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Too Much Information For a Paramedic?

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This is a coordinated post by our friends Greg Friese and Steve Whitehead.

 - Greg’s post on this topic can be found at: http://www.everydayemstips.com/?p=3628

 - Steve’s post on this topic can be found at: http://theemtspot.com/2010/08/25/too-much-information/

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“They Don’t Know What They Don’t Know”

It’s an established fact that 60% of fatalities within confined spaces are would-be rescuers. They see someone down in a confined space, enter the space, and are overcome by the conditions that took down the initial victim. The process sometimes repeats itself, with multiple would-be rescuers entering the space and falling victim themselves. It’s tragic really, but the cold, hard fact is that these people are victims of their own ignorance. They don’t know what they don’t know. They don’t know that there is a fatal set of conditions within the space, and they don’t know that whatever it is that killed the first victim, or subsequent victims, will kill them as well. It’s a well documented phenomenon that plays on the compassion of the would-be rescuers and ends up getting them killed.

They simply don’t know what they don’t know.

Hey Guys?? Guys?

So when I was approached by our friend Greg Friese from www.EveryDayEMStips.com the other day regarding a comment he received on one of his training articles, I was interested in doing a co-post with him. He also has contacted our friend Steve Whitehead from www.TheEMTspot.com and together we’re tri-posting on this issue. Their links will follow below and are just great as always.

The comment that followed this online training article was written presumably by a paramedic. It was a critique of the article that simply stated “too much information for a paramedic”. I read that, and immediately thought of confined space incidents, where ignorance can get a person killed. Lots of situations fit that scenario and it’s not always the rescuers who get killed. EMS providers who “don’t know what they don’t know” can and do kill patients. More often, they don’t provide the best possible care.

There’s this thing that we have made it our business to know how to repair. It’s called the “Human Body” and if you’re reading this article, the chances are good that you possess one. The human body is VASTLY complex. It’s the most complex machine we humans know about and we are still learning about it to this day. There are some amazingly smart people out there who have dedicated their lives to studying these meat machines that our brains pilot around and they still haven’t figured everything out yet. We can help set it back on course to heal itself in a lot of cases but we can’t construct a new one. We don’t know about all the minutia, the microscopic works inside of it that make it do all of the amazing things that it does. The levels of systems within systems that function seamlessly within still other systems are numerous and fascinating. I learn something new about it all the time, and still there are people who know vast amounts more about the inner workings of it and about the huge number of things that can affect it’s operating effectiveness than I do. The human body is remarkably complex yet elegant and perfect in its design.

C'mon... Don't be a wuss.

And we who call ourselves “medical professionals” are well advised to study every possible aspect of it. Consider it your “life’s work”. If your job is to fix and support the end users of the human body, you darn well better know everything you can about it.

“But”, you say, “There are people out there who are supposed to know much more about the human body than we are. They’re called Physicians, and they get paid a whole lot more than we do. We’re just paramedics. (or EMTs).” And you’d be right for saying that, of course. Physicians have the ultimate responsibility for knowing the human body. It’s their life’s work as well. Their patients live and die based upon their knowledge, skills, and talents they have for examining the human body and being able to figure out what’s going on. Their whole practice is based upon their knowledge, skill, and talent. The more they know when they’re working there, the better provider they are.

It’s that simple, and it’s exactly the same for us EMS people. The more we know, the better we are. Nobody is better served by dumbing us down. Nothing is gained by denying yourself knowledge. Not a single patient is better served by you not knowing everything you can know about what is going wrong with them and it’s your duty to learn as much as you can about what you’re supposed to know about.

What is the line for how much paramedics “need to know?” Is everything that we need to know covered by our initial training course? Is that everything we need to get out there in the world and start slinging IVs and Meds all willy nilly?

I look at the paramedic license as a “learner’s permit”. It’s the baseline knowledge level needed to function at that level under supervision. It’s a jumping off point from which the provider should immerse themselves in knowledge. I can certainly say that I’ve learned volumes past my initial certification and that the “extra” knowledge has saved lives. Did you know that Fentanyl can cause chest muscle tetany when administered too rapidly? Or how about that lasix, when pushed too rapidly can cause hearing loss?  Do you know that ST depression in the high V leads can signify a posterior MI? What about differentiating an acetabulum fracture from a “pulled groin”? Can you reliably predict the patients whose blood pressure is going to crash after Nitroglycerine administration by reading a 12-lead EKG? What about the clinical presentation of a non-ST elevation MI? Do you know the MEND stroke screen? What about the different neurological exams to find an intracranial bleed?

Etcetera, etcetera… The point is, there isn’t a cut off. The final exam we take for our licensures prepares us with the baseline knowledge to get out there and learn what it takes to make us truly great EMS providers. The true professional will learn this, and constantly seek the knowledge he or she needs. The average to sub-average provider will comment that they “don’t need to know” something.

Get out there, get fascinated, and learn as much as you can. It will never be enough knowledge… but your mind is a sponge for a reason.

Study Hard. Know Your Stuff. No Excuses.

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This is a coordinated post by our friends Greg Friese and Steve Whitehead. Be sure to read their posts on this

Greg’s post on this topic can be found at: http://www.everydayemstips.com/?p=3628

Steve’s post on this topic can be found at: http://theemtspot.com/2010/08/25/too-much-information/

Posted by Ckemtp on August 24, 2010 • Filed under: EMS, EMS Motivation, EMS Topics, EMS ethics, EMS practice, EMS rant, EMS training, Emergency Medical Services, Paramedic, Patient Management, Training & Development, Uncategorized, change, ems education, paramedic education, training-fire-rescue-topics

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

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

“Is that the best you can do?”

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

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

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

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

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

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

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

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

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

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

“Is that the best you can do??

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

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

Should EMS Improvise? And the Recipe for the “Kaiser Cocktail”

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Here’s the recipe for what I call the “Kaiser Cocktail”:

  1. Look in the patient’s kitchen cupboards until you find a box (or a bag) of some type of granulated sugar, powdered sugar, or brown sugar. (in a pinch, you can use honey or syrup)
  2. Find one of the patient’s own cups or glasses, wash it if you have to.
  3. Dump a bunch of the sugar in the glass.
  4. Look in the patient’s refrigerator until you find some soda pop or some type of sweet juice like orange, apple, or grape juice.
  5. Pour that in the glass with the sugar.
  6. Mix it up really well with some type of stirring device. Don’t use your pen or your finger. (Your partner’s pen or finger is ok though.) (Not really.)
  7. Serve warm, chilled, or tepid. Garnish with a peanut butter and jelly sandwich.

Have you guessed what the “Kaiser Cocktail is used for? If you’re in EMS I’m pretty sure you may have figured it out. It’s for sweetening up your local mild hypoglycemic… and no, it’s definitely not for serving to my son right before I drop him off with the in-laws for revenge purposes. The Kaiser Cocktail is for those patients who have blood glucose levels in the mid double digits but that still have the mental faculties necessary for drinking fluids and for protecting their airway while they do it. It’s a home remedy of sorts and it isn’t exactly the kind of thing that they teach you in EMT school. It works like a charm every time and I’ve never seen it not be well tolerated by the patients I’ve used it on or by the families that watch me do it. In fact, the families always seem more than willing to help whip one right up when I ask them to do so.

Picture this scenario: Your ambulance is dispatched to the “Known Diabetic with Altered Mental Status” at an address a short 8 minutes away. You respond to a well kept address in a nice neighborhood and are directed into the residence by a twenty-something female who tells you that her grandfather “Just isn’t acting right and won’t get out of bed”. Seeing no obvious hazards, you enter the residence with the granddaughter and follow her to the back bedroom of the residence to find a 60-something male patient sitting on the bed. He acknowledges you when you introduce yourself and you can see that he’s trying to talk but that he cannot seem to form the words. You say to him “Howdy! How are you feeling??” He answers: “Um… hello…” with a normal voice quality. His airway is patent, his skin is pink, warm, and sweaty, and he doesn’t appear to have any hemispheric neurological deficit. His pulse is bounding and regular at the radial and his respirations are normal. The granddaughter tells you that the patient is diabetic and that he takes insulin.

Got the case diagnosed yet? I’d bet you do. The next thing I would do with this patient is to take a quick finger stick glucose check. For the above fictional scenario, the reading would be 40mg/dl (which is um… “something’ MMOL for you British folk). It’s mild hypoglycemia. I ruled out a possible stroke (CVA/TIA) with the Cincinnati Pre-Hospital Stroke Scale and he patient’s cardiac function seems very normal with his bounding, regular pulse rate. The diaphoresis (sweating) and skin color are differential signs of hypoglycemia, and the patient’s past medical history helps clinch the field diagnosis. This patient’s blood glucose level dropped too low for his brain to function normally and he needs more sugar coursing through his veins in order to feed his brain.

You may be wondering why I brought forth such a common, run-of-the-mill patient presentation on the blog today. As pre-hospital providers, we have a few options available for us that could be considered proper care for this patient. Most EMTs have oral glucose paste at their disposal and a growing number of EMT-Basics carry Glucagon for IM injection. EMT-Intermediates and Paramedics usually have both of the previous medications available and almost all of them carry D-50, or 50% Dextrose solution in water, for IV administration. All of these treatments could be considered for this patient; however I would pull out my namesake concoction in this case. Call it experience, but starting an IV and giving D-50 seems like it would be risky overkill for this patient and an IM injection of glucagon saps the patient’s natural reserves of glycogen for quite a while after administration. Patients seem to hate the taste of oral glucose paste (Lemon?? Really??) and one tube never sees to do the trick. We only care two of them anyway.

