around the building, which turned out to be a huge place containing staircases, long hallways, and some epic leaps across chasms. There was even a part where we ran up a wall, Spider-Man style, where I had to grab on to steel cables and slide down them to get back to the floor. If I were really asked, I’d say the building looked… um… kind of like the Baltimore Convention Center where they hold EMS Today. I never caught up to the guy… in fact, I never went back to my vehicle because it turned out that I was actually in my old high school, I found some old friends I hadn’t seen in a while and we threw a party. We had a great time with lots of catching up, back-slappin’, laughing, and carrying-on. Then… and this is awesome, a bunch of people, a veritable parade of people I have had disagreements with over the years came walking in the room and I told them off quite eloquently. They all agreed they were wrong quite readily and invited a team of British Rugby players into the party who brought a keg of this really good beer. I had two or three glasses of the stuff. After that, I walked out of my high school and all the way to my childhood home where I could see my first cat, Katchoo, through the window as I was walking up the driveway.

And then… Doooooooo Doooooooo… this loud noise broke in to my dream from somewhere… I recognized it as a call and thought to myself… “I can’t go on a call! I’ve been drinking! Good thing I’m off-duty”.

But of course, I wasn’t off-duty. I was at work, and I woke up in my bunk-room to our dispatcher squawking about some lady somewhere with some pain in her belly. I stumbled to my clothing, still not fully realizing that I had been dreaming a minute before I was so rudely ripped from my slumber, and got dressed to groggily stumble out into the early-morning light.

I suppose at this point I should explain that this was a dream I was having while sleeping on-duty from about 2 through 3am this very shift. The dream colored the whole call for me. I must have been sleeping very soundly because while I’ve only gotten like 3 hours of sleep this shift, I feel fully rested and am writing this post at 0530 rather than attempting a triumphant return to my snug, warm bunk. I love having dreams like that… when I’m home in my own bed without the possibility of the radio waking me up. Dreams like that when I’m working tend to bleed into my reality when I’ve been ripped away from them to respond to a call. Sometimes like today, it’s no big deal other than the momentary thought that I’d made a HUGE error and quaffed some ETOH while on-duty (which I never have and never will). Other times, like when you’re having a nightmare about the Zombie Apocalypse and you get called to work a code in the middle of your epic chainsaw-intensive last-stand, the waking-from-dream thing can be detrimental. Ever had a dream about being attacked by zombie clowns and then wake up to work a code in a circus-tent? Neither have I… but it could happen.

Is this an interesting EMS post? No, not hardly. But for those of us that work our rotating 24 hour shifts and live, eat, sleep, and spend generally more than a third of our lives at work, it’s just one of the myriad things we find out about what this shift pattern and this job do to a person. Is it an occupational… hazard? I don’t know. I do know that it’s one of those odd things about working EMS that you’ll rarely find in other professions. I mean, how many times has your local hedge-fund manager had to wake up to manage some hedges and/or funds in the middle of dreaming about whatever it is they dream about?

I’d love to hear some of your stories on the same thing. I’m sure they’re out there.

Oh, and good morning everyone!

Posted by Ckemtp on April 25, 2011 • Filed under: Emergency Medical Services, EMS, EMS ethics, EMS Topics, Fire Rescue Topics, inside the mind of a paramedic, Paramedic, Uncategorized

Wheel of the Regulars: Turn Turn Turn

5 comments

“Howdy April! “

“Hi Chris”

“I gotta ask ya… How did I look in my underwear tonight? I wore a special pair just for you”

“Um… What?? What do you mean?”

“Well, you always seem to call me to come over here just after I’ve gotten into bed and right as I’m going to sleep. I figured you probably have a camera in my bunk room at the station or something”

“Uhhhh…”

“I wore the pink ones. They’re special. Just for you.”

This conversation pretty much actually happened the other night. No, her name wasn’t “April” (because I’ve changed the name) and I wasn’t actually wearing pink underoos (they were purple) but the sentiment was there just the same. Even in my relatively small jurisdiction we have our share of “frequent fliers”, the regular patients who call 911 all the time and seem to make up an extremely disproportionate number of our annual calls for service. They’re our regulars. We know their addresses by heart and cringe every time we hear them come over the radio. Sometimes the regulars are sweet people, nice folks in every way who call us for legitimate reasons… other times; they’re not.

Regardless, the regulars are fixtures at every single EMS station I’ve ever been to. Every service has their share and every service knows them by heart. We get to know them, and they get to know the crews as well as drug seekers get to know the local ER docs. Sometimes they even get to know our shift schedules and only call on days where they like the EMTs that are working. Sometimes they just don’t care and call when they’re lonely, or when their scalp is itchy, or when their feet are dry, or when they’re sure the kid down the hall is up to no good and they know the cops will come when they call for an ambulance… etcetera.

Sure, I could be a good little EMS blogger and give you a bunch of useful strategies on how to positively affect the lives of these patients and offer them resources on how to more constructively manage their healthcare/loneliness/insanity needs… but not tonight. Tonight is the second night of an unscheduled 48hr shift and I know… I JUST KNOW that the camera in my bunk room is very much functional and someone is going to see my polka-dot underwear and call for me just as my head hits the pillow.

So tonight I’m going to tell you about my new idea for a game we can start to play here at the unnamed ambulance service where I work.

I call it, the “Wheel of the Regulars”

I plan on making a “Wheel of Fortune” style game board complete with a rotating wheel made out of plywood. I will put a spinner on it and divide it up into sections. In each section, I plan on putting the initials of our most prolific EMS regulars… the ones who we are almost guaranteed to see multiple times in one week. I’ll make it so that the wheel can be spun manually, and will eventually stop with an indicator showing the initials of one of the regulars.

Each morning at Start of Shift, I plan to have each crew-member take a turn spinning the wheel. That will be their bet for the day… if the regular whose initials they have randomly chosen through their spin calls 911 during the shift, they will win a prize. Their bets can be hedged by the EMT estimating the time the patient will call down to the minute, and the employee who gets closest to the time the regular patient actually calls will win an additional prize. I have a feeling that we can get a pretty good pool going with this and that it will be loads more fun than the run-of-the-mill sports pools that go around this place. I figure that if the game gets big I can make a lucrative side business selling the game board and the system for playing the game.

