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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

An article on EMS that may actually “get” it

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I don’t usually like things in the media portraying what we do in EMS. Usually they’re too full of melodramatics, misinformation, or just plain callous misunderstanding of what we actually do in the field for my taste. Most of them play out like fantasy, showing EMTs and paramedics as the bumbling idiot “ambulance drivers” they think we are on old TV shows like “ER,” or the junkie borderline monsters like in the movie ”Bringing out the Dead,” or even like the camera-friendly vapid idiots on NBC’s (thankfully) ill-fated show “Trauma.” I just can’t bring myself to watch any of those shows, or even to read most articles printed in the mainstream media covering EMS. They just seem to make me mad as I read them because they don’t get it… and they don’t try to.

Most of them don’t try to get it I should say, because today I came across a piece in Esquire magazine that actually seems to try. Chris Jones, the author does a pretty good job of representing EMS and EMS people though an article he wrote after a series of ride-along shifts he did with paramedics in Canada.

Nice job, Sir. The article isn’t a perfect representation of everything we do out here on the streets, but it’s probably the closest I’ve ever read. You have done our profession a service and I appreciate you for it.

Here it is, you should read it too: “The Strange Happiness of the Emergency Medic” – Esquire Magazine

Posted by on April 20, 2012 • Filed under: Emergency Medical Services, EMS

Vive la solidarité! Something we have in common with our French friends

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Spoiler alert: There are a LOT of French jokes in this one. A LOT of them. You’ve been warned.

This should come as relief to those of you that are tired of measuring your suction catheters in “freedoms” instead of in French. While I was researching the French model of EMS delivery for the post I wrote last week (Hypocritically Speaking – My opinions about EMS models and philosophies) I stumbled across something in the Wikipedia article that made me want to raise a baguette in solidarity to our cheese-eating friends. You might just agree.

It is of note that the French model of EMS delivery involves physicians in all levels of the system. Unlike the American model, where physicians provide

oversight and only rarely respond to scenes, in France physicians are included everywhere from taking calls in the dispatch center to actively responding to scenes and taking care of patients. Their system is different than ours in many ways other than this, but the physician thing is pretty big. I’d always guessed that a system like that could only exist in the realm of near-total government funding, considering they’ve surrendered to the idea of socialized medicine over there. (Hey now, that was a French joke, not an American political statement. Cool your fondue)

But then, in the Wikipedia article, I read this:

“The situation is further complicated by the fact that the physicians staffing the SMUR units are among the lowest-paid in Europe. Although salaries have recently improved somewhat, in 2002 it was reported that these physicians, who are, for the most part, full-time employees of public hospitals, had a starting salary of only €1300 (£833; $1278) per month.[14] This economic reality has resulted in understandably high turnover and some difficulty in staffing positions. It has been suggested, however, that the recognition of emergency medicine as an in-hospital specialty in France and elsewhere in Europe is likely to result in the evolution of that system towards more comprehensive in-hospital emergency services.”

Garcon! Bring me my beret and your finest, cheapest cabernet sauvignon! It turns out that the low pay, little respect, and feeling that “once we’re viewed as a specialty the conditions will improve” isn’t limited to just this side of the Atlantic. Maybe if we’re both underpaid for taking care of sick people we might have other things in common. Maybe they can learn to like our cheap, watered-down beer and we can learn to like their stinky cheeses. Maybe there’s a common theme to EMS around the world that binds us all together. Maybe, just maybe, I can start calling my burn patients “French toast” and they can call their obese heart attack victims an “American Special”.

 

Or maybe not…

C’est la Vie, eh?

Posted by on April 18, 2012 • Filed under: appreciation, Economics, Emergency Medical Services, EMS, ems 2.0, EMS Management, EMS pay sucks, EMS Topics, humor, Paramedic, paramedic salary

Heat Emergencies for EMS – The Summer Time Blues

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It’s just about here! Summer time is awesome in where I live. It almost makes those long winter months seem worth it. Almost. With the warm weather close upon us it’s time to review some of the common complaints that EMS providers seem to see more of in the summer time. Gone are the days of frostbite and hypothermia and here are the days of heat stroke and bee stings. It pays to brush up on these complaints because we’ll be seeing them before we know it.

Heat Emergencies

We humans are a fickle bunch. Get us too cold or too hot and we tend to get sick as the dog days of summer. Since there’s little chance of hypothermia coming in the summer, a review of the hotter side of environmental emergencies couldn’t hurt. In emergency care, heat emergencies are generally classified into three levels in terms of severity. These are:

  • Heat Cramps
  • Heat Exhaustion
  • Heat Stoke

It’s important to remember that these classifications aren’t absolute and are harder to pin down when combined with concurrent medical conditions and other factors such as age, gender, and physical health. It’s also important to realize that some physical conditions, caffeine and alcohol consumption, and prescription medications can diminish a patient’s capacity for thermoregulation and precipitate heat injury.

