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April is Autism Awareness Month: Now Let’s Go Farther

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Since sometime in the 1970s the month of April has been recognized as “Autism Awareness Month” with April 2nd being “World Autism Awareness Day”. It’s a time dedicated to increasing awareness of this disorder that is affecting an increasing amount of the population. While just how many people may be affected is up for debate, the prevalence is growing. So much so that last I heard, 1 in 50 kids are born with a varying degree of the disorder.

You’ll hear different statistics out there than the 1 in 50 I just quoted since there is disagreement between various camps in the Autism Community. Understanding, diagnosing, and much more so treating autism is difficult by the fact that “Autism” is a blanket term covering the many manifestations of “Autism Spectrum Disorder” (ASD). ASD covers a complex array of conditions, symptoms, and behaviors that someone diagnosed as being “Autistic” can display. People “on the spectrum” can be minimally affected, or “high functioning” or can be “low functioning” if they are profoundly affected.  I can’t claim to understand it myself and I’ve been as immersed in it as I’ve ever been over the last few years.

Yesterday was “World Autism Awareness Day” and I’m posting this article on April 3rd. You may be wondering why I didn’t post this up yesterday instead of the recap of the fake “news” stories I posted for April Fools’ Day. I waited for two reasons: one being that while Autism affects my life and my family it is still important to show that life goes on every day. Humor is a big part of our family life out of both fun and necessity. Another reason is that I believe there isn’t anyone reading this that isn’t “aware” that autism is a thing that exists. I can’t imagine there is an EMS professional out there who isn’t aware of autism but if you’re not, here’s a link to the Wikipedia page on it, and here’s a link to the Autism Society of America. Go read and become aware. In fact, it’s probably a good idea to go read and understand more about ASD anyway. There is a lot to know. ASD is challenging and complex and even the so-called (and especially some of the self-proclaimed) “experts” may not know as much about it as they claim to. I’m no expert by far and I want to stay out of the politics of the debate so I’ll just say this. If you’ve seen one person with “autism” you’ve seen one person with autism. Every person is an individual and there is no one right way to think about how every person will manifest their symptoms.

So since you’re all aware of autism now, let’s get to the point of this post: increasing acceptance, understanding, and respect. I’m glad that we’re all aware that autism is a thing, as would most parents of children who are somewhere on the spectrum as well as the people who are on the spectrum themselves. However, I’m sure they would be even happier if they could simply run an errand with their child without having to fear the reaction of other people in public. I’m sure they would really appreciate people not reacting to them or their child out of fear and ignorance should the child manifest typical behaviors or make noise when they go into a restaurant to eat a meal. As a paramedic, I can say that we would really appreciate not having to live in fear of calling 911 and having the responders have absolutely no clue of how to behave towards our son. That’s what I’d say people whose lives are affected by autism really want. While “awareness” is super-neat and all, let’s move on to the next step of making life a little less hard for everyone. Chances are that nobody reading this blog is going to be capable of finding an effective treatment, but everyone reading this can do their part to make the disorder less of a bad thing by working on their own behaviors towards people on the spectrum.

As you may know, my girlfriend Amy has been a huge blessing in my life. Her son, Connor, has some special needs, one of which is being on the autism spectrum, specifically diagnosed as PDD/NOS or Pervasive Developmental Disorder/Non Other Specified. Living with Connor has changed my life in many ways and has taught me more about myself than I thought I could learn. I’m different now, and hopefully it’s for the better. ASD is very complex and I’m as aware of it as I think I can be but I wasn’t always this way.Amy has shown me a lot that I didn’t know I didn’t know. When Amy and I were early in our relationship, she used to come and ride with me on the ambulance on a somewhat regular basis. EMS was as new of a world to her as her world was to me and while never really got anything all that complex while she was riding with me, we did have one call that stands out.

We were the 911 service for a smaller city where everyone knew everyone and the public safety community all hung out together. It was normal for the police, EMS, and firefighters to eat their meals together and we all listened in to each other’s radio frequencies. So one day when I heard the police get called to the local supermarket for “A child wandering the parking lot alone who appears to have autism.” We decided to head over there ourselves with the ambulance to see if we could lend a hand. Amy was with us and she was very interested, and I was the shift officer and approved of us jumping the call.

When we arrived, we found the police out with a male child who couldn’t have been more than 10. He was very afraid of the police, appeared to be non-verbal, and was walking away from them whenever they approached him. When we arrived, he was walking back into the store. I walked up to the police sergeant and offered our assistance. I told them that our ride-along had a child with autism herself. That seemed to be enough for them. They parted like the Red Sea and let Amy take charge without knowing her from anyone. We followed the kid through the store keeping a respectable distance and watched him as he searched the aisles. Finally, the boy walked up to a man who was perusing the frozen foods section and got uncomfortably close to him. Being “official” like I was in my EMS uniform, I stepped between them until Amy grabbed me. “That’s his dad Chris, chill out.”

It was his dad and he was not aware of the fact that two paramedics, three police officers, and a ride-along were very concerned about what his child was doing wandering the aisles and parking lot of a grocery store. The kid hadn’t done anything wrong and neither had his father, but we were all highly aware of the fact that we were uncomfortable dealing with a situation that was normal for the father of the child. Sure, he probably should have been watching the kid more closely, but how often would the parents of a typically developing child let their 10 year old walk alone in a grocery store. I’m not overprotective and I know that my 9yo step-daughter is capable of fending off kidnappers should I let her go pick out a box of cereal while I look for a gallon of milk… should this father be condemned for the same?

This event got me thinking that I really didn’t know as much about autism or the world of special needs children, but an event Amy and I shared later really hit home for me. We were watching Annie, the girl-child, play a little league game in a local park when I saw a man mowing his lawn which was adjacent to the ball field. He mowed row after row of grass all with a teenage boy following him in lock step about 3 feet behind. Back and forth they walked together silently, the man mowing and the boy following. I thought it was odd but Amy’s perspective snapped me into focus, “He must not be able to leave his son alone in the house while he mows his lawn. I used to have to mow my lawn at night when the kids were in bed because I couldn’t leave Connor alone for that long.”

At that moment, I realized that there was a whole world I didn’t know about. Even though I had been a paramedic for years and thought that I knew some things, I was ignorant to how the special needs community lives and gets through daily events that are easy and normal for most. I was ashamed. I realized that the reason the police and both my partner and I were so quick to let Amy handle the little boy with Autism in the grocery store was because we were scared. We didn’t know what to do with something we didn’t understand. Give us a car accident, a robbery, a cardiac arrest and we’d be fine working as a team… but give us a small boy that didn’t understand that we were there to help him and couldn’t communicate back with us and we failed.

As a paramedic, I live in fear of the day that I have to call 911 for my step-son. I know most of the EMS people that would respond to a call for help in most of the jurisdictions that we travel in and while darn near all of them are top-notch, I’m still scared. I’m scared because I would be scared of the medic that I was just two years ago. Sure, I was “aware” of autism as being a thing, but I had absolutely no understanding of what it meant. I had no idea of how to manage behaviors from a person with ASD, and I really didn’t know how to manage my own behavior towards them. I had awareness without understanding. Even though now I’m much more well-versed in my behavior towards people with ASD and other special needs, I’m still not as good as I want to be. The subject is complex and requires a lot of study and personal growth. One day I might be as good as I want to be but today’s not that day. I still have a lot to learn.

As I said before, “Awareness” is super-neat and all and as the step-dad of someone with ASD I thank you for knowing that autism exists. Now I ask you to take the next step and give us all a little acceptance and understanding. Nobody here is probably going to find the next revolutionary therapy but we all can stop being rude when we see someone with ASD having a meltdown in public. We can give a little understanding and courtesy when someone with ASD is being themselves in a way that isn’t quite within the social norm because we understand they cannot help it. As caregivers, we can react with kindness and patience when we realize that someone’s communicative needs and thoughts on the situation at hand aren’t what we may expect them to be.

So you can go blue for autism. You can proudly display your puzzle-pieces. Heck, you might even put a ribbon on your car. However all I’m asking is that you give people a little leeway to be themselves and just be nice to people. Not everyone is the same and we all need your respect and maybe even a little help sometimes. That’s what would be really nice.

So in honor of all of those with Special Needs and also the people who love them, Happy Autism Month y'all.

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If you’re looking for training for your police, fire, or EMS agency on Autism, I recommend this group: http://autismalert.org/

If you’re looking for a window on understanding the world of families with children who have special needs, I recommend the “Imperfect community” at: www.ShutUpAbout.com

Posted by on April 3, 2013 • Filed under: Command & Leadership, Emergency Medical Services, EMS, EMS ethics, EMS Health & Safety, EMS Topics, Fire Rescue Topics, new perspective, News, Paramedic, paramedic education, Patient Management, Training, Training & Development

Pushing Down the Skills – Bringing New Tricks to BLS

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A post by Peter Canning, one of my favorite EMS authors who writes the blog “Street Watch: Notes of a Paramedic” has got me thinking. The post deals with what skills we should push down a level or two from the Paramedic scope of practice and allow EMT-Basics to perform in the field. In his very well written article “Where I Stand (Today)” He brings up many of the facets to this complex issue.

