Archives for ems-management

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

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

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

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

Revenue Preservation
Area Preservation
Ego Preservation
Political Capital Preservation

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

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

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

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

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

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

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

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

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

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

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

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

EMS Providers Carrying Guns – A terrible idea

34 comments

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

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

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

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

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

Here are some of the reasons why:

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

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

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

Pictured: A possible successor for the IO drill?

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

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

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

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

1 comment

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

I went with French toast. Yeah, it's tacky... but you try typing "French Model

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 Ckemtp 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

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

7 comments

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

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

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

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

Yes, their bus is cooler than your rig.

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 Ckemtp 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

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.

Soon to be the corporate ladder?

Posted by Ckemtp 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

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.

Pictured: Not generally a nurse's thing...

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 Ckemtp 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

GPS in the Ambulance – An overreliance on Ms. Kitty

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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.

We have 4 seasons in the Northern Midwest "Almost Winter", "Winter", "Still Winter", and "Construction"

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.

———————————————————————-

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

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Posted by Ckemtp 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
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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.
See? Excel! It's... not interesting...

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.

Here Excel is being used as a metaphor for Awesome

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.

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

Get a Pulse, Get a Steak? Random Incentive
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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.

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Posted by Ckemtp 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

Perils of Paramedics Pursing imProper Patient Refusals
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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.

My Thoughts on Fire-Based EMS

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

From the #WTF files – AL Fire Chief Flushes Twins down the Toilet?
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Holy crap! Read this: Odenville, AL Fire Chief Terminated FireLawBlog.com

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

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

Nobody? <sigh>

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

Eww.

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

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

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

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

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

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

We Oughta Look In to This – EMS 2.0
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It looks like something has been right under our noses all this time, and I think that it just might be looking into.

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

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

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

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

Also, this:

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

Huh.

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

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

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

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

Primary Care Paramedics? I think it’s time

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

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

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

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

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

Here, see for yourself!

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

I think it's a potential gold mine.

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

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

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

I think it has to change.

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

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

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

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

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

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

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

“When Medicare Helps Cover Ambulance Services”

“What Medicare Pays”

“What You (the patient) Pay”

“What to do if Medicare Doesn’t Cover Your Ambulance Service”

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

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

“Emergency ambulance transportation

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

You’re in severe pain, bleeding, in shock, or unconscious.

You need oxygen or other skilled medical treatment during transportation.

You need to be restrained to keep you from hurting yourself or others.

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

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

I just don’t think that they are.

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

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

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

And we as a profession have to change it.

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

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

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

Do you?

————————————————-

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

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

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

“A Shoutout Across the pond to our British Brethren”

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

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

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

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

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

Ahhh, this is SO much better than doing a report

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

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

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

I hate those kinds of EMTs.

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

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

I wasn’t surprised.

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

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

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

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

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

——————————————————————–

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

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

A Shoutout Across the Pond to our British EMS Bretheren
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Mark in his British Paramedic Uniform

If you don’t know Mark Glencorse by now, you’re either very new to the EMS blogosphere or have been living under a rock. In addition to being a fine paramedic by all accounts, Mark runs the EMS blog www.999medic.com which is a member of the www.FireEMSblogs.com family of which I also am a member. Mark has a comfortable, familiar style of writing that brings you right there next to him as you read his articles. It’s almost like you’re running the calls with him, experiencing the joys and pain of a British Paramedic as he experiences them himself. He’s one of my Best Blogger Buddies and I’m proud that I can call him a friend. I read most everything he writes.

I hadn’t been to his blog for a few days though and thought that today would be a good time to catch up on what he’s been writing. He’s got some good stuff up lately, but in addition to some of his more educational articles, I found some things that just floored me.

We here in the United States can learn quite a bit from our brethren across the pond. They have aspects to their system that could be very valuable for us here in the states. Their EMS system is similar to ours in a lot of ways, not the least of which is the fact that they respond to largely the same types of calls that we do, but is also vastly different in terms of initial education, pay, respect, and capabilities.

I’m going to explore three of his recent posts here and see if other fellow US paramedics and EMTs will be just as floored as I was. Here goes:

“The Clash of the Assessments” – 999medic.com

This post explores some friction that he and his fellow paramedics have been having with “Walk In Centers” (WICs) that have sprouted up all over his country. He describes these clinics as such:

“In the UK over the last few years, we have seen hundreds of NHS Walk in Centres (WIC) sprout up around the country. These are primarily Nurse led units that are placed strategically in various towns and cities to provide care for those residents who are suffering from either minor injury or illness. They most definitely have a place in the wider primary health care environment, but ask any Medic what they think of them, and most will tell stories of picking up patients from the Walk In Centre to take up to the Accident and Emergency department who clearly do not have any specific life threatening or emergent need, and who, in the paramedics opinion should have been treat and discharged from the Walk in Centre.”