Heat Cramps – Generally occurring in athletes or those undergoing physical exertion in a hot environment, heat cramps are muscle spasms that mostly occur in the abdomen or extremities. (Core temp 99.1-101.3)

Treatment for Heat Cramps includes general medical care, removing the person from the hot environment, providing oral fluid replacement, and cooling them gently.

Heat Exhaustion – Characterized by Fatigue, weakness, anxiety, intense headaches, profuse sweating, nausea/vomiting, and decreased urine output, heat exhaustion is caused by inadequate fluid intake and excessive fluid loss through sweating. It is essentially hypovolemia caused by hyperthermia and may be the result of several days of inadequate fluid replacement and dehydration. (Core temp 99-104)

Treatment includes much the same as the treatment for heat cramps. Do not give oral fluids to patients with a decreased level of consciousness. If your level allows, start an IV and consider a fluid bolus. Begin active cooling with ice packs to the axilla and groin. Monitor the patient’s vitals closely and watch for cardiac arrhythmias. BLS providers should consider an ALS intercept for fluid replacement.

Heat Stroke – This is a true medical emergency and aggressive treatment is warranted. It is characterized by a decreased level of consciousness, increased pulse and respiratory rates, and hypotension. Skin color, temperature, and moisture findings are not reliable but are generally hot and dry. It is becoming shown that patients that suffer near-fatal cases of heat stroke have a strikingly high 1 year mortality rate. (Core temp >105)

 

Treatment for Heat Stroke includes aggressive cooling with ice packs, evaporative cooling, and IV fluids. BLS providers should request an ALS intercept. Rapid transport is warranted. Manage the airway and other complaints such as arrhythmias as per protocol.

Watch your coworkers too. Make sure that your fellow EMS people are staying cool on incident scenes, especially when they may be wearing turnouts or other protective gear. When you're not actively performing tasks that require protective gear, strip it off to allow yourself to adequately cool. Push them to drink plenty of fluids and go to rehab when they need to. Be safe out there and watch each other’s backs. We need you out there.

Posted by on April 16, 2012 • Filed under: ALS Intercept, Emergency Medical Services, EMS, ems education, EMS Health & Safety, EMS Topics, EMS training, Firefighter Safety & Health, Paramedic, paramedic education, Patient Management, Training, Training & Development

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

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

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

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

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

I do have a few questions though:

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

 

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

 

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

 

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

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

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

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

Notice anything similar?

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

Hypocritically Speaking – My opinions about EMS models and philosophies

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I hate when this happens.

I recently had two separate conversations with people that made me think some of my opinions may be in conflict with each other. In fact, the outcome of these conversations made me realize that I may be a tad bit of a hypocrite when it comes to some of my long held beliefs. I hate when that happens. While I freely admit I will happily change any of my opinions in response to new and/or better information, I can’t seem to change my opinion on either one of these beliefs and it’s making me feel… well… like a hypocrite.

Let’s see if you can help me out.

Opinion #1: Modern EMS exists to bring care to the patient.

That’s an important sentence up there if you didn’t realize, because it represents two monumentally different schools of thought. I believe that the primary purpose of modern EMS is to bring care to the patient, not the other way around. That statement may not sound like much, but it is hugely important for the development of our profession. In the very beginning of what evolved to be EMS, back even before the Cadillac ambulances and hearses, EMS existed to bring the patient to care. Everything was based upon that fact. From the “Flying Ambulances” invented by Napoleon’s surgeons to bring injured soldiers to the surgeons away from the battlefield to the ambulances used in the US in the 60s and 70s, most everything that existed before the advent of paramedics and EMTs existed for the purpose of bringing the patient to the care that could only be provided for them in a hospital. That’s why the Cadillac ambulances had those big engines that could drive so fast and the qualifications for being an “Ambulance Attendant” involved mostly being able to burn exceptional amounts of rubber without killing the majority of the motoring public.