You should read the article, but this is my favorite part:

“I guess if I could summarize my position it would be this: The distinction between ALS and BLS should not be an artificial one where BLS gives no medication and does nothing invasive where ALS does. The distinction should be a common sense one made by medical oversight after weighing risk/benefit, cost, and need. BLS shouldn’t necessarily carry a medicine or do an intervention simply because they can. In our current system, they should be allowed to do these enhancements only if there is a demonstrated need.”

“Allowed only if there is a demonstrated need.” I like that statement, even if I can come up with arguments against it in both an academic and practical sense. As I stated some years back in a previous post: “A Late Night Rant about Petty Politics in EMS” there is a hierarchy of things that guide too many EMS decisions, and they’re not positive things, they are:

  1. Revenue Preservation
  2. Area Preservation
  3. Ego Preservation
  4. Political Capital Preservation

Make no mistake. Those four things are at play in this whole debate on what skills should be in the scope of practice for every EMS level. I’d bet that if I were to take an informal poll, most BLS providers would support their being allowed to perform many new skills now considered to be in the realm of the “advanced” provider. I’d also say that most ALS providers would not support giving a lot of those skills to BLS. There would be some disagreement, as some BLS providers would see the additional education required as being burdensome, and some ALS providers would see giving ALS skills to BLS providers as lessening their workload by reducing the number of calls where they are needed. However, I look at it as a very contentious issue.

Mr. Canning is correct when he says that this should not be an arbitrary decision based upon anything other than a demonstrated need and good information, however I can argue against that statement as well. I believe that patient physiology doesn’t change when one crosses a political boundary which is why I’m generally in favor of setting a national minimum standard for our profession. However, I also believe that there are places that have a better mix of available resources than other areas and/or a specific health complaint that is represented in their area and not in others. An example would be in my area of Illinois which is not known for jellyfish stings nor altitude sickness.

I’ve sat in meetings sponsored by EMS educational institutions and listened to groups of EMS and fire chiefs decry the academic standards that dictate the pass/fail standards for EMS students. Not a one of those chiefs ever wanted the standards increased. They simply wanted their personnel to pass the classes. I’ve also had a few EMS system directors make the comments that their protocols have to be written for the “lowest common denominator” of providers… because skills that were too complicated wouldn’t be appropriate for everyone. I say that EMS has an unfortunate downward-pressure on our educational standards as it is yet I agree with the EMS coordinators when they say that there are some EMS people out there who are simply too… dumb? Unmotivated? Non-academic? Oh what’s an appropriate word for it… “unable” to provide the skills that others could reliably and safely perform.

I’ve been on a lot of sides of this issue and I know that my opinion is not any more valid than some others on this topic, as the answer is probably data-driven and I’m not that smart. However I believe that there are skills that should be pushed down to BLS providers that they are currently not allowed to perform. I believe that these skills would most probably improve patient care and have other positive impacts upon the EMS systems in the areas where these skills were moved down. On the same coin, I believe that there are skills that a provider should only attain with the requisite educational background. For instance, the motor skills required to perform a surgical cricothyrotomy aren’t really that hard. If you can carve a turkey or change an oxygen cylinder, you can probably perform one. However, the background knowledge required in order to safely know when to and when not to perform one in favor of any of the alternatives is pretty vast and requires both a lot of experience and education.

Here’s the deal. If you are a BLS provider or someone in charge of BLS providers you should be looking for skills you can add to the BLS scope of practice. You should look first for what benefit will be added for your patients by providing the skill your considering and then look for the risks. All patient care interventions, from bandages to brain surgery have both risks and benefits that must be weighed carefully by someone well-educated before being performed on or withheld from a patient. My opinion is that if a provider’s educational level cannot be reasonably expected to carry the requisite knowledge required for safely performing a skill, than that provider should not be able to provide said skill. Things like BLS IV initiation, BLS narcotic pain medication administration, and BLS endotracheal intubation fall into that category. Sure, there are numerous patients who might benefit from having those skills performed by a provider of lower educational background, but there are many more that in my opinion would be harmed rather than helped by a BLS provider choosing to employ those skills improperly over the alternatives already available to them. Another one of my EMS mantras is that a provider should have “A reason for everything they do, and a reason for everything they do not do” for every patient. These skills are too risky, in my opinion, for BLS providers to perform due to the risk of harming more patients than they help.

On the flip side of the coin, this happens with ALS providers as well. A partner of mine (who, by the way runs a very popular EMS related business and Facebook page) related his own story about bringing a new device to the very progressive medical control system that is in charge of our service. He introduced to them a point-of-care testing device that would obtain lab values such as a troponin and other valuable tests using an easily performed prehospital blood draw. He thought that it would have been useful in cardiac care and help us dial in on both STEMIs with questionable ST elevation patterns and non-STEMIs alike. He was very disillusioned when the medical directors not only denied his request to incorporate the tool, but suggested that instead of using that device “if he really wanted to help” he should place EMS patients into patient gowns before arriving at the ED to make it easier on the ED staff. Would the devices have been helpful in our area? There are a handful of services in the state that use them, but in our area it was deemed to be not useful as we have a number of PCI capable facilities within a half-hours drive of most 911 calls and we would be taking any patient with a suspected cardiac issue to one of them anyway. In other, more remote areas, this is not the case and those services are using these devices in the field to varied success. The point is, when denied with what was considered to be such a flippant denial, our paramedics felt exactly the way I assume EMT-Bs feel when they have to call a paramedic to start an IV.

I’ve said before that there are providers of all levels that in all honesty cannot intelligently debate this issue. This is because “they do not know what they do not know.” Just as it would be unwise to call your neighbor if you were having chest pain and accept their diagnosis that you “probably just pulled something” as your neighbor would have no possible way of knowing, you can’t intelligently debate these topics if you’re not willing to dig as far down into the issue as it takes to fully understand it. That requires education, not necessarily formal education, but education none the less. As an ALS provider I have heard BLS ambulances transport patients who I considered to be in need of ALS interventions without calling for an intercept too many times. I’ve also heard their justifications for doing this and a vast majority of those justifications sounded like one of the four reasons above given to me by people who wouldn’t consider that they didn’t know what they didn’t know about the care the patient really needed. To be completely fair, those providers probably left the conversation considering me to be just another arrogant “paragod” and maybe I am, but I believe in my heart of hearts that I’ve got patients’ best interests in mind.

Also, always remember… there’s a name for BLS providers that have the ability to provide more advanced skills. They were called EMT-Intermediates (now called AEMTs) and they have more skills because they’ve had more education and have been held to higher standards. Come to think of it, that’s why paramedics have more skills than AEMTs do and why Doctors have more skills than paramedics.

This debate is going to continue on for a very long time and many potential paths can be taken. Every single skill that EMS providers at any level are able to perform requires knowledge, practice, and judgment. Each skill should have a thorough risk/benefit analysis that shows clear and real benefit to a wide enough subset of patients without producing undue risk. These skills should be easy to master, carry a low risk of harm, and be either better than the existing treatments or not have effective alternatives. If you’re going to make the suggestion, make sure you do your homework because our patients deserve that we know what we’re doing.

In a later post, I’ll detail what skills I believe EMT-Bs should all be doing. I believe we should expand their scope of practice and I’ll explain how then.

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Oh! And could you please look over on the Right hand side of the screen (close to the top) at the voting widget with the picture of my bathroom? I need your help! Please also take a look at the “I need your help!” page up on the top menu bar because I NEED YOUR HELP!

Posted by on March 15, 2013 • Filed under: Administration & Leadership, ALS Intercept, change, Command & Leadership, Emergency Medical Services, EMS, EMS Management, EMS Topics, EMT-Intermediate, Paramedic, paramedic education, Patient Management, politics, Scope of Practice, Training & Development, Uncategorized

Our Biggest Challenge may be Our Best Opportunity – Medicare Pay for Performance and EMS

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Winding our cot through the hospital hallways, my partner and I we’re trying to efficiently complete the task at hand. It had been a busy morning and this scheduled return trip from the hospital to the nursing home was all that stood between us and a well-deserved lunch. At least, that was what dispatch had assured us as they snagged us out of the report room to take the call. It was simple enough, a short trip from the inpatient Med/Surg unit of BigHospital to a nursing home three miles away. It wouldn’t take us more than a half-hour to get everything all wrapped up.

That is, until we got to the patient’s room.

At the time, I wasn’t the most experienced paramedic in the world, but I knew audible rales when I heard them… from the hallway. The patient was sitting in his bed working as hard as he possibly could in order to breathe. His lungs were full of pulmonary edema and he was obviously in crisis with respiratory distress. I walked over to the nurses’ station, conveniently located directly across the hall from the patient, and asked a nurse about him.

“Oh good, you’re here. He’s going back to NursingHome X. He’s all ready for you to take him. That’s his paperwork on the counter” said Anonymous Nurse. I asked her who his nurse was and if I could speak to her. As it turned out, Anonymous Nurse just so happened to be assigned to our soon-to-be patient.