This sounds pretty familiar to me. Here in the US we have plenty of Urgent Care Centers that have sprouted up all over the American Healthcare landscape. They are staffed sometimes by a Physician, but are largely staffed by Physicians’ Assistants (PA-Cs) and Nurse Practitioners (ARNPs). They handle minor medical complaints and urgent-but-not-emergent medical conditions. Most of these centers are perfectly adequate for treating most patients with day-to-day illnesses and minor injuries. They cost much less than an emergency room visit and help save the ER from having to handle all of these minor cases. I fully support urgent care centers and their use in the spectrum of healthcare. However, my fellow medics and I can all point to times where we’ve responded to urgent care centers for complaints that we did not believe to warrant an emergency response and subsequent transport. I can emphasize with Mark and his coworkers about their problem with these kinds of transports.

Here’s what Mark describes as the “Rant” he’s trying not to have:

“My service has direct referral pathways to the Walk in Centres. If I have a patient who I think fits the fairly strict criteria for assessment and treatment at a WIC, then I can contact one of the nurse partitioners on the phone and discuss my patient so that they know what I am bringing in and more importantly that they know they are suitable for their level of care and will not need to be shipped out to the A&E department at a later time.”

Wait… What?

“My service has direct referral pathways to the Walk In Centres”

Dude!! We have been practically begging for that here in the US for some time! That’s AWESOME that the British can do that! Alternate treatment and transport pathways are one of the cornerstone ideas for EMS 2.0. This practice would save a great deal of healthcare dollars, would lessen the burden on the overcrowded ERs, would be remarkably more convenient for the patient, and would help keep the ERs available for the more serious of illnesses and injuries. This is a slam-dunk that we here in the US just can’t seem to figure out for ourselves and here we see the program is already active in the UK. We should steal that data and use it to help justify our own programs.

The next two articles I’m going to explore are pretty entertaining. Mark was selected to ride along in a multi-disciplinary unit of both civilian and military police officers in a busy urban center that has been having problems with alcohol and young people trying to mix too often. The set-up is pretty cool. He rides around with the police officers, helps them with what he is able to help them with, and is available to handle any medical problems that might arise with a 2 to 3 minute response time. The program sounds great, actually and I think that it could probably be employed with some success in many areas of the US… but read this account of his first EMS call while with the PD:

Mark (Right) with the rest of the British Team

“Less than a minute later, a police van turns up outside of a bar, the side door slides open, and out jumps a paramedic!” (Apparently it’s novel for the Police to be around with the Paramedics there)

“After a few quizzical looks, I get on with doing my usual job and assess the patient. He has a small cut to his forehead where someone punched him whilst wearing a ring. It is a minor wound but will need either stiching or gluing. There was no loss of consciousness, he has no other apparent injury and his observations are fine. Its still early in the night and he has only had a couple of drinks and doesn’t appear intoxicated.”

Man… so the patient is drunk and has a head injury… All you US paramedics know what that means. Here comes an ambulance in to transport the patient to the hospital. He can’t refuse because of the ETOH on board coupled with the head injury, and you know you don’t want to be sued… Let’s see what Mark did:

“I advise him that he needs to be assessed at the local hospital so that the wound can be closed. After dressing his forehead, he promptly jumps into a waiting taxi and heads off to the hospital less than 10 minutes away. I complete my paper work, Dave completes his log and we are off again.”

“From time of call to patient leaving scene – 8 minutes!”

WHAT!? OH COME ON NOW! That’s just not fair! You mean to tell me that Mark was able to use his clinical judgment, assess the guy for his injuries, and make a common-sense treatment and transport decision? He put the guy in a Taxi??

That would be a potentially career-ending move for a US paramedic. The Brits do it regularly. Could you just imagine what the ability to make those kind of decisions would mean for the US EMS system? Could you just Imagine what that would mean for EMS 2.0?

Let’s see what happens with the next patient encounter he describes:

“As we are sitting outside one of the shops, Dave hears one of the door staff calling for police assistance. He has been assaulted and has a head injury.”

“Again we are on scene in less than two minutes. This time the wound is a bit worse and is still freely bleeding. A dressing, some direct pressure and a quick assessment later and he is sitting next to me in the back of the police van whilst we drive him the short 5 minute journey to the local hospital. Again, no need for an ambulance, just transport to the hospital. In this case, and many others, the team are happy to use the police van instead of calling an ambulance into the town centre. It is a real benefit having the hospital so close to the centre of the town!”

“Even though we transported this patient to the hospital, we were again back in the town centre and patrolling in under 20 minutes from the time of the call.”

Apparently this is British Medical Control

So he brought the guy to the hospital in the Police car. Actually I’m familiar with the fact that they do this over there. Mark is regularly staffed to what they call a “Rapid Response Car” which is part of their “Front-Loaded Model” where they send a paramedic first to emergency calls to determine what the best course of action would be for the patient. Many times they don’t send an ambulance until the paramedic makes the transport decision. One of those potential decisions is to simply transport patients in the car with them instead of the ambulance.