Maybe I ought to sell this idea to the people who brought out the EMS Monopoly game?

Nobody has found a really effective way to deal with regular EMS callers yet (Could I call them “Prolific Patrons”?) because the problem is as multifaceted as it is expansive. Sure, there are tools out there for our use, but none of them are very effective.

And until we find a way to fix the problem, we might as well have some fun with it. I even tried to come up with a song to sing while the wheel was spinning, but all I could think of was this:

Have a good night, everyone!

Posted by Ckemtp on April 19, 2011 • Filed under: 911 fail, ambulance humor, ckemtp rants, Emergency Medical Services, EMS, EMS Humor, EMS Topics, Fire Rescue Topics, Paramedic, Uncategorized

Change Medicare? Save EMS

9 comments

I’ve said this before, and I’ll continue to say it until I can do something about it: The Fee-For-Transport model has failed EMS. We have to change it and we have to change it soon.

In fact, I believe that the entire revenue model we use for our industry has failed. I think that the “Fee for Transport” model employed by the Emergency Medical Services industry is flawed, archaic, outdated, and is not conducive for the development of our profession. I think it stifles growth and development. I think that it is unfair to make this inequity up through local property taxes.

I think it has to change.

Don’t know what I’m talking about? Let’s hear what Medicare has to say on the subject:

“The Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. When multiple ground and/or air ambulance providers/suppliers respond, payment may be made only to the ambulance provider/supplier that actually furnishes the transport.” (https://www.cms.gov/manuals/Downloads/bp102c10.pdf)

Yes, that’s what that means: Medicare sees EMS solely as a “transport provider.”

Basically Medicare is saying that all they’re going to pay for is taxi service. Sure, they’ll reimburse some other expenses, but without the taxi component, they’re not picking up the tab. They’re certainly not going to pay for you to provide medical care for one of their clients on a scene. They’re not going to pay you for sweetening up an unresponsive diabetic and leaving them at their house, they’re not going to pay you for providing Community Paramedicine, and they’re certainly not going to pay you for other home health or primary care services. To them, we’re a medical transport industry. They pay for transportation and that’s it. Sure, they make a differentiation between “Emergency” transportation and “Non-Emergency Transportation” and use the term “skilled medical treatment” for some of the things done in the back of our rigs, but that whole “transportation” thing is always there. No transport, no payment. It’s as simple as that.

This very appropriate image was sent in to me by Matthew Rausenberg while I was writing this post. Thanks Matt!

Not sure about that? Well, here’s more reading on what Medicare WILL and WILL NOT pay for in this informative booklet that I just printed out for every EMT at my service to read:

That’s the link to the “Official Government Booklet” that explains:

“When Medicare Helps Cover Ambulance Services”
“What Medicare Pays”
“What You (the patient) Pay”
“What to do if Medicare Doesn’t Cover Your Ambulance Service”

I’ll admit, this is pretty light reading by government standards, but it’s important for all of us in the profession to read, understand, and know this stuff. Sure, I know that some of you out there are going to fall back on our old standby statement that “I’m not in this for the money, I just want to help people” or some other platitude just like that, and I understand and appreciate your altruistic motivations… but I will tell you that EMS needs money to operate. Whether you’re a volunteer or a full-time paid employee, your ambulance service needs money to function. Paid employees need to make a living, ambulances need fuel, stations need heat, equipment needs to be replaced, and communities need 24-hour ambulance coverage to meet both their emergency and non-emergency needs. Ambulance services are critical for any community, no matter their capacity, and all of that stuff takes money. Medicare, through the “Centers for Medicare and Medicaid Serivices” (CMS) sets the tone for the entire healthcare payment industry and by default they have become responsible for propping up a majority of ambulance services through providing the lion’s share of their total revenue in some areas. They’re the big dogs in the healthcare payment arena… and they’re holding us back.

Not that I’m solely picking on Medicare here… but let’s read further into their definitions, shall we? (From the second document I linked to above):

“Emergency ambulance transportation

Emergency ambulance transportation is provided after you’ve had a sudden medical emergency, when your health is in serious danger, and when every second counts to prevent your health from getting worse. The following are examples of when Medicare might cover emergency ambulance transportation:

You’re in severe pain, bleeding, in shock, or unconscious.
You need oxygen or other skilled medical treatment during transportation.
You need to be restrained to keep you from hurting yourself or others.

These are only examples. Medicare coverage depends on the seriousness of your medical condition and whether you could have been safely transported by other means.”

Clearly, Medicare thinks that only “Skilled Medical Care” provided whilst tires are rotating under a patient is valuable. They pay no attention to the fact that there are better and cheaper alternatives out there that our profession could offer them. I know that Medicare represents taxpayers and the payments they give out are tax dollars, and I appreciate and want them to be responsible with those tax dollars…

I just don’t think that they are.

Medicare has determined that the only way they can be responsible with our tax money is to deny as many payments as possible and to only pay for the bare minimum that they feel is important. That’s why ambulance services are “Transportation providers” in their eyes. However, this ignores so much potential in cost savings in my opinion. They pay no attention to the fact that while it’s nice that they pay for “Wait-and-return” ambulance transfers to and from nursing homes and clinics, those services could be provided in a lot of cases by paramedics who could take care of the patient’s needs on site and save them a ton of money by offering the new service. They ignore the fact that if they provided a $250-$300 benefit for an ambulance to come, fully assess, treat an unresponsive hypoglycemic diabetic, and then release them safely without transport, they could avoid the (estimated) $500 transport bill and subsequent $1000 ER bill. The savings are potentially enormous… and there are a ton of ideas like that waiting to be explored.

We, as a profession, just have to convince them that these ideas are worth being explored.

The healthcare payment system shapes healthcare. It certainly has shaped the way we operate in EMS. The pressure to do only what we’re going to get paid to do is so prevalent a force in the industry that it is almost the very foundation of what we do and how we’ve evolved. The payment system didn’t evolve to meet our potential; EMS has evolved to fit its limiting influence. This is why we do the BLS transfers that cost too much for too little benefit. This is why new products that can’t be reimbursed aren’t making their way into the hands of field providers. This is why treatment modalities aren’t expanding as fast as in other areas of medicine. The CMS fee schedule dictates all of this.