“Have you checked him recently? He seems to be having some difficulty breathing.” I told her, not really waiting for her to answer my question before I told her why I asked.

“Oh he’s fine, he was having a little earlier but he’s a DNR and the nursing home is ready for him” she retorted.

(Not to get away from the point of this, but the nurse’s statement is why I wrote THIS POST way back in 2009 during an angrier moment in my life, but I digress…)

“Um, I really think you should look in on him. He’s not doing well at all. He’s got rales so bad I can hear them from here. Really, if you listen you can hear them too. <pause for effect> See? I don’t think he’s so ready to go back to NursingHome X yet” I countered.

I’ll spare you the rest of the story because it’s not my main point but as the EMS people in the audience probably know already, the nurse got very angry with me when I refused to take the patient back to the nursing home on the grounds that he was rapidly progressing into respiratory failure and demanded that she call the patient’s attending physician. She was even angrier with me when the doctor had the patient transferred to the ICU based on the phone call. Yeah, she called my boss to complain but luckily there just so happened to be a social worker that overheard our exchange and called my boss as well to commend me on sticking up for good patient care while being just so darn polite about it.

This was the only time I can think of where I stood my ground and refused to take a patient out of a hospital for a discharge transfer because I believed they would die during the transport, but I can think of several times during my career where I have turned around and taken a patient back to an emergency room when they crumped on me during a discharge trip. It seems that it has happened during my career more so than the statistical likelihood should be if the hospitals were always being as conscientious as they could be when discharging patients. And I mean all of the hospitals. I’m not singling out any one of them. Every hospital has occasional times where patients are discharged a little early for a variety of reasons and have to be readmitted back in a very short amount of time.

And today, October 1st 2012 marks the day where that will become a real problem for all hospitals due to a change in Medicare regulations. Medicare will start fining hospitals that have too many patients readmitted for care within a 30-day period.

I don’t want to get all Chicken Little on you all but Ladies and Gentlemen, we have a problem. As I stated before in a previous post, hospitals are going to start to become very interested in how ambulances take care of their patients.  They’re tracking every single scrap of data they can devise a way to get their hands on and in my opinion, they will start tracking the performance of individual ambulance services much more so than they do now. If some ambulance services bring in (or transport back) patients who do better (or are readmitted less) than other services, they’re going to discover that if they don’t know it already. Trust me, they employ an army of people whose only jobs are to devise new ways to track data in preparation for this and other Medicare pay for performance regulations. They have to; there is an unfathomable amount of money on the line.

Read this article for yourself, and read it well. Understand every word because this signifies the coming change that will rock our entire industry: “Medicare Fines Over Hospitals’ Readmitted Patients” (AP)

There are a few quotes I want you to pull out of that and be sure you think about:

“About two-thirds of the hospitals serving Medicare patients, or some 2,200 facilities, will be hit with penalties averaging around $125,000 per facility this coming year, according to government estimates.”

“For the first year, the penalty is capped at 1 percent of a hospital's Medicare payments. The overwhelming majority of penalized facilities will pay less. Also, for now, hospitals are only being measured on three medical conditions: heart attacks, heart failure and pneumonia.

Under the health care law, the penalties gradually will rise until 3 percent of Medicare payments to hospitals are at risk. Medicare is considering holding hospitals accountable on four more measures: joint replacements, stenting, heart bypass and treatment of stroke.”

I am not debating the political ramifications of these regulations. I’m saying that they are here, they’re in effect now, and the amount of money they mean to almost every hospital you can think of is simply staggering. I’m saying that if your ambulance service has a higher rate of patients being readmitted to a hospital due to infection, you have a problem. If your ambulance service has a higher rate of patients who do poorly after being brought in from the field, you have a problem. Also, if you don’t believe me… well then you probably have a problem as well.

EMS needs to be out in front of this! We as an industry have to get up and be out there addressing the problems that these regulations are going to bring! Please tell me that I’m not the only one who sees this… please tell me that I’m just uninformed and there are smart people out there already working on this problem and have already come up with solutions… because if not then we all have a heck of a lot of work to do.

However, this may be the biggest opportunity for our profession that I’ve ever seen.

I believe that the future of EMS lies in community paramedicine. I believe that we have to expand the EMS business model so that we have more ways to serve our patients and generate revenue. To date, the biggest hurdles for community paramedic programs have been finding ways to pay for and generate revenue with them. I assure you that providing post-hospital discharge follow-up care as a way to make patients healthier and avoid subsequent readmissions is very much within the realm of a community paramedic. I also assure you and every hospital person reading these words that paying a community paramedic to perform those services is much, much less expensive than is being fined for having too many readmissions. Trust me, someone could easily pay for a rather expansive community paramedicine system for much less than 1% of their hospital’s total Medicare reimbursement.

I’ll leave you with another quote from the AP article:

"There is a lot of activity at the hospital level to straighten out our internal processes," said Nancy Foster, vice president for quality and safety at the American Hospital Association. "We are also spreading our wings a little and reaching outside the hospital, to the extent that we can, to make sure patients are getting the ongoing treatment they need."

I’ll say it again. We need to be out in front of this issue. Now.

EMS 2.0 logo

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If you’re interested in what I’ve said on this issue in the past:

Change Medicare, Save EMS

Primary Care Paramedics? I Think it’s Time

Posted by on October 1, 2012 • Filed under: Administration & Leadership, Ambulance, Command & Leadership, Economics, Emergency Medical Services, EMS, ems 2.0, EMS Topics, News, Paramedic, politics

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

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

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

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

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

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

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

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

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

And we in EMS are largely oblivious to this fact.

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

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

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

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

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

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

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

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

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

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

EMS Providers Carrying Guns – A terrible idea

34 comments

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

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

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

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

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

Here are some of the reasons why:

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

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

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

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

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

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

FIrefighter Pre-Hydration – Fight Fire like a Marathon Runner

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Has anybody else noticed that it’s sweltering outside? There’s no other way to describe the oppressive heat we’ve been facing without trotting out the word “sweltering.” The word itself is almost fun to say. I recommend that you work it into as many conversations as you are able these days while you toil outside in the intense heat. It won’t keep you any cooler, but at least you’ll be adding to the vocabularies of the other sweaty people working around you. It sure beats asking them if it’s “Hot Enough” for ‘em. That gets annoying.

In the last few weeks here in Southern Wisconsin we’ve been having some terrible fires requiring response from multiple area departments. Some of them have been heat related and some of them have just come at a bad time, but all of them have had one common denominator. They’ve all been dangerously hot. Not just the fires themselves, but the oppressive, dangerous, and potentially deadly heat on the fire ground due to the weather conditions has contributed to multiple firefighter injuries. Thankfully, most of the injuries have been minor and heat-related but some of them have been worse. I don’t know if the heat contributed to all of the injuries suffered by those brave firefighters, but it certainly couldn’t have helped.

In times like these, all firefighters need to remember the fact that active firefighting activities are nearly the same as competitive sporting events. Firefighters working on active fire grounds have the same or higher demands put upon their bodies as do athletes on the playing field. It is of extreme importance to remember that fact and take appropriate action to keep yourself and your brothers and sisters safe. Extreme weather is a great equalizer. It affects all of us no matter our station in life. Everyone on the scene has the responsibility to recognize the risk they’re taking by exerting themselves outside in these conditions and take appropriate steps to protect themselves. Nobody wants to see their fellow firefighters fall ill and even less than nobody wants to be the firefighter who goes down themselves.

By design, firefighting personal protective equipment provides an effective barrier to thermal energy. This becomes a problem in hot weather because it doesn’t allow for the shedding of excess body heat and raises the core temperature of the wearer quite sharply. While after years of promoting rehab, even the staunchest believer in their own invincibility can usually be coerced or threatened enough to go to rehab after heavy work on the fire ground, rehab is of even more importance during hot weather because it allows the firefighter to shed his or her PPE and allow that body heat to escape. However, it is important to remember in times of extreme hot weather like we’re facing now that rehab after working is not enough to keep you safe from heat-related injuries and illness. It’s simply too hot for normal people to work effectively without prior planning and preparation. Athletes spend days preparing themselves before competing in physical events by resting adequately, storing up calories and carbohydrates, and pre-hydrating. We should as well.

While it is important to keep yourself nourished with healthy food, I don’t recommend that firefighters load up on calories and carbohydrates before every shift like runners before a race. I do recommend pre-hydration. To pre-hydrate is to drink water before you need it and it is important to realize that one should drink water before they are thirsty to maintain normal hydration. While the adequate daily intake of water for healthy adults varies due to temperature conditions, levels of activity, and other factors, the Institute of Medicine (IOM) recommends that adult males take in 3 liters of water per day and adult females take in 2.2 liters. The water doesn’t need to come only from drinking water, and can come from water stored in food we eat. The IOM says that if a human is producing around 1.5 liters of pale yellow to clear urine per day and is urinating at least once every 3-4 hours they are at close to normal hydration levels. However, many factors affect our hydration and it is easy for a person to become dehydrated without realizing it. Dehydration leads to fatigue, headaches, tachycardia, low blood pressure, and other nastier symptoms that greatly affect firefighting performance and safety. It has been stated that it is not uncommon for firefighters to lose two liters of water through sweat while working on the fire ground in full PPE. If you start to sweat that much when you are already dehydrated, you will not be effective for very long.