You can find Part One of “Working A Police Medic Shift” – Here

And you can find Part Two – Here

I’m no fan of socialized medicine, but I have to give credit where credit is due. The US EMS system could learn a lot from the British system and I just can’t get over the fact that so many of the things we speak of for the EMS 2.0 movement here in the US are being done right now by our brothers across the pond. It would stand to reason that we could use the data that they’ve collected and created right now, steal a lot of their ideas, and begin to implement them right here in the good ol’ US of A.

Wouldn’t it be great if there was some kind of “Project” where an a British Paramedic could come to the US and explore the US EMS system? How about where an American Paramedic could come to the United Kingdom and learn about their system?

Oh wait, there is. The Chronicles of EMS has been doing just that very thing. If you’re a regular reader I’m sure you’ve already heard of it. If you’re not familiar with it, you should go right now to www.ChroniclesOfEMS.com and learn about it. It’s an amazing thing done by both Mark Glencorse and Justin “The Happy Medic” Schorr. If you’re an American EMS person, you really need to know about this and show them as much support as you possibly can.

And while you’re at it, check out some of the other fine British EMS Bloggers:

Insomniac Medic – http://insomniacmedic.blogspot.com/

“A Life in the Day of a Basics Doc” – http://basicsdoc.blogspot.com/

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Posted by Ckemtp on October 30, 2010 • Filed under: Administration & Leadership, Emergency Medical Services, EMS, ems 2.0, EMS Management, EMS Topics, ER, medicblog999, Paramedic, UK paramedics, united kingdom, universal healthcare, US economy, Your Happy Medic

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

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

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

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

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

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

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

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

-          Cat Puke Chicken

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

-          And Much, Much more…

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

“First, Do No Harm”

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

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

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

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

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

And frankly, I don’t care.

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

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

EMTs have an Oath as well...

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

I don’t usually talk about Political things…
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But when I do, they’re usually of the macro-local type and have something directly to do with EMS.

This is one of those things.

The village of Schaumburg bucked the national trend of raising taxes and fees to cover rising expenses when its board unanimously approved a 4.4 percent reduction to the 2010 property tax levy

You read that right: reduction.

But that’s not all. Village officials also did away with vehicle sticker fees and moved to have property taxes cover garbage removal.

Just for the record, Schaumburg is in Illinois, folks. The same state that sent our senator up to the White House last election cycle. Lowering taxes isn’t exactly the modus operandi for an Illinois municipality. In fact:

Schaumburg is an anomaly among Illinois municipalities. Others like Gurnee and Orland Park raising taxes and fees where ever they can. Northbrook, which has seen an increase in sales tax revenue stood pat.

Schaumburg is one of the larger municipalities in the sprawling conglomeration of suburbs surrounding Chicago. It faces the exact same economic challenges that other municipalities in the area face, but it seems to be doing much better, economy wise.

The measure, if you read the article, isn’t final, but it looks like it will pass. Schaumburg has a full-time Fire/EMS dept and pays their firefighters extremely well, they also seem to have great city services and every time I’ve been in the city I’ve liked what I’ve seen.

In fact, the recent NAEMSE conference was held in a hotel in Schaumburg, and they played a small part in paying the hotel tax.

As I’ve said before, I’m not one to wax too poltical on this blog. This is an EMS and Fire blog and you come here to read about things related to Fire and EMS. I understand that. I don’t want to hijack the discussion to the miasma that is our national political scene and end up alienating a different percentage of my readership every time I post something of an opinionated political nature. However, local politics affect EMS and Fire, and I speak on the politics of EMS quite a bit. This is one of those issues.

I have to ask the question here:

Businesses pay taxes, residents pay taxes, Visitors pay taxes… It goes to say that the more businesses, residents, and visitors a locality gets, the more taxes they’ll pay by sheer volume. People have a choice on where they locate their business, where they visit, and where they choose to live. If you were in the position to do any of these things, knowing that Schaumburg is lowering their taxes, and plans on removing their property tax entirely - just like they said they would – would you choose to do so in Schaumburg, or in the other towns mentioned in this article?

In additon, removing the stupid municipal car stickers, which are really just a massive inconvenience and hassle to the residents of a city, and covering garbage disposal fees through what’s left of the property tax?

Well, Schaumburg… you may just be an island of sanity in an insane state. May word get out and people flock to your borders. It’s called “competition” and usually only successful businesses are the groups that think of lowering their prices to become more attractive to the customer. Bravo.

Source: http://www.nbcchicago.com/news/local-beat/Schaumburg-Officials-May-Lower-Property-Taxes-103947993.html?dr#ixzz10vUpO9PP

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Posted by Ckemtp on September 29, 2010 • Filed under: Administration & Leadership, Economics, Emergency Medical Services, EMS, EMS Management, EMS Topics, fire, Fire Rescue Topics, Funding & Staffing, News, newspaper, Paramedic, Uncategorized

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

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

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

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

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

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

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

So do you see a problem there?