The conversation that brought this up was one I had recently with a Wisconsin EMT-IV Tech (think: NREMT-I 85 level) about a community of 15,000 people nearby that I think should upgrade their EMS to the paramedic level. Their ambulance service is operated by their local fire department and runs an excess 1000 calls for service per year. They have a fairly large state college in their jurisdiction that pumps up their population during the school year and increases the diversity of their response area. I believe that they should upgrade to provide their citizens better care. She believes differently. Her thoughts were that even though there is no hospital in the town, they have three within the area that they transport to. The closest is 10 miles away from their city limits in another town and the other two are both +/- 20miles away. She believes that they don’t need to offer their citizens paramedic service because they’re so close to the hospital. (This is Wisconsin, 20 miles is a run to the corner store ‘round these parts)

I trotted out my old standby, the one I wrote about above that says that EMS is about bringing care to the patient. I explained the two schools of thought and stated that they would be saving more lives and caring for their patients better by offering paramedic care immediately at the patient’s side, rather than withholding advanced care until they had driven a minimum of ten miles. While they provide good service at their current level, I believe that paramedic ambulances in our area bring with them the majority of the care a patient would receive in an emergency room for the first hour or so of their care sans most of the lab work and x-rays. Why wait to stabilize any patient’s condition? Why let someone deteriorate when there are tools out there that can help them?

She seemed to agree with me after I explained it using the “Bring to care Vs. Care brought out” analogy and I, for lack of a better term thought that I had “won” the conversation. (I like winning things) The next week, however, I had a conversation that completely challenged my original argument and made me resort to saying “Because I like it that way” when being asked my opinion about something somewhat similar.

Opinion #2: The US model of EMS is better than the French model.

There are a few competing models of EMS in the world, but two of the starkest contrasts are the French Model of EMS and the US model. In a nutshell, the US model employs paramedics and EMTs who provide limited stabilizing care on site and remove the patient to an emergency room to be attended to by a physician for definitive treatment. The French model relies on physician triage of emergency calls and then sends either a physician to the scene or an “ambulance” with the basic capabilities of a taxi. It’s more complicated than that, and you can read more on the French system on this well-written Wikipedia entry: Emergency Medical Services in France

My thoughts are that the French Model provides too in-depth of care on scene of an incident for severe complaints. For example, while most US paramedics can diagnose and begin treatment on most STEMIs (severe heart attacks) immediately and have the patient undergoing a cardiac cath by a cardiologist in under 30-40 minutes, I challenge the French system to do similarly. I believe that putting physicians on the ambulance limits the availability of EMS care and causes rationing due to the immense costs of having a physician attend to the patient. I also think that the economy lies in having a physician present in the ER where they have the best availability of their necessary tools and the ability to treat many patients at once.  However in truth, most my belief comes from little personal experience and more from media reports of incidents like the death of Princess Diana where the doctors sat on scene for two hours trying to treat her injuries rather than bringing her to a hospital with full capabilities.

The conversation I had that made me question this is one I had about a local helicopter ambulance service that provides either a physician/nurse or physician/physician flight crew. I remarked that I didn’t know how an on-scene interface with a physician would be and that I would be worried that they would over-treat a patient that needed to be swiftly removed to a trauma center instead. Of course, I’ve never seen nor heard of an experience like that with this service, I just was airing my biases. That fact was swiftly, and correctly, pointed out to me and I resorted to the shallow argument that I simply thought that EMS was “Our place” and that other professions needed to butt out…

And I was wrong, and admitted that I was. Then we all laughed heartily.

My potential hypocrisy lies in the fact that I want to support the neighboring community to pursue the paramedic level for their service but cannot seem to extend the same argument to support physician/physician crews on the helicopter. Isn’t it the same argument?

In addition… why don’t I support the French model of providing EMS over the US model for the exact same reason? Aren’t I the guy who thinks it’s time for Primary Care Paramedics in the US?

I’d like you to poke holes in all my arguments and call me out in the comments section, but before you do that, in my pre-defense I like parts of the French system and want to adopt them here. I like that they provide physician-level triage for 911 (or 112) calls and send out appropriate resources, provide instructions for self-care, and/or direct people to primary care by alternate transport. I like that they can treat-and-release on scene for appropriate complaints. I think that they have a lot aspects of their service I like, the same things I like about the British EMS model that are provided by paramedics. I also think that Paramedics are the experts in field care. We exist for the purposes of being the masters of the acute, the experts in the expedient, and the… somethings of the… people who need immediate stabilizing care. (Hey, you try thinking up a third thing). I like the US model because I think that it provides appropriately advanced care and proper specialized focus of training while allowing for cost-effective deployment, availability, and access across the broad spectrum.

But nobody’s perfect.

Your thoughts?