Pre-hydration is all about keeping your water tank full before you respond and is as simple as drinking water throughout the day and maintaining your hydration levels. Since fighting a fire in full gear can be compared to running a marathon, we may want to emulate their guidelines. Marathon runners are taught to drink 20 to 32 ounces of water 2 to 3 hours before running and then to drink 8 to 10 ounces of water every 20-30 minutes before they run. While actually running, they are advised to drink 8-10 ounces of water every 20-30 minutes as well. It is not advisable to intake a large amount of water before engaging in strenuous activity because it takes time for the water to move from the stomach to the large intestine and be absorbed into the blood stream. Too much water in the stomach at once can lead to nausea and vomiting during periods of strenuous activity. Sports drinks with electrolytes like Gatorade, Power-ade, and others like them should be consumed occasionally to replace any electrolytes lost through sweating however there is no need to pre-load yourself with them as the body does not store more electrolytes than it needs and excretes any excess quite rapidly. Replacing lost electrolytes through food is of great value, and most can be replenished by eating fruit like a banana. In addition, avoid soda pop, carbonated beverages, or beverages that contain high amounts of caffeine and/or sugar as these drinks can actually contribute to dehydration by acting as diuretics.

It is easy to encourage pre-hydration among your crews. People need to drink water before they feel thirsty, and should continuously drink small amounts of water through the day. Place water in conspicuous areas throughout the station and the living quarters. Water that is out of sight is out of mind and can be forgotten. By placing water right in the line of sight of everyone, they are reminded of the need to have a glass or two. You can make the drink more attractive by adding commercial flavorings like lemonade, crystal light, or Mio mixes that add taste without adding too much sugar. Another trick is to place the bottles of water in the engine next to every staffed seat and encourage every firefighter to drink a bottle during any response to a working incident.

By pre-hydrating, you will ensure that you and your fellow firefighters hit the fire ground with full water tanks and can perform at peak levels in this oppressive heat. Keep yourself hydrated and stay safe out there. We’ve sickened and injured too many firefighters lately and I don’t want it to keep up. Turn the tide and drink up. You’re worth it.

Posted by on July 9, 2012 • Filed under: Administration & Leadership, Command & Leadership, EMS Health & Safety, fire, Fire Rescue Topics, Firefighter Safety & Health, Firefighting Operations, Training, Training & Development, training-fire-rescue-topics

EMS 12-Leads – The Standard of Care

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I’m going to make a statement:

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

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

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

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

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

 

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

 

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

 

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

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

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

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

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

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

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

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

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It’s a crazy world out there.

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

As I said: Mayhem, it happens.

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

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

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

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

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

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

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

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

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

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

National 911 Education Month – What EMS can do

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

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

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

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

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

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

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

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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?

15 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

The Houston Medicare Problem – Formulating Better Instructions on Paying for EMS

1 comment

I’ll admit it. I’m kind of a nerd with Microsoft Excel.

I don’t have the programming skills needed for other database programs and I’m only taking baby-steps in MS Access, but with Excel I’m pretty darn good at making it do cool things. I think Excel is widely underused for being as powerful of a data analysis tool as it is. It’s one of those programs that everybody knows how to use… but nobody *knows* how to use. People learn parts of it and are able to do the kind of work that they do in it without touching the thousands of other tools that it offers them. It’s an insanely powerful system.

I use Excel quite a lot in my various jobs for data aggregation and analysis. Lots of my coworkers do too. Since most everyone knows that I’m an Excel nerd, some people ask me to help troubleshoot their spreadsheets for them. Some problems are quick fixes while others are maddeningly complex. Most problems, however, seem to have a common theme:

Computers always do what we TELL them to do but not necessarily what we WANT them to do.

Computers run programs. They don’t think for themselves. They don’t make their own instructions. They simply look at a list of instructions and run them. They don’t judge the instructions for merit, correctness, or morality (See: 99.9999% of the internet), they just do what they’re told without being able to think about it. When computers appear to be thinking, they’re simply running complex programs with multiple variables. Excel is no different. In fact, excel is very good at doing exactly what we tell it to do with no regard to what we may want it to do.

I sometimes agonize for hours on Excel problems when I can’t get my numbers to add up correctly. Usually these problems involve complex groups of numbers where I know the answers for a certain part of the problem, but want to use Excel to contain and crunch numbers for the parts I don’t know. I’ll write my calculations on what I know already to prove my theory, and then use those theories to expand the spreadsheet. Sometimes the formulas work the first time… and sometimes they don’t. When fixing the problems I have to keep reminding myself that Excel is doing exactly what I told it to do, not what I’m thinking I want it to do. If it’s giving me the wrong answer, it’s because I asked it the wrong question or gave it bad instructions on how to arrive at the answer. It can’t do anything but that.

I use Excel as a metaphor for a lot of systems in life. To be sure, humans have free will (we think) and are very complex in both our actions and motivations, but on the larger scale our systems affect our behaviors in predictable patterns. Just like we predictably follow the lines on the highway when we’re driving most of the time, with the outliers among us creating a need for EMS, our systems affect us predictably. Small changes to the systems we operate within can cause big changes to our behaviors on the large scale. Think of a small change to the width of a highway traffic lane causing more or less accidents, or daylight savings time creating savings in energy costs overall. While there will always be outliers when dealing with humans… the systems we create are instructions that society is given. Society will follow those instructions for both the benefit and detriment of our goals. The overall system will do just what Excel does, by doing what we tell it to do and not necessarily doing what we wanted it to do when we created it.

This Headline out of The Houston Chronicle made me think of this. Take a look at it:

“Private ambulances take Medicare, taxpayers for a ride – Companies make millions off the poor, vulnerable – whether passengers need services or not”

I want you to read the article when you have time (it’s a long one – here’s the link) but the salient point they assert is that unscrupulous private EMS organizations, in near criminal collaboration with the operators of unscrupulous “healthcare” organizations, are bilking Medicare for millions via unnecessary ambulance transports. According to the pretty well-written article there does indeed seem to be a problem. While I don’t like the fact that in my opinion, the article unfairly vilifies some of these ambulance services and shows a bias against private EMS providers as a whole, I can’t say if it’s my own stated bias as a proponent of well-ran private EMS that’s causing me to feel that way. However, even the headline “Private ambulance services take Medicare, taxpayers for a ride” shows a bias. My thought is that the headline should read “Medicare Rules allow people to take advantage of the system although most don’t” but I digress…

I would like you to look at the headline of an article I wrote recently that JEMS.com published as my April column, it reads:

“Medic Suggests Reimbursement Change – A different payment model helps EMS & Medicare”

In his article which includes references to Barbecue, I talk about the Medicare reimbursement rules as well, but from a different perspective. (Here’s the link if you haven’t read it). I offer a solution on how a small change to the Medicare rules (think: the instructions) could benefit all involved.

I think that the two extremes here show a poignant contrast. One extreme shows how the Medicare system can be abused due to its rules allowing for abuse and the other shows how the system can disallow beneficial services because of those same rules. It is a good example of how just like excel, the system does what we tell it to do rather than what we want it to do. Other than some unscrupulous people out there, nobody wants patients or ambulance services (*ahem* Private or otherwise) to be able to take advantage and get money in a way that is unfair to the rest of the system. However, I think there are few people out there that would rally against the change that I propose in my article. This is simply a case of the end result being a product of system design. Medicare, like any system, is a set of instructions that produce an end result. The instructions allow for the ambulance services in Texas to bilk the system in compliance with the rules while a different section of those same instructions disallow payment for treating and releasing patients who could clearly benefit. It’s simply a matter of the Medicare system producing results based upon the instructions it’s been given. In both cases, the system isn’t making a judgment, it’s just following the instructions it’s been given. There is no moral value assigned within the system.

Small, efficient changes need to be made here. Just like when troubleshooting an excel spreadsheet the smallest error in a formula can skew the whole result. The companies mentioned in the Houston article aren’t the product of private EMS being evil they’re the unintended result of a system that needs better instructions to act upon. The system is producing what we’ve told it to produce, not what we want it to. These problems wouldn’t exist if we would tweak the parameters of the system to disallow them.

So… what we need are some better instructions. Anyone got any ideas?

Here’s the link to the Houston Chronicle article again

Here’s the link to mine

Also, for more of my column on JEMS.com, here’s my page there with all of my articles listed.

Posted by on October 24, 2011 • Filed under: Administration & Leadership, Command & Leadership, Economics, Emergency Medical Services, EMS Management, EMS Topics, News, newspaper, Paramedic, politics

Get a Pulse, Get a Steak? Random Incentive

2 comments

Tonight the girlfriend and I had the rare opportunity to go out on an actual date. It's getting increasingly rare these days that we have time to do so, what with our schedules, work stuff, and my recent bit of travelling for the other job that I have. It was nice to actually get out, go to a restaurant, and not have to cook or eat bad-for-me fast food on the road.