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

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

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

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

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

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

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

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

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

————————————————————

For more tips on EMS documentation:

Soapy Pictures – The EMS Narrative Report

Six Tricks you can use today to improve your EMS narrative report

More on EMS Narrative Reporting

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

Automatic Window Roller Uppers and Other “Great” Ideas
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A few years back I had the chance to drive a 1997 Saturn 5-speed coupe for a while. It was a pretty nice car and I drove it back and forth on my tri-weekly 2 hour commute from the Quad Cities of IL to the Chicago Suburbs for my 24hr ambulance shift. It actually worked out well because the pay for paramedics was so much higher in the Chicago area than it was where I lived. I’d go up, do a 24 or a 48 hour shift, and have plenty of time to work my other jobs back home. I didn’t really mind the drive but I’d save so much money by driving the Saturn instead of my full-size truck that I’d drive it whenever the ex-gf would let me.

One thing about driving the highways around Chicago is the incessant amount of toll-booths that one must cross while driving there. There are literally more toll-booths than I can count and every one of them requires a person to get out of traffic, stop, and pay the toll. It’s annoying in a car with an automatic transmission and even more annoying with a manual transmission. It aggravates me to say the least.

One of the features of the 97 Saturn SL 2 Coupe is an automatic window roller downer (is there a better name for that?) where the window will roll all the way down with just one click of the button. It was actually pretty handy for going through a toll-booth in a car with a manual transmission. I could click the button, then focus on downshifting for the quickest stop possible. This feature is common on cars nowadays, but back in the primitive turn-of-the-century it was my first Automatic Window Roller Downer Feature and I thought it was pretty cool… Except for one problem:

The window only went down automatically, It wouldn’t roll back up with only one click and had to be *manually* automatically rolled back up again. Yes, by this I mean I actually had to use one whole finger to hold the button. It was kind of a minor annoyance when I had to reaccelerate while shifting the manual transmission. Back then I didn’t think it was a huge annoyance, mind you… but I thought that the simple addition of an automatic roller back upper feature would have been much better. I could just imagine that the simple change would make it more useful and I was a tad angry about the shortsightedness of the engineers. I mean, why couldn’t they have thought of this when it seemed so obvious to my 20yo self? If I had thought of it had to be a good idea, right?

Well then some years later, I rented a car that actually had both an automatic roller downer feature *and* an automatic roller upper feature. I was so happy to find that! It was SO COOL! Finally the engineers had listened to my private thoughts that I never shared with anyone and put in my feature! I was happy.

Then I tried it for a while… and it sucked.

Yea, having a “one click” roller upper feature means never just cracking the window open a bit. One click may bring the window down a touch, but the auto feature keeps it rolling down all the way. In the previous design, without the automatic roller upper, this could be stopped by one quick click in the other direction. However, with the automatic roller upper feature, the window just rolls back all the way up! Getting the window open just a little bit is nearly impossible. Then I thought that if a kid or a less-than-intelligent adult chanced to stick their head through the open window and the button got depressed, the window could roll all the way up and choke them. The automatic window roller upper feature is annoying as heck and wasn’t the great idea that I thought it would be. It was an idea that I didn’t think all the way though. I thought I was smart and well, I wasn’t. It’s probably a good idea that I didn’t get all fired up and start a national letter writing campaign to lobby the car companies to put in automatic window roller upper features (Which I would have urged them to rename to “Chris’s Awesome Mega RoLL uPPahhz”) because then I would have looked like an idiot to more people than just myself. It’s the reason why I rarely orchestrate nationwide letter writing campaigns: experience.

This got me thinking about all of the ideas that I’ve had about things in EMS and in other aspects of my career that I didn’t think wholly through. Steve Whitehead, the genius behind http://www.TheEMTspot.com wrote an article recently that spoke of the fatal flaws in the heroes of Greek Tragedy that I really liked. You can find the article here “8 Tragic EMS Behavior Flaws to Avoid” (I’ll link it at the end too, because you really should read it) but here’s what struck me so blatantly in the article:

The Critic – “This is all so stupid”

This is perhaps the easiest of all the hero flaws to slip into and the toughest to shake. The critic is convinced that the world desperately needs his or her opinions on the way things ought to be. They figure out that offering opinions is so much more fun and rewarding than working to solve a problem and then it becomes like a drug. Soon they’re framing everything they see with the question, “How should this be done better?” and then offering their sage analysis. Usually with a poor understanding of why the thing is the way it is in the first place.

The problem with the critic is that they genuinely believe that the world wants to hear their endless assessments and when an army of engineers doesn’t show up to start doing the hard work of implementing all their great ideas, they get frustrated. The second problem is that they jump to analysis without seeking to ever understand the nature of the problem. Research and implementation are hard, but critical evaluation is fun and easy. As long as they don’t build anything real, they never have to worry about the next critic showing up, spending a few minutes looking at what they built and offering up their sage criticism.