Posted by on April 11, 2012 • Filed under: Emergency Medical Services, EMS, ems 2.0, EMS ethics, EMS rant, EMS Topics, Paramedic, politics

12-lead EKG tips for EMS – Making the most of the squiggly lines

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The 12-lead EKG is one of the most fantastic advances in EMS treatment since the invention of the bandage. The movement of this powerful diagnostic tool from the confines of the hospital to the streets has been nothing short of revolutionary. It has given EMS professionals a wealth of information on how to best care for our patients and has driven hospital care and the development of medical care practices by providing clear and critical data that physicians had rarely before seen.

Did you realize that by moving this tool to the field, EMS has almost made heart attacks into a minor medical complaint that can be effectively treated if caught early? EMS has changed healthcare with that. We’re catching things that used to go uncaught and have vastly improved the lives and qualities of life for countless patients who pass through our care. Kudos to the visionaries that helped drive this change. No matter the level of the service, be it ALS, ILS, or BLS, a 12-lead EKG is an essential EMS tool and should be the standard of care.

Proper acquisition of the 12-lead EKG is paramount to getting the most out of this tool. An improperly acquired 12-lead does not provide diagnostic quality information and can render the tracing mostly useless. Here are a few tips to making sure that you get it done right:

Lead Placement

Traditionally, the limb leads go on the limbs, and while it’s acceptable to move them closer if you have to, try to avoid placing the leads over bony prominences or overly fatty areas. Look for a generally flat, clean, intact area of skin with muscle generally underneath.

The V-Leads go on the chest in a specific pattern. Leads V1 and V2 go in the 4th intercostal spaces (between the ribs) on either side of the sternum. To find these, go about 3 finger widths up from the xyphoid process, or bottom of the sternum. V1 is on the patient’s right, V2 is on the left.

V4 should be placed next, it goes one rib down in the 5th intercostal space, on the mid clavicular line. Place V3 in between V2 and V4.

V5 goes in the anterior axillary line (front of the arm pit) and V6 goes in the mid-axillary line. They go in the same horizontal line as V4.

Skin preparation

It is important to prepare the skin by cleaning it with an alcohol prep and by abrading it with a cloth towel to remove dead skin cells. You may need to wash the area with saline and dry it. Remove excess body hair by shaving. For females, place the leads under the breast tissue. You may need to lift and clean the skin underneath the breast to get a clear tracing.

Baseline

A quality 12-lead EKG has a smooth, flat baseline (called the isoelectric line). Baseline wander, or the vertical motion of the EKG line can mask important findings in the EKG tracing and result in a non-diagnostic EKG. The patient should remain motionless and lay as close to supine as possible for the acquisition of the tracing and the ambulance should be stopped and not moving during the process. It sometimes takes a few minutes for the EKG tracing to normalize and you should wait for it to do so. The goal is to be able to see the entire cardiac waveform clearly and be able to measure accurate ST segment levels. Skin prep is important to reduce artifact. A tracing with artifact or baseline wander can mask serious EKG findings and may cause a patient to be misdiagnosed.

Multiple EKGs

One EKG is a spot-check of the patient’s heart. Two EKGs are a trend of their condition. Try to obtain a symptomatic tracing of the patient before treatments like oxygen, nitroglycerine, or aspirin are given. While you shouldn’t  delay treatment, it has been shown that ST segment elevation can normalize quickly with EMS treatment and an EKG obtained afterwards that does not show ST segment changes can mask a STEMI that should be emergently treated by a cath lab. The 2 or 3 minutes you spend taking the symptomatic EKG can save the patient hours or days going without definitive treatment for their underlying condition.

A good rule of thumb is to capture a 12-lead EKG tracing at the patient’s side where you find them symptomatic, then again when you load them in the truck, and then before you arrive at the ER.

Conditions Requiring an EKG

A 12-lead isn’t just for chest pain.Acquiring one never hurts any patient and may help catch the odd presentation of a serious but vague condition. Obtain a 12-lead for possible strokes, altered levels of consciousness, weakness, dizziness, fatigue, palpitations, and otherwise vague medical complaints. Remember that diabetic patients, younger women, and various ethnicities often have atypical presnetations and may have “Silent MIs.” Be vigilant. You may just save a life.

Posted by on April 9, 2012 • Filed under: Emergency Medical Services, EMS, ems education, EMS Topics, EMS training, Paramedic, paramedic education, Patient Assessment, patient care, Patient Management, STEMI, Technology & Communications, Training, Training & Development, 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

Changing Cardiac Care – Being Suspicious

2 comments

Want another reason to lug the EKG machine out of the ambulance on your next call? A study recently published in the Journal of the American Medical Association and reported on by many national news outlets has found some information that may change EMS care.