She and I went to one of our favorite places, a midwestern type joint that specializes in mass quantities of beef. At this place you get to choose a large hunk of absolutely beautiful red meat from their cooler, season it to your liking with the wide variety of spices they have on hand, and then grill it yourself over their huge charcol grill while people bring you your beer. It is a concept that is admittedly getting a little more rare around the midwest, but it's certainly something that I haven't seen anywhere else in the country that I've been. These people have given their customers exactly what they want. All the beef one could possibly eat, a salad bar to go with it, cheap drinks, and a good meal will cost you about $17 bux. Yeah, beat that, California.

I noticed on the menu that the restaurant offers gift cards that employers can give their employees. They are good for a full meal for two and come personalized for the employer. Since I'm always on the lookout for a good way to help reward and motivate good EMS people, I mentioned to the GF that maybe I should buy a couple to give the guys as an occasional "attaboy".

"What would you give them out for?" She asked, then answered "How about every time they resuscitate a code?"

Now THAT is a good idea! I'll call it the "Get a Pulse, Get a Steak" incentive program. That way, every time a crew gets that magical cardiac arrest save they and their significant other get to celebrate by roasting them some posthumous cow. It sure beats knowing that all you've got to look forward to is a lengthy report and a horribly messy ambulance or scene to clean up afterward.

Then again, I'm sure someone will point out that it's just too subjective to base the reward on a code save because as we all know, even when everything is done completely "right", completely by the book, and the crew tries absolutely as hard as they can to get the save it still doesn't usually turn out the way we'd like it to. We all know that is true. It just seemed like a good idea at the time.

Thanks for shooting down my awesome idea, imaginary naysayer.

I've been trying to come up with some innovative ways to motivate, reward, and incentivise the best and brightest EMS people out there to want to come in and do the absolute best job they can for the service and the patients every day over the long term. Money and passion isn't enough to carry everyone along every day, people need more than that sometimes and there's simply no shame in it because we all feel that way at times.

I'd love to hear what you or your service is doing to motivate employees. (And don't tell me it's what they're doing in Louisville, because yeah… not cool)

Also, the steak was amazing.

Posted by on October 14, 2011 • Filed under: Administration & Leadership, appreciation, Command & Leadership, Emergency Medical Services, EMS, EMS Health & Safety, EMS Management, EMS Motivation, EMS Topics, EMT, Paramedic

A Medic Roast in Tennessee

20 comments

Some time ago I worked for a service that had a governing board made up of community members from various walks of life. Most of them were business leaders around the area and only one or two of them had any EMS experience. One day I overheard one of the board members talking about problems he was having with the quality control at a factory his company ran in another area.

I was fascinated.

It seems that the workers at this factory just didn’t seem to care about the quality of the product they created. Products came out with grievous manufacturing errors that turned a lot of their finished products into unsellable junk. He described these errors as things that any reasonable person would notice had they spent more than one day on the job.

Joining in the conversation, I asked him “So, how much does the average worker at that factory get paid?”

He replied with a wage that was actually above my hourly rate as a paramedic. It was significantly more, actually.

It shocked him when I said “So they make that much more than I do, and when I make a mistake someone dies and my career is over? That doesn’t seem right at all”

And no, it doesn’t seem right. Every human being on this planet is going to screw something up on occasion. We’re not perfect. Medical professionals and especially EMS people are constantly challenged to adapt their knowledge to unfamiliar situations with incomplete information. On top of that, the body of our knowledge is constantly changing and it’s up to us to know exactly how to seek it out so we’re consistently doing the best for our patients. It’s not easy to be a good EMT or Paramedic and it’s a responsibility that we’re largely not well-paid for. Top that with the fact that even one simple mistake can be a career ender and…

You get this article that I saw this morning in JEMS: Tennessee Paramedic Demoted after Drug Mistake

If you’ve been a paramedic in the field for any length of time and this article doesn’t scare you, you’ve not been much of a paramedic for any length of time. This is real folks. This is something we all should sit up and take notice to.

The article concerns a paramedic who made a medication error. While it doesn’t state what error he made, it seems that he had mixed a medication in a bag of normal saline and infused it to a patient while intending to give a different medication. The article doesn’t specify the medications given but from the patient’s condition an educated person may be able to infer what they were. It also specifically does not mention the condition of the patient before or after the medication was given, leading me to believe that the patient suffered only minor ill. Yes, I know that I’m assuming… but you can’t tell me that the newspaper wouldn’t have been more than happy to blast the headline “MAN DIES AFTER MEDIC POISONS HIM WITH WRONG MEDICATION” if he had died. My guess is that if they downplayed his condition, there wasn’t much to sensationalize about it.

The medic, who had been with the service for 9 years and who had only been disciplined once in that time for missing something on a rig check, had received “above average performance reviews” and more than one commendation in his tenure.

From reading the article, it looks like an experienced medic made an honest mistake. He was reprimanded for it, suspended for 28 days, and demoted to an EMT.

Yeah, you read that right. They voided 3 years of education that this man had completed and knocked his license all the way to EMT-Basic.

They did this for one mistake. One mistake that even the medic’s chief stated was “… accidental and an oversight on his (the medic’s) part”. An honest mistake that everyone reading this article has already made or will probably make in their career. A mistake that was apparently easy to make, even by an experienced paramedic that most probably did not result in grievous harm to anyone.

If the facts truly are as reported in the article and there are no other unreported wrinkles to this case, I call shenanigans. The discipline this medic received simply does not fit the crime. It’s too heavy-handed. The discipline seems arbitrary, unnecessary, and patently unfair.

The chief was quoted in the article as saying that their agency, which is reported as responding to around 29,000 emergency calls each year, has a “success ratio” of “100%” and that “this is not the norm.”

So he’s saying that the all of the EMTs and Paramedics that must handle 29,000 emergency calls per year are expected to be 100% perfect 100% of the time or he will negate their education, harm their lifetime income potential, and defame them in the national press? I know that he probably didn’t *intend* to say that… but he very much did say it. I know of no other single profession that has so much at stake every time they go to work. To my knowledge, no other profession has so much risk of long term harm to their lives, their family, and their professional career riding on a very much unrealistic goal of being 100% perfect 100% of the time. It’s shockingly unfair… and terrifying. No human being can maintain those expectations. We’re just not able to always be perfect all of the time for an entire career.

And when you think that the pay for Paramedics and EMTs in this country is by and large pathetically low, you might wonder why anyone would ever consider doing the job at all.

I’ll say again, if the facts in this case are accurate and complete as reported, this is an outrage. It’s an abomination. It’s enough to generate national attention about the unfair working conditions and haphazard disciplinary standards that EMS must endure.

I’ll say this too: I support this paramedic and formally place a letter in the file of the agency responsible for doing this to him.

(This part is for Google) If you work for WRCB TV in Tennessee, please feel free to consider this my opinion.

(You can find the original article HERE: http://www.wrcbtv.com/story/15463233/ems-used-wrong-iv-in-melvin-davis-transport)

Posted by on September 15, 2011 • Filed under: Administration & Leadership, Command & Leadership, Emergency Medical Services, EMS, EMS ethics, EMS Health & Safety, EMS rant, EMS Topics, Ethics, News, Paramedic, patient care, Patient Management

Perils of Paramedics Pursing imProper Patient Refusals

7 comments

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

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

Ok, ya back? Good.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

DC BLS Ambulances out of service as Hot Weather Arrives

<sigh>

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

Excuse me, I mean "FEMS."

<sigh>

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

 

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

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

7 comments

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

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

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

Nobody? <sigh>

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

Eww.

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

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

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

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

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

 

 

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

Remebering My Father, Chief Richard A. Kaiser

5 comments

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

And I hadn’t remembered.

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

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

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

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

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

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

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

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

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

Because I miss my dad.

Call 911 for chest pain. Just FREAKING do it.

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

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

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

Lazy EMS – Encouraging the RMA

17 comments

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

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

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

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

Ahhh, this is SO much better than doing a report

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

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

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

I hate those kinds of EMTs.

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

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

I wasn’t surprised.

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

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

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

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

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

——————————————————————–

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

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

I am not immune

14 comments

I’m going to make an announcement:

I am not immune to the things that I thought I was immune to.

You see folks, I am human, and as a human I am fallible, faulty, and flawed… Just like everyone else. I have emotions, thoughts, feelings, vibes, good stuff, and bad stuff that I carry with me inside this noisy brain of mine. I am not immune to the events that affect my psyche, nor am I immune to carrying the baggage that I obtain or the sadness that splashes on to me in my daily travels.

Of course you know that, right? Because for the longest time, I sure didn’t seem to.

I’m a long-time full-time professional EMS person and as such, I thought I was immune to so much of the stuff that I see on the streets every day. I’ve always said that I will jump right in and work in whatever conditions the job and my life seems to throw at me. I just tried never to get any of it on me personally. Death, destruction, abuse, trauma, pain, sadness, loss, grief… all that stuff seems both very real and yet still surreal to me.  I thought that I could bear witness to unfathomable human tragedy on a daily basis without any problem. For many years I still seemed to myself to be able to function normally. I thought I was ok with all of this.

