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Right in the Nick of Time: Patient Saves his Medic

3 comments

 

04/01/2013 – Peoria, Illinois

Calling it “A save right in the nick of time” Paramedic Jules Slatterly thanked chronic system abuser Wade Fugman for waking her up at 03:37am last Thursday.

Paramedic Slatterly explains “We had been running pretty hard all day on our 24-hour shift, with around 11 calls between noon and 1am. I finished all of the reports I was down around 0300hrs and was finally able to catch some sleep in the bunk room.” She added “I was so tired I didn’t even take my boots off.”

But that’s when Paramedic Slatterly’s early morning took a turn towards the disturbing…

“We all know that when you’re chronically sleep deprived that you can sometimes have some weird dreams. Well that night, I was having me a doozy of a nightmare. First I was naked in my Freshman English class, then every boy who ever forgot to ask me out on a date came by to laugh at my lifetime income potential as an EMS provider. If I would have been awake I would have been in tears.” Paramedic Slattery stated as she described her nightmare that affected her short amount of sleep that night.

But that’s when Mr. Fugman stepped in for the rescue.

“I was hungry and there ain’t no food like hospital food fo when you’s hungry.” Mr. Fugman told us. “You know them little juice cups? I get most of my Vitamin C from those Cranberry ones. I can’t get enough of ‘um. So sure enough, my sciatica started actin’ right on cue and 911 is just a phone call away.” Mr. Fugman, who calls 911 at least “four or five times a week” stated that he didn’t know he was saving Paramedic Slatterly from her short-lived nightmare, but he said he wasn’t surprised.

“I give those ambulance drivers their workout, I do. Since my sciatica is so painful I can’t be bothered to walk down the stairs from my apartment, let alone walk out of my back bedroom and down the hallway. It’s not my fault that the elevator’s broken. Let them ambulance drivers earn all those millions they get.”

At press time, Paramedic Slatterly was only slightly hallucinating from sheer exhaustion while working at her second part-time job.

Posted by on April 1, 2013 • Filed under: Als, EMS, ems education, EMS Humor, EMS Topics, Fire Rescue Topics, Paramedic

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

7 comments

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

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

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

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

I do have a few questions though:

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

 

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

 

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

 

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

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

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

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

Notice anything similar?

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

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

12 comments

I’d like to ask a question to all of you medical-type folks out there, and for this one I’d like other healthcare professionals to weigh in, not just EMS. Of course, Paramedics and EMTs are encouraged to answer this question, but so are Physicians and Nurses (RN and LPNs), as well as CNAs and Techs. 

A conversation I had on Twitter regarding administration of 10% Dextrose IV (D-10) as opposed to 50% Dextrose IV (D-50) for hypoglycemic ambulance patients has me wondering something about how we paramedics can create major savings and improve patient care in a short amount of time. We need to look for more “Low Hanging Fruit”.

It is common practice for known diabetic patients presenting with low blood sugar (hypoglycemia) to receive a treatment with IV D-50, IM Glucagon, oral Glucose, or even with the “Kaiser Cocktail” and then sign off with an AMA refusal. The patients are encouraged to eat something containing protein and complex carbohydrates and are usually left in the care of one of their family members and/or friends who can watch them for a while and make sure they’re ok.

I’d say that calls like this make up a fairly large percentage of all calls for an ambulance. While I have no statistics to back me up, I would guess that it could be something like 5% or better. This complaint and resultant treatment pathway is something I do quite frequently in my own practice. Judging from my own experience, I would say it happens quite frequently in most other paramedics’ practices as well.

The question about administering D-10, as brought up by my twitter peep @un_ojo, is if all patients getting treatment with D-10 as opposed to D-50 should be transported to an Emergency Room. My answer was that I believe a 100% transport policy in this case would result in a lot of people being transported to an ER when they probably didn’t really need to be. This would result in a large population of non-emergent ambulance patients going to the ER who in the past would have been “treated and released” (at least under the guise of an AMA refusal) by EMS crews.

And that got me thinking about this question:

If paramedics did not currently have the means to treat hypoglycemia and every one of those patients were being transported to the ER, how much of a burden on the emergency healthcare system would be removed simply by giving paramedics D-50? Probably quite a bit, right?

What other common medical cases would be as appropriate for field “treat and release” (or “Treat and AMA”) care by EMS? If we save a few hundred trips to the ER by being able to sweeten-up and then release common hypoglycemics, what other conditions might we be doing the same for as safely and effectively?