From CBSnews.com:

“The study looked at 1.4 million patients who had experienced a heart attack between 1994 and 2006 to investigate the relationship between age and gender and heart attacks, specifically symptoms and death rates. Data revealed that 14.6 percent of women hospitalized with a heart attack died, compared with 10.3 percent of men.

Women were also much more likely to have a heart attack without any chest pain – 42 percent, compared with 30.7 percent of men.”

http://www.cbsnews.com/8301-504763_162-57382624-10391704/heart-attacks-in-women-greater-death-risk-fewer-feel-chest-pain/

Think about how the media represents heart attack symptoms to the public and about how we educate the public to recognize heart attack symptoms. Think about how even our EMS training has prepared us to recognize the signs and symptoms of a heart attack. We all pretty much look for the same thing, chest pain or pressure with radiation down the left arm. However, this study shows that a staggering 42% of women don’t have that symptom and that 30.7% of men don’t either. It tells us that nearly half of the patients who have this deadly condition don’t present with the symptoms we’re classically trained to recognize.

The study’s other finding that more men than women who had myocardial infarctions died after having the condition help illustrate another point: When looking for heart attacks, we all tend to assess everyone like they’re a 45 year-old white male. It is important to remember that age, gender, ethnicity, and culture play a role in how symptoms present. Comorbid conditions such as diabetes can change the way a heart attack presents as well.

This study helps confirm what we pretty much all know, that no two heart attacks are alike. When the heart doesn’t get blood flow to a part of it, it doesn’t work well, and it sends signals to our bodies that we may misinterpret. The classic “Chest Pain” symptom of a heart attack may well present as Jaw Pain, arm pain, weakness, diaphoresis, back or abdominal pain, or even making the patient feel like they have to burp. Unexplained fatigue with exertion, the inability to lie flat, or even dizziness and/or fainting may point to a heart attack.

EMS plays an extremely important role in cardiac care. It could be one of the biggest areas where the appropriate field assessment, working diagnosis, treatment, and transport decisions made by EMS improve the quality of life for the population as a whole. The proper assessment and working diagnosis by EMS can set the patient on the proper path through the healthcare system and make a huge difference in their quality of life.

What does this mean for your care today? It means that should you suspect that a patient has a possibility of having cardiac ischemia or is otherwise presenting with a cluster of symptoms you can’t pin down you should try to perform a 12-lead EKG with your first set of vital signs. While delaying treatment to perform a 12-lead is not anyone’s goal, emerging evidence is suggesting that significant ST elevation can normalize within as little as 4 minutes of common EMS care, including just the placement of a patient on oxygen. If we capture a symptomatic 12-lead at the point where the patient’s symptoms are most acute we can properly make the diagnosis and save the patient precious minutes, hours, and days of diagnostics to pin down the cause. Serial 12-leads, taking multiple 12-lead EKGs at various time intervals can prove beneficial as well. Remember that one 12-lead is a reference, two are a trend.

Gathering the best information we can on all patients in order to help guide their treatment through the healthcare system is one of the most powerful benefits of EMS care. Let’s help all of our patients get the care they need.

Posted by on February 24, 2012 • Filed under: EKG, Emergency Medical Services, EMS, ems education, EMS system, EMS Topics, EMS training, News, Paramedic, paramedic education, Uncategorized

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

3 comments

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

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

This just in:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Issues: I’m Scared of something, Have a Rhythm, and A New Column Up, Too.

2 comments

First off, my newest column is up over at JEMS.com – You might like it. I’m challenging the status quo. Like I do:

“EMS Provider Questions 3-Dose Nitro Rule – JEMS.com”

Did you read that and then come back? Good! But if not, I’ll link it again for you at the bottom. I’ve got a few other things that are on my mind today. Like this:

If you haven’t noticed yet, my posts are back in a rhythm.

I’m really enjoying all of the feedback and participation I’m getting on the blog since I’ve been hitting it regularly lately. I’m trying to do good, solid posts on Mondays and Wednesdays, with something on Friday to carry me through the weekend. On Tuesdays and Thursdays I plan on the occasional link love and mention of some of the other great bloggers out there. I hope y’all like the schedule and what I’ve been putting out lately.

But this week? The schedule is a tad off…

I wrote a detailed, strongly worded, journalistic, researched, and somewhat opinionated piece on a topic I care deeply about. It went long, so I broke it into two parts and planned to run it this week on Monday and Wednesday.

However, you’re probably noticing that you aren’t reading that post right now. That’s because the post scares me.

I am playing with fire with this post. Literally. It involves a burning issue that’s impacting a fire department that I am very familiar with. They, in turn, are very familiar with me. Their city council just voted to end their ambulance service in a move that they deemed purely financial. In the piece, I gave them strong advice and tough love after thoroughly exploring the issue as best as I was able.