And no… no I wasn’t that’s abundantly clear to me now.

You may have noticed that the blog’s been silent lately, and well… that’s for personal reasons. If you’ve been following me on Twitter and Facebook you probably know why I’ve been silent, but on the blog here I’m just going to say that I’ve had quite the personal upheaval. This, combined with a huge change at work has left me little time to sit and think about writing. It’s not that I didn’t want to write, because I truly love this blog and all of the fantastic people it has brought into my life. I just didn’t want to write crappy or say something I’d regret… so I remained largely silent on here.

I have, however, learned some things and have some things to say:

First of all, to my guys at the Rescue Squad: You are more than my coworkers, you are my brothers. Thank you for everything you’ve done for me. I wouldn’t have gotten through this without you. Family doesn’t begin to describe it. Thank you.

Second of all, to my local friends and Family: Ditto the above. I’ve gotten the chance recently to reintroduce myself to all of my old friends. I’ve missed you guys. Thanks for being you and thanks for being there for me.

And Third, to my blog followers, fans, and interweb friends:

I chanced to look at some of the facebook profiles of the people I’ve been talking to online lately. It’s amazing to me how many mutual friends I have with people I may have never met in person or have only met a few times. The names I see out there on the web are common names in my daily life. Since I started this little place on the interwebs the relationships I’ve been able to make with hundreds if not thousands of fantastic EMS people are amazing. You’ve all been there for me as well and I am literally so appreciative of it. You’ve rejuvenated my EMS career and shown me that there is indeed a future for us all in this business. I can’t tell you how much I appreciate it… it’s amazing.

It’s too common for us EMS people to ignore the crap in our own lives and simply drive on towards the next call. We shake off whatever is going on in our personal lives, shake off the sadness and grief that splashes onto us from the streets, and drive on like nothing has happened. We are mission-focused and are confident in our abilities and our immunity. I sure was. I ignored the bad stuff in my own life and focused on my responsibilities. Just like I would have gone on to the next job after a tragic call, I ignored a lot of things and kept my eyes forward. All EMS people tend to do that… we probably have to. The thick shells we develop are most probably a defense mechanism. Personally, psychologically, and physically we ignore what we need and focus on meeting the needs others place upon us. The long hours, the hard calls, the low pay… they do take a toll on us and we have to do more for our own well being than simply paying it lip service. None of us are immune. All of us are human.

It is shocking to me when I look around me at my EMS friends and coworkers and see how much strain they place upon themselves and yet are still able to take the next call. Nobody I know in EMS takes care of themselves like they should. All of them ignore their own well-being. I did that too, and even when I say that I’m going to focus in on taking care of me for a while, I feel selfish.

Well take it from me, you’re not selfish for putting your own needs first every now and then. It will make you a better person, and a better provider. If I could do things over again, I would have met some of my own needs and I bet that things might have changed for me… but I didn’t, and I can’t… and that’s ok. We all have new beginnings in our lives and this is my opportunity to do just that.

To my EMS people out there: Evaluate yourselves right now. Refocus on what’s truly important… don’t play SuperMedic because you’re just as human as I am. I also am issuing a challenge to everyone out there: Just as my coworkers became my surrogate family after my issues and watched me to make sure that I was ok, you all have to do that for your coworkers and friends as well. We depend on you, you should depend on us too.

Stay safe out there.

Posted by on December 10, 2010 • Filed under: Administration & Leadership, appreciation, ckemtp, Command & Leadership, edemse, Emergency Medical Services, EMS Health & Safety, EMS Topics, Fire Rescue Topics, In the Line of Duty

Primary Care Paramedics? I think it’s time

20 comments

Clinically speaking, there’s a whole lot of medicine out there that I don’t know.

I mean, paramedics like me go though a few thousand hours of training in emergency medical care. We get a few years of classes covering the things we need to know about treating the most common of truly emergent medical conditions. Heart attacks? Check. Strokes? Check. Airway Management and Respiratory Support? Check and Check. We paramedics are experts in the acute medical emergency. If you’re dying, we are well equipped and trained to support you until a doctor and a team of medical people in a hospital can take over your care. If you have a medical emergency somewhere outside of a hospital emergency room, we’re the first people you want to see.

The Medic is In

But, what if you have a particularly nasty case of Strep Throat?

Well… that’s called “Primary Care” and it covers a lot of non-emergent medical conditions. Strep throat hurts and it makes a person feel like crap. The times that I’ve chanced to become infected with a nasty strain of Strep “A” it’s made me feel like a warmed-over Code Brown Sandwich. It sucks being sick and that’s why people go to the doctor. Patients present to doctors’ offices for myriad reasons. Pink Eye, Influenza, the “creeping crud”, bronchitis, and gastrointestinal problems are common occurrences there. When I worked at an urgent care clinic we saw plenty of those. Up to two-hundred patients per day came in with just these kinds of complaints. There were lacerations, fractures, and other kinds of cases that came in too. Rarely did we need to call for an ambulance and while we did sometimes advise people to go to the ER on their own, that was rare as well. A good primary care doctor can catch most minor conditions and adequately treat them right there in the clinic, negating any need for an expensive emergency room.

However, the problem lies in actually getting access to a primary care physician to take care of you when you’re sick.

Yesterday, my mother-in-law (I call her “MIL” for short) called me up. One of the people she works with had an injury to his fingernail. He tore a good part of it clean off while working out in their warehouse. It hurt, of course, and it was bleeding. Their company is a small five person shop that they’re building from the ground up. A Workers’ comp claim would go right against their small and shared pocketbook and start-ups don’t have the cash for that kind of stuff. She wanted to know the proper first-aid for this and was trying to avoid the doctor. He was too. As owner of the company he didn’t want to have to pay for it and a fingernail injury just doesn’t seem all that severe. Still, it hurt and they were worried about infection. The guy understandably wanted proper treatment.

I told him that fingernails either grow back, or they don’t. Eventually it would be fine if he cleaned it with mild soap and water and put a non-adhering bandage over the nail bed to keep it clean and protected. I told him in a day or so to put some Vaseline-based antibiotic cream on it as well to keep it moist and stave off infection.

Don’t worry, I wasn’t practicing medicine without a license. I have my First-Aid Merit Badge from the Boy Scouts of America and that was covered somewhere in there, I’m sure. However, you’re right to think that fingernail injuries aren’t covered anywhere in the National Standard EMT or Paramedic curriculum. We are taught to bandage it up and take it to an Emergency Room.

Yep, if he would have presented to my care on the ambulance, I would have had to transport the guy to the ER for a physician to do what I told him to do. If he refused the $500 (or so) transport fee and the (astronomical) ER fee, I would have had to have him sign an “Against Medical Advice” (AMA) refusal form and could not legally give him any medical advice other than to be transported to the ER.

It’s maddening.

Fingernail guy didn’t have an option for treatment where he was other than to go to the ER. In the area where he was located, there aren’t any Urgent Care facilities. There certainly aren’t any cheap ones anywhere you go, but their cost is much lower than the local ER he was near. He didn’t have an option, so he had his coworker call her son-in-law (SIL) for advice. I gave it, and saved everyone involved a few hundred if not a thousand dollars. Sure, the guy could have called his primary care physician and gotten an appointment a month later… but I would think that as a self-employed small-business owner he probably doesn’t have access to health insurance at a less-than-oppressive cost.

A while back, I wrote the piece “Did I do Good?” regarding what I think EMS 2.0 should become. I think that Paramedics should be educated and empowered to step into the realm of primary care and be able to provide primary care in the field. Now to be sure, as Rogue Medic will point out, there’s evidence that states that Paramedics and EMTs are bad at triage and we are not currently equipped with the right education to provide these services at this time. However, I think that educating a group of excellent paramedics to the proper standards, giving them the proper tools, and empowering them with the proper legal authority could revolutionize healthcare.

Every community has a group of paramedics and/or EMTs and nearly every community (I would say every, but I have no stats in front of me) has less-than-optimal access to primary care across the spectrum of patient populations. To me, there is a clear solution that makes sense. Could Paramedics, once properly educated, equipped, and empowered, provide limited primary care services, appropriate triage, and transfer in the field? How about at fixed sites and clinics? We could follow protocols, utilize tele-medicine, and function much as we do now, but with a much lower-acuity class of patients.

Sure, there are Nurse Practitioners, Physicians’ Assistants, and other healthcare providers that can provide these services, but let them work with us as we work with them. There doesn’t have to be an adversarial relationship. We all have different training and that one set can be used to compliment the other. 

EMS 2.0 is about thinking outside the box for EMS. It’s about finding new ways to face the challenges. Thinking the way we have in the past won’t fix the problems that it failed to fix before. My belief is that with Paramedics providing Primary Care, we would greatly increase access to care, more properly triage patients to the proper healthcare pathways, save gobs and gobs of money, and just might “fix” this whole healthcare mess without all that legislation and legal wrangling.