And we as a profession have to change it.

Imagine what EMS would be today if we could bill for any service we thought provided benefit to our patients and our communities? To be sure, this would cause some “waste, fraud, and abuse” in the initial phases… but that exists in today’s system. Could you imagine if Community Paramedicine was fully reimbursed? Can you imagine that if instead of providing a wait-and-return BLS transport for a nursing home patient needing a surgical wound re-check, you came, assessed, took some pictures on a cell phone camera and sent it to the physician wirelessly? Can you imagine if you could charge for responding, assessing a patient with a minor medical complaint, and then having the patient transported to an urgent care center that would continue your care? Can you imagine how different everything we do could be?

Well, at least I can start to imagine. I see additional revenue streams that would come into our industry and improve the profession, strengthen our patient care, and save the healthcare system a boatload of money while improving access to primary healthcare. I see paramedics and EMTs not being taxi drivers. I see a real career and a bigger impact upon the overall health of our communities. I see more fiscal responsibility. I see lots of great potential.

And I don’t know how to do this yet, but maybe somewhere, someone reading this might have an idea.

Do you?

————————————————-

I’ve written on this before, and maybe you’d be interested in reading some of those ideas:

“What is the next ‘Low Hanging Fruit’ of EMS 2.0 and US Healthcare Reform?”

And to look at a real-life example of how our British brethren are handling this issue and are having success across the pond:

“A Shoutout Across the pond to our British Brethren”

Posted by Ckemtp on March 17, 2011 • Filed under: Administration & Leadership, change, EMS, ems 2.0, EMS Management, EMS Topics, Funding & Staffing, new perspective, Paramedic, paramedic salary, politics, potential, profession, Uncategorized, universal healthcare, US economy

EMS 12-lead Case – Ischemia and Failure

8 comments

If you haven’t been to www.EMS12Lead.com, Tom Bouthillet’s wonderful EMS educational blog… well then I’m going to just come out and say this:

What are you doing here when you should be over there reading his stuff??

Considering how Tom dwarfs my humble traffic numbers (which is something I always kind of knew he did, but didn’t really know how much until I had a few drinks with him at EMS Today and weaseled his numbers out of him) I’ve figured that I’m going to have to do something. I’m going to straight up steal his shtick and write an “educational” EMS 12-lead EKG post of my very own for your reading enjoyment and educational purposes. Heck, I might even be able to make a point or two. Let’s find out.

I keep an archive of interesting tidbits from my EMS career locked up in a vault in my basement and among the oddities and whatnot I have a binder full of 12-leads. I blew the dust off of the old tome and pulled the EKG that I’m using for this story out of the archives. Oh my, this was a doozy. As always with my stories about patients, I may not have ran this one myself and even if I did, I don’t remember where it was that I ran it nor do I remember the age, location, or even the gender of the patient in question. I also have taken the liberty of lying about all of that stuff just to make it even more confusing and difficult for me to write. So, if you think I’m violating the female Hippo, you’re mistaken.

As I recall, the call was toned out with the dispatch information of a “64yo M Pt unable to breathe”. It wasn’t a long distance away and Our Intrepid Paramedic (OIP) responded in a response vehicle being followed up by an ambulance which arrived shortly after He did. It was a nice, well kept residence and the wife of the Pt let OIP in the door as he entered the home. She indicated that the Pt was in a back bedroom of the house and motioned down the hallway. OIP made the trek and found the Pt sitting upright on his bed, Conscious, Alert, and Oriented times 3 (CAOx3) with somewhat increased work of breathing. The patient stated that he had been experiencing pain that he indicated began at the level of his mandible and continued to his epigastrum (his Jaw to his Gut). He stated that the pain had simply become too much for him this evening and that it became very hard to breathe when he laid down for bed. A good look at him was all it really took for OIP to make a working diagnosis after feeling the patent’s weak and irregular radial pulse and pale, cool, and moist skin. OIP placed the patient on 6-LPM oxygen via Nasal Cannula and told the ambulance medic to break out a 12-lead. The initial rhythm strip showed a sinus bradycardia with an IVCD and lots of multifocal ectopy, including multifocal couplets and triplets. The 12-lead was no better. It showed bad, bad mojo. This poor guy was sick.

EEEEEEEeeeeeeeeeeeek

As the ambulance crew was packaging up on the stretcher to take the Patient to the ambulance, OIP had a few moments to speak with the patient’s wife. She told OIP that the patient had been experiencing pain in his jaw for the last week. She also told OIP that the patient had gone to see his Primary Care physician two days prior and had been told to take advil for the pain in his jaw. She told OIP about how the patient had been very lethargic lately and about how he would become winded when taking out the garbage and walking even shorter distances. She told OIP about how the pain had been getting steadily worse… and also how the doctor said he was fine.

And with a symptom profile of exertional fatigue, difficult breathing, jaw pain, substernal chest pain, and diaphoresis… what doctor wouldn’t say that… right? Oh wait… hopefully most of them.

The patient wasn’t having a heart attack… he had been having a heart attack for days and now the damage had been done. This was a clear case of the patient not being educated to the symptoms of a heart attack… or of ignoring them in the hopes that they’d just go away. The physician did not obtain a 12-lead nor do lab work and did not diagnose the problem as being cardiac ischemia (Heart attack) when the patient presented for care.

But OIP did… about 2 minutes after meeting the patient he woke up the cardiologist and the cath lab team at a hospital a half-hour’s drive away to help take care of the man. You’ve seen the 12-lead above. It indicates a heart that is in serious trouble. The patient was treated per protocol, which included high-flow o2, bilateral IVs, NTG tablets and paste, and I’m not sure what else the ambulance paramedic did because OIP didn’t accompany the patient to the hospital. That, and it was too long ago for me to remember what happened… I just know the patient made it there alive to find out whatever his prognosis was going to be from the cardiology team at the ER.

Here’s the deal, once this patient called the ambulance, his care was stellar. OIP and the other EMTs did a fantastic job at rapid recognition, appropriate stabilizing care, and swift transport to an appropriate care facility as none of the local hospitals had the capacity to care for this guy. The EMS people did what they were trained, equipped, and supposed to do. The problem is they were called way too late to make much of a difference in the patient’s continuing quality of life.