That’s why I use a Kaiser Cocktail with these patients. As long as the patient can maintain their own airway and there’s not an aspiration risk, I can’t think of any contraindications once you rule out a possible stroke. It’s cheap, easy, and it has worked like a charm for me every time I’ve tried it. I like using it too, as it feels like a “Mr. Wizard” type home remedy that always fascinates the patient’s family members who watch me make it up.

Here’s the rub though, nowhere in my protocols does it give me authority to give a patient any nourishment or fluids by mouth. In fact, I can’t give a patient anything to eat or drink that isn’t specifically allowed by my standing orders. In EMS, even something as innocuous as sugared-up orange juice can be a legal difficulty. Common sense isn’t allowed by lawyers, unless of course they’re saying you should have used some. The reality is that every time I whip up a Kaiser Cocktail, I’m putting my license at risk.

I used a Kaiser Cocktail as recently as of the day I’m writing this post and I’m asking for a debate here. I’d like it if you would please answer some questions for me below the post in the comments section:

  1. Do you think that the Kaiser Cocktail is an appropriate treatment for mild-to-moderate hypoglycemia in a known-diabetic patient with a patent airway?
  2. Do you see any contraindications or risks that I have missed?
  3. Would a tube of oral glucose paste (or tablets, if you use them) be more appropriate than the Kaiser Cocktail?
  4. Should EMS providers be allowed to improvise treatments such as the Kaiser Cocktail for these and other like situations? Why or Why not?

I can’t wait to see your answers.

Posted by Ckemtp on June 21, 2010 • Filed under: Administration & Leadership, Ambulance, EMS, EMS Topics, EMS ethics, EMS protocols, EMS training, Emergency Medical Services, Paramedic, Patient Management, Protocol development, SMG, SMO, ems 2.0, ems scenario, ems scenario based education, medical ethics, paramedic education, scenario, scenario based training

Police Car Drivers, Ambulance Drivers, and their responsibilities

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

What are their jobs?

What are their areas of expertise?

What would you expect them to be responsible for?

                                     

 

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

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

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

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

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

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

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

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

Be careful out there.

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

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

A Slap in the Face to Paramedics Everywhere?

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

 Ambulance Staffed by RNs

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

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

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

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

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

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

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

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

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

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

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

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

What do you think?

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

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

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

Saved by the Bell? High School Student EMS

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

Wait, what?

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

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

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

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

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

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

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

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

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

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

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

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

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

Your thoughts?

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

Trust… It’s everything

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Dooooo Doooooo! Beep Beep Beep Beep Beep Beep Beep  - Attention AMBULANCE ONE, Ambulance One. Respond Code 3. 1234 Anystreet lane, 1234 Anystreet lane for the (Insert Age and Gender Here) patient found unresponsive, unknown if breathing.

Imagine you heard that dispatch go out just now. Imagine you’re at home, off duty, and just happen to be listening to your dispatch channel. Perhaps you’re a volunteer, perhaps you have a scanner, but picture yourself hearing that and realizing… “Oh My God… That’s So-and-So’s house! A (blank) aged Male/Female? That’s gotta be So-And-So!!”

As an EMS person who lives in your district you know the people who work on the service. Now you’re sure you know the patient too. It’s someone you care deeply about and it sounds like they may be in mortal danger. As someone “in the know” you know what you’re going to do next, right? You’re going to listen intently to whatever traffic happens to come out next on the radio, aren’t you?

“Come on, Come on, Come on!” you think to yourself as you wait the agonizing seconds for the crew to acknowledge the page and go enroute to the scene. “What’s taking them so long!?” you ask yourself. “Ambulance 1 is enroute to 1234 Anystreet Lane” says the crew of Ambulance One over the radio. You don’t think that they sound excited enough. They must not know that this is So-and-So! To them, this is just a routine response for an unresponsive patient. They’re going to do a routine, every day job and perform their routine, every day care. They don’t have any idea that this patient is special to you and they’re going to give this patient the same care they’d give anyone else.

Now, since you’re sitting at home and unable to respond, you’re going to be glued to that radio, right? You’re going to know from the voice on the radio exactly who it is that will be taking care of “So-and-So”. You’re going to either be relieved or horrified by your knowledge of who’s on that responding ambulance. If you have trust in the medic on the truck, you’ll feel slightly better about So-and-So’s chances of survival. If you don’t have trust in the medics, you’ll probably feel a lot worse… right?

It’s always been a sticky ethical situation for a healthcare provider at any level to work on someone they know well and care deeply about. Try it just once, or more realistically for an EMS provider, have the situation thrust upon you, and you’ll see that “Stuff gets real” really quick. We have a vested interest in the care that our loved ones receive and while some of us may know that it isn’t always best that we personally be the one caring for them, we all understandably want them to receive the best care possible.

Trusting a provider to care for your special “So-and-So” is a big deal. I’m sure we all have secret mental lists of our colleagues whom we’d want caring for our loved ones and also our lists of who we wouldn’t. It is a supreme responsibility to be a healthcare provider in charge of the care of any patient and I believe that EMTs and Paramedics hold that responsibility every bit as much as or more so than any other healthcare provider. It is a responsibility that I don’t take lightly and one that I hope my colleagues do not either. We are the first people that our patients and their families want to see walk through their door when the unthinkable happens. When the situation is critical, and skilled, complex, time-sensitive care makes the difference between life and death, we are the ones out there doing just that. A good paramedic must be knowledgeable, highly skilled, and experienced to provide that level of care. Not just that, they must do it every time they get in their truck; because every patient is somebody’s “So-and-So”.

Speaking of “stuff getting real” I have to ask you: What kind of provider are you?

Are you out there every day earning the trust of your peers?

Do you work hard enough, study hard enough, and train hard enough?

Do you do your absolute best for every patient, every time?

When it does happen (and it will) that you are sent to care for a colleague’s “So-and-So”, are you the kind of provider they will trust?

If you think about these questions, you know the answers already. If you can honestly say that you’re good enough, I salute you. If not, well then we have some work to do, don’t we?

Earn it. Study hard. Know your stuff. Do your best. Every patient. Every time.

Posted by Ckemtp on March 15, 2010 • Filed under: Administration & Leadership, EMS, EMS Motivation, EMS Topics, EMS ethics, EMS training, Emergency Medical Services, Ethics, Fire Rescue Topics, Paramedic, Patient Management, Training & Development, edemse, ems education, everyday ems ethics, medical ethics, paramedic education, patient care, pride, profession, professionalism, scenario

3am with Ckemtp – (See Gus? I can do that too)

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(The title? My friend Gus writes the blog http://3amwithgus.blogspot.com – Occasionally I throw him a shoutout)

I don’t generally do this much anymore, but this is kind of a personal blog post.

It’s 19 degrees outside and the clock is nearing Midnight here in Illinois. About 20 minutes ago I was snuggled up with my beautiful wife in bed trying to get some sleep before I have to get up at 3am to drive to Milwaukee to catch a flight at 6am. Tomorrow brings something that I’ve been looking forward to for what seems like forever, but really has only been a month or two. Tomorrow I’m heading to Baltimore, MD to attend the JEMS conference, EMS Today 2010.

This is going to be my first big, national conference. Really, I’ve never had the incentive to go before. I’ve always wanted to, but they have always seemed to be too much of an expense and have always seemed far away from what I’ve been doing in the field. Tomorrow I get to see for myself just what the hubbub is about.

But that all seems pretty far away right now as I sit here in my fire station covering the ambulance. 25min ago (now) I was snuggled up all comfy like just in the twilight stage of my sleepy-time cycle when Mama Juggs, the night dispatcher tonight set off the vile tones a few times and sent all of the on-duty paramedics out to the various hospitals, leaving the district uncovered. She toned out for any available paramedic to come in to cover and…

Yes, the above was a horrible way to end a paragraph, (and Greg Friese recently told me I use the elipse (the “…”) too much) but I have to make this statement. Both my wife and I are firefighters and EMS people on the same volunteer/POP/POC/Takes-up-all-of-your-free-time department. We’re both dedicated as the next guy too, and she’s in paramedic school right now. So when the tones went out, I got “the elbow”. No, I didn’t go on the other calls but we had an ambulance crew at all 3 stations with an engine crew on-duty backing them up. There wasn’t a need for me to head in for the EMS calls, until they took all the medics off of the street handling them. They needed a medic to come in for the next call, and I have a Gina at home elbowing me in the ribs to head out into the 19 degree weather to go cover the district. Yes it’s now Midnight, and yes I have to be up at 3am to catch my flight.

I’ve spoken before about the responsibility I feel when I’m the only paramedic available to cover the emergency medical needs of a jurisdiction. Right now, there’s 30k people (roughly) whom for if they have an emergency medical need, I’m now the first person they want to see. If that happens (and now, one of the trucks is returning so the chances are lessening) I better be on my game when I get there.

Anyways, I’m sitting next to Mama Juggs (The Dispatcher, remember?) blogging away, and I should probably be a good conversationalist and talk to her because I haven’t gotten much of a chance to chat with her lately. So, in parting, if you are at EMS Today, come up and say Howdy! to me. If you’re not, be sure to follow me on Twitter and Facebook (the links are over there on the Right. I accept all friend requests that seem like fans.) and I’ll be sure to try and give you a first-hand look at what it’s like at a Big National Conference.