Any suggestions on where we begin?

Posted by on October 28, 2010 • Filed under: Administration & Leadership, Command & Leadership, Emergency Medical Services, EMS, ems 2.0, EMS Topics, new perspective, Paramedic, paramedic education, patient care, Patient Management, potential, Training & Development

A Late-Night Rant about Petty Politics in EMS

16 comments

I had to think about a Facebook comment that I just posted on my personal Facebook page. Admittedly, I’m pretty angry right now and I probably shouldn’t be writing. It’s been a long night, you see… and I’ve had it up to my eyeballs with what I’m angry at.

However, this blog is my therapy and I can use it to get some stuff off of my chest whenever I see fit, right? Good, then here goes.

Tonight I’m going to forget that my computer has been acting up on me and has lost two 1000word-plus articles that I was lining up for the end of the week. I’m not even going to mention that I’m behind on a lot of projects because I’ve been overwhelmed with work. I’m not even going to talk about how the workload that I’ve let pile up has been making the blog suffer… Nope. I’m going to jump to the front of the line and bring that Facebook comment right here, to the front of this blog page where a few thousand EMTs and Medics might read it this month.

“Revenue Preservation, Area Preservation, Ego Preservation, and Political Capital Preservation” – These things are the top priorities of some EMS agencies I’ve dealt with over the years. Patient care is on the list, but its way down on the bottom of these agencies’ priorities. Some agencies have their priorities straight, but more it’s more common than I’d like to admit that EMS agencies have those four things at the beginning of this paragraph firmly implanted into their unwritten mission statements.  

I’ve written at length about EMS politics and how I hate them. For example:

-          Is What You Do “The Best You Can Do”

-          Volunteer Fire/EMS – Taking the High Road and Letting Go

-          Two Cases, One Letter: From One Paramedic’s Struggles, Change Can Come

-          Cat Puke Chicken

-          EMS 2.0, Bernoulli, Fluid Dynamics, and Changing the World

-          And Much, Much more…

And tonight, again, I’ve seen yet another example of the worst kind of EMS politics. I’ve seen these situations countless times before and I’ll see them countless times again, I’m afraid. People who don’t put the patient first have missed the whole point to this EMS thing. We’re here for the patient. We’re here for the citizens. There is a selfless aspect to EMS that must be respected in the preservation of the greater good. To miss that for almost any reason is to disrespect not only the foundation that EMS was built upon, but also the foundation of the entire healthcare system.

“First, Do No Harm”

Yea, that’s the first pledge of the Hippocratic Oath, the same one that Physicians take when they become doctors. EMS people are an off-shoot of physicians and we should follow those four words up there as much as they have to. Using the citizens of your jurisdiction as pawns in a political game is to violate those most sacred of oaths. EMS people tend to feud for the flimsiest of forgettable reasons. These feuds escalate unchecked for years until every action taking by the opposing party seems only to reinforce the perceived validity of the petty feud, even when the original actions or inactions that caused the feud were lost to history or died with the people who started the feud to begin with. Often, neighboring squads hate each other for no reason that they can remember. Factions within a single EMS agency may feud internally for no good reason whatsoever. These things escalate and escalate until patients are harmed by them… for no reason at all.

And if there ever has been a reason to harm a patient for a petty feud between services, between cliques, or between individuals, I’ve yet to hear it. In my opinion, using a patient as a pawn in a political game is the worst kind of offense.

These petty EMS politics, these laughable feuds, and the little kingdoms must have the light shown upon them. As I said in my probably politically incorrect Facebook post:

“I don’t like it when Petty People play petty politics with peoples’ lives. Really, people die from the kind of stuff I’m angry at without ever knowing that they were pawns in a political game. EMS politics must be exposed to the light so that the people that play them can be scattered like the cockroaches they are.”

Do you see anything that I’m going to be in trouble for tomorrow when people read that post? Remember, that’s on my personal account… not the blog account. Yes, I do take personal responsibility for everything I say on this blog page or in any of my public speaking or writing for that matter, but there’s a chance that people I know and may or may not have been talking about will read that tomorrow. My guess is that I will be the bad guy for saying it.

And frankly, I don’t care.

As I said in the post that I linked to above, Volunteer Fire/EMS – Taking the High Road and Letting Go – I am willing to bury each and every hatchet I do now hold or have ever held and solemnly pledge to conduct myself in friendship, mutual understanding, and for the good of the ideals in which we all should share. My guess is that there are people out there tonight who should do exactly the same. Don’t let petty politics harm those whom we’re pledged to serve. It’s not about us. It’s about them. It’s about our ideals.
It’s bigger than us. We are more than the sum of our parts. Don’t forget that.

I know that this hasn’t been the most polished piece I’ve ever posted up here, but everything I’ve said I believe. That’s why I’m a blogger. It’s why I’m a paramedic as well. Thanks for letting me rant.

The EMT Oath as adopted by the NAMET

EMTs have an Oath as well...

Posted by on October 27, 2010 • Filed under: Administration & Leadership, change, ckemtp rants, Command & Leadership, edemse, Emergency Medical Services, emotions, EMS, EMS ethics, EMS Management, EMS rant, EMS Topics, Ethics, everyday ems ethics, Fire Rescue Topics, medical ethics, Paramedic, politics, professionalism, rant, Uncategorized

EMS case law? AMA Refusals, Death, and Documentation

18 comments

Our friend Valerie DeFrance, who runs the EMS House of Defrance from way up in the Vast Frozen Wasteland facebooked this article this morning and you need to read it.

http://www.leagle.com/unsecure/page.htm?shortname=inmoco20100921246

Yep, check that URL. It’s from a site that specializes in putting out snippets of case law and this one’s simply all-too-common.

You should read the article, or at least skim through the salient points, because this affects you personally. You as an EMS provider should know about this. Pay attention to this case and what it means to you.

In this case, a Paramedic/EMT-B ambulance responded to a person experiencing Chest Pain and Difficulty Breathing. This is a quote from the article: (The emphasis is mine)

The unit arrived at decedent’s home and Respondents performed a primary survey of the decedent ten minutes after the initial call was placed. Respondents followed up on their primary survey with a secondary survey a minute later. They then obtained a set of vital signs. Based on their examination, Respondents diagnosed decedent with acid reflux and recommended a treatment of over-the-counter Maalox/Gaviscon. Believing decedent was in no immediate medical danger, Respondents left the home fifteen minutes after arriving.

The next morning at approximately 10:30 a.m. decedent again called 9-1-1, still complaining of difficulty breathing and chest pains. An ambulance unit from Community Fire Protection District was again dispatched to decedent’s home arriving five minutes later. This unit was manned by a different two-person team than had responded the night before. After finding the decedent was experiencing pain across the chest and into the back, shortness of breath, diaphoresis and nausea, the team began administering emergency treatment with oxygen, aspirin and EKG. At 10:55 a.m. the team initiated emergency transport of decedent to DePaul Health Center where he was admitted ten minutes later. At the Health Center decedent was diagnosed with cardiac arrest and pulmonary embolism and began receiving treatment. The treatment was unsuccessful and decedent died at 4:00 p.m. on 11 July 2008.

So do you see a problem there?

First off, I’m assuming they obtained an AMA refusal form (and if they didn’t, they’re idiots). This case highlights exactly what I’ve always said about refusals being worthless. There’s no mention of the patient having refused transport here. In fact, this isn’t a case on whether or not the EMTs actions were correct or incorrect. This is simply a case to see whether or not they have protection under the doctrine of Sovereign Immunity. It looks to me like they were basing their defense on whether or not they have that legal protection, not basing it on their thought that they provided proper care. It looks like they were assumed not to have provided it. In this case, a signed refusal meant nothing. If they were successfully sued with no mention of the AMA form, what good is it?

Second off, it’s in the official record that their PRIMARY survey took less than a minute… and I can believe that if they were solely attempting to rule out an immediate life threat. That’s what the primary survey is for. As evidenced by the fact that the deceased lasted another ten hours, I can assume that there was no immediate threat to his life. However, they then did a “secondary survey” one minute later and cleared the scene with what I assume to be an AMA refusal in just fifteen minutes. So if we time this out, they made it to the patient’s side in one minute, did two assessments, obtained a refusal, and cleared the scene in 15 minutes? That’s one minute to grab gear and walk to the patient, a minute to rule out immediate life threats, a few minutes to do a secondary assessment and vitals, with no mention of an EKG, and a few minutes to carry whatever gear they took in back to the truck, get back in the truck, and clear? Um… Either these are the fastest medics in the West, or they did a very poor assessment.

And the guy died. And they got sued. And they lost. And they freaking deserved to lose.

The second crew seems to have provided proper care for the patient, and that is evidenced in the case outcome. In fact, the lawyers and the judge seem to have made it a point to show the poor care provided by the first crew in contrast to the proper care provided by the second crew. It’s clearly evident here and I’ll bet that if we were to go to that agency and inspect it, we could probably see the difference in dedication and motivation between the first and second crew. The first paramedic comes off as lazy, callous, and stupid whereas the second paramedic comes off as competent and caring. I’d be willing to bet that this is honestly the case. That the first medic was a “good enough” medic who often encouraged AMA refusals and performed just to the bare minimum and the second medic was somewhat better than the first.