I can understand that patients don’t necessarily know when they’re having a heart attack. To a layperson, jaw pain and fatigue could just be the flu. Chest pain could just be heartburn, and exertional dyspnea could just mean that a person has been “pushing themselves too hard lately”. All of those symptom profiles could mean any number of things… but they could also be a heart attack. I can understand how people want to think that they’re not having a heart attack. I get that no one wants to have one. They’re not fun and we as a society may hype them up too much so that people think there is a stigma to the diagnosis. I don’t know if that statement is true, but it sure seems that way sometimes to me.

What I can’t understand is how a patient can present for treatment at a physician’s office with clear symptoms of cardiac ischemia (heart attack) and not be checked for it. I’d like to think that a paramedic would rule it out first and foremost… and I don’t understand why someone wouldn’t.

Then again, I don’t know the information the physician was working with. Perhaps the patient wasn’t honest with his symptoms and tried to minimize what was going on. That’s possible too, as this patient was a proud man who has lived his life like he could handle anything. People do that. Nobody wants to be sick.

The lesson here is to have a high index of suspicion. Patients sometimes minimize their symptoms, and sometimes they over-dramatize them. Some people don’t want to be sick… and some people want to be sicker than they are. I personally will buy into false drama from someone who’s not as sick as they want to be than chance missing the minimized symptoms of someone who’s sicker. I tell my patients that as a paramedic my job is to “Treat for the Worst, and hope for the best.”

But for this guy, OIP never got the chance. This was too late for that. The damage had been done.

This patient’s quality of life was greatly impacted by the fact that he didn’t call 911 at the first signs of his illness. Had he done so, his prognosis would be much different. A quick exam, 12-lead, and appropriate care would have made this guy’s story quite a bit different. Where was the failure? Was it the patient’s fault for not recognizing and/or minimizing his symptoms? Was it the fault of “health education” in general for not reaching the patient in a manner in which he could understand? Does the fault lie with OIP for not spending enough time educating the public about the symptoms and danger of heart attacks? Does the fault lie with this patient’s doctor for missing the diagnosis and/or not providing proper education beforehand?

I don’t know the answer to the above question either. I just know that OIP and the EMS team treated him well once the call came in. I just wish that something different would have happened in the chance of events that lead up to all of this. It would have made the above 12-lead a lot different.

Be vigilant out there.

Posted by Ckemtp on March 15, 2011 • Filed under: EKG, Emergency Medical Services, EMS, EMS Topics, EMS training, Paramedic, paramedic education, patient care, Patient Management, physician, Uncategorized

I don’t always link new Bloggers

No comments

But this guy’s different.

My good twitter (and real life buddy) @NJdiveMedic is a Certified Diver Medic and an EMT in New Jersey (Clever twitter name, eh? It delivers what it promises) He has a resurrected blog entititled “A look at EMS from 120 feet below”. He’s written an awesome post that’s worth a read.

http://njdivemedic.blogspot.com/2011/03/veterans-day.html

Nice job bud.

Posted by Ckemtp on March 11, 2011 • Filed under: Uncategorized

Thinking about the ones that got away… at Midnight on a Wednesday

2 comments

A conversation I had tonight with a very good friend of mine made me think of two older posts that you may not have read. They’re… well they’re very personal posts, but I still read them from time to time when I need to put stuff in my head other than the crap that usually floats around in there these days. Replacing over-thought-about current sadness with past sadness? Who knows if that’s healthy, but sometimes it just has to happen.

Anyway, these two posts are worth a read I think, if you don’t mind an old medic rambling about people he didn’t save in years past.

Thanks, friend. I needed to think about these things tonight.

My first… – My very first cardiac arrest patient

In an Instant – A perspective on a tragic death of a young person after years on the street

Maybe I’ll elaborate on these posts tomorrow… tonight’s not the night for it. I’m on duty and the bunk is calling. Who knew that I’d be shaped so much by my career? It is nights like these where I’m sure that I’m motivated to be a paramedic by things way more important than money… Not that I’ve ever been not sure of that fact… and not that there’s ever really been enough money to convince me otherwise.

Anyway, enjoy the above links. They’re in my brain tonight. I hope you like them.

Posted by Ckemtp on February 24, 2011 • Filed under: bad calls, cpr, cpr fail, Emergency Medical Services, emotions, EMS, EMS Health & Safety, EMS Topics, EMT, Fire Rescue Topics, Line of Duty, Paramedic, Uncategorized

Looking for the link to NIMS training? ICS 100, ICS 200, ICS 700, ICS 800

5 comments

Howdy everyone! This is kind of an odd post for me, I know, but I needed a place where I could put up the links for the FEMA NIMS training classes for the EMS employees (EMTs and Paramedics) at my ambulance service. On this page, you’ll find the links to the FEMS National Incident Management System ICS classes required by all EMS people, Firefighters, and other first responders.

ICS 100:

IS-100.b – (ICS 100) Introduction to Incident Command System

ICS 200:

IS-200.b (ICS 200) ICS for Single Resources and Initial Action Incidents

ICS 700:

IS-700.a National Incident Management System (NIMS), An Introduction

ICS 800:

IS-800.b National Response Framework, An Introduction

If you’re an EMS person, or especially if you’re an employee of the ambulance agency I work for (which I remind the guys NOT to put the name of in the comments section) you should take ICS 100, ICS 200, and ICS 700. While I believe that ICS 800 is not required for line employees, it’s probably a good idea to take it as well.

Posted by Ckemtp on February 21, 2011 • Filed under: Uncategorized

Want to read what I said somewhere else?

1 comment

Because if you want to read some stuff I said about EMS somewhere else, like on another web page… You can.

http://www.jems.com/article/administration-and-leadership/where-ems-headed

My first bi-monthly column is up on JEMS.com. Go have a read.

Posted by Ckemtp on February 18, 2011 • Filed under: Uncategorized

Remebering My Father, Chief Richard A. Kaiser

5 comments

I was walking out of a nursing home last night after a simple transport when my brother sent me a text. We talk fairly often; my brother and I, so this wasn’t very significant… except for this text said “11 years today, RIP Richard Kaiser.”

And I hadn’t remembered.