Would this require some easily attainable training? What about new medications and/or equipment?

I look at this as the “Low Hanging Fruit” if you will, of EMS 2.0, and also of healthcare reform. I am a proponent of EMS crews handling more primary care duties, or failing that, of at least having more options in regards to treatment pathways.

That’s what I’m looking for here, folks. What could we do within six months that would make a big impact?

Please discuss in the comments section, and feel free to shoot me an e-mail at ProEMS1@yahoo.com. You can also weigh in on the LUTL Facebook page if you’d like.

Also, would you do me a favor and invite some of the other healthcare people to the party? I’d love to get some of their opinions on this.

Posted by on July 26, 2010 • Filed under: Administration & Leadership, Als, Emergency Medical Services, Emergency Nurse, Emergency room, EMS, ems 2.0, EMS system, EMS Topics, Paramedic, physician, potential, Protocol development, us

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

The Paramedic Intercept – Rural EMS

6 comments

It may shock some of my more urban readers out there, but not everywhere is a city.

Why did I say that? It’s because there’s not much talk out there regarding rural EMS. I live rural EMS and I believe that someone who calls 911 in a rural area deserves just as good of service as someone who lives in the city. To further my goal of increasing the dialogue, I’m writing about some of the issues facing rural EMS and the techniques that we use. Hopefully it’s educational.

Here’s the first part in my series on Rural EMS: The ALS Intercept:

Not every 911 call for an ambulance brings forth a paramedic-staffed Advanced Life Support ambulance. There’s a lot of ground in this nation covered by dedicated volunteer EMT-Basics that answer the call for their communities day-in and day-out. In fact, I got my start at one of these all-volunteer 911 EMT-Basic squads. We covered 275sq miles of sparsely populated terrain in the rural Midwest and ran about 200 or so calls for service per year. I have to say that it made me a very good basic, because there wasn’t any back-up for our BLS skills. However the patient presented, they got treated with the best that our Basic Life Support ambulance had to offer.

Of course, back then we had an ace in the hole. The big-city hospitals that were 45 minutes away at a minimum laid in the service area of ambulances with paramedics in them that could be called to head out our way and meet up with us for an “ALS intercept”. It still happens that way in a lot of communities, in fact, I ride around in an “interceptor” while at one of my jobs, which is an SUV with lights, sirens, and a full complement of ALS gear in it. Working out of that vehicle I respond first-due in our own jurisdiction and upon call for some of the surrounding communities. We meet up either on scene or enroute, and I hop in to dazzle the crew with a stunning display of ALS-sy goodness.

I have to tell you, I remember that from the perspective of an EMT-basic racing to the meet-up point with an “Oh-My-God” critical patient, having the paramedic jump on board was such a feeling of relief. Now, from the perspective of the paramedic who jumps in, it’s sometimes a bit of a pucker factor… because now you’re working with an unfamiliar audience watching your every move.

ALS intercepts are a great tool in the arsenal of rural EMS systems. There are a lot of small communities out there that do not have the capabilities to staff and support full paramedic ambulances. Even if they have the money to pay for all of the equipment and training needed for paramedics, they may not have the call volume needed to keep the paramedics busy and their skills sharp. That’s why consolidating the paramedics and sharing them between multiple services makes sense to me. The community volunteers respond as an initial stabilization, and a faster, more mobile unit runs out to meet them with higher skills. It’s a truly tiered response system.

Rural paramedicine and rural EMS take a different mentality than does urban EMS. For instance, the distance that we must cover mandates long response times. At my previous all-BLS service, we covered the 275sq mile 911 area out of one station. We had under 5000 people in that jurisdiction and that made staffing more than one ambulance infeasible. To cover the gap, we had outfitted volunteer EMT-Bs as “Satellite” First Responders to augment the response. It worked… if they were home or in the area.  Nonetheless, the response times went up to and over 30 minutes in the most remote areas. “Call Early” and “Call First” were necessary philosophies for the community. In addition, the longer transport times made necessary some long protocols that had lots of tools in them to keep the patients stable for the long time we were with them.