This is the part of Steve’s article that really got me thinking. Have I been “The Critic” too often in my career? I mean, I don’t try to do this… but I find faults in a lot of aspects of contemporary EMS. I look at things and try to find ways to make them better. If you’re a regular reader, in-fact, that’s probably why you come to read what I have to say as often as you do. New ideas are great.

However, as my Automatic Window Roller Upper debacle (that yes, wholly occurred only within the boundaries of my own cranial cavity) has shown, some ideas that come to me and seem so obvious can also be bad ideas. My experience has proven to me time and time again that I need to think things through. I try, but EMS doesn’t always allow us the time to consider all options, let alone every aspect of every option. The Law of Unintended Consequences abounds and rears its ugly head quite often.

As the years have drug on, I’ve been trying to analyze my “Great” ideas more fully, but one person rarely has the ability to completely devise the correct answer to every problem. Two heads are better than one a lot of the time and systems have a way of developing themselves.

So as we go forth to change this thing we call EMS and usher in the new world of EMS 2.0, let’s remember to consider as many reasoned opinions as we can. We need your input and we need your participation. The more we grow together, the better our ideas become.

Oh, and here’s that link to Steve’s Article again: “8 Tragic EMS Behavior Flaws to Avoid”

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Posted by Ckemtp on August 16, 2010 • Filed under: Administration & Leadership, ckemtp, Command & Leadership, Emergency Medical Services, EMS, ems 2.0, EMS Management, EMS Motivation, EMS Topics, Fire Rescue Topics, Firefighter, grumblemedics, inside the mind of a paramedic, Paramedic, paramedic education, Training & Development, training-fire-rescue-topics

You Can Nap if You Want To! Or You can Leave Your Calls Behind!
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What a week! You’ve been pulling at least a double shift a week at your full-time ambulance job and have been hitting it pretty hard at your part-time job as well. Both services can’t seem to keep their schedules filled and everyone’s been working lots of hours in order to keep the doors going up and the trucks going out. To top it all off, the citizens just can’t seem to be good lately and both services’ call volumes have been high.

You were tired when you got up this morning and were seriously considering a nap after your morning shower, but after a gallon or two of coffee you were bright and shiny in your uniform at your station, ready for another day of EMS greatness.

That was five hours ago though, and the early barrage of calls fired at you this morning has turned into an afternoon lull. Now you’re sitting at your main station, close to the brass, with the words in the educational article you’re reading fading in and out of your bleary, cross-eyed vision. Since the activity level has decreased, you’ve gotten yourself a case of the sleepies that you just can’t shake. Since you’ve been consuming the steaming bean juice religiously lately, your stomach just won’t let you think of having another cup of the acrid station coffee and there’s no shift chores left to do, since you did them an hour ago fighting the same lethargy.

Unfortunately, in three hours you can see a long distance transfer scheduled that you’re probably going to have to do. Four hours of monotonous highway driving and the radio in the truck doesn’t have that great of reception. You don’t have any idea how you’re going to stay awake enough to drive the truck and that’s not even considering the fact that if the tones went off right now for an emergency you probably wouldn’t remember how to put on a band-aid, let alone remember a drug calculation.

You’re tired, you’re fatigued, and your body’s telling you that you’ve been pushing it too hard. It wants to shut down for a while. Your brain won’t think. You’re mouth won’t talk. You can’t keep your eyes open and wake up with a startle when you’ve realized you’ve dozed off for a bit. This is torture.

Sleep deprivation is no stranger to EMS people. We’ve all fought the lethargy caused by long 24, 48, and more-hour shifts. A great number of us work more than one job to make ends meet and pack as much family time and recreation into our off time as we can. A lot of us are going for more education and all of us get woken up from our sleep a lot more often than is healthy to run on calls. I regularly miss full nights of sleep and rarely have a night when I can say I got a full night’s sleep. We get use to it some of the way, but our bodies just aren’t meant for chronic sleep deprivation. We need to reset and reorder our brains and let our bodies recharge once in a while.

Unfortunately, our communities need us and we have to be there for them. EMS is important and it’s easy to get sucked in.

That’s why in this situation, I have very little dispute with taking a “Safety Nap”.

"SSSS-AAAA-FFFF-EEEE...."

The “Safety Nap” is a quick power nap. A shut-down and reset period where a person who never knows when they may be called to be up all night without sleep can rest and relax for a while and ensure that they’ll be wide awake and alert for whatever they may be called to do. I took an hour last shift around 3pm as a matter of fact. I didn’t get to sleep until 1am afterwards and I was up at 5am for a call. EMS is like that, shift work is like that. We have to ensure that we’re well-rested enough to make quality decisions of the type we have to when they need to be made… and we can’t do them well when we’re drooling on ourselves from exhaustion. One of Murphy’s laws for EMS states that “You know you’re in EMS when your favorite hallucinogen is sheer exhaustion” and I have to tell you, I’ve done that while on duty before. It’s just not safe.