Has it really been 11 years? Did my father, Chief Richard Kaiser really pass away 11 years ago? 11 years? Eleven? Years? Has it been that long?

My dad passed away in his sleep, the cause of death being listed as cardiac arrest of an unknown cause. He probably was a victim of Sudden Cardiac Arrest (SCA), possibly precipitated by a heart attack (MI) that he either wasn’t aware he was having, or didn’t report that he was having. My educated guess is that my father ignored chest pain. If I had to guess about my father, the proud, healthy and vigorous man that he was, I would say that he probably felt some chest pain and ignored the symptoms. I’d guess that he believed, as so many of my patients through the years have believed, that his body wasn’t telling him anything important when he chose to go to bed and see how he felt in the morning. I’d guess that he had been experiencing the pain in his chest all day and didn’t choose to do anything about it.

My father was a volunteer Fire Chief in the small town I grew up in for well over a decade. The department and the community there still benefit greatly from his legacy. He owned the hardware store in town, was the president of the town’s small water company, and was the general fix-it man for many of our community members when they needed something done. He was always willing to help out anyone in need and was a genuine example of a genuinely good man. I benefit greatly from having his example to lead me in my own life and I am blessed to have had him for the twenty years that I did. I will always be thankful for his legacy and the path he left me to follow.

I’m a career paramedic and firefighter and I would say that it is probably him that got me interested in the Fire Service, which blossomed into my love of the Emergency Medical Services. Without his lead, I don’t know if I would have gravitated to the ambulance game. Perhaps my bank account would have benefited more so if I had chosen to adopt his entrepreneurial spirit, or even maybe his MacGyver-Like ability to look at something and make it fixed… but I took on his love of helping people. In fact, as his legacy I’ve tried to impart in the kid that I consider to be my own son that “Our family helps people”… and a lot of that comes from my dad.

After he died, I lead an unsuccessful attempt to place AEDs throughout the part of the county where we lived. The area is very rural. In fact, the town I grew up in, Edgington, IL, is an unincorporated bump-on-the-map surrounded by vast amounts of corn and cows. There isn’t even a post-office. The ambulance that responded was actually the first ambulance I ever ran a call in, and it came from 13 miles away staffed with EMT-Basics. An EMT did respond direct to the scene from her house and began CPR, but she wasn’t equipped with a defibrillator… and ALS care was coming from the city 30 miles away. I was an EMT then but I wasn’t home.

Needless to say, when someone drops dead out in that area, they tend to stay that way.

Since my father passed away at age 53, most probably from ignoring pain in his chest, I have been hyper-vigilant on diagnosing and treating heart attacks and chest pain. As a paramedic, my number one pet-peeve is patients who ignore the symptoms of a heart attack and don’t call 911. Trying to “Tough it out” cost me my father. It cost my father his life, and I have got to tell you… there are times in my life since where I really have wished I had him around to talk to. I have tried to stop questioning how different my life would have turned out had my father simply chosen to call 911 and get his symptoms checked out. I have come to terms with the fact that it was his time and that we can’t second-guess or play “what-if”. I’ve even reconciled my feelings that I can’t always be there for everyone all the time, no matter how much I may have wanted to be.

But people who ignore chest pain and other serious medical symptoms simply because they believe they’re tough or that it can’t be happening to them still bug me. My ambulance partners will tell you, I give these people “the speech” where I expound upon the fact that they should always call 911 for chest pain. Sometimes I even get through to them.

In remembrance of my father, Chief Richard A. Kaiser of the Andalusia/Edgington Volunteer Fire Protection District, I am asking each and every one of my readers to do me a favor. Please spend some time evangelizing to your friends, family, and other loved ones that they should never ignore chest pain or other symptoms of a heart attack. Tell them to learn the symptoms and make the call to 911 when they have them. You do the same for yourself. Don’t try to tough it out or do anything stupid like that…

Because I miss my dad.

Call 911 for chest pain. Just FREAKING do it.

If you’d like to share something on your Facebook pages, twitter accounts, or print something out and pass it to your friends, please click on this link: “Heart Attack? Call 911 – Don’t Just Burp” It’s a piece where I write about the same topic… just without this level of emotion behind it. I’d like that piece to go as far around as it can go. If my father’s legacy can save any more lives, this is one of those ways.

Rest in Piece Dad, I love you. Thanks to you all in advance for helping me spread the word.

Posted by Ckemtp on February 17, 2011 • Filed under: Administration & Leadership, American Heart Association, Command & Leadership, cpr, Emergency Medical Services, emotions, EMS, ems 2.0, EMS Topics, EMT, fire, Fire Rescue Topics, In the Line of Duty, Line of Duty, Paramedic, Patient Management, STEMI, volunteer fire department

You know what this call needs?? Mo Hi-Lo!

8 comments

The High/Low siren, or the “Hi-Lo” as the cool kids call it, is at not only the coolest thing ever to grace emergency response, but it is also the most effective warning tool ever invented. While it is sadly starting to be phased out of some brands of electronic sirens in recent times, this is mostly due to misunderstandings and is a sad reminder of the cynicism of the modern age. The Hi-Lo is not only highly effective, recognizable, and entertaining, but it has a good beat and you can dance to it. It’s use must be preserved and today, February 17^th, 2011 has been declared “National Use Your Hi-Low Siren Setting for Some Reason Day” by the National Federation for Things I’ve Just Made Up (NFFTIJMU).

So, in observance of this groundbreaking and dare-I-say, highly relevant National Holiday, the NFFTIJMU recommends that every emergency vehicle, nation-wide, utilize the Hi-Lo setting on their sirens exclusively today. It will add cheer to your responses, promote spontaneous dancing among the passengers inside your emergency vehicle (I mean, come on… who DOESN’T dance to the Hi-Lo?) and will let your community members know that you’re cool.

It is recommended by the NFFTIJMU that those crews operating emergency vehicles not-equipped with Hi-Lo settings on their sirens be required to only function as dialysis and hospital discharge units in observance of the national holiday, except for in cases of emergency.

Here are some “Facts” about the Hi-Lo Siren that you need to know:

- Responding in an emergent fashion with the Hi-Lo siren makes an emergency responder -05% safer, and 110% cooler.

- Transporting victims of cardiac arrest to an ER may never be appropriate without ROSC, but if you must, using the Hi-Lo has been shown to increase survival rates by 12% overall.