Oh, and the Biggest meetup of EMS and Fire Bloggers is happening Friday night at a pizzeria. BE THERE. If you need info, tweet me and I’ll getcha there. (Connections? I has them)

G’night all.

Posted by Ckemtp on March 5, 2010 • Filed under: EMS Conference, EMS Topics, EMS ethics, EMS training, ems education, ems garage

Guest Post – From JDmedic on Two Cases, One Letter

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This is a guest post coming to you from a Mr. John Fekety (JdMedic) who took the time to leave a thoughtful comment on the recent post I wrote “Two Cases, One Letter… From One Paramedic’s Struggles, Change Can Come”. He doesn’t have a website for me to link to, but his resume is pretty impressive. I gave him the opportunity to flesh out the thoughts he wrote in the original comment, and I’m turning the post over to him. Good Stuff.

As promised, I’ll put a plug in for his friend’s Safety Training Business: Http://www.Source4Safety.com – Safety & Health Solutions, LLC

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Many good comments were made regarding the anonymous letter published here last week. Here are my two cents on the things raised in the letter by Ckemtp and others. First, I confess that I also routinely rant about other healthcare providers not understanding our profession, what we are capable of and what we required to do at times. However, the point of the matter is it is not in their job descriptions to educate themselves about us. We must become much more proactive in educating professionals and the public about whom and what we are. Granted, in a situation like described with the cancer patient with heated emotions, educating someone is not easy – if indeed possible. However, we need to begin to relate one-on-one during down times and talk about what we do and the things we come up against. Will it solve all of the problems? Obviously not, but it may crack open a door for dialogue in the future that can help defuse a tense situation.

Secondly, as both the letter writer and I have learned you have to pick your battles. Would it have done any good to bring up the MRSA issue with the sending hospital? Probably not. They could have simply said, “We told them.” Or more abrasively, “Are you questioning our professional ability to give a simple transfer report?” I think the suggestion of Dave Konig represents the best of both worlds. You let it slide with the sending facility and keep your relations there happy. However, you protect the patients in the other facility and maintain your professionalism by giving the receiving facility a heads up. Before the patient reaches the room you may say something like, “While I was checking the patient’s history during the transport I discovered a history of MRSA and I wanted to make sure you knew.” Everyone wins. Another part of this lesson is the patient does not leave your litter until you are comfortable with releasing the patient (more on this below), or you have no other choice.

Thirdly, we have to educate ourselves about the programs and people we deal with. In that regard, Dave makes a good point about hospice programs as well. Many hospice contracts require a patient to agree not to go to the ED in exchange for the hospice services, including in-patient care when appropriate. Under those circumstances, a patient who goes to the ED is dropped from the program and becomes responsible for all medical bills. Given the cost of just medications, conditions like this alone could drive a patient and family members over the edge. Whether that was the case with the patient in this instance is unknown. One service that I worked for had the director of a hospice service come out to a meeting and give us a presentation (did someone say education?). She explained the various services of hospice, why they may need a patient transported, and what we could do – within our scope of practice – to make things go as easy for the patient and family. It’s about communication folks.

Fourth, like others here I have been in the situation where I needed to be a patient advocate. I was doing an interfacility transport of a trauma patient who still rated pain at 9 out of 10 after meds. I asked the nurse about additional meds and she said the patient had already received everything he/she could recieve. I could have taken a chance, loaded the patient and called for pain management en route but I chose a more direct approach. I tracked down one of the ED docs and asked him to check on the patient with me since I did not feel comfortable accepting the patient in her current condition. (I learned that once the patient is on your litter nobody is willing to help since the person is now your “problem”.) When he saw the girl, he readily agreed she required more meds and not only ordered more immediately but gave me orders for addtional meds en route if needed. No arguments with the nurse, no bad feelings and the patient got what she needed. However, there are those times when feelings be damned and you have to take a stand for your patient.

An example of that situation was when I did an interfacility transport of a patient going for a cardiac cath and other procedures. The patient, in addition to having flunked his recent stress test, had a hisory of a previous MI. When we arrived at the receiving facility nobody knew where he was supposed to go because there was a question about which of two procedures were to be done first. We were finally sent to one location only to find it empty. We were redirected to another location to put the patient in a room until things were sorted out. We got to a hospital room with no monitor and an aid told us to put the patient in the bed. I asked about the monitor, she said there was none, and since he was not going to be there, long he did not need it. I explained that he came from a monitored bed, he required a monitor in the ambulance and he was not leaving my litter until he could be placed on a monitor. She huffed out of the room and came back with a nurse who restated that a monitor was not available and not needed. When I once again explained that the patient was not leaving my litter until a monitor was found. She left in a huff saying she was going to get a nursing supervisor to “… straighten you out.” I thanked her since getting a supervisor was better than us waging war. She came back without a supervisor, but with a monitor and told me the supervisor said I was to leave. With the patient in the bed and on the monitor, I thanked her for getting it and asked her to sign that she received the patient. Not unexpectedly, she refused. However, the patient’s wife who witnessed me ensuring that her husband received the proper care was more than willing to witness my note that the nurse refused to sign.

If we and the rest of the medical community (and/or the public safety community) want to use polite words, EMS is the redheaded stepchild.(Ckemtp here: “ouch”) In not so nice terms, we are the bastards. Either way, we are the new kids on the block and we still have to prove ourselves everyday. It has not been easy nor will it likely get any easier for quite a while, but there are ways we can stop shooting oursevles in the feet. When we hit the street if we keep the following in mind, maybe we can begin to level the playing field.

1. Look professional: If you wear a hat – one that is appropriate – wear it correctly, not to the side or backwards. How you chose to dress/look on your own time is your business. If your dress impacts me and my profession it becomes my business. Although I slack at polishing my boots, my uniforms are always clean and neat (at least at the start of the shift – stuff happens). Take a couple of seconds to tuck shirts in.

 2. Act professional: Everyone likes a joke. And, God knows many times with what we see we need humor to get through. However, remember what your parents said about a time and a place for everything. The parking area outside the ED is not the place to have a water fight with syringes. Nor is it appropriate to run up and bang on in-coming units.

3. Talk professionally: You do not need to be a walking dictionary or memorize Grey’s Anatomy. For the most part just dropping the slang and cursing would go a long way. “Thank you.” You’re welcome” Have a nice day.” would not hurt either. And out of respect for Thom Dick, let’s get rid of “No problem.” as a response to a thank you.

4. Respect your patients: If you call your patient, any one of the degrading words used in EMS to refer to, especially nursing home, patients (such as cheese or GOMER), go get a job for FedEx or UPS and deliver packages. You will make more money, not have to put up with mouthy nurses or winey patients. These are people we are supposed to be caring for. Many times, there may be nothing we can do except listen or hold a hand – and many times that is enough.

A final thought comes from a quote supposedly said by Mark Twain. “It is better to keep your mouth closed and let people think you are a fool than to open it and remove all doubt.” Whenever it may be possible for you to be an example of an EMS professonal, act like one rather than acting as our detractors characterize us and provding their proof.

There are many things all of us can point to and complain about EMS and the systems, institutions and people we work with. I have worked in other professions and with all of the problems EMS has, I would not want to work anywhere else, as it sounds like so many other people feel.

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Great Post, JDmedic. (Yes, this guy has more education than I ever want to sit through). He’s a lawyer-turned-paramedic and that just brings a smile to my face, I have to tell ya’.

Comments are, as always, very much welcome.

(Would YOU care to guest post? Shoot me an e-mail at ProEMS1@yahoo.com – Or Tweet me @ckemtp)

Posted by Ckemtp on March 2, 2010 • Filed under: EMS, EMS Motivation, EMS Topics, EMS ethics, EMS training, Paramedic, profession, professionalism

Why I am Passionate about the Chronicles of EMS

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If you’re an EMS professional, you should be paying attention to the Chronicles of EMS.

I think every person involved in EMS on any level needs to pay attention to the work of three of the profession’s upcoming giants, Mark Glencourse, Justin Schorr, and Thaddeus Setla. Their collective project is a warp-leap forward for how our profession is presented to, judged by, and thought about by our internal and external observers, customers, and colleagues. With their efforts come Hope… Hope that one day soon EMS will take its rightful place as a true profession; Hope that our profession will get the paid the attention that it deserves; Hope that our educational standards, resource needs, and compensation will finally be improved; and Hope that we will be able to improve our total service to our patients and our community through shedding a new light on our profession.

If this works… everything could change. Everything could change quickly, incredibly, and wonderfully. Imagine if EMS became “cool” and the public finally thought about who we are, what we are, and what it is that we do for them. Imagine if people demanded that their community leaders pay as much attention to EMS as we need them too… Just Imagine.

EMS needs a strong, unified message. The Chronicles of EMS can be that message. It is a professional, smart, and uber-cool message aimed straight at where we want to be going. It is not lip service, it is not Hollywood glamour, and it is certainly not dramatized for profit. It is being prepared by industry-experts who are still working the same streets that we are everyday. Everyone involved is one of us. Everyone involved is passionate. Everyone involved wants this, and they want it as bad as you do.