But I’m scared to put it up here, honestly.

Any Fire-Based EMS vs. The World issue is a hot issue, fraught with peril for anyone who should so dare offer an opinion that isn’t “FIRE RULES!!! WHAT ARE THOSE IDIOTS WHO DON’T LIKE FIRE DOING!?!?!?!” I didn’t offer that opinion. While I support those firefighters and my good, long-time friends among them, I simply can’t blindly repeat that dogma. This issue is much, much more complex than that and unfortunately for my friends, that dogma isn’t going to work here. It has already failed and it will continue to fail if they continue to use it. The landscape has changed. Down is now up. Dogs and Cats are living together… Mass Hysteria! is happening and they need some new strategies.

Our friend Chief Reason wrote on the topic on his blog over at Fire Engineering and you can read his opinion on the issue I’m talking about here: “City Fires; Chief ‘retires’.  (Oh, and Art? We miss you over here at FEblogs)

Chief Reason does a good job of explaining the issue. I respect that man’s opinion a great deal and always have… and I’m not saying he’s wrong at all. I’m just saying that the argument he’s using to defend the position he’s defending is well… dated. The reality has changed as I have said and that kind of argument just isn’t going to work anymore.

Read Art’s post on the subject for more. I’ve written on it but am holding the post for a while. If anyone from Moline cares to talk about my opinion, I’d be happy to speak on it. However, I didn’t just write it for Moline. There is a much, MUCH wider issue at hand.

Here’s the deal: This thing that happened in Moline? It’s coming to your town. It’s coming to where you live and if you defend yourselves the same way I see them defending themselves, you’re probably going to lose your fight. (Not that I want them to. I support quality EMS in the City of Moline. I have a lot of friends and family that live and work there and I want the EMS there to be the absolute best it can be)

I’m going to think about posting the piece. Till then, if you care to read it before I decide, e-mail me at ProEMS1@yahoo.com or hit me up on Facebook and I’ll send it to you.

Also as I mentioned up at the top, my newest monthly column is up over at JEMS.com – Pop by and have a read. I’m challenging beliefs there, too.

“EMS Provider Questions 3-Dose Nitro Rule – JEMS.com”

Posted by on November 2, 2011 • Filed under: Ambulance, ckemtp, ckemtp rants, Emergency Medical Services, EMS, EMS Humor, EMS Topics, EMT, Fire department, Fire Rescue Topics, Funding & Staffing, News, Paramedic

Tripping at the Hospital – A Teachable Moment for EMS

6 comments

Quick: Name the safest place you can think of to have a medical emergency.

Would it be inside of a hospital? Maybe an ambulance base? Perhaps a concert venue with medical staff on site?

Back when I worked in a hospital, we used to have a procedure called a “Code Green.” We’d call one on the occasion of “A medical emergency occurring in a non-patient care area of the property resulting in a need for emergency medical care.” It was implemented in the early 2000’s in response to the disorganized response we had been seeing to on-property medical emergencies in areas such as the parking lot or the hospital lobby. Usually Code Greens would result from someone falling however they occasionally resulted from some other type of medical problem. I even think they even worked a cardiac arrest in the parking lot on a day I wasn’t on-duty. My position at the hospital was a cross between a Security Guard and an EMT as I progressed through Paramedic school. At that chain of hospitals with three campuses and around 500 beds, the Security department operated an ambulance service to do interfacility transports between the ERs and inpatient units. It was an interesting system. As Security/EMTs we naturally became the primary responders to “Code Green” calls, which seemed to happen once or twice a month in my recollection.

I was reminded of our Code Greens when I read this article coming out of Niagra Falls, Ontario (Canada) concerning an elderly woman who fell while walking out of a hospital.

According to the article from The Toronto Star, the 87 year old woman was leaving the facility after visiting her terminally ill husband when she suffered a fall and fractured her hip in the hospital parking lot. The article has a fairly critical tone towards the hospital and its staff; blasting them for having to call an ambulance and for the time it took to get the woman off of the ground. The woman, who in the article is stated to have a previously fractured arm, is reported to have laid on the ground for “Nearly 30 minutes” while waiting for the ambulance to transport her to the ER, which is stated by her son to be “only 50 yards away” from where the fall occurred.

I linked this article today because I believe the opinions expressed show a great deal of information towards the public’s perception of the roles of healthcare workers. The article seems to think that it’s quite ironic that an ambulance was called by hospital staff… to a hospital. When, according to the article there were two nurses on the scene. The article places the orthopedic surgeon who happened by “eventually” and “moved the woman into a wheelchair” as the hero of the story.