- The Hi-Lo siren was invented by people WAY SMARTER than the people who invented the “Wail” and “Yelp” settings. They also have more fun at parties.

- You can’t help from dancing while driving while employing the Hi-Lo setting on the siren. What can the NFFTIJMU say?? It’s got a beat.

So in observance of the holiday, use em’ loud and use em’ proud! Play em’ Hi and Play em’ Lo!

(Note: Don’t believe any of this, just use the hi-lo)

Posted by Ckemtp on February 17, 2011 • Filed under: EMS Topics

Heart Attack? Call 911 – Don’t just burp

7 comments

“I’m just sore… I must have pulled a muscle in my chest or something.”

“I keep taking these antacids, but they’re defective or something. They aren’t working like they should.”

“I have drank like 5 sodas… if I could only belch I would feel so much better!”

If you’ve been in the EMS business long enough I’ll bet you have heard those exact words before from different people in disparate situations. They’re describing the uncomfortable feeling their having, and not the one they’re sure they’re not actually feeling in their chests. They’re describing to you the uncomfortable feeling they’re having within their psyche. They’re describing fear. They’re describing doubt. They’re describing the hope they want to have that they’re not actually feeling pain in their chests. They don’t want to be having something wrong with their hearts. They don’t want to be having a HEART ATTACK. This couldn’t be happening to them… this can’t be. They’re sorry they bothered you with a silly 911 call. They didn’t want to have all this fuss made for them by the ambulance and the fire truck and the police officers and the ER staff and the Doctors. This is all just so silly! Can’t we all just understand that if they could only belch that they’d feel better?

But, unfortunately that’s just not the case. That won’t be their path. That won’t be happening for them today. Today, they’re having a myocardial infarction and they’ve got a blocked artery in their heart that is causing it to tell them something… they just don’t want to listen. Honestly, the artery in their heart has been narrowing for a while now, they’ve just been ignoring the warning signs and not taking care of the problem for so long that their heart is becoming annoyed with them. Today, it is getting downright angry at them. Soon, their heart might just become “Pissed Off” and go on strike if they ignore what it’s telling them. Today it’s screaming at them and they’re still trying to do just that… They want to ignore the feeling they’re having, but now they’re scared and they’re starting to bargain. They don’t want to be someone who’s having a heart attack. This can’t happen to them. They don’t have heart attacks. That is something they’re worried about happening to other people, you know… people who aren’t them.

And yet the pain is there. It’s constant. They can’t seem to shake it or rationalize it away. Belching won’t help, and neither will taking antacids, drinking water, stretching, breathing deeply, or calling their friends to ask them about it. The pain, the weird feeling, the sickness, the dread… it’s not stopping and now it has been going on for hours.

And now? Now it is getting worse.

Fear creeps into these patients quickly but still they deny that anything is really wrong. When finally they present for treatment, whether by driving themselves to an urgent care center, by calling their doctor, or by even going to the local emergency room, they’re always shocked and in denial when they’re told “This could be a heart attack”. They defensively react and think that the medical care that is being “forced upon” them is “stupid” or unnecessary, or is “Just too much fuss”. They will still try to not believe it… well, part of them will try. They usually maintain a front. They don’t want to know that they could be indeed having a HEART ATTACK and that now is the time they need to trust the medical profession more so than they ever have trusted it in their life. They can’t fix this on their own, they can’t wish the pain away, and they can’t self heal the problem. By this time… no rationalization or self-healing thing will work. They need hard, conventional medical care… and they need it now.

As a paramedic, I have seen the type of patient I’ve described above many, many times. I have diagnosed acute myocardial infarctions in multitudes of patients who were angry at me for bestowing even the possibility of the diagnosis of “Heart Attack” upon them. Some have sworn at me, some have been relieved when I believed them, and all were scared. As a paramedic, I can diagnose and begin treatment on many types of cardiac conditions that fall into the “Heart Attack” category people fear so much. Paramedic and Ambulance care in the first stages of a heart attack can make a huge difference in how bad it gets and how much damage is prevented. Ambulance care during a heart attack saves not only lives, but it saves muscle. Consider the fact that during a heart attack, 1% of heart muscle is lost EVERY MINUTE it is left untreated. EMS can intervene, make a working diagnosis, and provide treatment and medications that will help slow or stop the damage.

And people really just need to forget about doing anything else other than calling 911 when they may be having one.

Really, if you’re even the least bit concerned that you could be having a heart attack, you should drop everything and just call 911. Don’t call your mom, your son, your friend, your spouse, or even your doctor. Call 911. Don’t do anything else… call 911 and just sit there. Someone in an ambulance will show up that knows what they’re doing. They’ll help you and you need their help. Now is the time to trust them and to let them do their job. Don’t ignore the pain, don’t worry about bothering them, and don’t feel bad for asking for help. You need an ambulance. They’re the best thing for you.

As a paramedic or EMT who is presented with a patient like this, you have a hard job. Not only must you provide appropriate diagnosis and treatment, but you also have to convince the patient to believe you and allow appropriate care. Reading a 12-lead EKG is easy compared to telling the patient and their family that you must bypass the closest hospital that they want to go to in favor of taking them to a bigger hospital, farther away, that has the cardiac surgery capabilities and cardiology services that they really need. This is the time to become a politician. This is the time to earn trust. This is the time that your skills as a caring and compassionate healthcare provider are going to be put to the test.

And if everyone stopped ignoring the problem and trusted their feelings, a lot of lives would be saved.

In the community that I serve, it is actually better medicine for a person having a heart attack to call 911 than it is for them to present to the emergency room. Even if that person immediately presents to the ER at the first warning sign of a heart attack, the ambulance still would have provided better care for them. Today’s ambulances bring appropriate care and highly trained medical professionals right to the patient’s side. Paramedics and EMTs can recognize the signs, help rule out mimics of a heart attack, perform diagnostic tests and an EKG, and can begin treatment with medications that stop, slow down, or even reverse the damage to the heart tissue in progress. The paramedics or EMTs in the ambulance can communicate with cardiologists and ER physicians at the local facilities and have a system in place to bring patients having a heart attack right into the facilities best prepared to take care of them, bypassing facilities that cannot provide the surgical intervention they may need… right away. Being immediately and appropriately treated by a paramedic and the emergency cardiology team early enough in a heart attack can make it almost seem like no big deal.