The reason I write about EMS is because I want to improve our profession and our service to others. I want to make this better so bad that I can taste it and I’m willing to work as hard as I have to. Our patients and our communities deserve the best we can give them and I believe that key to fixing EMS is communication and the spreading of our message. This blog exists for that reason and so do the other blogs in this genre. The other bloggers, authors, speakers, and writers I’ve met have all spoken to me of the same goals. Our profession exists to save lives and alleviate suffering and improving our profession help us save more lives and alleviate more suffering in our communities. EMS does indeed make a difference out there in the world and we’re the ones doing it. The Chronicles of EMS is a great beacon of hope in our collective quest.

EMS Deserves More. Our Patients deserve more; Our Families deserve more; and yes… We deserve more. Mark, Justin, Ted, and everyone involved in the Chronicles of EMS are working hard to give us just that. They deserve our support and our attention.

I’ll be in San Francisco on March 11th for the premier of their pilot episode. I wouldn’t miss it for anything. Look out world, EMS is moving forward.

Posted by Ckemtp on February 8, 2010 • Filed under: Administration & Leadership, Command & Leadership, EMS, EMS Blog, EMS Health & Safety, EMS Management, EMS Topics, EMS blogosphere, EMS training, EMT, Emergency Medical Services, Fire Rescue Topics, Firefighter Safety & Health, Happy Medic, Line of Duty, News, Paramedic, Patient Management, Public relations, change, ems 2.0, ems education, humor, medicblog999, paramedic education, pride, profession, professionalism

Ten (or so) things that you should try to do with every patient

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I am not a perfect medical provider. In fact I’m really only practicing prehospital medicine (Ha ha!) but there are a few things that I try to do with every patient to improve my care for them and improve their comfort level as I care for them. I can’t claim that I always remember to do these things, but I really try to. I think that you should too.

Here they are (in no particular order other than ZIP code):

  1. Always introduce yourself and your partner to the patients and their loved ones using your first name. I wouldn’t want some upstart guy in some uniform type thing just randomly poking at me. I think that it reduces patient anxiety when you properly introduce yourself to your patient. I say “Hi, I’m Chris and I’m a paramedic with F&B Ambulance Service and Taxi Squad. This is my partner Fuzzy McGee. What is your name Sir/Madame?”

     

  2. When you’re in the back transporting the patient after you’ve given them most of the care you were planning to give them, go over your assessment again. Ask the patient questions that get them to expand on their original answers. Challenge yourself to find anything that you may have missed. 
  3. Play a game with yourself. Try to have the patient diagnosed by the time that you get them to the ER. If you can’t figure it out, fire up the internet when you get back to quarters and look it up. You’ll learn a lot of good medical information by doing this. I have.

     

  4. Once you get the patient in the back of the ambulance if they’re not facing an immediate “Life-or-Death” crisis ask them “Is there anything I can do to make you more comfortable?” Maybe another pillow or moving the head of the cot up or down would help them. Do it if they ask.

     

  5. Try not to have the pillow stuffed under the patient’s shoulder blades. It makes it uncomfortable when they’re lying on the cot. Moving the pillow up from under their back and placing it under their heads makes them a lot happier. They won’t know to ask for it. Just do it.

     

  6. If you find a patient down with an isolated fracture or dislocation get pain meds in their system before you start splinting or packaging them. It does take a bit more time, but you’re not being very humane if you don’t.

     

  7. You are the patient’s advocate when you walk in to the imposing world of ER care. Your job is to present them to a medical system that is overworked and overtired. Stick up for them and make sure that the medical care providers that are following you learn about what is wrong with the patient before you throw him or her to the wolves… er, um, nurses. I mean nurses.

     

  8. Before you hand off your patient to the ER, ask them: “Is there anything that I haven’t addressed? Is there anything that you would like me to be sure and tell the ER about?”

     

  9. Explain to the the patient WHAT you are going to do and WHY you are going to do it.

     

  10. Approach EMS with a servant’s heart. No matter what some EMTs may think, we are here for the patients. It’s not the other way around.

     

By trying to do these things you’ll provide better patient care. I think that I’ve grown as an EMS professional by doing these things. I’ve also grown as a person by doing these things. Let me know how this works out for ya.

Posted by Ckemtp on February 7, 2010 • Filed under: Ambulance, EMS, EMS Health & Safety, EMS Humor, EMS Topics, EMS training, EMT, Paramedic, Patient Management, comfort, courtesy, patient care

Mental Quickness – Do Smart Alecks Make Better EMTs?

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Alright, I admit it. Driving to work this morning was a bit of a challenge. We had two inches of fresh snow and the tires in my car are in desperate need of replacement. Yes, I drive a Subaru and usually it’s all-wheel drive does awesome in the snow… but I cheaped out on the tires, and they’re honestly a bit mismatched size-wise. Therefore driving it in conditions even remotely slick is hard as heck. I would have driven the SUV and had no problems at all but the wife had to drive the kid to school and then had to drive into the city afterwards and I wanted her to have the safe vehicle. Who cares if I go into the ditch? Work can do without me if they have to, but I need my family to be safe.

Since I think of things to write about when I drive, this morning brought my thoughts to how hard I had to concentrate on the road and the minute adjustments of the steering wheel and the accelerator needed in order to keep the car safely on track. Like everyone who knows about driving in slick conditions, I kept my eyes on the road ahead of me in order to “read” the changes in the road surface before I got to them in order to be ready to quickly make the adjustments needed to keep the car heading in the right direction. See a dark shiny patch? Foot off the gas, be ready to steer slightly away from it when the car slides in that direction. See a pile of snow with a frozen rut running through it? Minutely avoid it if possible and steer into the slide with just enough change in the gas to power through the slide. I made it to work, but I had to call in a favor to have a guy stay over for me for ten minutes. I let him know the night before that he might have to, and I did leave early… but I’m not wrecking the car just so I can save a few moments.

I consider myself a pretty good driver in the snow. In a vehicle with good tires I wouldn’t even worry about anything less than 6 inches this far into the winter season, but today was hard. I’m not patting myself on the back here, because if I would have put good tires on the car in the first place I wouldn’t have been in this position, but isn’t that most of what we do in EMS? We end up using our mental prowess to clean up other people’s messes caused by their lack of planning all the time. Today wasn’t much different. The amount of mental power and concentration needed to keep a car moving forward safely in snow-covered conditions is actually quite staggering when you think of it. You have to make quick observations of rapidly evolving conditions, surmise what you think the presentation of the road surface means to vehicle’s path of travel using your limited observations paired with your past experience and knowledge, and come up with a near simultaneous decision on how to handle the situation ahead of you. If you find yourself to be wrong, based upon the car not reacting the way you want it to, you have to instantaneously correct the situation while adjusting for the conditions ahead… or crash.

Now picture yourself managing a challenging patient presentation, one requiring a handful of pharmacological and physical interventions. You’re pretty much doing the same thing as driving in snow. Just like playing a game of chess, you have to be “thinking a few moves ahead” in order to keep up with what the patient’s physiology is going to throw at you. Do you have a fall victim with a broken hip in need of pain control? Did you think that they’re possibly going to drop their blood pressure with a dose of morphine? Well then you better be ready to give fluid to bump it back up to acceptable levels. However, what if you’re treating a CHF patient that would suffer further from the added fluid? What if they were a patient with Chronic Renal Failure? Would that affect your initial dose of morphine based upon the unknown factor of untoward hypotension? In my Northern system, I’d choose to use Fentanyl over Morphine in that case because of the lessened risk of hypotension, but in my Southern system I’d just have to start with a lower dose of Morphine and slowly titrate to an acceptable level of pain control once I gauged the patient’s response to the med.

How about a patient with a large anteriolateral MI? Their Left Ventricular function is soon to be compromised if not treated in a cath-lab. You need to increase blood flow to the Left Ventricle and decrease overall cardiac work by decreasing afterload with use of nitrates, but that’s going to decrease their cardiac output and blood pressure by decreasing their preload as well. You need to stabilize the infarct as best as possible while maintaining the patient’s hemodynamic state, and you may need to consider supporting their left ventricular function with the use of a vasopressor such as dopamine to treat possible cardiogenic shock. In this case, careful observation of the patient’s presentation and all information available to you is of paramount importance in order to make the minute treatment decisions necessary for your patient’s best possible outcome.

It all comes down to “Mental Quickness” or having the mental prowess and state needed to rapidly intake complex information, process it against your knowledge base, and then make reasonable decisions on a course of action in a very short period of time. We call people who are good at this “Quick Witted” and it applies to myriad situations in daily life. People who are good at this are usually funny, are quick to react to new situations, handle change fairly well, and make darn good EMS providers. I practice by trying to have a joke ready for any situation… so you could also call a person who’s mentally quick a “smart ass”.

You can practice your skills at being mentally quick the same way I do. Use humor and try to make good comebacks to the hooks and barbs that your coworkers and friends throw at you. When we’re sitting around busting each other’s chops… we’re actually practicing our EMS skills, right?

Think about it. Exercise your mind through reading, learning new things, and trying to come up with new ways to think of existing information. You’ll be funnier, more popular, will be able to knock your buddies down a peg better, and will improve your patient care.

Posted by Ckemtp on February 2, 2010 • Filed under: Administration & Leadership, EMS, EMS Health & Safety, EMS Humor, EMS Topics, EMS paramedics, EMS practice, EMS training, Emergency Medical Services, Fire Rescue Topics, Paramedic, Patient Management, Training & Development, change, ems education, ems scenario based education, inside the mind of a paramedic, mental imagery, paramedic education, patient care, scenario based training, training-fire-rescue-topics

EMS practice

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Did anyone else play a sport (or sports) in high school? I did, actually I played football for a few years. I was on the line, which in my small high school meant that I played every position on the line, both offense and defense, because there just weren’t that many kids out there to play. My graduating class was 83 in my small, small town.