My thoughts here are that the nurses who were called to the scene of the fall most probably identified the woman as being at a high risk for further injury from additional movement as evidenced by the fact that she had a previous arm fracture and what I would guess to be an obviously fractured hip. Their concern was probably that further movement of the patient in an incorrect fashion would have aggravated her injuries and could have resulted in further damage. As far as I know, Canadian nurses (like their US counterparts) aren’t trained to move patients with potential spinal injuries and obvious hip fractures who aren’t prepackaged by EMS crews or otherwise immobilized. They also most probably did not have access to the proper equipment needed to do so. In fact, the physician who picked up the patient “with the assistance of an aide” and placed the woman in a wheelchair would have been lambasted if he were a paramedic. While I’m going to assume that an orthopedic surgeon would have extensive knowledge of the human skeleton, it’s not exactly optimal care to bend a hip fracture the 90 degrees to move a patient from a supine (or prone) position to an upright seated one. In this case, packaging the patient on a long spine board with full cervical spinal precautions would have been the best medicine. Everyone has their areas of expertise and as we’ve all observed, or at least became aware of by watching the trial of Dr. Conrad Murray in the MJ death fiasco, doctors aren’t always the best experts in emergency care. That’s what Paramedics and EMTs are for. EMS people are the “Masters of the Acute”. Our specialty is those things that are happening in the here and now. It would have been irresponsible for the nurses to move the patient in this article without having the requisite training and equipment and even the physician that did move her risked causing further injury. While the article lauds him as the hero of the situation, the headline just as easily could have been about how he paralyzed her or lacerated her femoral artery when he moved her obvious fracture 90 degrees.

In my opinion, the statement of the hospital administrator is laughable. It’s doublespeak and must have been given for purely political reasons… I hope.

From the article:

“The supervisor of the Niagara Health System said the incident stemmed from a communication problem among staff.

“We shouldn’t have called the emergency room,” said Dr. Kevin Smith, who was hired on to aid the beleaguered region at the end of August. He said when a person is hurt in hospital, staff should call a “code,” meaning a team — not necessarily in the ER — is paged to help immediately.

When asked why staff felt the need to call for an ambulance, Smith said that may have been an old rule at the hospital. He said staff has now been briefed on the correct policy and a review is underway.

He could have mentioned any of the above things that I mentioned and it would have been just fine. It might have even been a non-issue if Canada’s less-litigious society is taken into account. Instead of stating that nurses aren’t paramedics and aren’t trained to do the same things, he backpedaled and blamed “communication problems” and “old rules”. I can’t say… but maybe this hospital administrator just doesn’t get the difference in emergency healthcare professionals either.

The writer of the article sure doesn’t.

We need to get the word out that EMTs and Paramedics are highly specialized emergency healthcare professionals with expertise in handling acute emergency situations. We are not interchangeable with other healthcare disciplines. Saying that a nurse or even a physician is a good substitute for a paramedic is missing the point that emergency healthcare is different than other specialties. EMS is truly a specialty requiring expertise, practice, and study. A person cannot just be thrown into the position and be expected to perform… no matter what the setting of the emergency happens to be.

This article provides our profession with a teachable moment. I just wish we all had the ability to seize upon it and spread the right message.

The safest place to have a medical emergency? It’s right next to a paramedic. No questions here.

Posted by on October 31, 2011 • Filed under: Ambulance, Emergency Medical Services, Emergency Nurse, Emergency room, Emergency Room Nurse, EMS, ems education, EMS Management, EMS Topics, hospital, News, Paramedic, Patient Management, politics, RN

A Predatory Ambulance Fee?

14 comments

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

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

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

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

Here’s what sets me off:

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

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

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

This is not fair.

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

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

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

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

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

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

Is anyone else doing this?

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

GPS in the Ambulance – An overreliance on Ms. Kitty

16 comments

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

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

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

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

Her:       “It’s what?”

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

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

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

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

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

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

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

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

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

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

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

Ain’t modern technology great?

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

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

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

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

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

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

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

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

“Teamwork” on the ‘bambilance – Shown as a video metaphor

No comments

I read a good article written by (the highly educated) Guy Haskel on JEMS.com today called "Persona Non-Grata" and I've got to tell ya, I've been right there. I've been on the recieving end of exactly what he was talking about in the article and I have all kinds of empathy.

Here's the article - Read it and remember that you simply can't please everybody.