And that’s what we all want our heart attacks to be if and when we have one: No big deal.

So I’m telling you all out there. Don’t guess, don’t rationalize, and don’t hope it will go away. At the very first realization that the feeling you’re having, the pain, the ache, the soreness, the unusual heartburn, or however you describe it may be a heart attack; Call 911. Then sit and wait for us. We promise we won’t be mad if it’s something less serious.

But you’ll feel better, much better, no matter what it is.

Please, just call 911.

Posted by Ckemtp on February 9, 2011 • Filed under: Ambulance, attack, Emergency Medical Services, Emergency room, EMS, EMS Topics, letter to the editor, Paramedic, Public relations, STEMI

Lazy EMS – Encouraging the RMA

17 comments

I had an EMT friend call me the other day with a problem she’s having at work. After listening to her and being less than helpful, I thought that I’d share this with you and see what you’d all have to say about it. I’ll give you my advice to her, but I didn’t honestly have all that good of advice to give her. Let’s see what you think.

My friend who we’ll call her “Ann” even though that may or may not be her real name, is a former partner of mine. She’s a cool girl. She’s as much of the caring, kind, and competent EMT as you’d ever want in a partner and she’s also pretty fun to work with. I liked working with her and was sad to see her move away. I was happy for her when she got this BLS 911/Transfer job on a “big city” ambulance service, but she’s had some troubles there. Now, I’ve worked with her for a year as one of my regular partners and I know she’s good at what she does. I also know that the reputations of all of the ambulance services in this “Big City” aren’t all that stellar. Frankly, I’d take her word over theirs if I was pressed to answer a about it.

She called me and asked my opinion on what she should do about a situation that’s developing with a new partner of hers up there in the big city. She explained that this guy is a know-it-all type who encourages RMA’s (refusals, Against-Medical-Advice, etc) on almost every patient. She says that he won’t touch anything unless it’s a true emergency and tries to dissuade every patient who he feels is beneath wasting his valuable BLS time on. She says that it’s reckless and that he does it to excess, even when it’s clearly not in the patient’s best interest in her opinion. She says that he rationalizes it by saying that the patients won’t pay their bills anyway, and that some of these patients are simply being a burden on the system in general and that he’s just doing his job.

And I can understand that… to a point. I mean, who among us has ever rolled their eyes as a drama-filled patient tries to overplay their conditions to get sympathy and a transport or simply doesn’t even try and expects a free ride to three hots and a cot… I get that. In fact, I see it all the time. It bothers me to no end… and yet I rarely, if ever, encourage an RMA.

Ahhh, this is SO much better than doing a report

In fact, there are only certain times that I ever will encourage a refusal… and that is when there is a clear benefit to the patient not be transported to an ER via ambulance. I will do this at times when the patient will be better served by something like an urgent care center, or by a quick trip to their primary care doctor. I’ll show up, provide a full and detailed assessment, and actually talk to the patient about their options for medical care. I’ll tell them that maybe the stitches they need would be done faster and cheaper at the Urgent care down the street than at the ER, or that their need for a simple x-ray or throat culture could be handled somewhere else. I’ll even tell them when I think they can save money and still be safe by being transported to the ER via private car rather than by my ambulance. I feel comfortable doing that when it’s clearly in the PATIENT’S best interest – NEVER when it’s in MY best interest. Even then, if the patient still wants to go via ambulance to an ER or is unsure that my option is the best option for them I transport them without complaint. It’s just safer for my career to do that. Ultimately, I’m not a physician and I can’t make the final legal determination on what’s best. Only the patient or a physician can do that and I am usually not the patient.

However, that’s not what Ann says this new partner of hers is doing. She says that he tries to defer every transport on the grounds that he’s lazy and then he writes very sloppy reports about the calls he refuses. She says that he’s been in trouble for this before and that while he was working at another service, he was actually almost terminated for this behavior.

I know the type of EMT he is… He’s the “So, do you want to be transported or what?” kind of EMT. The kind of EMS person who feels that he or she doesn’t ever respond to “Check someone out” and that only the patients that absolutely have to be transported to an ER for an “awesome” enough medical complaint are truly worth their time.

I hate those kinds of EMTs.

She is concerned for her job, her license, and her career while she works with this guy. She doesn’t want his bad behavior to get her roped into a complaint, lawsuit, or worse… she wanted to know if there was a way she could protect herself legally from his actions while she was working with him.

I went with my stock answer on this. Being an EMS supervisor myself, I asked her if she’d talked to her superiors about this. She said she had done just that, and it hadn’t gotten anywhere.

I wasn’t surprised.

Unfortunately for my friend, there’s just no reasoning with this kind of EMT. I’ve worked with their kind before and I know how painful one’s working relationship with these people can get when you force them to *gasp* do their jobs and take people places while treating them for whatever they say their medical complaint is. They tend to get growly at you when you tell them you’re having trouble hearing them over the sound of you not caring what they think. It makes lunch time a tenuous situation and totally ruins the Christmas party.

My next pearl of advice to her was to tell her to actually send a written letter to her supervisors, detailing her complaints and stating her concerns in writing. My thoughts would be that then, there would be a paper trail that shows she at least tried to do something about it. Unfortunately, I also had to warn her that it may end up branding her as a trouble-maker when the bosses realize that they now have a paper trail too, only they actually have to do something about it. They may retaliate against her instead.

Then I told her to CC a copy of the letter to the medical director, just for emphasis. It’s because I’m a devious trouble-maker myself.

Situations like this are all too common out there and they are the things that hold our profession back. Yes, I know that there are system abusers out there in patientville. We’re not going to fix that with our current system and really need to get more options out there for appropriate treatment pathways. However, putting people at risk by encouraging RMAs because you’re a lazy provider hurts our efforts by setting a bad precedent. Please don’t do this people. Take it from me. I’d never let you get away with it on my shift.

Does anyone else have any better advice for my friend Ann?