I didn’t touch the ball though. Coach told me just to go out there and hit people. I haven’t touched a football since.

Every day after school we went out there no matter rain, shine, snow, heat, or better things to do and practiced for three hours every night. We did this all season and I hated it. It sucked and sucked bad. However, it did make me a much better football player. It kept my mind focused and kept me in shape. I was a much better “Go out there and hit people” guy than I would have been had I just taken a football class and then played parts of the game every day.

Does anybody do this with EMS? Sure, we all do Continuing Education, but do we really practice as hard as we should as much as we should?

We play parts of the game every day but just as sure as I didn’t intercept a pass and run in a touchdown every game, I don’t perform a pericardiocentesis every shift. I can plink in an IV in my sleep (and do… a lot…) and I probably can treat a STEMI as good as the next guy. Playing the parts of the game that we do more often than the others gets us good practice on what we do most often, and if we don’t allow ourselves to get complacent, that’s just fine. However, how many times have you calculated a dopamine drip lately? Even if you live in the busiest, most dopamine swillingest jurisdiction on the planet you’ve still interpreted Normal Sinus Rhythm a lot more than you’ve shown off your math chops.

The other day I missed a tube. I was caring for a patient who crashed in front of me while heading to the ER. The Pt went from CAOx3 to very obtunded in a matter of a minute or two. The first time I went to tube, (the Pt) was clenched and by the time I got the etomidate ready we were close enough to the hospital that bagging was my best option. When the Pt got sux and sedate juice in the ER I tried again…. and missed.

I freakin hate that! Man, I never miss a tube! At least almost never. I hate it when I do and beat myself up about it. Probably more hard than I should, but that’s just me. I take this stuff seriously if you can tell. The next shift I spent an hour playing with our two intubation dummies and our “Fred the head”. I tubed over and over again every way I could think of. For an hour. Yes, I know that it’s not exactly like the real thing, but it was all that I had access to for practice.

Something cool happened right after I got done with my hour long tubing pennance. I sat down for lunch and immediately got toned out to intercept a code with CPR in progress. I pointed my SUV towards the rural address and hit the gas. When I got on scene, the BLS crew told me over the radio that they were having difficulty with the airway. I walked in, and got the most beautiful tube that I think that I’ve ever gotten. Right in, right through, and right hole.

I think that my football coach would have been proud.

Posted by Ckemtp on February 1, 2010 • Filed under: ALS Intercept, EMS, EMS Health & Safety, EMS Topics, EMS practice, EMS training, EMT, ET Intubation, Emergency Medical Services, Fire department, Paramedic, Patient Management, ems education, ems scenario based education, intubation, paramedic education

Be the Glow Worm – HazMat for EMS.

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I am not a glow worm.

Full disclosure – This is a repost from 09/2009 – It deserved a bump-up and to fix the video. Make sure to watch the vid!

Hazardous Materials, or “HazMat” as it is commonly known, is scary stuff. At least for me that is. In public safety circles, they’re mainly the concern of firefighters and I’ve never received training on them outside of the realm of the fire department. My EMS only agencies have always told me that we remain in the “cold zone” and wait for patients to be brought to us after decontamination.

And that’s just fine with me. Ckemtp is NOT a glow worm… did I mention that?

But, since I’m also a firefighter I finally broke down one weekend and gave in to the pressure I was under to get my HazMat Operations certification. 40 hours of class, lots of homework, and some very dry PowerPoint slide shows. After the first weekend of the class there’s some things that I’ve learned and figured out.

1. HazMat’s still scary.

2. Ck’s still not a glow worm.

3. EMS agencies really need to train more on HazMat.

“We know hazmat” you say. And I know that you’re saying it because that’s what I would have said before those last 20 boring hours spent learning that I knew nothing about hazmat. HazMat is something that we take for granted in that we think that it won’t happen in our jurisdiction, or that it won’t affect us on our day to day. I happen to hope that it won’t hit during my duty days.

This video is from Seward, IL. A small town in the middle of a lot of corn that found itself one day having a big problem. The video is from a surveillance camera on the side of a grade school in the middle of town. The vid starts slow, but has a definite “HOLY CRAP!” moment about halfway through. You’ll see what I mean, all hell breaks loose.


 
See? Holy hell on crutches! That’s anhydrous ammonia, a common chemical used in farming (and in methamphetamine production). A tanker truck full of the stuff sprung a leak and flooded the town with a toxic cloud. Thankfully, nobody was killed. There were a few firefighters sent to the hospital, and some very scary moments, but it all turned out to be ok. This one’s from the same school. It’s just as scary.

Remember this, a HazMat incident doesn’t have to be the once in a while overturned tanker truck full of MethylEthylBadJuJu. Any every day response can turn quickly into a hazardous materials incident.

Not too long ago, an EMS only agency that I may or may not work for received a call for an “eye injury” in one of our really rural response areas. This call generated a single ALS ambulance only response out to the farm where the injury happened.

The medic and the EMT responded out to the scene, which was about a 15minute emergent response. Arriving at the farm, they were directed to the dairy barn to find their patient.

Their patient was in a lot of pain.

Apparently, he worked for a dairy services company and was delivering product to the farm when he was injured. If you don’t know much about dairies, milk processing leaves a byproduct called “Milk Stone” which is the dissolved minerals in milk solidifying on dairy equipment. Think of hard-water stains. Dairies use products containing phosphoric acid to clean it out. It’s like Lime Away on steroids. This stuff is pretty nasty. Dairies use it in a diluted form, but the supply companies carry the concentrated stuff. This patient was filling a container with the high-powered stuff to dilute it into the customer’s container when the concentrate fell. He reflexively looked right down at the falling container and got a face full of the stuff when it splashed back up at him.

Do you remember that chemical burn stuff you were trained on? He had them. Do you remember the decontamination training you had? What about proper personal protective equipment, do you have it? Do you know when to put it on? Do you know how? What do you know about the chemical?

While treating the patient, one of the paramedics noticed that his EMS gloves was turning white. It was the acid eating through it. A lot of water was used to irrigate the patient, and the providers, before transporting the patient to the hospital.

This was an everyday incident that actually happened. Think about how you’d handle it, because tomorrow it could happen to you.

And once again, Ck is not a glow worm.

Posted by Ckemtp on January 20, 2010 • Filed under: EMS Topics, EMS safety, EMS training, Fire Rescue Topics, Firefighter Safety & Health, HazMat, Major Incidents, Special Operations, Uncategorized, Videos, accident, disaster, training-fire-rescue-topics, volunteer fire department, volunteer firefighter

Uh oh, is it that time again? EMS Recert Time Cometh…

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I’ll betcha that a lot of you reading this are in the same boat that I am… Here’s the reminder!

Yesterday I had the occasion to pull out all of my various certification cards and licenses, photocopy them, and turn them in to one of my departments for verification that I still had them. Much to my chagrin I noticed that it is indeed that time again… the time for me to start gathering up all of my hard-won continuing education hours and credits, compiling them into packets, and begin sending them off to the various places that I hold licensure through.

So let’s see… that’s Illinois, Iowa, Wisconsin, and the National Registry of EMTs. Actually, the Illinois license is on a 4 year schedule, so this is an off period for them. Thank goodness for small favors. Unfortunately though, I also noticed that my ACLS card expires this month and I hadn’t noticed it till now. Now I have to frantically find a class to sit through and get me some learnin’ at. Here’s hoping it’s not like the last time I took the class… It was horrible. Since I had let my card expire by, ahem, a “short amount of time” (3 months) I had to take the full class. Worse yet, the only class I could find happened to be when one of the big hospitals near me was pushing through a bunch of OB/Peds nurses through the class so that they could accept regular med/surg patients on their units. The nurses, suffice to say, were less than thrilled to be there and answered most of the questions with “I don’t know, what does the Doctor order me to do?” The instructor, who was also a nurse, actually accepted that answer for most of the questions. Really. I listened to them give waaay off the wall answers that were accepted as correct by the instructor.

I don’t think any one of them has ever been in charge of a code resuscitation… at least not a successful one. But I digress.

The State of Wisconsin EMS bureau has been changing the rules for renewing your licensure quite a lot this year. Frankly, I don’t quite understand what I have to do as of yet but I’m working on finding it out. As far as I know right now I have to take a “refresher” program. I *think* that by completing a National Registry refresher program I will be fine. Feel free, however, if you’re in the know for Wisconsin EMS renewals, to set me straight on this in the comments section. It’s kinda important for my livelihood.

My Iowa EMS license is much easier. All I do is send them in the exact photocopied packet I send in to the NREMT, fill out a short little form, and a few weeks later I get a shiny new license in the mail. Thank you State of Iowa EMS! Keep Being Awesome!

For the National Registry, I’ve heard faint rumblings about this whole “Computer test based” renewal program. It sounds cool, from what I’ve heard… but I’d have to do the exact same CE for my Wisconsin and Iowa licenses and I wouldn’t get the CE bump I need for the 4 year Illinois license. So much for that, then.

Lucky for me, there’s an awesome NREMT recert class they put on in Davenport, IA. I’m heading out that way to get me some high-quality learning and have me a little bit of fun as well. Thanks EICC and MEDIC EMS!

