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Coming Soon – The Law of Unintended Consequences meets the fire service

2 comments

Remember the post I put up a few days ago entitled “A Predatory Ambulance Fee”? It talked about how the Elgin, IL city council is planning to help recoup their costs for Fire and EMS services by charging for refusals.

(This is the link if you didn’t read it: “A Predatory Ambulance Fee”)

This just in:

Apparently they’re not done proposing new fees in the city. They seem to be very serious about recouping their costs and finding new ways to monetize their services. According to this article posted on Firefighter Nation, they’re planning on adding quite a few new fees to their repertoire.

Here’s the link: “Illinois Department Considers Charging Non-Residents for Fire Services” Read it and see what you think.

The article only mentions two specific fees, a $500 per hour fee for an engine response and $2200 for “a serious car accident where someone has to be transported by helicopter.” These fees are interesting enough, but the article also hints that there are further fees forthcoming.

The chief is quoted as saying that he expects most of these fees to be covered by insurance. After all, he says… that’s what insurance is for.

The chief may be very correct with that statement; insurance exists to pay for the unforeseen costs of bad things that happen to people who pay for it. Insurance companies pay these costs based upon rigid contracts they sign with their customers and charge their customers rates based upon the average risk they assume on behalf of the customer. They will only pay for what they are contractually obligated to pay for. While I have no knowledge of whether or not insurance will actually pay for the charges Elgin is proposing in practice, I’m assuming the city of Elgin doesn’t either and if they don’t seem to care whether the people they are saddling with these kinds of fees are insured for them or not, why should I?

It’s not like these insurance companies aggregate risk across all of their customers and will pass the overall cost of these fees to everyone in the area causing everyone’s insurance rates to go up, right?

Remember, I am not against fire departments, cities, and/or EMS services finding new and innovative revenue streams or ways to defray costs. The City of Elgin is not a villain here. It is very expensive to operate a service and I completely understand wanting to recoup some of those costs. These kinds of fees are somewhat the result of a rigid and over-regulated EMS payment system that chains our entire industry and squashes most hopes of innovation. I believe in EMS payment reform. In fact, I demand it.

But guys? While you’re by far not the only department in the US proposing and implementing things like this… you’re all opening Pandora’s Box. Your citizens are going to fight this, the press won’t be good, and you may end up creating more of a wave of dissatisfaction than you’re really prepared to endure. Think about Moline, IL and what they’re going through right now. Could you imagine their chances of winning their fight if they had implemented these fees?

Then again, perhaps they should implement them in Moline and let the revenue sources balance their budgets… In Moline they say they’re operating at over a $340,000 budget deficit and maybe these kinds of fees would offset that deficit enough that they could make their EMS financially viable.

Or maybe the marketplace will decide and departments that do this kind of thing will be put “out of business” (for lack of a better term) by competitive forces.

I would be willing to bet that there’s someone out there that would only charge $450 an hour for an engine response and only $2100 for a “serious car accident”. There are probably plenty of people and companies that would be happy to do fire response for profit. That’s what happens when governmental services start acting like monopolies in a capitalistic system, they get replaced by free market alternatives. Back in Ben Franklin’s day the fire service was a private endeavor that was only made public when the cost of providing protection wasn’t profitable enough to serve the ends the people wanted it to serve. Make the fire service profitable and private industry may find a way to make a solid business model out of it. Don’t believe me? Think Fed Ex and UPS versus the US Postal service.

I’m not saying it’s a good or bad thing. It’s why private industry exists. If there’s an opportunity to make money doing something, someone will step up to make money doing it. These fees, if they become lucrative, may just be the opportunity for private industry to find a business model that didn’t exist before.

I am able to understand why Elgin wants to implement these fees… but I think that this is a situation ripe for the Law of Unintended Consequences. If I could give cities proposing these kinds of fees some advice I would tell them they should find every single efficiency within their existing budgets before they set about increasing revenue through raising fees. Make no mistake, within the contemporary political climate; citizens are going to scrutinize every aspect of your budget when you start trying to get them in the wallet. You may not like what they find.

I don’t have the ultimate answer but I’m keeping an eye on this story. You should too.

Posted by on November 4, 2011 • Filed under: 911 fail, Administration & Leadership, ckemtp rants, Command & Leadership, Economics, Emergency Medical Services, EMS, ems 2.0, EMS Management, EMS Topics, fire, Fire department, Fire Rescue Topics, Firefighting Operations, Funding & Staffing, News, northern illinois, politics

A Predatory Ambulance Fee?

14 comments

I just read an article on JEMS.com that's got me concerned. Since I'm a blogger, I thought that I'd share it with you. It's kind of what I do.

The article concerns a city in Illinois that wants a fee increase for their fire-based ambulance service. At first it looked like just another city wanting to increase its charges for providing transports. That’s hardly newsworthy for ambulance services in Illinois these days as they’re mostly all trying to recoup more expenses.

However, read the story and try and see if you see what I saw: “Ambulance Fees May Jump 25% in Elgin”.

It’s way at the bottom. Did you see it?

Here’s what sets me off:

“A new charge for refusing advanced life support upon the arrival of emergency responders also is proposed. For nonresidents, the charge would be $400 each time. For residents, the charge would be $300 after the third occurrence in a 12-month period.”

A new charge for refusals? According to this if you’re not a resident of the city, have a minor fender bender that someone calls an ambulance for, and sign a refusal of care form, you’re going to get a $400 bill. What if it’s not auto-related and you slip and fall on some ice and someone calls? Is that worth $400 if you’re not hurt and an ambulance shows up? This sounds to me like every time someone plays "Cell phone hero" and calls 911 for something where nobody is hurt the service is going to get paid. Sure, it'd be nice for the ambulance service… but I don't think it's fair to the poor people getting the bill.

What about if you see an ambulance down at the local coffee shop and they ask you how you’re feeling… is that worth $400 too if they ask you for your autograph?

This is not fair.

I can see what they’re probably trying to do. They’re probably trying to crack down on their system abusers by making them financially responsible. I support a lot of those efforts if they’re well thought out. This one is not. This isn't neccesarily a case where someone is getting something for free and should be charged for it. According to the article, this fee would apply to all refusals of care regardless of whether or not any services were provided. 

I am a fan of treating and releasing patients in certain circumstances and I've written a few published articles on the topic, like this one regarding treatment coverage for hypoglycemic diabetics we sweeten up then sign off, and also this one that covers a procedure that I call the "Enhanced Refusal". I agree that both of those circumstances should be covered by a fee. I believe that if EMS provides a necessary service to someone that we should be able to recoup our costs and make it worth our time. This is not one of those cases.

Think of it this way. This is akin to you telling your neighbor you think your air conditioner is on the fritz in a casual conversation. Your neighbor, being a helpful person calls a heating and air conditioning contractor without your knowledge.  The contractor shows up at your house to your surprise, and when you tell him your air conditioner is just fine and you don't need any repairs he charges you $400 for his time.

You'd be outraged and wouldn't pay it.

Of course I know that this most probably is not the line staff proposing this change. This one has all of the hallmarks of some uninformed bureaucrat all over it.

I will not be signing one of that ambulance service’s refusal forms. I suggest you don’t either.

Is anyone else doing this?

Posted by on October 28, 2011 • Filed under: 911 fail, Administration & Leadership, Command & Leadership, Emergency Medical Services, EMS, EMS Topics

GPS in the Ambulance – An overreliance on Ms. Kitty

16 comments

Actual conversation between me and my partner a few years ago right after receiving an emergency call:

Me:        “Lemme get this on the map… I think it’s South of us. Head South… Southeast! Yeah, it’s Southeast of us”

Her:       “Whattaya mean Southeast!? I don’t know directions. You’ll have to tell me Left or Right!”

Me:        < Scanning the map> “Um… Ok, we’re heading North, so make a Right up here on River Drive and head to Mulford. The street is right off of State and Mulford, one West and two South”

Her:       “It’s what?”

Me:        “Just head to State and Mulford and I’ll get ya in”

Remember that? Remember those days when we used to use paper maps? I do. Man, those days were crazy… back when we had to use those archaic things, right?

Actual conversation between me and a different partner in the much more recent past while driving to an emergency call:

Me:        “Dang it! The GPS won’t get satellite signal! I can’t lock in the address”

Him:       “Where do I turn? What street is it off of?”

Me:        “Hang on, I’ll try to look up the address from my phone… Gah! Why is the connection so slow!?”

Him:       “I’m going to turn down this street… what was the address again??”

Me:        “Um… I think it was… 432 Mulberry… I think… Don’t we have a paper map in this truck???”

Him:       “I didn’t see one. Maybe I can get the address on my phone.”

Me:        “Wait, is that a cop up ahead? I think he’s at the call, drive up there.”

Cop:       “Hey! What took you guys so long!?”

Ain’t modern technology great?

It was only a few years ago that we got GPS machines in the ambulances I ran in. Previous to that we had survived off of our “Stacy Maps” which were these awesome map books designed by a local company. They weren’t sexy or technologically sufficient for the times… but they always got the job done if you knew how to use them. Sure, they were hard to read by yourself if you were the only one navigating the truck, but they worked… every time. No outside force could stop them from working. If you had one, you weren’t lost, period.

Now, with our increasing reliance on the magic voice in the GPS box (I call my GPS voice Ms. Kitty) we seem to be able to get to our calls seamlessly and smoothly… 90% of the time. There are times when the GPS doesn’t work, times when it’s just too darn slow, and times when it doesn’t have an address to lock in to. The GPS just isn’t always optimized for emergency response. I’ve found that my GPS is great when I am dispatched to 9933 Harrison St as a physical address… but not so much when I’m dispatched to “The bike path in the field behind Costco off of the side road next to the blue house”.

I remember a call I got once when I was working a relief shift at a contracted rural station. We had just cleared a call from a downtown hospital when the service got a call for a nasty auto wreck out in the country. Their dispatch asked us to respond as the third ambulance. I usually worked in the city the hospital was in so I knew how bad the regular routes were clogged with construction, being as it was summer in the Midwest. I drove and was able to use my knowledge of the city to get us around every bit of it. I took State St to Prospect, Prospect to Guilford, Guilford to Highcrest, Highcrest to Springcreek, Springcreek to Springbrook, Springbrook to Perryville, to… well, you get the idea. I was able to bob and weave through that city so much that we arrived at the scene in record time… which was just in time to be cancelled and sent back to quarters.

What I’m saying is that I knew the city so well because I had been forced to learn how to navigate it by reading paper maps. A skill that sadly, I’m afraid we’re losing as we increase our reliance on the magic directional box and the voices inside of it. GPS is a great tool, but since a huge part of our effectiveness as EMS people is actually being able to arrive at an address in a timely manner, it can’t be our only tool to find one. If you're relying on your GPS as the only tool you have to find the address of an emergency call, you're turning your GPS machine into a life-safety device. I'm sure the manufacturer will agree that It was never intended to be one of those.