So how, as EMS providers, how do we protect against the precedent set by this case law?

The answer is still now as it always has been, do a thorough assessment every time, kick the decisions up to the physician, and document, document, document. This case was in 2008 and if you were doing EMS back then, you know that a 12-lead EKG was the standard of care. This patient should have had a working diagnosis (Chest pain), attempts at making a differential diagnosis (lung sounds, History and Physical Exam, EKG, SpO2, and trended vital signs and 12-leads) and should have been transported. If the patient wanted to refuse, the physician medical control should have been contacted and this should have been documented. The time limit of 14 minutes of assessment and/or care in this case is evidence that this didn’t happen. The medics blew his call for help off and the patient died.

Here’s what I would have done: I would have performed a thorough patient assessment including lung sounds, ABD assessment, and a history. I would have gotten the OPQRST of the patient’s complaint, and performed serial 12-lead EKGs. Then I would have transported. If the patient refused, I would have transmitted the 12-lead EKG, spoken with a physician about the case, and attempted to have the physician speak with the patient. This all would have been thoroughly documented.

Patients have the right to refuse care if they are conscious, alert, and oriented. They have this right even if they’re being stupid. We have the responsibility to help them make a proper, rational decision and to show that we made every effort to provide them with the best possible information. Proper patient care and excellent documentation are the way we protect against these types of lawsuits… and that really hasn’t changed.

This kind of situation can and does happen. Protect yourself and your agency by never becoming lazy. Document! Document! Document! Do your best every time. Be thorough and don’t succumb to mediocrity just because it’s easy. It will catch up to you just like it did to these two.

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For more tips on EMS documentation:

Posted by on September 27, 2010 • Filed under: Administration & Leadership, Case law, Command & Leadership, Emergency Medical Services, EMS, EMS ethics, EMS Management, ems narrative, EMS narrative report, ems patient care report, ems report, EMS Topics, EMS training, Management, narrative, narrative report, Paramedic, paramedic education, Patient Management, scenario, scenario based training, Training & Development

What are you doing reading THIS?

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When you could be reading Happy’s explanation of EMS @.0 over at the Chronicles of EMS website?

Go read it. Print it out please, and share it with the world.

http://chroniclesofems.com/ems-20.htm

Thanks, Happy.

Posted by on September 7, 2010 • Filed under: Administration & Leadership, Command & Leadership, EMS, ems 2.0, EMS Topics, Uncategorized

EMS: Is what you do the Best You Can Do?

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Not too long ago I was reading an article in Entrepreneur Magazine when I came across an article speaking on negotiating tactics. I wish I could find it, but unfortunately it was long enough ago that I’ve disposed of the printed issue (I subscribe) and cannot find it on the web. It was a good article and it taught me some words that I’ve since used quite a bit in my own life:

“Is that the best you can do?”

From the time our parent’s first put us out there in the world most of us have probably been told to “Do our Best” when we try to do something. No matter if we win or lose, we’ve been told that it’s ok as long as we “do the best we can” while trying. We seem to feel better at the outcome of almost anything if we feel that we’ve “Given our best shot” when we try to accomplish what we’ve set out to do. We all like to do our “best” and we hope that our “best” will be good enough.

This begs the question… is what you’re doing today in EMS “the best you can do?” Career wise, operationally, with your service’s treatments, with your own personal training and education, and with your own attitude… is this really “the best you can do?”

I would like to think that I “try my best” in my own EMS career and paramedic practice. I would also like to think that I work for an EMS organization that is trying to do the best it can for its people and its collective patients. However, there are quite a few situations where I have felt that I have not done or have been prevented from doing my best for a number of reasons. Some are reasonable and others are not. I’d think that all of us would give the answer that we always want to provide every patient with our “best” possible care. However, I’d also guess that everyone reading this can think back to any number of situations where they feel that they didn’t give it. Sometimes this reason comes down to the skill set of the individual provider. This could be a situation where the provider didn’t have the best possible information or knowledge available to them. They may have provided an ineffective or even harmful treatment modality or might have failed to act upon a missed assessment finding, such as by giving a medication for which a patient has a documented allergy because the provider didn’t know or simply forgot that the patient had the allergy. Sometimes the actions of others in the organization can prevent a provider from rendering the best possible care. This could be by failing to check, clean, or restock a needed piece of equipment or by providing inadequate care prior to a provider assuming patient care such as in the case of a first-responder crew failing to place a patient in full c-spine precautions when indicated prior to moving a patient to the transporting ambulance and the transporting EMT not having enough manpower to safely immobilize the patient. Sometimes the organization can hinder an EMS provider from doing his or her best by doing things such as providing inadequate equipment or medical protocols, or by mandating that a provider regularly work past exhaustion-level hours.

People inherently want to do well at whatever they choose to do for their careers as well as at other tasks where they feel strongly about the outcome. I may have accepted that I’ll never be as good of a basketball player as Michael Jordan, nor the same-level of cartoonist as Scott Adams, nor the best noodler in the world… but I’m certainly going to try to be the best paramedic I can be.

THIS guy, however, may be The Best Noodler In the World

Sometimes our own personal biases prevent us from doing the best we can do and for this I’m not talking about bias regarding any protected classes or topic, rather I’m talking about our own version of the status quo. A personal example of this would be my ALS Quick Response Vehicle at work. We went a solid week without having the proper forms available for the daily equipment checks and I didn’t have the computer access to print more off. During that week, I got in the habit of not using the forms and simply checked the truck based upon my knowledge of what was supposed to be in there and what was supposed to be checked. The way it played out, I ended up continuing to not use the check sheets when checking the vehicle, even though the forms had been replenished. A few weeks later, someone found that there was equipment missing in the vehicle that had gone unnoticed for some time. At that point, I realized that I had developed my own bias against using the forms for a reason that is even unbeknownst to me. I had gotten in the rhythm of not using the forms, and that caused me to miss that the infrequently-used piece of equipment was missing. I had developed a personal mental bias that prevented me from “doing my best” and thoroughly checking the truck.

Another preventer of best practices can be organizational politics, both internal and external. As a paramedic who regularly responds to other ambulance services to provide “ALS Intercepts”, I have observed that the politics between the services we work with can affect patient care for both the negative and the positive. While I am not saying that any of these arrangements result in inadequate patient care, I can say that the services with whom I interface most frequently and most pleasantly get a better provider out of me than do the services with whom my relations are less frequent or are strained due to political turmoil. When I respond to a request for an ALS intercept, I am being called to the “house” of another group of providers. While I am the highest level of care on the scene, I’m also a guest in their house. They have their own internal biases and I have mine. Sometimes the synergy in our working relationship can be strained, which results in a palpable difference in the flow of the scene and the teamwork exhibited at it. While I will ensure that I “do my best”, it’s easier to do it when I work well with the team I’m working with.

So how do we change things? We’re all human and we all have things that prevent our “best shot” from being the only thing that we “give it” in our EMS careers. This may be consciously, as in the case of internal politics; Subconsciously, as in the case of my not using the check sheet; or Involuntary, as in our service not providing us with needed equipment or our coworkers failing to replace an item in the ambulance that we did not have an opportunity to check. As in most things, the easiest thing for us to change is ourselves. Changing ourselves is a great place to start and will make serving as an example to others your main tool to use to try and get the best out of them.

Most situations can be made better and almost all of us can try harder. The secret is to attempt to do our “best” at all times and to try and ingrain our own best practices into our daily routines. This can be as simple as always trying to check the truck in the most thorough way possible or by making sure that you always check and recheck things to ensure that they’re done right. It helps to continuously seek out and recognize one’s own personal biases, (remember my check sheet?) to make sure that our own preferences and routines aren’t leading to suboptimal performance. Consistently ask yourself if what you’re doing is the “best you can do” and then ask yourself what you can do to make it your best. Mentally prepare yourself for your shifts with adequate rest when possible, manage your stress level so you can keep your thoughts focused on your care, and train hard. Ingrain your best efforts into the systematic way you do things and make your best way your normal way of doing things. We can’t change everyone around us in an instant, but our quiet positive efforts can pay large dividends in how people around us think, feel, and act. Our best may in turn get the best out of our partner, which may in turn get the best out of the next crew, and so forth. Soon enough… deciding to give our best may change your organization, our industry, or our profession.

And I assure you, doing your best will indeed make the difference in someone’s life. It’s just what we do, Folks.

“Is that the best you can do??

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For more on doing your best in EMS and in getting the best out of your EMS people read:  “The Shine Factor”

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Posted by on August 19, 2010 • Filed under: Administration & Leadership, ALS Intercept, Ambulance cleaning, Command & Leadership, edemse, Emergency Medical Services, EMS, EMS ethics, EMS Topics, EMS training, Fire Rescue Topics, Firefighter, Management, Paramedic, Patient Management, politics, pride, profession, professionalism, Training & Development, training-fire-rescue-topics, Uncategorized
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