This post doesn’t have much of a message to it other than for me to gripe about having to yet again put all of this stuff through. I am all for education, and I research EMS stuff nearly every day, but unfortunately I haven’t thought of a way yet to translate stuff I learn from my colleagues on the EMS blogosphere and the other sites on the interwebz into hard Continuing Education credits. Maybe I’ll spearhead that issue too once I get time. Maybe…

Posted by Ckemtp on November 20, 2009 • Filed under: AHA, EMS, EMS Health & Safety, EMS Topics, EMS training, EMT, EMT-Intermediate, EMT-Paramedic Specialist, Emergency Medical Services, Iowa, Iowa EMS, Paramedic, Training & Development, ems education, paramedic education, wisconsin

Education vs Training: The “Professional Ambulance Cleaner”

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Imagine if you will this hypothetical scenario:

You and your roommate have just graduated EMT school together and go to work at competing ambulance companies in the same city. He works for HIS ambulance service, and you work for YOUR ambulance service. Both services have similar fleets, similar deployment patterns, and similar call-volumes. In fact, there’s really no way to tell them apart other than the fact that the HIS ambulance service uniforms are sickly green jumpsuits, and YOUR ambulance uniforms are Macho Blue Shirts with navy blue pants.

You both go off for your first day on the job which understandably includes several hours of training on company policies. For both of you, the whole day turns out to be a long class on how to clean the inside of ambulances.

Here’s the differences, though. At YOUR ambulance, you learn about the biological functions of bacteria and viruses. You learn their strengths, their weaknesses, how they reproduce on inanimate environmental surfaces, how they create biofilms to increase their reproductive capabilities and life span, and how pervasive they are in randomized samples from real-life ambulances. You learn how grime collects in the ambulances, how it adheres to the surfaces that you will be cleaning, and what the various types of substances are that you will most commonly find in real-world applications. The whole first day is spent on nothing but learning about dirt, grime, and germs and how they contaminate ambulance interiors. They even threw in the types of materials that the ambulance interior is made from and what the specific dirt-holding and germ-breeding properties of each material are. You see samples and scenarios pertaining to germ and dirt proliferation on ambulance interiors.

Not only that, there’s homework, reading material, and a report due the next day.

The second day that you report to YOUR ambulance service, you learn all about different types of cleaning products, tools, and disinfectants. You learn how to properly choose the detergent needed for optimum dirt-dissolving power on what type of surfaces you may have to clean; You learn the proper disinfectant to choose for each type of commonly encountered bacteria, virus, and fungi spore; and you learn the proper contact times to leave each product on for optimal disinfection and/or dirt dissolving power. Then you learn about every different type of sponge, mop, rag, fabric, and tool used to clean the ambulances. You spend a few hours in the laboratory they have testing out the material and performing experiments in the name of learning.

Oh, and after that day too, there’s a lot of homework and reading material.

Your roommate, on the other hand, went to work and found out that he too had to learn about ambulance cleaning. He learned that they also expect clean ambulances, however his choices and training are much simpler. He is told to clean the ambulance using two bottles: One marked “Cleaner” and the other marked “Germ Killer”. He is given ten rags and is told to clean the ambulance for inspection by the owner of the company using the tools given in the time allowed. He does so and is told “Good, now do it again tomorrow”. The next day, he again cleans the ambulances using the tools and training provided, and is again told “You did a good job”

In the above scenario, the first ambulance service, “YOUR Ambulance, uses a form of advanced education to teach their people how properly to clean the ambulances to their specifications. The education is rigorous and in-depth.

At “HIS Ambulance” they use training, and vocational experience to teach their employees how to properly clean the ambulances.

Here’s some questions I have:

  1. Which ambulance service do you think will have cleaner ambulances in the long run?
  2. Which employee do you think will do an overall better job in cleaning the ambulances?
  3. Which employer, “YOUR Ambulance” or “HIS Ambulance” do you think has the better philosophy?
  4. Which ambulance cleaning class will result in the better, more motivated, happier employee?

Anyone else see the relationship to EMS training/education here? Which one results in a more “Professional Ambulance Cleaner” that is better equipped to handle the job?

Posted by Ckemtp on November 12, 2009 • Filed under: Ambulance cleaning, Ambulance maintenance, EMS Management, EMS Topics, EMS training, Emergency Medical Services, Management, Paramedic, Training & Development, disinfection, ems 2.0, ems education, ems scenario, ems scenario based education, paramedic education, profession, professionalism, sanitize, scenario based training, training-fire-rescue-topics

Cardiocerebral Resuscitation – Change brings Fantastic results

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Hold on to your brains here people, because I’m about to blow your mind. 

With new research comes new treatment modalities, and with new treatment modalities comes a change in our profession’s very foundation. This change is hard to accept and hard to convince others to implement, but it is necessary for us to do so. 

I’m talking here about CCR, or Cardiocerebral Resuscitation. Hold on, because it’s coming, it’s fantastic, and it will shake the very timbers of our profession.

 First off, if you don’t know what I’m talking about, here are some things you should read first. Go ahead and read them, then come back and read this. I’ll give you a teaser on why you should read forward:

40% – 60% resuscitation rates are possible in witnessed V-Fib cardiac arrests.

 Is that enough incentive for you?

 First, go visit: Http://www.CallandPump.org to read about the ongoing research project.

 Then, read my first post on CCR: “Advances in Resuscitation – CCR, if you’re not doing it now, you will be”

Follow the links on that post to see the article outlining the research project and the subsequent article published in the Annals of Emergency Medicine.

 Did you read them? Good.

 So here are some things you should know about CCR.

 It’s about moving blood – Good compressions make all the difference. Press hard, press fast (100 compressions per minute) and switch out compressors every 1 minute. Yes, do this even though you’re going to complain that I “don’t know how it goes in the field”. Yes, I do because I’m a practicing paramedic with a decade or so of experience and two full-time EMS jobs. I know it’s hard and unwieldy, but the results are almost magical.

 When I first became a CPR instructor for AHA some years ago, I taught my students, incorrectly, that chest compressions were all about compressing the heart between the sternum and the spine. It turns out that I was wrong. The point of effective compressions is to vary total intrathorascic pressure creating both a positive total pressure that forces blood out of every vascular space and organ in the chest including the heart and aorta and also then creating a negative total pressure to pull blood back inside. The more blood you can get flowing, the higher pressure you create in the arteries moving blood through the vascular system and perfusing the heart and the brain. By continuing compressions, you boost the arterial pressure higher to the point where it will perfuse the heart and the brain adequately to maintain some amount of metabolism and prevent some cellular necrosis. When you stop, even for a few seconds, the pressure falls to almost nothing and must be worked back up to the level needed to provide some perfusion of the critical organs. 100 compressions per minute isn’t a request, it’s a mandate if you wish your patient to survive. Switch out compressors every one minute. We’re human beings and we’re fallible. It’s been shown that we cannot maintain adequate compressions for more than a minute. Pop on your ETCo2 monitor and watch the number fall after one person does compressions for longer than that and you’ll believe me.

 Transport is deadly – One of the tenants of CCR is that every intervention that interrupts compressions must be proven to be of more benefit than continued perfusion of the heart and brain. If we are to maintain adequate compressions to continue this perfusion until the heart restarts and begins moving blood on its own, we must not move the patient from a hard, level surface. One of the biggest interruptions of compressions is the act of moving and readying the patient for transport. We jostle them around, put them on a narrow cot, bounce them from wherever they fell, load them into the ambulance, and then bounce them along the road to the ER. All of this decreases arterial pressures by negatively impacting our ability to adequately compress and also by limiting our ability to effectively compress and increase intrathorascic pressures to the extent possible. Therefore, transporting the patient is deadly because it harms our ability to resuscitate our patients.

 Of course I want you to take them to the hospital eventually (hopefully once they’re resuscitated) just don’t be so eager to get them there. Work the patient where you find them. You’ll do your best work on scene and will be pleased with the results.

Be prepared to use more and less common medications – How many medications do you carry on your trucks? One service I work for that doesn’t use the new CCR protocols carries 6 prefilled syringes of Epinephrine 1:10000 on the trucks. Let’s see… One Epi every 3-5minutes x 6 syringes equals 18-30 minutes of epinephrine for the arrests we run. I put the officers on notice that I will be needing a second truck to respond to codes that I attend. In addition, since more patients are being resuscitated, the need to practice post-resuscitative care is increased. Be prepared to hang antiarrythmic drips. Be prepared to hang dopamine. Practice caring for patients post resuscitation. You may want to consider researching induced hypothermia to mitigate reperfusion injury to the heart and brain.

Also, remember that Vasopressin and Amiodarone are in the AHA ACLS protocols. Does your service use them?

Approach cardiac arrest with a clear game plan – If you’re in the emergency services, you should be familiar with the Incident Command System, or ICS. Resuscitations should be no different. One person is the “Code Commander”, one person is the “CPR Sector Officer” and so forth. Train on these like you would train for any other major incident and watch your success rates climb.

I’ll be posting more on this in the coming days. I’m really excited about CCR and the possibilities that it holds for our patients and our profession. You will be too, trust me

Posted by Ckemtp on November 11, 2009 • Filed under: CCC, CCR, EMS Topics, EMS training, Paramedic, Patient Management, Protocol development, Training & Development, cpr, cpr save, ems education, paramedic education, save

A Motivational EMS Article Geared towards Newer EMTs

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The following article is what I submitted to my Fire/Rescue/EMS department’s monthly newsletter for this month’s EMS column. It has a readership of every one of the the 110 or so members of the department, their families, and a good percentage of the 30k or so people in our district. They know me personally as someone who (Imagine this) likes EMS.