My advice is to learn to love your paper maps. Read them. Study them as much as you study your medical protocols. Drive around your wider response area without turning on your GPS. Get lost in it every now and then and try to find your way around. Be sure to pay attention to the hundred blocks, the street names, and the short cuts. Don’t become clueless when Ms. Kitty takes a coffee break.

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For more of my “You Kids Get Off My Lawn!!” ramblings, you may want to check out “Those Darn Kids!”

Posted by on October 26, 2011 • Filed under: 911 fail, Command & Leadership, Emergency Medical Services, EMS, ems education, EMS Health & Safety, EMS Humor, EMS Management, EMS Topics, EMS training, Fire Rescue Topics, Paramedic, paramedic education, stories, Technology & Communications, technology-communications-ems-topics, Training & Development, 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:

 

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 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

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 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

A Weighted Issue? A Burning Issue… Wow.

5 comments

I’ve always said that I love EMS and that I’ve taken from it far more than I could ever give back to it. The same is true with this blog. From my readers and people who comment, I learn more than I can teach and enjoy more than I can entertain.

This weekend proved all of those facts quite well.

If you didn’t read the blog over the weekend, you missed an amazing discussion on my last post. The post, “A Weighted Issue, The Fire Service Helping Private EMS” discussed the case of a private ambulance requesting a fire department for assistance in carrying a bariatric patient back into her home on a long-distance hospital discharge. The private ambulance was 5 or 6 hours out of their area of operations and the Fire Department was a full-time municipal department.

I linked to the stories that had popped up on www.JEMS.com and also on www.EMS1.com. I wrote my feelings on the issue, explored the case a bit, and then opened up the floor to the readers for their comments.

And what happened floored me, just knocked me over.

Predictably, I started getting comments on the post… Then some more… then more.. then a LOT more.. then a TON more. The post spread like wildfire and attracted some of the most intelligent discussion I’ve ever had here. It’s by far my most commented post with 86 at the time I write this.

And I read them all. I love comments, they come to my BlackBerry. Really. I read the discussion, the back and forth, and the wide spectrum of opinions as they came in, sometimes two and three at a time.

And my opinion has been swayed… my original perception that the Fire Department was Evil has been tempered. My original perception that the Private Ambulance could have dropped a dime and handled the issue with a phone call before the incident has not changed. However, I now focus my ire on the system that caused this issue.

The reimbursement structure holds the ambulance service hostage. No private ambulance would be reimbursed for hauling the patient with extra people. The service wouldn’t have been reimbursed for a 2nd rig and the patient had to be taken home. My guess, as was stated by a handful of commenters, is that the service was taking the patient as a favor to garner more business from the rehab hospital. I have no way of knowing that for sure, but it makes sense to me.

Not only did I get a TON, just a ton of great discussion… but the post spawned a few others as well.

This event has taught me something that should be the takeaway for us all. That is this: Issues like this are not going away. In fact, they’re only going to get more common. Private EMS isn’t evil and the “Private Transport Industry” is necessary for the functioning of our healthcare system. Fire-Based EMS will have to help and could never handle the strain of not having private EMS.

Sorry to both parties here, we’re all needed in the current system. Healthcare needs us all.

So play nice and help each other out. Remember the Golden Rule.

And remember the five P’s: “Proper Planning Prevents Poor Performance”

I shall leave you with two things:

http://lifeunderthelights.com/2010/09/a-weighted-issue-the-fire-service-helping-private-ems/ – A link to the post for you to wade into the comments if you haven’t (you should. Bring a snack)

And this, a  video that this experience has brought to my mind. “The Hats of Incident Management” It’s about highway incidents… but you’ll get the point. It’s a classic.

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Posted by on September 21, 2010 • Filed under: 911 fail, Administration & Leadership, Emergency Medical Services, EMS, EMS Topics, Fire department, Fire Rescue Topics, Paramedic, professionalism, Uncategorized

Police Car Drivers, Ambulance Drivers, and their responsibilities

12 comments

Look at the pictures below and see if you can identify the three occupations represented by the people in the pictures.

What are their jobs?

What are their areas of expertise?

What would you expect them to be responsible for?

                                     

 

Yep, pretty much everyone reading this and almost every lay person you can think of should probably be able to answer the above questions. The Police Car Driver chases bad guys; The Fire Truck Driver squirts water at things; and the Paramedic takes care of people who are sick and hurt, right? Sure, their jobs sometimes overlap and so does some of their training, but the jobs and the requisite education and responsibilities are different and separate for a reason. The different roles up there are different, specialized, and require expertise in order to be effectively performed… right?

And before you think that I’m opening the Fire Based EMS can of worms, I want to direct you to this news story I just read on EMS1.com – Kentucky EMTs not called for 5 hours until coroner ruled woman was alive. Go read this and then come back please. It got me all riled up and I’m sure it will you as well.

The moral of the story, is that police officers were called for a dead body found in some bushes some where. They started doing their cop stuff and didn’t call EMS to evaluate the body because their cop training told them that the woman was obviously dead. Unfortunately for all involved, when the coroner arrived he told them that their police-issued medical training wasn’t adequate and that the woman was indeed alive.

And yes, I am 100% sure that nobody intended for that to be the tragic result.. people make mistakes, I know… but:

How many times have you been called out in your ambulance to a potential medical emergency and then cancelled while en route? Have you ever wondered who is cancelling you and for what reason? When we arrive on scene, we evaluate the patient and determine their need for transport. We have extensive training to help us do this and we function within a complex set of laws and regulations to help ensure that bad outcomes like this happen as infrequently as possible. Unfortunately, however, things like this do happen, even to experienced paramedics. How many times have you heard news stories about paramedics calling someone dead only to have them be found alive later on? How many times have you heard about occult neck fractures and other severe injuries being found later even after a patient was evaluated by a physician? It happens, folks… and it happens to us medical people too. Even with the training, knowledge, skills, and experience we have that is specifically geared to emergency medical care that is again enhanced by the fancy tools that we carry with us, we sometimes still make mistakes…

So why in the heck would a police officer, who as stated above chases bad guys and does other kinds of “cop stuff”, want to make the decision that someone was dead or not? It simply doesn’t make any sense to me. I have always been leery of having police officers call us off of medical scenes. Even when I know the officer and trust his or her judgment, I know that my medical training and tools are superior to theirs. That’s the way the system is designed, we do medical stuff and they do cop stuff.

I think that there’s a pervasive trend out there that causes dispatchers to send police units first to things like auto accidents and possible crimes in progress and then potentially forget to send EMS. Most of the time, it’s perfectly ok and turns out just fine. Other times, incidents like the above happen. How many times, also, has a police officer determined an auto accident to not require medical response and an occult injury been found later? I don’t know and haven’t seen any statistics… but I’ll bet it happens a lot more than is ever reported.

My advice? I promise to let the cops to their cop stuff. They just need to always remember to call me out to do my stuff. I don’t mind doing the report if I’m not needed or I get a refusal, I just don’t want anyone to suffer needlessly.

Be careful out there.

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Want more of my thoughts on Fire Based EMS? See: “Fiddling While Rome Burns… The ambulance “industry”

Posted by on June 15, 2010 • Filed under: 911 fail, Administration & Leadership, Ambulance, Command & Leadership, Emergency Medical Services, EMS, EMS Topics, EMS training, Firefighter Safety & Health, Paramedic, paramedic education, patient care, Uncategorized

A Slap in the Face to Paramedics Everywhere?

89 comments

As some of you probably know, last weekend I went to the Fire Department Instructors’ Conference (FDIC) in Indianapolis, IN and I spent a great deal of time wandering the convention floor, looking at cool things and talking to cool people. There were plenty of great things to see and great new things to learn about and I immersed myself in doing just that. One of the things I’m always interested in is looking at the new trends in ambulance design and the manufacturers always have their coolest new vehicles on display to feed my interest. However, while walking the conference floor, I came across an ambulance that did more to tick me off than it did to promote their new vehicle design. Seriously, it was like someone slapped me in the face. Here’s the picture I took from my phone:

 Ambulance Staffed by RNs

Does anybody see anything wrong with that picture? I was immediately ticked off…  I’m talking a level 7 hissy fit. I was livid for quite a while and if you follow my twitter feed, you probably saw the three or four times I TwitPic’d it.

I mean really? They had to put “Staffed By Nurses” in six inch high script on three sides of this thing?

I blocked out the name of the service that runs the ambulance and in all fairness to the manufacturer, this truck is awesome. I would be quite happy to work in this truck although being that it has no bench seat, its usefulness as a 911 truck is hampered by its inability to carry more than one patient at a time. However, I would flatly refuse to work in this truck or for the ambulance service that puts it on the street. I happen to know the service that bought it and I’m trying to avoid naming them directly, but they serve a midsize city in Illinois.

Before you go all West Side Story, whip out your switch blade and zip gun, and prepare to have a dance fight with the nurses out there, realize that I’m not mad at them. Sure, mostly they’re well-paid and have climate controlled jobs inside of well-lit buildings, but they didn’t do this to us. My beef is with the management of this particular ambulance service.

So, let’s say that you’re the manager of this particular ambulance service. Obviously, sitting there in your office you must think that your paramedics and EMTs are contemptible morons who live simply to cause you problems. Furthering your view of the world, you probably think that the rest of the medical profession and the members of the general public in your area view them the same way and simply don’t trust them to provide medical care when it’s like *really* complicated and stuff. You probably feel that everyone would feel safer knowing that their patient or loved one is traveling via the companionship of “nurses” whom you must view as actually being like actually *Competent* and stuff.  

And that’s what this rolling billboard to your contempt of your employees and their profession says about you. It’s a slap in the face to the good men and women you have working for you and there is flatly no excuse for it.

Here’s a tip, anonymous ambulance manager person (AAMP). There isn’t a need to have your precious ambulance be “staffed by nurses” when you have sufficiently equipped and prepared paramedics working in it. Paramedics are acute care specialists. We’re also experts in mobile medicine. Our education, training, and experience prepare us for the unique environment that we create when we move patients from one place to another. Critical Care Paramedics have the intensive Care experience, training, and background needed to operate in a critical care ambulance environment, nurses do not. Sure, ICU and ER nurses are great at Critical Care. However you shouldn’t regularly staff a critical care nurse in the transport environment for the same reasons that you wouldn’t put a critical care paramedic inside of the ICU. The professions are like in a lot of ways, but they’re separate for a good reason.