This article got me thinking about some of the more interesting relationships I've had with coworkers and partners over the years. Some of them have been very smooth and friendly and have resulted in some good friendships. Some have been smooth but less-than-friendly and resulted in some comfortable times at work… others?? Well… I'm sure you all can guess.

Have you ever had an ambulance or fire-department shift that felt like this? (This is such a good metaphor)

 

Posted by on October 21, 2011 • Filed under: Emergency Medical Services, EMS Health & Safety, EMS Humor, EMS Topics

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

Enhanced EMS Refusals? Read this, then look for more

2 comments

Howdy everyone!

Yep, I’ve been quiet for a while, but that’s because I’ve been busy doing… um… doing, uh… Doing stuff that you’ll be hearing about later. Don’t worry about me though, because I’m certainly not going anywhere.

A while ago I came up with an idea for what I call the “Enhanced EMS refusal” and it’s an idea that I think EMS could start using tomorrow that would be a big step in ushering in EMS 2.0. I wrote about it in my August column on JEMS.com

Here’s the link on JEMS.com:  “Paramedic Uses Enhanced Patient Refusals” – Chris Kaiser NREMT-P

Look for more on this coming up on the blog, I have a lot to expand on the idea, including sample policies and documentation.

Good to be back, y’all.

Posted by on August 25, 2011 • Filed under: Administration & Leadership, Emergency Medical Services, EMS, ems 2.0, EMS Topics

What Does “Brotherhood” mean?

12 comments

I read an article yesterday in the Milwaukee Journal Sentinel that unfortunately, didn't surprise me all that much. It regards a professional, career firefighter who chose to opt out of his union due to his political beliefs. He's a conservative, and due to his stance on the political causes championed by the union, he's decided to take his money elsewhere and invoke a little-used "Fair Share" legal clause that allows him to drop his union membership and only pay pro-rated dues for his share of the collective bargaining. He does not pay for the union's wider political activities.

And this? Well, actually I can support it. He's voting with his feet based upon his beliefs. I respect anyone of strong conviction that truly does what they believe to be right. I like that, in fact… no matter a person's political spectrum (Well, almost no-matter their political spectrum)

I rarely talk about politics here, but this case is different. It seems this firefighter has constructed a float commemorating his brothers who died in the Sept. 11th, 2001 attacks and wants to run it in the local Racine, WI 4th of July parade.

The union thugs (Yea, I said "Union Thugs". That's what they are) have issued a fatwah barring any union firefighter from riding on or marching with the float in the parade. They won't comment further on the issue. They just don't want to support the "fair share" firefighter.

Here's the article, you should read it yourself "Firefighters' Union Throws Cold Water on 9/11 float"

As I said, I am not at all surprised by this. I'm still saddened, though. It makes me think it's time for me to pull out my favorite Paul Combs political cartoon.

Kind of says it all, doesn't it?

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Also on another note,  did you read my last monthly JEMS column on Ambulance Service Disaster preparedness? You really should:

http://www.jems.com/article/major-incidents/ems-agency-plans-natural-disasters

 

 

Posted by on July 3, 2011 • Filed under: Administration & Leadership, ckemtp rants, Emergency Medical Services, EMS, EMS ethics, EMS Topics, Fire department, Fire Rescue Topics

Blood Pressure – Vital Knowledge for EMS

12 comments

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

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

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

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

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

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

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

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It can diagnose Orthostatic Hypotension

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

What does this mean?

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

(Read More? http://www.medicinenet.com/orthostatic_hypotension/page2.htm)

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It can help diagnose a Thoracic Aneurism

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

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

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 It can help detect increased intrathoacic pressure and other conditions

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

What does this mean?

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

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

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

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

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Want to learn more stuff about stuff? Check out:

 

 

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

Perils of Paramedics Pursing imProper Patient Refusals

7 comments

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

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

Ok, ya back? Good.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

DC BLS Ambulances out of service as Hot Weather Arrives

<sigh>

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

Excuse me, I mean "FEMS."

<sigh>

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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

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

4 comments

Howdy everyone!

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

And let me just say, good luck with this.

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

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

Including this one:

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

Uh huh.

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

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

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

This guy’s one of us.

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

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

 

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

A Shoutout Across the Pond to our British EMS Brethren

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

EMS Narrative Report – Ckemtp on the MedicCast EMS Podcast

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

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

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

Otherwise, you can view it here.

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

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

 

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

Eight Ways you can Ace your Patient Assessment – EMS

3 comments

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

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

Take a look at the three general types of assessments:

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

 

 

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

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

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

 

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

                                                    

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

 

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

 

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

 

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

 

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

 

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

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

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Want more information on the patient assessment?

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

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

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

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