There are problems with this, I know. Some will say that we shouldn’t allow ourselves to be scheduled this many hours and that it’s irresponsible to do so. Well, then they can come talk to my bosses and pay my mortgage. Some people will sleep all day if they let them, and won’t put any effort into their shifts unless they have to. That has to be monitored. With that said, a balance has to be sought. I see nothing wrong with the occasional safety nap and I believe that EMS managers should allow it. They also should be unafraid to throw a cup of cold water on the Rip Van Winkles among us to ensure that they pull their weight with the non-call-response aspects of an EMS job.

What do you think? Does your employer allow “Safety Naps”? Do you take them?

I’d write more but Zzzzzzzzzzzzzzzzzz

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Posted by Ckemtp on August 4, 2010 • Filed under: Administration & Leadership, Ambulance, ambulance humor, Command & Leadership, Emergency Medical Services, EMS, EMS Health & Safety, EMS Humor, EMS Management, EMS safety, EMS Topics, EMT, Ethics, Fire Rescue Topics, Firefighter Safety & Health, Management, Paramedic, patient care, Patient Management, salary, shift length, Uncategorized

Modern (f)Art
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Howdy Everyone!! It’s Ckemtp, your friendly neighborhood EMS and Fire blogger with a few things I’d like to bring to your attention. I’d like to talk to you today about politicians. Not the politicians that are doing such a great job at managing our collective money on the national level… I want to talk to you today about the local ones, the ones who do the important work of making sure our traffic lights aren’t burnt out, that our roads are pot-hole free, and that our sewer systems don’t back up and discharge raw sewage into lakes and rivers and stuff.

Specifically, I’d like to talk about Local Politicians and public art.

My favorite writer, the legendary Humorist Mr. Dave Barry, wrote a piece about public art a few years back that you just have to read before continuing on with this post. It’s actually one of many of his articles that include things about public art, which he defines as “Art that is purchased by experts who are not spending their own personal money” it also involves the phrase “a naked man the size of an oil derrick” and has references to nuclear weapons and alcohol. I love Dave Barry, I really do.

Read this: “Does Public Art Make Sense” – Then come back once you stop ROFL’ing

This is "Art" I think... Oh I know! It's a bus stop

Then, g’head and read THIS ARTICLE from Michigan Capitol Confidential which talks about the REALLY SMART city of Ann Arbor, Michigan… which is planning an $850,000 piece of public art. It’s really interesting to me that they’re planning this… and I really hope it isn’t made of flammable material because the city is “Facing a multimillion dollar budget deficit” and is planning on laying off firefighters to handle the budget crisis.

Here’s that article again: http://www.michigancapitolconfidential.com/13219

Yes, Ann Arbor, MI, the REALLY SMART city that it is, is laying off firefighters while spending $850,000 (That’s EIGHT HUNDRED FIFTY THOUSAND DOLLARS) on a “three piece public fountain”.

Oh, right… if it’s a fountain, it probably won’t burn down. That makes sense. Of course it might get filled with trash, since they’re laying off the city’s “Solid Waste Coordinator”. Y’know… the guy who oversees the trash pickup for the city. On the other hand though, they are hiring an “Art Coordinator” to, I don’t know… look at the art maybe? Maybe he’ll pick up the trash from the fountain.

Taxpayers, I’m talking to you here. Inefficiencies and, in this case, abject stupidity in local governments are killing us. If I was having trouble keeping up with the maintenance and mortgage in my own house, the first thing that I would do would not be to buy new paintings to hang on the walls. I certainly wouldn’t buy paintings at the expense of paying for trash pick-up, sewer service, or portable fire extinguishers. I think that I would pay for necessities first and niceties second. Responsible people take care of the whole Maslow’s Hierarchy of Needs thing; Food, clothing, and Shelter first and buy pretty things after that. You do the things you HAVE to do well before the things you’d like to do.

At least responsible, SMART people do that… and apparently that’s not the kind of people that the voters in Ann Arbor, MI think would make good city council members.

Or do they?

Maybe they can call this "Art"

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Posted by Ckemtp on July 27, 2010 • Filed under: Administration & Leadership, Command & Leadership, dave barry, Emergency Medical Services, EMS, EMS Management, EMS Topics, Fire department, Fire Rescue Topics, Funding & Staffing, News, politics, Uncategorized

As AmboDriver Always says… For all you EMS types
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The good folks over at EMS Magazine and Http://www.EMSresponder.com have seen fit to publish some of my EMS type ramblings in print format. It’s an article on Partnering With your Community as an EMS agency and if-I-do-say-so-myself it’s got some useful information in it.

So take a trip on over to have a read at http://emsresponder.com/print/EMS-Magazine/Community-Partnerships/1$13742

Or, you could go ahead and wait till your magazine arrives in the mail of course… you do subscribe, don’t you?