If you like this article, feel free to steal it and use it for your purposes. All I ask is that you keep the links intact and give byline credit. Shoot a comment to me too so I can see if it indeed does go anywhere.

Oh, and here’s a thought. If you would like a short EMS related piece to put into your department’s newsletter, shoot me an e-mail at proems1@yahoo.com I’ll be happy to come up with something.

————————————–

It’s well known around the department that I like the ambulances and EMS in general. I do, and I’ve always been proud to be a part of (My Department’s) EMS program. I think that the level of dedication and professionalism in our department is second to none and that our program is certainly one of the best in the region and in the state.

With that said, in EMS there is never a time to slow down and rest on our laurels. The science that drives our brand of medicine is constantly evolving and the only constant is change. In my EMS career, I’ve seen “The Right Thing to Do” for my patients change more times than I thought possible. Continuing education, reinforcing the basics, and studying the latest research is key in keeping oneself in step with how best to care for our patients. As with any community based Emergency Medical Services provider, our citizens are our families, neighbors, and friends. We have the responsibility of being the first line of defense against the very worst times in peoples’ lives and it is our duty to be at our best when we are called to make a difference. The people we care about most are depending on us.

Just as in firefighting, in EMS, the little things make the biggest difference. It really is the Basic Life Support care that makes everything else work and our calls run the smoothest. Patients do not necessarily perceive the skillful application of Advanced Techniques or medications given to them, but they certainly appreciate the attention given to treatment of their ABCs, their comfort on the cot, pain relief and stabilization through proper splinting techniques, the compassion of the care providers, and the cleanliness of our ambulances and equipment. It has been said that “Perception is Reality”, meaning that the way someone perceives you or your organization affects their own reality. In EMS, good perception actually has been shown to provide for better patient outcomes. Really, if you have more confidence in the skill or effectiveness of your medical provider or a technique, you’re statistically more likely to have a better outcome.

It is so important for us as healthcare providers to focus on providing the best care possible for our current patients, but also to keep an eye out for future patients. Start now by making sure that the ambulance is thoroughly cleaned at the start of every day and after every call. Make sure that your equipment is ready to go and that you’re an expert in its use. Read something educational every day to keep yourself in the right mindset and to keep your skills sharp. Pull things out and practice with them. Come up with questions to ask the more experienced providers and don’t be afraid to ask them. It is every EMTs duty to become an expert in prehospital care and you are the only one who can expand your knowledge enough to become one. Study every day.

Here are some resources I use every day, they teach me something every time I use them:

-          Http://www.happymedic.com – A San Francisco Firefighter/Paramedic and his adventures in EMS.

-          Http://www.999medic.com – A British paramedic working EMS with our neighbors across the pond.

-          Http://www.theEMTspot.com – Educational tidbits, tips, and tricks from a Colorado Paramedic.

-          Http://www.EveryDayEmsTips.com – A Social Media, training, and EMS guru with daily tips to improve your care.

-          Http://paramedicine101.blogspot.com – In-Depth Educational Articles for EMS providers.

-          Http://www.LifeUnderTheLights.com – Your’s Truly’s random musings on the EMS.

Of course, getting your hands on a copy of JEMS or EMS Magazine is great too. Learn something every day, take pride in yourself, your service, and the care you provide. Your next patient could be your loved one, make sure they’d get care that you’d be proud to give them.

Posted by Ckemtp on November 3, 2009 • Filed under: Ambulance cleaning, EMS, EMS Motivation, EMS Topics, EMS pep talk, EMS training, EMT, Emergency Medical Services, Patient Management, Public relations, Training & Development, Your Happy Medic, courtesy, ems education, medicblog999, profession, professionalism, technology-communications-ems-topics, volunteer fire department, volunteer firefighter

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What do you think?

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

Advances in Resuscitation – CCR If you’re not doing it now, you will be

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Visitors to my old blog probably know that at my ambulance service we tend to bring back a lot of codes. I talk about it a lot. Back in 2004 our medical director, Dr. Michael Kellum, got us involved in a “Demonstration Project” to bring Continuous Compression CPR or Cardiocerebral resuscitation to a rural area. Since that time, the results have been more than dramatic. Depending on what statistics you look at, we may be “Saving” almost 50% of witnessed arrests found to be in ventricular fibrillation.

It’s all explained at Http://www.callandpump.org But if you want to go right to the whitepaper that explains what we do, why we do it, and how it’s done then you want to go here: http://callandpump.org/assets/Proposal_Current.pdf – This link is explains the demonstration project initiated by Dr. Kellum et al. in the two county area that I work in. This paper was published in 2004 at the beginning of the project.

This is a link to the results published in the Annals of Emergenc Medicine in 2008 – http://www.ncbi.nlm.nih.gov/pubmed/18374452?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum 

You may be interested in this part:

“RESULTS: In the 3 years preceding the change in protocol, there were 92 witnessed arrests with an initially shockable rhythm. Eighteen patients survived (20%) and 14 (15%) were neurologically intact. During the 3 years after implementation of the new protocol, there were 89 such patients. Forty-two (47%) survived and 35 (39%) were neurologically intact. CONCLUSION: In adult patients with a witnessed cardiac arrest and an initially shockable rhythm, implementation of an out-of-hospital treatment protocol based on the principles of cardiocerebral resuscitation was associated with a dramatic improvement in neurologically intact survival.”

This is good stuff. Remember, the above is only reflective of those included in the study, who are “Witnessed arrest(s) with an initially shockable rhythm”. Anecdotally, I’ve personally attended those that were not in a shockable rhythm and witnessed greater effectiveness as well.

Here’s the short version of our protocols for Witnessed V-Fib Arrest: (and for those of you who want more, email me at: proems1@yahoo.com and I will be happy to send you a copy of the protocols)

We follow an acronym called MCMAID in our resuscitation protocols, it stands for:

Metronome – We carry a metronome in our monitor/defibrillator bags that clicks out at 100 beats per minute. We are to compress at 100bpm. No more, no less. This metronome keeps us on rhythm and reminds us to be on the chest.

Compressions – 100 compressions per minute. Do not stop. Initially, we are to administer 200 compressions (2 minutes) before our first shock. We are to limit any interruptions in compressions absolutely as much as possible, charging our defibrillators while compressions are ongoing, and recognizing V-fib through the compressions if possible. Compress hard and deep, completely releasing tension on the chest upon recoil to maximize the compression and decompression of the chest.

Monitor – Place the monitor on the patient using fast patches. Do not stop the 200 compression cycles to determine the rhythm. Shock at max joules biphasic. If you can anticipate V-Fib, charge the defib during the compressions and only stop long enough to clear for the shock. Don’t check the pulse, get right back to compressions.

Airway – Initially, a BLS airway will be placed in the patient and a non-rebreather oxygen mask will be placed on the patient. If the airway must be controlled by more advanced means to protect and ensure a patent airway, now is the time to do so.

Intravenous Access – Most of the time, this is accomplished through the means of the Ez-IO drill that we carry and love. (See: Alternative Circulatory Access Strategies – Hi Ho IO) This can also be obtained through peripheral or EJ IV access.

Drugs – Epinephrine 1:10,000 1mg IVasopression 40 IU, Amiodarone 300mg, then Epinephrine 1:10,000 1mg q 3-5min. If refractory, we may give an additional 150mg Amiodarone IV.

To see the full MCMAID protocol (I put it up in a post) you can see it by clicking here.

Today Dr. Kellum came down again for our monthly training and let us know the latest breakthroughs and orders in the project. He is stressing the importance of End-Tidal CO2 (ETCO2) monitoring and states that no pulse check is necessary without a spontaneous increase in ETCO2. He expects every intubated (or combitubed) patient to have ETCO2 monitoring in place.

He also expects that we will monitor ETCO2 readings as a way to prove effectiveness of compressions. Rescuers who cannot get ETCO2 readings consistent with other personnel when providing compressions shouldn’t be doing compressions.

Rescuers should switch off compressions EVERY ONE MINUTE whenever possible. This is providing some fantastic results in preliminary trials.

He also stated that the effectiveness of the CCR protocols are showing a marked increase in refractory V-fib. He hinted that the protocols might soon show a need for thrombolytic use in treatment of refractory V-Fib.

Stay tuned folks, I am happy as heck to be included in this. I will bring updates, with permission, as many times as I get them.

Posted by Ckemtp on October 17, 2009 • Filed under: CCC, CCR, DNR, Do Not Resuscitate Order, EKG, EMS, EMS Topics, EMS practice, EMS protocols, EMS training, ET Intubation, Emergency Medical Services, IO, IV, Paramedic, Patient Management, SMG, SMO, STEMI, Training & Development, cpr, cpr save, ems 2.0, ems education, ez-io, intraosseous, new perspective, paramedic education, patient care, save, southern wisconsin, technology-communications-ems-topics • Tagged: , , , ,

Daily Training Topics 10/16/09

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Just about every 24 hour shift that I work up in my Northern job I put together a little impromptu training session. It’s a way for me to address things that I think are important for the crews to refresh on as well as a way for me to read up on some things and make sure I remember the stuff I should know. I try to learn the latest things on the chosen topic with a bit of research before I present the class as well. It keeps me sharp, which is good.