Today, I respond to my calls with some of the most advanced EMS protocols that I know of in the region. For example our service and our resource hospital is committed to meeting the AHA’s goal of a 90minute symptom onset-to-balloon time for STEMIs (ST segment Elevation Myocardial Infarction or, the classic heart attack) this requires either ground-bypassing the closest community hospital ER by almost an hour to make it to a hospital equipped with a cath-lab. Most urban services that I’ve worked for carried Nitroglycerine, Aspirin, and Morphine for these cases. For our rural protocols, we add Nitro Paste, a bolus of Heparin, and IV Metoprolol. We also carry transport ventilators on the trucks to free-up a pair of hands from bagging during the long transports with minimal personnel. It takes a strong and independent paramedic to be able to handle anything that’s thrown at them as a single medic. It takes a very strong an independent medic to handle it with an unfamiliar team of EMT-Basics in unfamiliar circumstances.

The relationship between the ALS provider and the EMT-Basic services that they support must be strong in order to be effective. There has to be a high-level of trust between both organizations and the providers working within them to keep the service level high. Holding joint trainings and understanding that everyone has a role within the continuum of patient-care is necessary. Dispatch protocols that pre-deploy ALS resources make a difference as well and take the responsibility off of the BLS provider to make the decision on whether the ALS response is necessary. I personally subscribe to the idea that it is good to be proactive with ALS dispatch protocols and in addition to sending ALS to the obvious complaints, such as Unresponsive patients, Chest pains, and difficulty breathing calls; it is also a good idea to send them ALS to non-specific dispatches such as the unknown medical. BLS providers that arrive first can always cancel the responding ALS if they determine that they’re truly not needed.

And always, always, always… the ALS and BLS providers must check their egos at the door and realize that what’s best for the patient is the most important consideration.

The ALS intercept is a great tool that extends the reach of paramedics into areas where we can’t be effectively based from. It takes work, but it’s good for our patients and our communities. Rural EMS takes different strategies, and this is a good one.

What are your thoughts on this?

Posted by on December 18, 2009 • Filed under: Als, ALS Intercept, Emergency Medical Services, EMS, EMS Management, EMS paramedics, EMS protocols, EMS Topics, Paramedic, patient care, Patient Management

EMS 2.0 & EMS Ethics – How far would you go?

13 comments

Throughout my EMS career I’ve heard a lot of the same complaints from paramedics that seem to be endemic within the system. One of these is the quality of physician medical direction and whether or not theirs is considered “Progressive” or “Permissive” by the EMTs and Paramedics that work within the protocol system. Some systems seem almost regressive. They don’t seem to show any trust in the providers that work within the protocols and end up being putting forth “Mother-May-I” protocols that disallow aggressive field treatment and require hand holding over the radio or cell phone to a base station. Others, are fairly progressive and allow quite a bit of treatment to be provided in the field.

However, even in the more progressive of the systems out there the medics always tend to have their own personal “wish list” of things that they’d like to be permitted to do. I currently work in the most progressive protocol system I’ve ever worked in and yet there are a few things that I would like to be allowed to do further than I can do now. Toradol for pain control, and the inclusion of a paralytic to our Medication Assisted Intubation protocols would be examples.

However, there begs a question here that I haven’t seen explored before: What if this was reversed?

Say tomorrow you head on into work and get there to hear the news that your medical director up and left for Tahiti with a new love interest with whom he or she will be very happy. Incidentally, you’ve now got a new medical director that just graduated medical school after spending 10 years as a field paramedic. There’s a “Get to Know Me” meeting scheduled in a half hour,

In the meeting the new medical director, who emphatically insists that you call him “Dr. Pat”, and then changes it to “Just Pat” outlines the new protocols that you will be functioning under starting as soon as you all can get through the trainings and meetings that are scheduled. These protocols are amazing. For example, your protocols for treatment of severe asthma used to include just oxygen, nebulized albuterol, and subcutaneous epinephrine. Now you’ll be giving Albuterol mixed with atrovent for your nebulizers, Epi 1:1000 sub-q or brethine (terbutaline) sub-q, epi 1:10000 IV for severe cases, Solu-Medrol (an injectable steroid), and Magnesium Sulfate infusions for refractory cases. For pain control, you used to have to call for orders to give Morphine. Now you give Morphine in 2mg increments titrated to effect up to 20mg if the blood pressure is over 100mmhg systolic, Fentanyl 50mcg – 200mcg, Toradol 60mg IM, and/or Nitronox (Inhaled Nitrous Oxide). The protocols are really advanced and have at least twenty new medications, some of which you’ve never even heard of.