And you, AAMP, don’t respect that. Perhaps it’s because you’re burnt out. Perhaps it’s because you’ve beaten the system you’ve created into such a pulp that nobody wanted to staff your new Critical Care Truck. Perhaps it’s because of a lot of reasons, but it’s certainly not because you wanted the best in patient care or to show that your employees are capable of operating your shiny new “special” ambulance. No, you wanted “nurses” to “staff” that truck… and not only did you want the medical people you’re contracting with to know this, you wanted everyone who saw the truck to know it as the 6 inch high letters stating that fact clearly show. Do you think that the public views your crews as incompetent? If so, do you think that furthering the notion by advertising that your “special” truck is “staffed by nurses” will help that situation?

If your protocols are so draconian that even critical care certified paramedics cannot be allowed to staff that truck, then your protocol system is in the Stone Age. If your educational system isn’t up to the challenge of preparing your most experienced medics to staff it, then fix that problem. I know that there are great medic/nurse combos out there and I know that flight nurses have garnered quite a bit of respect out there in the world… and heck, I’m not knocking them for doing it. However, this is the time for Paramedics to step up and claim our turf. This ambulance clinched it for me. AAMP, your shortsightedness has caused me to lead a revolution of sorts here. You’re contempt for your staff has indicated to me that now is the time for paramedics and EMTs, such as the ones that work for you, to stand up and start claiming what is rightfully ours. Frankly, AAMP, your ambulance and your attitude is ridiculous and thinking like that must be stamped out right now by the good medics among us.

And I should also say this to the nurses in the audience before you start skewering me for knocking you: Have you looked at the debates in your circles concerning the use of paramedics in the ER and in other hospital units? Have you ever seen the term “Unlicensed Assistive Personnel”? Well I have, and it’s what the upper nursing echelon calls me and my professional colleagues.  It’s offensive, but hey… our jobs are different. You have the hospitals and the fixed facilities. That’s what you do. We have the field. It’s what we do. There’s a line, respect it. If you want to do EMS, go through a real paramedic program. If we want to do nursing, we should go to nursing school. Really, it’s that simple. The transport environment is difficult and requires the use of specialized personnel… which we have, they’re called paramedics. The medical care we provide is close to the care that you provide, except we have autonomy that you do not and we are use to working independently in the environment in which we operate. Your focus is different than mine.  You may be the best transport nurse out there, but even though you personally may be awesome, my profession needs to have people as awesome as you working on our side. That’s what this is about, not to knock your transport nursing skills, but to kick us paramedics in the shorts and get us to step up and maintain ownership of what we should own.

The responses I got back on Twitter show me that there are a lot of like minded individuals out there. Perhaps some of them might work for you, AAMP. You better take that into consideration because if I have my way the paramedics are going to get the notion that we’re not just a bunch of contemptible morons and we’re soon going to take control of our own profession. On that day, managers like you will be obsolete. Perhaps you can get a job managing nurses.

Here is my personal ‘thumbs down’ for the graffiti against my profession that you had someone slather on your shiny new truck, AAMP. My advice? Take it off and reconsider your staffing patterns. What you’re doing is bad for my profession. It affects me negatively, it affects my profession negatively, and it shall not go unanswered.

What do you think?

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Be sure to check out the follow-up to this post “A Slap in the Face? How about a Wake-Up Call?”

Also, for more of my thoughts on the state of EMS in the State of Illinois, check out “Dear Illinois EMS”

Posted by on April 26, 2010 • Filed under: 911 fail, Administration & Leadership, Ambulance, Ambulance Driver, ckemtp rants, Command & Leadership, Emergency Medical Services, Emergency Nurse, EMS, ems 2.0, EMS Management, EMS Motivation, EMS rant, EMS Topics, EMS training, Paramedic, paramedic education, politics, potential, pride, profession, professionalism, Scope of Practice, Vehicle Operation & Ambulances

Foot-in-Mouth-Itis. Stupid Things We Say in EMS

21 comments

A letter I received from a reader who states that she is a paramedic student has gotten me thinking. I’m going to include her letter in this post with her permission, but before I do I would like to speak a little bit about things that we say to patients. EMS and all of emergency medicine tends to be full of emotionally charged situations being handled by emotionally drained people. Sometimes our experience in dealing with situations that lay people find to be traumatic can lend itself to our making comments that we find perfectly acceptable to make at the time we make them, and yet upon reflection seem like the wrong thing to have said. I can’t tell you just how many times I’ve been in trouble for my mouth. I will say something that I intend to relieve the tension of a situation and to provide comic relief that I think is cute and funny, completely thinking that it is above-board and not-offensive to anyone, and then find out that some wet-blanket took offense.

Honestly, I make it my policy never to make a dirty joke. All of my “patient friendly jokes” are clean enough to tell to my five-year-old with nary an off-color word or adult reference in sight and sometimes still people look at me like I’ve dropped a live weasel in the ball-pit at the McDonald’s Play Land. Like some random time ago where a patient who had overdosed, scratched her wrists with a dull knife, and was found trying to hang herself apologized to me during my assessment of her because she hadn’t shaved her legs. I said “Oh that’s quite alright, Ma’am.. You weren’t planning on needing them anymore and besides, you shaved your wrists real nice”. I believe the question I got from my partner after the call was “Does your Brain-Mouth filter even work anymore?!” He was laughing as he said it, so obviously it was funny. The patient laughed too.

I have stock comments to the common questions and situations that come up on calls that I trot out when needed to liven up the situation. Some are movie quotes, some are lines that I’ve stolen from other providers, and some are straight up from my strange brain. Like when I find someone lying in bed that needs to be lifted over from the bed to the cot with a sheet and a couple of people. Some beds are way too wide for me to work from my feet and it’s often useful to crawl right in bed alongside the patient to lift them over. I ask them “So when was the last time you had a strange man in your bed?” The unconscious ones almost always laugh. I have yet to have an older lady blush and be embarrassed and the comments I get back are always entertaining. Also, when I’m palpating an area of a patient’s body to see where they’re hurting such as for an injured extremity or the like, if the patient yelps out in pain when I touch something I excitedly declare “Found it!!” It’s much to their relief to know that I know where it is that they hurt. I also have what I call the “Poor Man’s X-Ray”. If someone thinks that something’s broken on their body, I grab it, give it a good squeeze and a shake, and ask them if it hurts. If they say “Yea that hurts” it’s probably not fractured. If they say “YEeeeeEEaaargh!!!” it probably is.  

So, exactly how serious do you think I’m being with all of that above there? Here’s the test. If you took me serious enough that you want to call my medical director to tell him to pull my license… I was joking!! Ha Ha!

I remember probably the worst thing that I’ve ever said to a patient ever, and in all seriousness I still feel bad about this comment to this day. Early on in my career I worked as a Security Guard *slash* EMT at a big regional 400 bed hospital/trauma center/psyche center/everything center. Usually I worked alone on weekend nights and it was an absolute zoo. While this was one of the most enjoyable jobs I’ve ever held, I was in way over my head for an eighteen year-old country boy working in the big city. One day we had a patient come in who had been witnessed swallowing baggies full of what was presumed to be crack cocaine during a traffic stop. He was belligerent as all heck, swearing at us and trying to swing at the police officers who brought him in, the nurses, and myself. He looked at me and said “So what the (colorful word) is going to happen to me now you (something my mother would be unhappy with me if I typed on my blog, or even thought about for that matter)” I asked him “So, are you a religious man?” To which he replied “Blankety-Blank No!! You Blankety Blankin Blank blank!” I said back to him “Well you probably should be, because you’ll need to be saying some prayers”. Then he seized and went into V-Fib. I have no idea if he survived. I honestly feel really, really bad about that. I wish I hadn’t have said it.

So when you read this letter, go easy on the paramedic student who sent it in. She seems to feel pretty bad about saying what she said and since I’m going easy on her, you probably should too.

Here it is:

I did something colossally stupid today.   Something so… irresponsible and cocky that I truly can’t believe I allowed it to happen.

I allowed myself… to assume.

To assume that as a paramedic student I knew enough about a patient’s condition that I could safely make a statement to a family member, when in reality, I should have just kept my mouth shut.

It was careless. It was reckless, and it resulted in a family being given false hope.

He was brought into the ER by two of his daughters for a syncopal episode. He hadn’t been feeling well for a few days, and his daughters had been forcing him to eat. When they found him on the floor next to his bed writhing in pain, they loaded him up and drove him over to the local ER.

His VS upon arrival were… less than ideal. Hypoglycemic, hypothermic, hypotensive.   He had the hypo’s covered. His coloring was even less impressive than his vitals. A few amps of D50 and some warm blankets later and we had 2/3′s of the hypo’s resolved. He was no longer altered, he was flirting with the nurses, and the color had improved.

Still, his BP was crap. His tank was dry. He needed fluids, and after his third liter bag, his BP in the 60′s started to creep it’s way towards 70 and 75. I did a happy dance in my head.

Then it happened.

I was removing some of his blankets and replacing them with some that were straight from the warmer when daughter number 3 asked me a question. “His blood pressure is still so low, should we be worried?” Me. The only one in the room with them that had any medical experience.

Five sets of eyes were on me in an instant.

I finished tucking a piping hot blanket in and casually said something to the effect of, “His BP is coming up, he’s just a bit dehydrated. One more bag and I’d be willing to bet that his pressure is better than mine.”

Ugh. How could I let myself say something like that?

I didn’t know that he had a fractured hip.
I didn’t know he was in kidney failure.
I didn’t know he had a leaking AAA.

I didn’t know the complete picture, and I should have just kept my mouth shut.

I guess it goes without saying, but his blood pressure never came up. It dropped, and it dropped again, and it dropped again.

The family was informed of the complete picture. A DNR was signed. Hospice was called. He died before he could even make it to the inpatient hospice facility.

A family was given hope, because I gave it to them. And I had no right to do that. Watching them emerge from a family consultation room, one by one with blood shot eyes, holding each other when just two hours earlier they had been laughing and joking with their father…

That was probably the hardest lesson that I’ve learned in school. It’s one I’ll never forget, or forgive myself for.

——————————- 

So the student who wrote this letter expects to be flamed for it… I’m willing to bet that the response will be just the opposite. We’ve all been there. We’ll all be there again.

What about you?

Posted by on April 20, 2010 • Filed under: 911 fail, ambulance humor, Emergency Medical Services, EMS, EMS Humor, EMS Topics, Fire Rescue Topics, funny, humor, Paramedic, patient care, Patient Management, stories

Red Lights to the Left of them, Blue to the right! – Coloring Emergency Lighting

51 comments

So you’re driving down the road in an unfamiliar state, let’s say that it’s Iowa or Wisconsin, when in your rear-view mirror you see flashing red lights on a big utility truck coming your way. You can’t really make out what kind of truck it is, but you see red lights flashing so you pull over to let it go by. When it does, you realize that you’ve just pulled over for a tow-truck.