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Posted by Ckemtp on July 1, 2010 • Filed under: Administration & Leadership, Ambulance, Command & Leadership, Emergency Medical Services, EMS, EMS Management, EMS Topics, Fire Prevention & Education, Fire Rescue Topics, Management, Paramedic, volunteer fire department

Master Paramedics? I’m asking you a question
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Let me ask YOU a question. What do you think about this:

How do we recognize the best and brightest among us? How would we distinguish the EMTs and Paramedics who have earned the respect and admiration of their peers for being “Really Good” at what they do? I don’t mean just a little bit good, or “pretty” good. I mean masterfully good. The kind of Paramedics that Johnny and/or Roy would have wanted to be had they grown up watching them on Saturday mornings. The kind of people that have worked in the profession for as long as they can remember but that never lost the passion for the job. The kind of people who read everything they can, study everything they can get their hands on, and always seem to have the answers to the most challenging of EMS trivia, as well as the most mundane.

What would we call them?

The old trade guilds used to call their most experienced and skilled members “Master”, as in the term “Master Craftsman”. As their members worked through the years and learned the ropes of the trade, they progressed through the various levels until they reached “Master” status. Some unions still use those terms and honestly, I’m unfamiliar with what all of them are. That’s ok with me because I see Paramedicine as a profession and not as a trade, but I do respect their tradition of honoring those that have earned the title of “Master” by thoroughly mastering their craft.

So what do we EMS people do? How would we recognize a “Master Paramedic” or “Master EMT”?

I’ve been thinking about this for quite a while, honestly. As I progress in the profession and in my career path, I’ve seen the people who were my mentors keep working alongside of me. They’re my colleagues now, and although they still mentor me in some ways, they have been progressing along their own paths just as I have this whole time. Some of them have become true masters of the profession. Some of them have not. Some of them could really be called “Master Paramedics” and I would like to know how we as a profession should recognize those people. I see that these people don’t tend to be treated very well by the profession in general and I think that it’s a crying shame. Think about it, new paramedics walk in the doors to the profession and are allowed to work in the same capacity as our master medics within a relatively short time. Employers tend to not want to keep these people around when budgets get tight because these people tend to be on the upper end of the pay scale. In some agencies there’s a defined career path and upward ladder, but in a lot of (and dare I say most) agencies there is not.

So what if there were a certification, or some way to define a “Master Paramedic” and/or “Master EMT”? What would be the qualifications? What would be the benefits? How would we define those people who have earned (Yes, really EARNED) “Master” status?

This is one of the things I’m asking you to think about. If you would please, put some thought into this and write what you think would make a “Master” paramedic or “Master” EMT in the comments section. No, I don’t think that this is silly. I really want to know what you all think about this.

Here’s what I think:

-          Minimum Years in the Profession: The Master EMT or Paramedic should have more than 10 years of FULL TIME service (15 years if volunteer, depending on call volume)

-          Minimum Experience and Type of Calls: The master EMT or Paramedic should be experienced in a broad spectrum of the different types of EMS. 911 response within diverse response strategies, Medical Transports, and In-Hospital medical care.

-          Teaching and Precepting Experience: The Master EMT or Paramedic should have experience teaching EMS classes and in mentoring new providers.

-          Command Experience:   The Master Paramedic of EMT should have experience in being in command of different types of emergency scenes and large scale responses.

-          Knowledge: The Master Paramedic or EMT should have to pass a complex series of tests that show not only rote memorization, but also complete conceptualization and deep background knowledge of a broad spectrum of EMS and Medical related knowledge.

-          Acknowledgement by Peers: The Master Paramedic or EMT should have the support and admiration of his colleagues, coworkers, and peers and should be able to get them to vouch for him or her when asked.

Now, I also ask you. If you were to recognize a person that could pass the standards that I’ve set, or that you and others set in the comments below, how should we show our respect to these people for their professional achievements? How should our profession honor and acknowledge our highest achievers?

I’m very curious about this issue. Please feel free to add your thoughts.

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Posted by Ckemtp on June 8, 2010 • Filed under: Administration & Leadership, appreciation, Command & Leadership, Emergency Medical Services, EMS, ems 2.0, ems education, EMS ethics, EMS Management, EMS Motivation, EMS pep talk, EMS Topics, Paramedic, paramedic salary, pride, profession, professionalism, Training & Development, training-fire-rescue-topics

EMS 2.0 as Explained to My Brother
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My brother is an engineer. Yes, he’s a firefighter and occasionally he still drives the Fire Truck, but I’m not talking about being an engineer as it relates to the fire service. I’m talking about a pocket-protector wearing, slide-rule-sliding Engineer who draws lines on paper and calculates weight to strength ratios and the like. It’s math that’s way over my head and I’m glad that he’s the one that has to do that type of work every day and not me. When he explains his job to me my brain starts to overheat and I’m surprised that my hair hasn’t caught on fire yet. It started smoking once, but I was able to catch a glimpse of “The Hills” on the TV and it slowed my mental activity just in time.