Soon after you start reading the new protocols you start noticing things that frankly, scare you a bit. Never mind the fact that you don’t know how you’re going to calculate amiodarone drips and use propofol for conscious sedation, you’re frankly scared that the protocol system directs you to perform emergent C-Sections to save a viable fetus in cases of limb presentations in pregnancy. Really?

Mannitol and induced hypothermia for head injuries? Wow. You also now have needle crics, surgical crics, Needle decompression of the chest, pericardiocentesis, retrograde intubation, and what are those words? Thoracostomy (Chest Tubes)?? Thoracotomy? Holy crap! There’s almost nothing you can’t do! 

After the meeting you head out on the streets with your partner. You’re honestly feeling a little nostalgic for the days when your Tahiti-bound regressive medical director wouldn’t let you be responsible for hardly anything. It’s completely opposite now. You’ve gone from one extreme to the other. There’s nothing that you’ve ever thought of doing in the field that you can’t do anymore.

On one hand this would be very exciting for me (and yes, I went a little overboard with plausible treatment modalities to make a point here) but on the other hand, I’d have to ask the question:

Where would be the line where progressive treatment protocols cross the line? When would be the point where paramedics are given too much responsibility for complex invasive treatments?

I’ve never seen the case I’m describing. I love working under a progressive and liberal protocol system. However, in a meeting the other day when the possibility of administering thrombolytics for refractory ventricular fibrillation in cardiac arrest came up I had a thought that I’d never had before:

“I don’t get paid enough to have that much responsibility. I take on a lot of liability and have to put in a lot of uncompensated education time for the meager wage that I get paid now… how much is that going to have to increase for no more money?”

I don’t want to think that way, and I’d have to question the dedication of any paramedic in any of the protocol systems that I’ve examined that would say no to being able to provide potentially lifesaving treatments to their patients. I can’t imagine refusing to do something because I didn’t think that I was compensated enough to take on the responsibility of doing it. I’d be happy to sit through the required education, but I doubt that they would increase the compensation of the medics in the above example.

Could it happen? Has it happened? Will it happen as treatments progress and professional responsibility increases? I’ll firmly say that I’m nowhere near adequately compensated for the responsibility I have today. Where would I be if the above scenario happened to me tomorrow?

EMS 2.0 needs to seek out and find answers to the questions that we haven’t asked yet just as much as we need to find answers to the questions we’ve been struggling with for years.

What do you think?

Posted by on October 18, 2009 • Filed under: Als, change, edemse, Emergency Medical Services, EMS, ems 2.0, EMS ethics, EMS protocols, ems salary, EMS Topics, EMS training, Ethics, everyday ems ethics, medical ethics, Paramedic, paramedic education, patient care, Patient Management, physician, politics, SMG, SMO

2 comments

The Happy Medic does a great bit on his blog entitled: “You make the call”. In these posts, he lays out a situation and invites the audience to comment on what it is that they would do.
As a currently ill paramedic/blogger, I think that I can do this too. You see, today is my first day back to work after my recent illness. I thought that I was mostly over it and well on the road to recovery… until this afternoon when a rather explosive gastrointestinal thing happened that I won’t get into other than to say um… oh, I guess this happened to a “friend”.

Yea, a “friend”.

Anyway, so you are driving around town in your ALS intercept vehicle talking to your friend’s wife… Um, I mean your wife if you are the friend (this is confusing) when you hear a neighboring service that you would be due to respond to for ALS assistance get a call for a roll-over auto accident on a rural highway. Nobody is on scene yet and you don’t know if they’re going to need your paramedical skills because they’re about ten to fifteen minutes from making the scene.

Then it hits you… the explosive gastrointestinal thing. (I mean, it hits your friend)

What do you do?

Do you float towards the call in the chance that they might need you for the wreck and take the chance of an unfortunate gastrointestinal incident?

Or, do you beat feet to the station and fix your immediate medical condition so that an unfortunate personal gastrointestinal incident does not, in fact happen? Who knows if they’re going to need you, um… I mean, need your friend.

You make the call…

————————-

They didn’t need my friend, and all turned out to be well when my friend went to the station. Good thing there are lights and sirens on those trucks

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Posted by on June 11, 2009 • Filed under: Als, ALS Intercept, Ambulance, EMS, EMT, Paramedic
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