Or how’s this? The same thing happens, but it’s a flashing blue light in Colorado. When you pull over, you realize that you just got pulled over by a snow-plow.

I live in Illinois and work between IL and Wisconsin and there’s quite a bit of a difference between the different lighting colors and upon who can use what color light for what purpose. As a volunteer paramedic/Firefighter in Illinois I run a blue light with no siren in my personal vehicle. Even though I rarely turn it on, I have it in case I get stuck behind a 20mph Grandma on my way to the Big One. Interestingly, the blue light gives me no legal authority or any legal leeway on traffic laws and I must obey all traffic laws even while running the light. I Wisconsin, however, volunteer firefighters and EMS people may use red lights and sirens in their personal vehicles. They have the same legal status as governmental emergency vehicles when they’re driving with their lights activated.

In Iowa, volunteer firefighters may run blue lights in their personal vehicles with no legal authority granted them, and EMS volunteers may run clear (white) lights in their personal vehicles. Volunteers for fire and EMS combination agencies may run a mixture of both, however if a person volunteers for both a separate Fire department and a separate EMS agency, they must be careful to run the clear light for EMS responses and the Blue light for fire responses.

Of course, that’s just for personal vehicles right? Allowing emergency lights in the personal vehicles of emergency volunteers is a debatable issue in some circles. I argue for responsible control of their use and think that they are needed in some communities and not needed in others. Out of the 400-500 volunteer runs I respond to annually, I probably turn on my blue light for less than ten percent of the runs. I use it judiciously, but I know others that I can say did not.

However, this isn’t a post about volunteer emergency lighting and the pros and cons of it. It’s about the messed up spectrum of colors that we use on emergency vehicles in this country. Sure, we have the same stock colors pretty much everywhere. Red, blue, amber (yellow), green, clear (white), and in some states purple (Yes! Purple!). In the southern states, blue lights are for law-enforcement only and red is for fire only. In Wisconsin, law enforcement runs red and blue lights and fire and EMS is red only. In Iowa, up until a few years ago everyone ran red lights except for volunteer firefighters. They changed the law and now allow blue on the Passenger side only. In the City of Chicago, the Chicago Police Department runs blue only and the Fire department runs Red and Green. Downstate Illinois (Read: Outside of the City of Chicago City Limts) runs red and blue for all “Authorized Emergency Vehicles” and blue lights for the volunteers. Green lights are only permitted on stationary vehicles for command lights but can also be used for private security officers. As I mentioned before, in Iowa and Wisconsin, tow trucks run red lights. In Colorado, snow plows run blue. In some states, funeral processions run purple.

Confused?  I sure as heck am.

Consider this: Different lighting colors exist because different members of the driving public see different wavelengths of light in the spectrum (i.e. “Colors”) better or worse in differing ambient light conditions. Also, different colors penetrate different atmospheric and/or ambient light conditions better than others. You can see blue forever at night or in the fog, but not so much in the bright light. Red washes out to amber in the day light but is still fairly visible. Clear lights penetrate for a very long way but can be confused with light reflecting off of a surface almost the same as amber lights. We need a diverse spectrum of colors emanating from our response vehicles in order to ensure that the highest amount of drivers out there are able to see the lights. If someone’s color blind to the particular light color that we choose, they’re not going to see us all that well, are they?

The arguments that I hear for the use of lighting colors don’t hold much weight with me. Who cares if the public is able to see that an approaching emergency vehicle is Fire, EMS, Law Enforcement, ASPCA, Haz-Mat, Tech-Rescue, Volunteer, or miscellaneous. They just need to pull over and get out of the way. One color lighting schemes may give the agency a sense of personality or whatnot, but they’re certainly not the safest way to be seen. An emergency vehicle needs to throw out a lot of light across the spectrum of visible colors in order to help ensure the safest response possible.

So why are we having this hodgepodge of warning light colors? Why do people think they’re a good idea? I can think of a few advantages of having “law enforcement only” colors, as in reducing false traffic stops from people impersonating police officers, but having one color and one color only simply makes it easier for a criminal to get a hold of that one color of light. Why fire would only need red lights is a question that I can’t come up with a good reason for.

So good luck driving out there! If you see me, I’ll be on the side of the road letting a tow-truck go by. Then I’ll run my blue light in Wisconsin because we got a house fire in my district that touches the WI state line and I’ll get arrested for impersonating a police officer. Then I’ll be at work getting into a crash because someone driving out there was color blind to the color red.

Anyone want to add to the confusion? What colors do your state or country use? Is anybody else in favor of a national standard?

Posted by on April 7, 2010 • Filed under: 911 fail, accident, Administration & Leadership, Ambulance, Ambulance Driver, Ambulance maintenance, ckemtp rants, code-3, Command & Leadership, drive fast, Emergency Medical Services, EMS, EMS Health & Safety, EMS Management, EMS rant, EMS safety, EMS Topics, Fire Rescue Topics, In the Line of Duty, Iowa, Iowa EMS, lights and sirens, Line of Duty, Management, politics, Technology & Communications, technology-communications-ems-topics, Vehicle Operation & Ambulances, Vehicle Operations & Apparatus, volunteer fire department, volunteer firefighter

Advances in Prehospital Analgesia and Conscious Sedation

10 comments

Pain is endemic within Emergency Medical Services, whether it’s the pain from a grotesque traumatic injury, the chest pain from a heart attack, or the emotional pain suffered by the local teenage drama queen in response to a minor texting-while-driving incident. EMTs and Paramedics must become better at overall pain management and in conscious sedation. Luckily, there are researchers and pioneers working on new and innovative strategies for just that end.

Researchers at the Plover, WI Polytechnic Institute of Cosmetology and Cheese Making  (PPICCM) have been bringing some cutting edge research to the forefront of Prehospital Pain Management and Prehospital Conscious Sedation and have released some new technologies for use in the field. They have field tested these devices in the dive bars in and around Plover on Friday and Saturday nights and even once or twice on the infamous “TwoFer Tuesdays” down at MoeLarry’s Curly Fries and Cheese Bar. They have come up with compelling data that your agency should consider for your own use.

Tradtionally, EMS providers have had a few choices for use in prehospital analgesia and conscious sedation. Advanced providers and paramedics have injectable medications for use, and basic level providers and EMTs have basic splinting and positioning for use in controlling severe pain and the secret weapon for use in putting people to sleep. These medications, including Morphine, Fentanyl, Toradol, Aspirin, and sometimes Nitronox have proven to be very effective, but all of them carry with them side effects and the risk of allergic reactions that can prove fatal in some patients. So can the medications used in Drug Assisted or Rapid Sequence Intubation Techniques: Etomidate, Succynocholine, and the like. To reduce the risk of poor outcomes from these medications, the researchers at PPICCM have developed the following tools:

  • The Open Handed Slap – This is effective as a calming technique for persons who have become hysterical due to superficial trauma to their fingers as well as for family members overcome with emotion due to their loved-one’s bout of indigestion. An example is included below:

 

  • The Mallet Method of Anesthesia Induction – Pioneered by the indomitable Drs Moe, Larry, and Curly (and previously by Dr. Shemp), the use of mallets in induction of conscious sedation is well documented. Simple, yet elegant in it’s use, cranial contact by the fast-moving business end of a mallet is highly effective in reducing any complaints of pain from a patient. In fact, just the visual feedback recieved from opening the case the mallet is stored in and showing the patient that you are preparing to use said mallet is effective in reducing complaints from most alert patients. However, if needed for use, one or two blows in rapid succession is shown to be quite effective in the literature. An example is included below:

 

  • Transcutaneous Oxygen Therapy (TOT-WTYTR) - This method involves pressing the external wall of a “D” sized oxygen cylinder against a bony prominence of a patient in the throws of a violent reaction towards EMS providers. Use of TOT can be handled by both Basic and Advanced providers and it’s effects are determined by the speed and location of the bony prominence that the side wall of the oxygen cylinder is applied to. Lower extremities can be calming while the head and cranium can induce anesthesia and facilitate Rapid Sequence Intubation in most patients. Unfortunately, there is no accompanying video literature for this particular therapy, however it is a simple technique to learn.

Thanks to the brilliant scientists at the PPICCM, prehospital anesthesia and analgesia is in good hands. These simple yet powerful techniques are scheduled to be released for use by my agencies on April Fools Day and should NEVER EVER be used by yours. Ta’ Y’all. Happy Spring.

Posted by on April 1, 2010 • Filed under: 911 fail, Als, Ambulance, crisis, Emergency Medical Services, EMS, EMS Health & Safety, EMS Humor, EMS Topics, Fire Rescue Topics, funny, humor, Paramedic, paramedic education, Uncategorized

Saved by the Bell? High School Student EMS

61 comments

Ahhh, High School. The classes, the lockers, the bells, the peer pressure, the parties, the immaturity, the congestive heart failure, the overdoses, the emergent response, the…

Wait, what?

I’ve been hearing a lot recently about Emergency Medical Technician training being held in High Schools (9th – 12th grades) with teenage high school students being trained to be EMTs. At first blush, it actually seems like an innovative way for communities to meet the EMS staffing shortage problem head-on. In addition, it would seem to be a great way to get young people interested in EMS. In fact, THIS ARTICLE posted recently by Zoll EMS&Fire on their Facebook page seemed like a good idea to me at first. A county partnered with a technical high school in order to train new EMTs to swell the rosters of their county’s services. It’s gotta be a good idea? Right?

Then how about this service in Darien, CT. that is ENTIRELY STAFFED BY TEENAGERS AND HIGH SCHOOL STUDENTS? (Dept. Web Site)

Or this service, in Hoboken, NJ that has a student emergency response team that “respond(s) with the school nurse to non-emergency calls”? (additional article)

I have been hearing about such things for a while now and even spoke about it with Tiger Schmittendorf on the March edition of the Firefighter Netcast, however I didn’t give it very much thought until I read the “Last Word” section of JEMS Magazine in what I believe was the March 2010 issue (although I can’t find it anywhere on their web site www.jems.com). It talked about our friends in Darien Connecticut that run Post 53 EMS, a service that is staffed and ran almost entirely by high school students. I was a bit peeved after I read that. Then yesterday when I read the article about the service in Sussex County, I got just plain mad. I don’t agree with this at all. In fact, even though I might have been for it without thinking it through, now I am coming out completely against it.

There, I’ve said it. I am against beginning Emergency Medical Technician training in high school and I am most certainly against persons under the age of 18 staffing ambulances. I also must strongly condemn persons under the age of eighteen responding to emergencies, operating emergency vehicles, or taking responsibility for professional level patient care.