My brother, Captain Kaiser, is a volunteer fire captain and he used to be an EMT although he let it lapse due to the fact that it limited time with his family. I guess that I got the EMS genes and he got the “go to college and get a real job that pays well” genes. I say more power to him and he’s one of my best friends. I don’t get to see him as much as I should, but we talk often on the phone. He has always been interested in hearing all of my tales of EMS glory, and I listen to tales of his two daughters. Raising daughters sounds waaaay different than raising my son.

The other day I was talking to him about “this blogging stuff I do” and I breached the subject of EMS 2.0. I haven’t written much about EMS 2.0 by name lately, although the concepts I’ve been bringing forth fit into my model of it, but trust me when I say there has been a lot of behind the scenes activity. It turned into an interesting conversation with my brother. He was an EMT but never got past the volunteering when his community needs him stage. That’s an honorable place to be, no doubt, but he didn’t delve into the level that I take it to. So explaining EMS 2.0 to him was close to explaining it to an educated lay person.

In the conversation, I brought up the scenario that I used to write the post: “Are We the Gatekeepers to the Emergency Healthcare System?” (Unofficially titled, “Did I do good?”) and explained to him how I evaluated a patient in a nursing home, performed a full assessment on her including a 12-lead EKG and a review of her recent lab work, held a telephone conference with her Primary Care Physician and the Nursing staff on scene, and triaged the patient to the Primary Heathcare System as opposed to the Emergency Healthcare System. In the process, I saved the healthcare system (in the form of Medicare) thousands of dollars and provided better care to the patient by deferring her from the emergency room. I explained to him that my ambulance service could not bill the patient for the care I provided her because we did not transport and that the current system needs to recognize the value in having EMS provide such services in terms of cost-savings. If I would have transported, our service would have made the revenue, but Medicare would have paid thousands of dollars in unnecessary care overall. Since I didn’t, I saved Medicare thousands, but the service wasn’t valued and we didn’t receive any compensation for our work.

Basically, the conversation wound up being that he agreed with me that EMS has a powerful position to improve access to primary care and “save” healthcare as it were by increasing access to primary care, properly deferring patients from the emergency healthcare system when their care could be more appropriately managed in the primary care setting, and by saving millions of dollars in the overall healthcare setting. He agreed with me that it would require deregulation of the EMS industry to allow us to attempt programs and offer new services outside of our current mold and would require increased education of street-level EMS providers to get this done. He also agreed with me that money we’re already collectively spending should be allocated from inefficient programs and given to efficient high-performance EMS systems to do this in order to realize greater savings.

Remember, he’s an engineer. He’s good at math. He may not be a healthcare provider currently schlepping patients around in a shiny red and white bus that makes “woo woo” sounds, but he’s as smart as they come…

And when I told him that he’s exactly who we should be getting our message out to, he disagreed. He thinks that we should be out there talking to politicians and Insurance Industry executives. Honestly, he chastised me for not being in my local congresshuman’s office to do just that.

So, here’s a shoutout to the politicos out there: “EMS can ‘save’ healthcare through a free-market, grass-roots, innovative solution using currently available resources. We can save millions and improve the entire healthcare system just by putting in place a few good ideas and allowing EMS professionals the ability to think outside of the box”.

So do me a favor, y’all. Go tell your local politico to e-mail me at Proems1@yahoo.com. I’d love to have a talk with them. You should too.

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Posted by Ckemtp on May 26, 2010 • Filed under: Administration & Leadership, Command & Leadership, Economics, Emergency Medical Services, EMS, ems 2.0, EMS Management, EMS system, EMS Topics, Fire Rescue Topics, Management, Paramedic, paramedic education, PR, profession, US economy

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SeekerCenter: An Option for the Pharmaceutically Denied

Ambulance Roll-Over in Milwaukee – To my friends at MedaCare

School is in Session… Torticolls what now?

Link: Where Should Special Needs Kids be Special? – Autism Awareness in the Community

Another Good Cause

Pushing Down the Skills – Bringing New Tricks to BLS

EMS Fights the Flu – The 2013 influenza epidemic

Look for the Helpers

Rockford REACT Crew Memorial Fund

Tragedy Strikes Rockford

On the Topic of Ectopics – Ectopic Pregnancy for EMS

Appendicitis – An EMS Case Review

Routinely Not Routine – Good EMS Makes the Difference

Prehospital Pain Control

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

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

Tracking Traction – When Traction Splints Should Pull Their Weight

EMS Providers Carrying Guns – A terrible idea

FIrefighter Pre-Hydration – Fight Fire like a Marathon Runner

Comments – Recently Recieved from the Field

Blurring Lines Between BLS and ALS | 1-Union-801: The Webcast on Pushing Down the Skills – Bringing New Tricks to BLS
Lesley on Ideas from the Field
ben on Remembering Earl
Ckemtp on Right in the Nick of Time: Patient Saves his Medic
ALEX on Right in the Nick of Time: Patient Saves his Medic
yah trick yah on Right in the Nick of Time: Patient Saves his Medic
mr618 on Who Needs Them Paragods?

Oldies but Goodies

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Pushing Down the Skills – Bringing New Tricks to BLS

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