——————————————————————–

Also, it may be helpful to read this post: a primer on the people I call “Grumblemedics”

Posted by Ckemtp on January 30, 2011 • Filed under: Administration & Leadership, Command & Leadership, Emergency Medical Services, EMS, EMS ethics, EMS Management, EMS Topics, EMT, everyday ems ethics, grumblemedics, medical ethics

Go Vote!! 2011 Fire/EMS Blog of the Year

1 comment

Hello everyone!!

I know what you’re thinking… you’re thinking that whenever I start a post like that, I must have something up my sleeve. Perhaps I’m about to shout another in-your-face opinion about EMS, or paramedicine, or EMS 2.0, or something like that. Maybe I’m going to make you mad; maybe I’m going to make you think; or maybe, just maybe… I’m going to inspire you to action.

Well it’s that last one, the one about the “inspiring to action”.

Every year, our friend The Fire Critic runs the annual “Fire/EMS Blog of the Year contest”. Last year, the winner was our good friend and “mate” Mark Glencorse over at http://www.999medic.com. It was great to see him win it… I wasn’t jealous at all!

Anywho, this year is a whole ‘nother year and just like that, there’s a whole ‘nother contest. Only this time, Mark is out of the running and THIS VERY BLOG is a finalist!

I know what you’re asking… you’re asking yourself: “Where can I vote?!? Oh why?? WHY am I not voting THIS VERY MINUTE for my FAVORITE EMS BLOG that just so happens to be THE BLOG I AM READING RIGHT NOW!?!?!?!?!?!?!?!”

Well never fear, my friends. Never fear at all.

You can go vote for your favorite EMS blog, *cough* Life Under the Lights *cough* multiple times, once every six hours, that is. So if every reader of LUTL goes and votes every 6 hours like clockwork, not only would we crash the servers, but we’d also show some other bloggers…

(bloggers who stoop to crass pandering like this one HERE)

That we optimistic, thinking, and oh-so-handsome readers of this blog can ROCK THE VOTE like none other.

Go vote!! Here’s the link! Go vote HERE!! Please??

I’ll be your friend! I’ll buy your beverage of choice! I’ll bake cookies!! I’ll… be your friend!! I may even etcetera.

Posted by Ckemtp on January 24, 2011 • Filed under: EMS Topics

« Previous Next »

A Day in the Life of an Ambulance Driver

Close preview

Loading...
Conservative Firefighters

Close preview

Loading...
Dani's Anatomy

Close preview

Loading...
Fire Geezer

Close preview

Loading...
Firefighter Net Cast

Close preview

Loading...
Firefighter/Paramedic Stories

Close preview

Loading...
Gomerville Dot Com - This guy's awesome

Close preview

Loading...
Greg the HazMat Guy's Training Success

Close preview

Loading...
I Just Call It As I See It

Close preview

Loading...
If you got stopped, you deserved it

Close preview

Loading...
Jeramedic's Blog

Close preview

Loading...
Just Me, Just My Blog

Close preview

Loading...
Life in ManchVegas

Close preview

Loading...
Medic 999

Close preview

Loading...
Not Trained, but We Try Hard!

Close preview

Loading...
Notes from Mosquito Hill

Close preview

Loading...
Paramedicine 101

Close preview

Loading...
Pedro the Paramedic

Close preview

Loading...
Pepper Spray Me

Close preview

Loading...
Pink Warm and Dry

Close preview

Loading...
Queen of the Dogs

Close preview

Loading...
Red Lights, Hot Spots, and Disaster

Close preview

Loading...
Rescuing Providence

Close preview

Loading...
Rogue Medic

Close preview

Loading...
Run To the Curb

Close preview

Loading...
See Jane Nurse

Close preview

Loading...
Street Watch - Notes of a Paramedic

Close preview

Loading...
That's BLS, not BS

Close preview

Loading...
The Fat Fireman Blog

Close preview

Loading...
The Happy Medic

Close preview

Loading...
The Insomniac's Guide to Ambulances

Close preview

Loading...
The um, "tactical Pants" blog

Close preview

Loading...
Three Mouse Clicks from Disaster

Close preview

Loading...
Too Old to Work, too young to Retire

Close preview

Loading...
Trauma Queen

Close preview

Loading...

Archives for

Blood Pressure – Vital Knowledge for EMS

Perils of Paramedics Pursing imProper Patient Refusals

Death Rate to Increase in London – and – The Medicare Tomato

EMS Narrative Report – Ckemtp on the MedicCast EMS Podcast

Eight Ways you can Ace your Patient Assessment – EMS

Keeping an Eye on the Sky

From the #WTF files – AL Fire Chief Flushes Twins down the Toilet?

We Oughta Look In to This – EMS 2.0

Remembering the True Heroes – D-Day, June 6th 1944

Announcing the EMS All-Call

Wake Up! You may have a call…

EMS Week 2011 – WANTYNU

Dreamland Paramedics…

Wheel of the Regulars: Turn Turn Turn

Change Medicare? Save EMS

EMS 12-lead Case – Ischemia and Failure

I don’t always link new Bloggers

Thinking about the ones that got away… at Midnight on a Wednesday

Looking for the link to NIMS training? ICS 100, ICS 200, ICS 700, ICS 800

Want to read what I said somewhere else?

Remebering My Father, Chief Richard A. Kaiser

You know what this call needs?? Mo Hi-Lo!

Heart Attack? Call 911 – Don’t just burp

Lazy EMS – Encouraging the RMA

Go Vote!! 2011 Fire/EMS Blog of the Year

Connect with Ckemtp and LUTL

Get your Daily Life, Under the Lights

Care to Search the Blog?

Random EMS Articles from LUTL

My Most Recent Posts

Comments – Recently Recieved from the Field

Oldies but Goodies

The EMS Blogosphere - and others

FireEMSBlogs.com Community

Featured from across Fire/EMS

In a totally unrelated note……

Class Announcement: Forcible Entry 1 &…

“Old School” Captains ……

Help Jonesy Get to Houston!…

Archives for

Connect with Ckemtp and LUTL

Get your Daily Life, Under the Lights

Care to Search the Blog?

Random EMS Articles from LUTL

My Most Recent Posts

Comments – Recently Recieved from the Field

Oldies but Goodies

The EMS Blogosphere - and others

Tags Across FireEMSBlogs.com

FireEMSBlogs.com Community

Featured from across Fire/EMS