Look at the words there and understand just how much I condemn the actions of the politicians and officials that permit this. You are endangering the public, harming the profession of EMS, and creating a systemic negative impact on patient care throughout the system. You run the chance of increasing patient morbidity and mortality, run the risk of getting teenagers injured and/or killed on an emergency scene, and are exposing youth to situations that they cannot possibly be experienced enough to understand.

I am fully aware that the above paragraph is inflammatory and I am aware that the proponents of these situations are not going to like what I have said, but that doesn’t make it less true. Look for a minute beyond the arguments that you are going to make about the kids themselves, who I am sure are all upstanding young citizens who are surely beyond reproach. Look for a minute even beyond the fact that evaluation of the kids themselves must be taken on “a case by case basis” as I’ve heard before when this issue is argued. T o be certain, there are kids that are capable of functioning to the EMT-Basic level with proper, adult, professional supervision… However, I want to know why there is a perceived need?

The communities that support and offer these plans where students are trained to the EMT level and especially those communities where persons under the age of 18 are active emergency responders generally purport to be offering these plans in order to combat a “shortage” of trained emergency responders. This is where my biggest grievance lies. This “shortage” of which they speak is manufactured. It’s false, and it’s created by the very attitude that causes the local political powers to think that a program that provides a consistent stream of young, inexperienced, naive EMTs who are willing to work just for the “excitement”, “honor”, and “cool factor” that these programs seem to offer is a good idea. Here’s the thing, these communities don’t have a shortage of adult, professional EMTs who are willing to do the job. They have a shortage of adult, professional EMTs who are willing to work for peanuts in a system that has no respect for what they do.

Get it? If you have such little respect for EMS and the EMTs that provide it that you are comfortable letting teenage kids work your trucks, you obviously have such little respect for EMS that you provide horrible pay and working conditions to the point where no self-respecting adult can make a living on the wages and conditions you offer them. There’s no shortage of EMTs willing to provide excellent EMS. There’s a shortage of pay and professional respect that causes them not to be able to survive working the available jobs. Trust me, if these communities paid better and provided better jobs there would be no shortage of EMTs. It’s manufactured by their willingness to just have someone with a pulse and an EMT card on their trucks. It’s manufactured by their thought process that EMS is simply childs’ play and that since “any idiot can do it” they might as well put kids on the trucks. The EMT shortage has always been created by lack of pay, poor working conditions, and an unwillingness of local politicians to provide adequate amounts of these things. Creating high-school EMT programs reinforce this by always providing a stream of fresh meat willing to work for nothing. Young people don’t worry about such things as pay high enough to support a family, nor do they care so much about things like insurance, benefits, or retirement plans. They just want to get out there and go to work. 

I make the argument that putting inexperienced high-schoolers on ambulances increases morbidity and mortality using my experience as an experienced long time paramedic. I offer the full body of research that proves that experienced healthcare providers provide better healthcare than do inexperienced ones. The fact that there’s such little research out there does not diminish the fact that you have no such research that shows safety in what you do. I say that your communities would be better served by adult, professional, well compensated providers. I say that they would save more lives and reduce more suffering than do your high-school kids. It is well known that patients have better outcomes when they trust their healthcare provider and you ask your patients to put their trust in high school students. There are many possible scenarios out there where the patient’s very life and/or death rest upon the skilled interventions provided by an EMT. In these situations, even experienced providers make mistakes. You’re telling me that the incidence of these mistakes will not be unacceptably higher using teenagers?

When your Wife, Son, Husband, Daughter, or friend is lying there, dying on the floor, the roadway, or on the cot, will you feel comfortable with your decision to put a high school student at their side to be in charge of their continued comfortable survival? I make the charge that you will not. Your community members do not need a child coming to them in their hour of highest need. They need a professional, adult provider and your system denies them this.

I support EMS education in high schools. I support explorer programs that give firsthand experience and education to teenagers and younger students. I support CPR and First Aid Training at any age. I will support students coming to the EMS station, cleaning the trucks, taking classes with the crews, learning about EMS, and even staffing first-aid stations and special events under the watchful eye of an experienced adult provider. I do not support students responding in ambulances for the reasons I’ve stated above… but in closing I also offer this:

In one of the articles above, someone stated that these programs prepare students for a career in the emergency medical services. They might. However, by their very existence they prepare students for a career in a low-wage, low respect industry that might as well be provided by teenagers. These programs are a slap in the face to our profession. We will never advance when mindsets like these are allowed to propagate and flourish

Your thoughts?

Posted by on March 29, 2010 • Filed under: 911 fail, Administration & Leadership, ckemtp, ckemtp rants, Command & Leadership, edemse, Emergency Medical Services, EMS, ems education, EMS ethics, EMS Health & Safety, EMS Management, EMS rant, EMS Topics, EMS training, EMT, Ethics, everyday ems ethics, Fire Rescue Topics, Firefighter Safety & Health, medical ethics, politics, rant, Training & Development, volunteer fire department, volunteer firefighter

The Perfect Emergency? Well, almost

16 comments

So a while ago, I went to an emergency medical call that was about as perfect as an EMS call could be.

Picture this if you will. Our ambulance was in service. The system was at normal operating levels which are well funded and are adequate for our response loads 90% of the time. I had thoroughly checked and cleaned my ambulance and the equipment inside of it at the beginning of my shift and I had even gotten a chance to have a cup of coffee or two before the call came in. When the call did come out over the radio, it was merely a short walk to the ambulance for my paramedic partner and I. We climbed into our dual paramedic staffed, well maintained, state-of-the-art ambulance, and rolled out to the scene of the emergency which was about 8 blocks away through light traffic. We arrived within 4 minutes of the 911 call and were informed by our dispatcher that the residence was equipped with a “Knox Box” entry system so we could quickly gain entry. We retrieved the key from our ambulance, were able to open the Knox Box, and easily entered the residence using the key inside of it. While entering, we noticed that the resident had a “Vial of Life” sticker on the front door, which signified that the patient was most probably participating in our “Vial of Life” program, meaning that the patient had all of their medical information written down properly on one of our stock forms. In fact, we found the “Vial of Life” right in the refrigerator door, where it was supposed to be.  The patient, an elderly person, had used a (Non brand-name specific) home emergency call button to summon assistance, which we also had recommended to him/her during the public outreach that convinced her to have everything else in place for our arrival.

In short, this patient had done almost everything right. He/She had paid taxes throughout his/her long time living in the district and had supported us in order to allow us to have quality, state-of-the-art equipment. He/She had supported us so that we could get good training as well. He/She had listened to us when we suggested that He/She wear an emergency call button as he/she got up there in years, had written down his/her medical information in the “Vial of Life”, had put the Vial of Life in the correct place, and had even installed a Knox Box on the home so we could gain access quickly.

So what wasn’t right with this call? The patient had been experiencing symptoms consistent with a stroke. In fact, it was an easy diagnosis from across the room type of stroke. The patient had noticed that he/she was possibly having stroke-like symptoms and had decided that it would be best to get cleaned up, get dressed, clean up the house a little, and call a neighbor over to see if he would take him/her to the doctor’s office before the neighbor convinced the patient to press the button and call us out to help. By that time… well let’s hope the doctors can work some magic.

With all of the bloggers, paramedics, EMTs, and everyone else out there harping about “BS” 911 ambulance calls, one would find it easy to overlook cases like the one above. I for one will come right out and say that I will gladly run 100 nonsense EMS calls rather than miss just one of the above… I don’t want someone to die or suffer further morbidity simply because they were too scared, or polite, or timid to call an ambulance.

I don’t know how to fix the problem, I’d just like to remind you all out there that our job is indeed to take care of people when they’re scared, when they’re sick, and when they’re just plain-ol’ stupid. We’re healthcare providers and it’s our duty. No exceptions.

Remember that.

Posted by on February 22, 2010 • Filed under: 911 fail, Emergency Medical Services, EMS, EMS ethics, EMS Management, EMS system, EMS Topics, Ethics, everyday ems ethics, Fire Prevention & Education, Fire Rescue Topics, Paramedic, patient care, Patient Management, scenario, scenario based training

Fiddling While Rome Burns – The “Ambulance Industry”

14 comments

Allow me if you will to allude to some Roman history here. I know that it’s a little heavy for an EMS blog but if you would please search the dusty recesses of your memories to think of the Roman Emperor Nero, it would help this post. You know, the one who “fiddled while Rome burned”

I am way oversimplifying this, but the way that I remember the story was that Rome was being swept by the “Great Fire of Rome” that burned for days and decimated the city. Popular legend has it that Nero, unconcerned with the plight of his citizenry, played the fiddle while the city was burning.

 (Although, the MOST TRUSTWORTHY SITE ON THE INTERNET *Other than Mine* has this on the subject: http://en.wikipedia.org/wiki/Great_Fire_of_Rome)

Recent events and some things that I’ve been reading lately have brought some EMS issues to light in my mind, and thoughts about good ol’ Nero have popped into my head.

Are we Fiddling while Rome Burns?

There’s a few competing EMS system design models out there that have various people in their camps. Mention the virtues of one over another and you will get passionate and snarky responses from the various members of these camps. Trash Fire Based EMS and you’ll get a ton of people that will take a break from lifting weights and will bombard you with reasons while Fire Based EMS is awesome while wearing their T-Shirts emblazoned with “FIRE RULES!!”. Mention that 3rd service and not-for-profit EMS may have their downfalls and the EMS Chess Club will bring forth obscure research that shows how much better they are for the patients than everyone else is. Trash Private-for-profit EMS and um, the employees thereof will trash it right along with you and their management will be too busy putting out fires to care.

Try as you might to convince me that one is better than the other and I’ll agree with you on some points and disagree with you on others. I will only endorse what I call “EMS based EMS”, which is EMS provided by truly dedicated caregivers who base their decisions and actions simply upon what is best for their patients and their communities. I have my beef with fire based services that place protecting firefighter jobs and the “fun” stuff involving spraying water on things that happen to be on fire over solid patient care. I have my beef with private-for-profit services that always default to the bottom line, and admittedly, I have a bias towards third service and not-for-profit EMS agencies. However, no one system has ever proven to be a good fit for every community, none are inherently evil, and other professions find their fit within lots of configurations.

If the system design models out there are really locked into a competition for the soul of EMS then they’ve all got a lot of work to do. In this piece, I’m going to ignore patient outcomes, efficient use of tax money, and all of the stuff that I usually talk about… and focus on one thing and one thing only.

The way EMS people are treated by the competing systems will probably decide this debate we’ve got going on here. The model that treats the paramedics the best will win and will take over the industry. Why wouldn’t it? What paramedic with half of a brain would continue to work in a service model that didn’t pay and treat them the best?

Here in Northern Illinois, there are very few options for a paramedic that doesn’t want to do Fire Based EMS for one reason or another. The few options that there are don’t pay nearly as well as the fire-based groups and this creates an endless revolving door of young paramedics entering the system, working the “privates” for a while, while trying to get a “real job” with a fire department. The private services suffer for it, and the fire based services reap the benefits while fostering a system that (gulp, here it comes) focuses less on the healthcare and more on the fun stuff.

So I challenge the private, third-service, and not-for-profit services out there with my next statement.

You’re fiddling while Rome burns.

If you aren’t out there doing your absolute damndest to treat your employees well and pay them what they deserve, you’re failing. You push your employees away. You push the best and brightest into other professions and into fire-based EMS which hands down has the best pay and benefit structure. Your lack of interest in caring for your caregivers is killing our profession. You fiddle whilst complaining about decreased reimbursements and failing to do anything about it. You fiddle whilst focusing on minutia like stupid rules and regulations that degrade the dignity of the adults who work for you. You fiddle while worrying about protecting your jurisdictional boundaries and contracts while they’re eroded away by the constant stream of departing employees.

Nero could have been an ambulance manager in some of the services I’ve been to, worked for, and observed from the outside. Could he be you?

You have got to find a way to pay your people better. I don’t know exactly how it’s going to happen either, but it has to be priority #1 for every ambulance manager out there. Trust me, if you don’t do it you will find that your capital city has burned to the ground. You will lose your empire and it will not come back. If you aren’t out there doing every possible thing you can to keep your employees as happy as you can get them, you’re fiddling, and you’re failing our profession.

This blog has a lot of content on it that explores new revenue sources for ambulance organizations already. Coming soon: Ways for each individual EMS professional to take control of our own income potential, own our profession, and improve our care to our patients. I’ve said it before and I’ll say it again folks, hang on cuz it’s going to get fun.

Posted by on January 6, 2010 • Filed under: 911 fail, Administration & Leadership, change, ckemtp rants, Command & Leadership, Economics, Emergency Medical Services, EMS, ems 2.0, EMS Health & Safety, EMS Management, EMS paramedics, EMS pay sucks, EMS rant, ems salary, EMS Topics, Funding & Staffing, Management, Paramedic, paramedic salary, politics, profession

EMS Pay Sucks!! Part 2 – Identifying the problem

33 comments

Welcome back to the “Life Under the Lights Bar and Grille”, your local dive bar filled with lousy food, tepid beer, bad ambiance, and great friends. Like any local Midwestern dive bar, it’s a come-as-you-are-and-sit-on-down-and-hang-with-your-buds kinda place. A conversation has broken out on the topic of “EMS Pay Sucks!! Let’s DO something about it!!” and me, your local blogger has decided to write a series of posts explaining the issues as I see them.

 So, if you haven’t been here to read the last two, I suggest you go back and read them before you read this. If you don’t, well then that’s your choice. It’s a pretty informal place we have here.

 Part 1: “EMS Pay Sucks!! Let’s DO something about it!!”

Part 2: “EMS Pay Sucks!! (Part 2) – Identifying the Problem (you’re here)

Part 3: “EMS Pay Sucks!! (Part 3) – Who or what is at fault here?

———————

The way our country compensates its EMS personnel is an abomination. It’s almost criminal, it’s inhumane, and it’s just plain wrong. Paramedics and EMTs do not deserve to live at, near, or below the poverty line simply because they chose to make a career out of helping others. We do not deserve the shame of being struggling from paycheck to paycheck. We do not deserve the hardships of trying to raise a family and continuously have to explain to them just why it is we have to work so many hours and have such little in our paychecks to show for it.

I know that EMS compensation is frankly despicable… but you don’t have to take my word for it. There is a lot written on the subject that comes from some very credible sources. Some examples:

Favorite Quote (but the read the link to get even angrier):

“Paramedics

What they do: Paramedics respond to emergency situations and attempt to provide the necessary medical care, whether it involves transporting participants to a hospital or treating them on the scene.

Surprising salary: $27,070. Seeing as paramedics have high stress jobs that require them to be on call and ready to save lives at a moment’s notice, you might expect their mean annual salary to be higher.”

”Other workers in occupations that require quick and level-headed reactions to life-or-death situations are:

All those links work, by the way. Here’s a little pre-test question for you: Of those “occupations” listed above, which one is markedly the lowest paid??

I’ve been in full-time EMS for over ten years and currently work two-full time paramedic jobs. Not only do I feel the low wages, awful benefits, and long hours personally, but I also see what my coworkers go through with their lives and their families. What does one do when their calling is something so vital to the community, yet is so unappreciated financially that it hurts their families and their future?

In my travels throughout the nation I have had the chance to seek out and speak with EMS people in a lot of localities. I tend to visit odd places and I make it a point to seek out and get into conversations with interesting strangers. Luckily, all of the EMS people I know seem to fit the description of being “interesting”. I’ve heard them speak of the same problems that I’ve experienced. I’ve seen the pain and embarrassment in their eyes as they describe their love for the job and try to downplay the fact that they’re struggling financially. I’ve heard the same stories almost every time I’ve spoken with them. When they were young and new to the profession the long hours and low wages didn’t matter all that much to them… However, once they spend about five to ten years working the box they tend to experience the same struggles that I have. Spouses and Children don’t like it when the EMS person continues to work 100 hours a week to earn a paycheck that only comes close to covering the bills. They don’t like not having any disposable income. They don’t like the 24/7 demands of the job too much either. These facts rear their ugly heads when the EMS provider reaches a certain point in their life, and a career in EMS gets harder and harder to justify. Ever wonder why you don’t see many EMS professionals that have been continuously working full-time EMS for more than ten or so years? It’s for this reason. Sure there are a lot of exceptions, but I would think that the statistical clustering would bear this out. Eighteen-to-twenty year olds enter the profession, become family people around five-to-ten years later, and realize that the hours and the money they get for those hours are killing their family life… then they get other jobs, or stay in EMS and become very bitter about it.

So if I were to be asked to identify the problem using words that everyone could understand, I’d say this:

“The public is counting on the people in Emergency Medical Services to protect the lives of themselves and their loved ones. They then turn around and compensate them for this task at about the level they compensate fry cooks. They demand that there is a paramedic or EMT immediately available to them at all times to help them when the unthinkable happens, but they aren’t willing to pay them more than they do their bartender or waitress. People need advanced care immediately available to them in order to maintain the quality and presence of their lives after an emergency, and they need highly trained, experienced, and dedicated people to provide that care, but all that care seems to be worth to them is poverty-level income. What is wrong with our priorities?”

What is wrong with our priorities indeed.

I think that the above information is enough to identify that I think there is indeed a problem here. It’s an almost overwhelmingly complex problem as well. However, if it were an easy problem to fix, it would have been fixed by now. Fixing this has become mandatory for me, as it is mandatory for all of you. I’m writing this to contribute to the solutions that we’ll have to put into place, and by participating in this, you’ll be too. Over the next few days, I’ll be posting parts in this series, because I don’t think that one post will provide as many angles as I feel I need to.

One thing I do know, we’re going to act on what I put out here and on what you add to the discussion in the comments section and in your daily lives. We can no longer hope someone else will act. I ask every person who reads this to participate for our own well-being and the improvement of our profession. We’re not going to agree on everything, but “perfection is the enemy of the Good Enough”. Complete consensus is not necessary, action for our collective professional well-being is.

Coming tomorrow: EMS Pay Sucks!! Part 3 – Who or what is at fault here?

Posted by on December 29, 2009 • Filed under: 911 fail, Administration & Leadership, change, ckemtp rants, Economics, Emergency Medical Services, EMS, ems 2.0, EMS Health & Safety, EMS Management, EMS pay sucks, EMS rant, ems salary, EMS Topics, Funding & Staffing, Paramedic, paramedic salary, politics, salary

Swinging a Sledgehammer and Thinking about the UK… Strange times

10 comments

So here’s the good news. The ambulance service I work for up North, “Ambo’s R’ us” has finally taken the leap and is getting us a new station. Yep, that’s right folks. I will no longer be living in squalor whilst working up here in the vast frozen wastelands.

Except for one little hitch in the gittyup.

In big ambulance services, when one gets a new station, usually the service employs people to work on the station, build and/or remodel the station, and move the stuff from the old location to the new one. Not so in a small, rural ambulance service. Nooooo…. Here, a paramedic is expected not only to work on the ambulance during their shift, they’re also expected to put on their tradesman hat and get their hands dirty.

So, yep… today Ckemtp was not *just* a paramedic. Today yours truly was a demolition man, a moving man, a wall-paper remover, and a carpenter’s apprentice. All of my crew mates were today too, as were the crews yesterday, and so will be the crews who are unlucky enough to come work ambulance shift any time in the next couple of weeks.

But here’s my mea culpa confession folks: I’m not handy.

There, I said it. I am so not handy that hardware stores actually have my picture up on their walls stating that I must ask for staff permission to enter their premises. Apparently they want someone to follow me around with a fire extinguisher because there’s a concern that I might come into contact with a carriage bolt or something and the resulting sparks will start a fire. I, like most of my colleagues, became paramedics because we’re generally not handy enough to get a good paying job in the construction and/or “real job” industry.

What’s that you say? You’re a full-time paramedic/EMT and you own/work/watch a construction business on the side? Well good for you. I don’t. I write stuff about stuff and ride ambos.

The dreaded “other duties as assigned” clause in my job description is being stretched so thin here that you can hear it singin’ in the wind. I didn’t sign up for this. It’s actually very hazardous to my health and well being for me to be doing anything remotely construction or “handyman” related.

There’s a lot of reasons why, the risk of fire, explosion, and/or structural collapse being amongst them… but they’re not the real reasons that I’m so worried about this. You see, I have a lovely wife named Gkemtp(it) who is the absolute light of my life. However, together we own a home which happens to be the scourge of my existence. Like EVERY guy who owns a home, my home is full of things that are disintegrating at an alarming rate. There’s ALWAYS something that needs fixing and they rarely respond to an IV, o2, and monitor. Heck, even my clock radio didn’t do well with defibrillation. I can’t give my clothes dryer Epinephrine to get it started again, my clogged drain didn’t respond to a heparin bolus, and my leaky faucet leaked right through an occlusive dressing. I just don’t understand my home and its malfunctions the way I understand humans and their maladies. It’s awful.

So my wife knows that I am the opposite of the handyman… and she’s pretty ok with it, lest she nag and have me end up breaking something much, much worse than it was before I tried to fix it. I *like* that she’s ok with it… And I don’t need her to think that I came to work, built us a shiny new ambo station, and learned how to be Bob Vila with an NREMT-P patch. It’s bad enough that I clean toilets, vacuum, and do dishes here at work. If she found that out, she might make me do more of that at home.

So I’m stuck here. I’m destined to make anything I fix much worse than it was before, I’m destined to demolish something I’m not supposed to demolish, and I’m destined to make an egregious wiring error that’s going to burn the place down while I’m sleeping inside of it and I won’t even get to go to the fire because I’m on ambulance detail!

Maybe I should move to the UK and work with my good buddy Mark Glencourse, of Medic999 fame. One of the biggest things I took from the Chronicles of EMS, his and Justin Schorr’s (The Happy Medic) foray into cross-national EMS exchange (Soon to be an AWESOME TV show!!) is that UK firefighters DON’T CLEAN THEIR OWN STATION! Yes. They FREAKING HAVE CLEANING CREWS THAT COME IN AND CLEAN UP ALL BUT THE MOST SUPERFICIAL MESSES! Hell, they even have a bona-fide chef to cook for them.

And here I am, scrubbing toilets and swingin’ a sledge hammer here in the ‘States.

So, I’ll keep toiling until I break something so bad that they make me go post somewhere where I can’t hurt myself, and Mark will keep living in the lap of luxury.

Maybe being a Limey isn’t so bad.

Posted by on December 20, 2009 • Filed under: 911 fail, appreciation, ckemtp, ckemtp rants, EMS Health & Safety, EMS Humor, EMS pep talk, EMS rant, EMS Topics, Fire Rescue Topics, grumblemedics, humor, Line of Duty, medicblog999, UK paramedics, united kingdom, Your Happy Medic

Guest Post – An Open Letter to Wisconsin Physicians Concerning Do-Not-Resucitate Orders

32 comments

This is a guest post written by a local paramedic that has an important message to get out about Physician involvement with Do-Not-Resuscitate (DNR) Orders. I’ve included it in its entirety. It’s an important issue. It takes such an emotional toll on the EMS providers and the families of our patients. Please share this with your colleagues and loved ones.

———————————————————–

An open letter to the Physicians of Wisconsin:

“Medic 1, Engine 7 respond to 123 Anystreet for a male unresponsive. Time out 21:19.” 

This simple statement spoken by a dispatcher starts a series of events that will place an EMS crew in a moral dilemma, a family in a confused and angry state, and a personal physician sitting at home, unaffected.  As the responding EMTs and Paramedics enter the home in response to this call, they see an elderly female cradling an elderly male in her arms. She is sobbing and distraught.  The elderly female holds in her hands the lifeless body of her life long partner and soul mate who seems to have finally given up his long suffering in this world.  The lead EMT quickly approaches the patient and finds that the patient is in cardiac arrest.  The female states that she always knew that he would die in her arms.  She states how long and difficult these last months have been with his terminal illness creeping into their lives and stealing her husband away.  The Lead EMT asks if the patient has a DNR (Do Not Resuscitate) order. The wife states that he does.  A quick check of wrists and ankles does not produce the state approved DNR bracelet.  The EMT’s crew stares at Lead EMT looking for direction.  They know that unless there is a valid DNR bracelet on his wrist they must start CPR and perform life saving measures.  The Lead EMT knows that the clock is quickly winding down, they must act soon.  She asks the spouse again about the DNR and where it might be in the house.  The spouse states that there is a copy of the DNR at the hospital.  She states that she filled it out at the months ago at the doctor’s office.  The spouse says, “I never got a bracelet.  The doctor knows that he didn’t want anything does, can’t you call him?”

Meanwhile, a county away, a physician sits at his desk, dictating the notes of the day.  He is completely unaware of the drama that is unfolding in the darkness of night and the darkness that is enveloping one spouse’s life.  This physician has practiced medicine for years, graduating medical school in the early 1960’s.  He has been kind, caring, and concerned for every patient he has seen and is highly regarded within the medical community.  When he first started in medicine, ambulances were simply Cadillac station wagons that whisked through the night.  They moved the sick and injured from point to point without offering much more than a fast ride.  Over the decades the rules changed, medical advances occurred, and now an ambulance is a rolling emergency department with full advanced life support abilities.  Unfortunately, unless a physician takes an interest in EMS this change has occurred without notice.

The lead EMT removes the patient from his spouse’s arms.  They move him to the floor and start CPR.  The crew has no choice, they have no valid DNR order and they have been summoned by a 911 call from the spouse.  The spouse screams at and pleads with the crew to stop, she doesn’t understand why this is happening.  Her husband has filled out papers; they have them on file at the hospital.  She thought this wouldn’t happen.  The spouse watches as I.V.’s are started, defibrillator pads applied, and an endotracheal tube is placed into the airway of her spouse.  The spouse is now frantic.  This was never supposed to happen.  Why aren’t the EMT listening to her? She knows what her husband wanted, they were together for over 50 years.  Medications are now being given and the EMS crew is trying to coax a pulse out of a tired heart.  The crew shoots looks at each other questioning what is right and wrong.

The lack of a DNR order puts EMS crews in a terrible moral and ethical dilemma.  They must proceed as the law states; but their hearts are heavy and they are unsure if they are truly doing the best for the patient or the family.  They sat in on the trainings years ago about the DNR bracelet.  The instructors said it would eliminate these situations, patients would speak to their personal physicians, sign all the necessary forms, and then the patient would be issued a DNR bracelet that would clearly state the patient’s wishes.  Yet time and time again, this scenario repeats itself and each time the frustration grows.

After 45 minutes of CPR and three rounds of ACLS medication, medical control is contacted.  The ED physician is advised of the situation and advises the crew to terminate all efforts.  The crew cleans up and a mournful wife sits by her husband’s side again, holding his hand.  This is where she wanted to be all along, just holding his hand and looking for support in this darkest time in her life.  Instead, she had to witness the brutality of a full ACLS code.  The ribs breaking, the I.V.’s being placed, the monitor screaming out orders in its electronic voice.   The peaceful, honorable death she had hoped for has been taken from her, she will now have the visions of CPR and strangers doing procedures to her husband that neither of them ever wanted.  These are events that we can never go back in time and change.

Our physician is now walking to his car.  Rattling through his pocket looking for keys that he can’t seem to find.  He will receive a call later tonight from the county coroner explaining what has happened.  He will be honestly horrified to hear of the efforts by the EMS unit and will wonder why this has happened.  Ironically, he doesn’t know that he set these events in motion years ago by not securing a DNR order for his patient that EMS crews are able to honor.

“Medic 1 and Engine 7 are clear, no transport, coroner on scene.”  This will be another long ride back to the fire house.  Emotions are running high, the crew is upset.  They can’t figure what is making them angrier, the fact that this happened or the fact they know it will happen again.  The cycle continues.

I would ask that each primary care physician look into the laws as they apply to DNR orders and EMS providers in the State of Wisconsin.  We do not have the luxury of time.  We must make decisions within seconds.  We NEED the DNR bracelet.  All we need to know is “yes or no” to CPR.  We have NO time to read through long winded orders or other legal documents.  This is a problem that we must fix and fix fast. You have the power to fix this. Please do so.

Respectfully,

Todd A. Bluhm, Paramedic

Posted by on December 3, 2009 • Filed under: 911 fail, cpr, cpr fail, crisis, DNR, Do Not Resuscitate Order, Emergency Medical Services, emotions, EMS, ems 2.0, EMS ethics, EMS rant, EMS Topics, EMT, EMT-Intermediate, EMT-Paramedic Specialist, Fire Rescue Topics, medical ethics, Paramedic, patient care, Patient Management, physician, professionalism, rant, southern wisconsin

Dear State of Illinois EMS…

16 comments

State of Illinois EMS… It’s time that you and I had a little talk. You see, I’m an EMT-Paramedic holding licensure in your fair state. I’m also a mostly life long resident except for a short, torrid affair with residency in the State of Iowa. I moved back, you welcomed me back with your open arms and I’ve been here ever since.

Except for now, State of Illinois EMS, while your EMT-Paramedic licensure will always be the first card I carry… I’ve been flirting with other states. Yes… it’s true. I have my licensure in Iowa as a Paramedic Specialist, and my Paramedic card from Wisconsin too. I don’t want to hurt your feelings, State of Illinois EMS but frankly their paramedicine is more exciting than yours is. Yes, State of Illinois EMS… the magic just seems to have gone out of our relationship. I can do so much more in the other states. They UNDERSTAND me and my need to take care of my patients to the best of my ability. They’ve given me exciting advanced techniques, medications, protocols, training and technology that enables me to breathe new life into my practice. They let me LIVE, State of Illinois EMS! They help my patients to live longer, fuller lives.

And now, State of Illinois EMS, this conversation comes on to the prospect of what we should do about our relationship.

Yes it’s been a torrid love affair, State of Illinois EMS. Really it has. Unfortunately, I’ve changed. It’s not you… it’s me.

Literally. It’s like you haven’t changed in ten years. What’s up with that? Medicine’s changed. Techniques and research have changed. Evidence based EMS practice has changed… but, State of Illinois EMS… you haven’t hardly changed a bit. You’re not a national state, your CE requirements are strange, your license hasn’t gotten easy reciprocity anywhere I’ve tried, and your policies are dictated by the ‘Little Kingdoms’ that you call EMS systems and EMS regions, and well… it’s just not working for me anymore.

I’m not leaving you, State of Illinois EMS. I wouldn’t, you mean too much to me and a good chunk of my income is dependent on that little green card I carry with your picture on it. Remember when you gave me that card, State of Illinois EMS? It seems like just yesterday… but it was a while ago I guess. We’ve been together a long time, haven’t we? I think that our relationship is worth salvaging, don’t you?

Here’s what I think we should do, State of Illinois EMS: Let’s work together on a plan that I’ve come up with. It’s a plan that I think will help fix everything that is wrong with our relationship. I think that the way you’re all set up, the way you’ve parceled yourself into EMS regions and the Little Kingdoms that you call “EMS Systems” has given too much control to local politics and individual egos without enough accountability. I think that the EMTs and Paramedics that work within these EMS systems, you know the ones working for actual EMS agencies, are actually “customers” of these EMS systems. Only these EMS systems seem to treat the EMTs and Paramedics like “Bothersome Bastard Stepchildren”  instead of the customers they are and don’t give them any support or service.

Yes, I know that not all of these Little Kingdoms that you call EMS systems function like this, State of Illinois EMS… some actually treat their EMTs and Paramedics like (gasp) People. However, in my decade or so of toiling in these Little Kingdoms, State of Illinois EMS, I’ve seen that to be the exception and not the rule.

So here’s what I propose to you, State of Illinois EMS. I propose that we inject these three things into the whole system: Information, Competition, and Accountability.

Yep, I think that we will both benefit by adding healthy dashes of those three items into our relationship. I’ll explain:

  • Information: I want to put every little policy, procedure, and standing medical order from every EMS system in Illinois on the interwebs. I want every form, personnel roster, and individual quirk of every Little Kingdom in the land to be posted up for scrutiny by every individual EMS provider and provider agency in the state and elsewhere. If they do something, I want everyone to know how and why they do it.
  • Competition: When EMS systems compete, we win. Really, if your hardware store sells your widgets for cheaper than the store across the street, you’ll get more business. If they lower their prices to match yours but your service is better, you still get the business. If their service is just as good but your widgets are of better quality, you still get the business. They have to improve their service, quality, and price just as consistently as you do. It’s called competition and it’s healthy in any food chain or market. Right now as things stand, there’s barely any competition in the EMS systems in the state. EMS provider agencies stay within their systems usually no matter what the conditions are and only rarely change. It’s difficult for new and better ideas to flourish in the current system. It’s also hard for the EMTs and paramedics working under the systems to get any kind of service. Remember, I think that the EMTs, paramedics, and EMS provider agencies are customers of the EMS systems. Now they kneel… with competition and information, they can vote with their feet. EMS systems will be forced to improve or wither and die. The cream will rise to the top, the others… well they may be floaters or sinkers if you know what I mean.
  • Accountability: Are EMS systems accountable to anyone? I mean, if there are complaints against them, to whom are the complaints addressed? If the paramedics and EMTs working under the system are treated like diseased cattle and they are unhappy mooing and coughing like that, whom do they complain to… their EMS provider agencies that don’t want to switch systems due to the immense amount of effort for no real perceived benefit? We need to make them accountable not only to competition, but accountable to a public airing of grievances and peer evaluation.

So there you have it, State of Illinois EMS. Three little words that I’ve come up with that I think will fix our long-term relationship. Sure, I’ll probably keep dabbling in the other states… but I feel entitled to because I know that I’m not your only one either. We can tell people that we have an “arrangement”.

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Look, Illinois EMS could use some repairs. Not every EMS system behaves badly or treats their members poorly, and that’s just it. Those systems should be encouraged to flourish and expand. I don’t think that one blog, one blogger, or one paramedic can disband the Illinois practice of creating EMS systems… but I do think that there should be competition and accountability injected into the system.

So, could we do that?

If there’s any fellow Illinois EMS people out there reading this, feel free to interject. I’d love to get a conversation going on this. Grassroots activism to change EMS from the professional level up? Wow, that’s way EMS 2.0

Posted by on October 28, 2009 • Filed under: 911 fail, Administration & Leadership, change, ckemtp rants, Command & Leadership, crisis, edemse, Emergency Medical Services, EMS, ems 2.0, EMS ethics, EMS Management, EMS protocols, EMS system, EMS Topics, idph, illinois, Iowa, Iowa EMS, new perspective, northern illinois, Protocol development, southern wisconsin, wisconsin

Someone Failed… Is it the System? Everyday EMS Ethics

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A tempestuous night is blowing outside the station walls. The cold night air is stirred wildly, blowing splatterings of rain against the glass window of my bedroom. The wind howls through the trees conjuring up fantastic images of the disturbed environs of the world outside my bunk room. Having gone to bed early, I cannot remember the dreams I must have been having but judging from the fact that my sheets were in such disarray when I awoke, they must have not been pleasant.

I awoke to a familiar but unwelcome voice, the night shift dispatcher coming from my radio. He spoke of a seizure in the next town over. The local ambulance service from that jurisdiction was calling for a paramedic to intercept and assist them with their call. I was due, it was my turn to be ripped from the warmth of my bed and respond to their aid.

I pulled on my clothes and zipped up my shoes. Since whomever controls the seasons in my area has decided to outright skip Fall and move straight to Winter I pulled on a jacket as well. Stepping out into the night air I halfway expected there to be a late September frost on the ground. As I started my truck and keyed the address into my GPS I cranked up the heat to stop my shivering. Hopefully this wouldn’t be too challenging for me in my sleep deprived, freshly woken up state. Hopefully I can wake up enough to safely drive. I shook my head violently to clear the sleep from my bleary eyes and keyed up the mic:

“Dispatch, Medic 84 is enroute to intercept Anytown”

The night shift dispatcher answered me and I switched to Anytown’s frequency:

“Anytown, Medic 84 is enroute to your scene”

With the red lights flashing over my SUV I pointed out into the deserted city streets. Anytown was about ten miles away from my station over country roads. The address was a few miles into their city limits. Curiously, the address they called me to was just a few short minutes from Anytown Hospital and it was strange that the EMT-Intermediate volunteer service had called me to an address where they would usually just scoop and run ILS to the ER. I figured that this must be one of those “Seizures” where the patient seized because of the fact that their heart stopped. People will oftentimes have a seizure when their heart does something funky, like stop, and blood flow is slowed or stopped to their brain. An old paramedic instructor I had once put it this way “Brains need blood flow to be happy, stop the blood even for a second, and the brain gets pissed off”. Everything seemed to get pissed off to that guy. An MI causing arrythmia was a “Pissed off heart”. Diabetes was a pissed off pancreas. A drunk at the bar was pissed off at his liver and so forth.

I wondered what this patient had that was pissed off for her.

The roads were open but the night was pitch black. The wind was blowing my small SUV in all directions but straight. Thinking that this was probably a bad call, I pushed the gas as hard as I felt was prudent with the driving conditions. I didn’t meet any traffic to get in my way. Just as I was coming into their town, a familiar voice crackled over Anytown EMS’s frequency:

“Medic 84. We still need you to respond but you can slow it down to non-emergent. We’re short an “I” and it’s going to be you”.

Ohhhh, so they couldn’t staff the truck fully and responded using me to make their full crew. Now I understood. Anytown EMS is a good service with dedicated people, but sometimes even the best volunteer service needs a hand. That’s what mutual aid is for. We have an arrangement with them in such circumstances so that our intercepting paramedic can make up a full crew for them by partnering with one of their EMTs.

I turned off the lights and just cruised silently through their deserted town. Yes, I popped the lights on momentarily to get through a couple of stop lights, but who’s counting, right? Arriving on their scene the EMT came out to me and said:

“You don’t need to bring anything. This is her third ambulance ride in 24 hours. She spilled a glass of water and (a family member) called because she thought she was “having a seizure” and needed to go back to the hospital”

Oh, now I remember this address. I don’t even work for this town and I’ve been here like umpteen times this year. The patient is one of their frequent fliers. Every community has them. I swear, without our frequent fliers we’d be short like a thousand annual calls. Think of the sleep time I could get.

Climbing up into the ambulance, I met the patient for the umpteenth time this year. She was in no distress and this is where her part in the story ends. My question isn’t about her. Honestly, the question here could be about any frequent flier in any community that has an ambulance response.

Why do we have them? Why do they depend on us so much?

The patient in this example had been to the ER twice already in the previous twenty four hour period, both times being transported by EMS and both times being taken home in a private car by family. Both previous times she had called her General Practitioner physician and had been referred to the ER because she said the word “seizure”. I can hardly blame the GP for recommending she call 911 rather than phone triaging her and suggesting she come into the office. But remember, it’s not about her. I can think of probably ten patients right now that I would consider to be among my personal roster of repetitive patients (I only have ten fingers) and their use of the emergency healthcare system for management of their chronic complaints is staggering in comparison to the use of it by the general population. Last year, every shift for two months we would respond to the same gentleman’s house to wake him up by popping in an IV line and giving him some D-50. We got pretty tired of it, as you can imagine. Most people with diabetes manage their illness pretty well and only occasionally need the assistance of an ambulance crew. This guy chose to manage it by drinking hard alcohol. I swear that I wanted to just leave the IV in place so that I wouldn’t have to start one the next day.
We fixed it by refusing to treat him on scene and release him anymore. It is common practice in my area to “sweeten up” a comatose diabetic with low blood sugar by popping in an IV and giving IV sugar (D-50), or in milder cases, by giving them high-sugar foods and making them eat until they regain full mental faculties. Once they regain their senses, all but a few of these patients sign a refusal of treatment form and do not wish transport to the ER. However, for this patient, we would find him unresponsive, so we would pack him up, move him into the ambulance, start the line and sugar him up while enroute to the ER. Once we were transporting, he couldn’t refuse to go and would end up at the ER for hours. Finally, he started managing his diabetes better because it was more convenient than waiting at the busy, urban ER we would take him to (yes, it was the closest. I work in many different jurisdictions).

However, the above solution just passed our problem we were having with the ambulance response onto the already overburdened Emergency Room. Yes, it “solved” the problem by increasing the patient’s level of personal inconvenience (although we still go to this guy about once or twice a month), but at what cost?
Who or what is causing the failure for these people? Who or what is causing the failure for this whole patient population? Is it the system that fails to adequately educate them on how to properly care for themselves or cure their ailment? Or is it the patient who is unwilling, or incapable of caring for themselves?

For both of the above named patients, socialized medicine already exists for them. They’re wards of the state as far as healthcare is concerned. One of them owns a house, one of them is in a free, government subsidized apartment, one
is in one state, the other is in another. You and I pay for their healthcare and almost their every need.

Is this the system’s fault? Is it their fault? Who should pay for the failure?

I’m writing this after coming back into my bunkroom and finding my sheets and blankets twisted into a ball. Everyone else in the house is snoring because of the abrupt weather change. (and DDex, if you read this YOU FREAKING SNORE WORSE THAN NACHO!) Whatever dreams I was having before this call came out must have been strange.

Until the next…

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Update:

My blogger buddies Happy Medic and Medic999 took off from this post and wrote their point of view on their respective blogs. Here they are. Join the discussion.

Posted by on September 29, 2009 • Filed under: 911 fail, ALS Intercept, Ambulance, edemse, emotions, EMS, EMS ethics, medical ethics, Paramedic, politics, socialized medicine, universal healthcare

CPR Fail – Shout out to Ambulancedriverfiles

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http://ambulancedriverfiles.blogspot.com/2009/06/cpr-u-r-doing-it-rong.html

Kelly, over at Ambulancedriverfiles, has an interesting post. Like me, he uses Sitemeter to trak how many hits he gets, how those hits get to his site, and even the search terms in google that get people to him.

He got the one that you saw up there. Look at the Google search words.

OMFG is all I can say. That’s a 911 awareness fail if I ever say one. Wow. I have written about how PR saves lives a lot. I strongly believe that the more we get the word out on how to properly use 911 (or 999 for you Limeys – HA! Limeys) the more lives will be saved.

So let his post be a rallying cry for you all to get out there and promote the proper use of 911.

Related Posts:

“Huddled Masses. Healthcare. Honor. EMS”
“The Profession that is EMS”
“Oh No You Didn’t”

Posted by on June 17, 2009 • Filed under: 911 fail, Ambulance, cpr fail, EMS, EMT, Paramedic
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