Also, (and let’s talk about the important things here) it gives me a cheap and easy blog post which I like because I’m really trying to bump up my posting frequency with this Fancy New Blog and all that.

Today’s training topics were a refresher class on intravenous access as well as BLS Airway Management Skills. We have a good number of EMT-Basics, EMT-IV Techs (here in Wisconsin) and even an EMT-Intermediate ‘99 that are on-duty today. My partner and myself (incidentally, both named Chris) are the duty medics.

So, without further ado, here’s what I taught them. Remember, this was a BLS class, and is geared to newer providers.

- IV Skills: I didn’t do anything on my own here. One of the benefits of the EMS blogosphere is that I have a wealth of training information at my fingertips. A lot of the time, I’ll pop on over to see what Greg Friese is doing on Http://www.everydayEMStips.com – And if I’d like some in-depth EMS knowledge, I’ll head over to Http://paramedicine101.blogspot.com.

For this training, however, I took the tips laid out by Steve over at Http://www.theEMTspot.com – where he wrote “Six Techniques to Nail the IV Every Time” I put it up on the projector and wrote down the bullet points on the white board. (and I gave him the credit for the easy and valuable training both in the class and on here)

- BLS Airway Management knowledge:

For this one, I pulled out every airway and oxygenation management tool we carry in the truck, which in my service includes:

- The Oropharyngeal and Nasopharyngeal Airways

Do you know when to use one over the other? Here’s some tips. First, if the patient is unresponsive enough to take an oropharyngeal airway without triggering a massive gag reflex, the patient NEEDS an oropharyngeal airway. (or an ET tube/Combitube/King LT for that matter)

Nasopharyngeal airways are used for patients unresponsive enough to need an airway adjunct but that still have an intact gag reflex. DO NOT USE nasopharyngeal airways in cases of head or facial trauma. (Why? Because the nasopharynx is separated from the rest of the cranial vault by the Cribiform plate, which is a very thin piece of bone that can be fractured very easily with significant head trauma. If it is fractured, you run the risk of placing the nasopharyngeal airway – or the nasogastric tube for that matter – right into the cranial vault… which is bad. 

The oropharyngeal airway is measured from the corner of the mouth to the angle of the jaw. The Nasopharyngeal airway is measured from the nare (nasal opening) to the earlobe.

On a side note, do you know how to check for a gag reflex? My almost never-fail method is to use the eyes. If the patient is unresponsive, running your finger lightly through their eyelash should elicit a response (i.e. wiggling) if the patient has an intact gag reflex. Further, a variation on the theme is to lightly open their eyelids with your gloved fingers and lightly blow into their eye. Don’t do it hard, and certainly don’t blow hard or use any pressure with your fingers, but if a person isn’t unresponsive and can tolerate that without flinching… they aren’t human.

- The Combitube

Honestly, I’ve not had a good track record with the combitube. I prefer the King LT. (Sorry Happy)

- The Endotracheal Tube

For this part of the training I looked at the various parts of this procedure that an EMT-Basic might be asked to participate in, such as preoxygenation with a BVM before the procedure, setting up the equipment for the ALS provider before he/she needs it, choosing the various adjuncts to assist the ALS provider in confirming tube placement, and various methods to secure the tube.

- CPAP

This is a miracle treatment. CPAP, or Continuous Positive Airway Pressure has revolutionized the management of congestive heart failure and pulmonary edema. Every EMT should know how to use this, when to use this, and how to properly apply this wonderful thing.

- Non-Rebreather O2 mask, Nasal Cannula (Adult and Peds)

If you don’t know how to use this, you probably should.

- The Nebulizer set up (We use Albuterol (Proventil) and Ipatropium Bromide (Atrovent)

We covered the proper set-up of the nebulizer and the various differing ways that it can be employed. Sure, you can use the duckbill for the patient to hold, but you can also pull the reservoir bag off of a Nonrebreather mask, insert the nebulizer chamber where the bag went and you’ve got yourself a handy mask neb.

We also went over the proper way to connect the nebulizer to the Bag Valve Mask. Depending on your equipment this setup could vary. Ours did like 3 ways. Check yours.

- Bag Valve Masks of assorted sizes

Learn how to properly seal the masks, the proper ventilatory rate (8-10 per minute) and the proper size for each variation in patient population.

- A Pocket Mask

Haven’t used one of these in a while, have you?

- The Surgical and Needle Cric kits

The basics don’t need to know how to use these, but it’s good to practice. Three of us had to hold the student down to do it, but we got it in on the second try!

I’m really liking my new home.

Posted by Ckemtp on October 17, 2009 • Filed under: EMS, EMS Topics, EMS training, ET Intubation, Emergency Medical Services, Patient Management, ems scenario based education, intubation, paramedic education, patient care

Could it be? A Good EMT-B Student?

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What is with students these days?

I precept and mentor quite a few students these days. Maybe it’s because I’m old and my memory is going south on me, but I don’t think that I acted quite like this current crop does when I was a student. I think that I took it seriously. I think that I respected the elder members of my profession and did what they told me to, right?

I always tell students that I’m a real jerk when I’m precepting them. I’m not… but I like the whole Mr. Myagi (old reference, look it up youngins) thing. You know, “Wax on Wax off” equates to something EMS related or what not. I try to reinforce the things I think that are important for them to know to be a good provider at whatever level they’re currently working on. Everyone has to work on their assessment and patient communication skills. Everyone has to get good at MANUAL BPs, listening to Lung Sounds, Abdominal Sounds, and their patient’s stories. Everyone has to get good at not being afraid to assess the patient in a competent, professional way. I figure that once they get the assessment and the friendly, professional communication thing down, the rest can be reinforced pretty easily.

Recently I’ve been adopting the “Dr. Cox” school of mentoring students. I love the TV show Scrubs. On the show, Dr. Cox torments his young protoge’ relentlessly and calls him a different girl’s name every time he addresses him. I think that it’s funny as heck and I’ve been doing that lately. The first student I did it to left the program after a week (Not my fault! He was running with another medic a lot more than he was running with me!) and the second, well… the second student I pulled this on really surprised me.

He was an EMT-B already, but was fresh out of class and was working for a fairly slow volunteer service that one of our part-timers volunteers for. She had brought him over to get some experience on a busy service and since I was her partner for the day, he got to be subjected to my whims as a preceptor. I think his name was Stacy, Jennifer, or something.

We had two calls right off the bat. A refusal at a “Nursing Home” that called us for a patient with pink eye, and a “Elderly Man out of Control” at a farm house way out in the country where the County Sheriff ended up transporting on. This kid seemed to be good luck, considering that we weren’t having to go to any coffeeless hospitals that early in the morning. Our streak of luck ended when we caught a tranfer from an ER to a secondary admitting hospital for an elderly lady with a GI bleed.

This was perfect for the kid. It was about an hour-long ride with the patient. Plenty of time to teach the kid “friendly banter” skills with the patient and also to have him do a reassessment q 15min while I sat back, cracked jokes, and worked on the three reports. Win win. We picked up the patient at FavoriteSmall Hospital ER and got her in the truck. He was quiet at first, as all students are, but I made a deal with the patient. I asked her if she could help me get the student over his shyness. Oh boy, she did. She talked his ear off the whole way and he participated in the conversation like a champ.

Yes, I think that it’s important to connect with your patients on a human level. He did that pretty well, actually.

The only thing that I thought he needed work on was how he took blood pressures in a moving truck. Admittedly, that’s a hard skill to master. One of my cardinal sins is to make up a BP and tell me the made-up number you “think” it is. He may have done that.. but I didn’t call him on it right away. Instead I waited until after the trip because the patient was very stable.

“So Denise, how sure are you on those BPs you took? Because… I didn’t know if you could really hear them or not..” I asked him.

“Uhhh, well I was pretty sure… mostly… a little I think” he stammered.

“Stacy, just make sure that you tell me you’re not sure if you’re not sure. I’d rather use incomplete information than fictional information anytime. I’m not accusing you, just curious here.”

After we got back to quarters, the calls died. The other truck ran a DOA but we didn’t get anything for hours. Knowing me, I sat down and worked on the blog for a while and ended up putting a couple of hours into the new site design. After two hours, in walks the student and takes a BP on me. Apparently the kid had spent the last few hours taking Blood Pressure readings on every person at the base!

I think that his name was Joe. He can ride with me anytime.

Posted by Ckemtp on October 16, 2009 • Filed under: Administration & Leadership, EMS, EMS Humor, EMS Topics, EMS training, Emergency Medical Services, Paramedic, Patient Management, ems education, paramedic education, training-fire-rescue-topics • Tagged: , , ,

Scenarios. A lot of EMS, a little Einstein

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A while back ago I had a kick where I did a scenario-based EMS ethics piece that took a look at a possible situation that could be faced by some Paramedics and asked readers what they would do in that case.

The response was pretty good. You should add your opinion here.

I use a lot of scenario based training for the EMS people that I teach. I teach a lot. Being the old, grizzled veteran that I am (shameless self plug but looking at the kids these days entering the profession sometimes I feel like shaking my fist at them, hiking my jeans up to my navel, and yelling at them to “Get off my lawn!”) I have the opportunity to mentor a lot of newer providers and precept a fair amount of students. During our slow periods, I find that giving the students an informal scenario helps them to step outside their thought processes and really think about what they would do when faced with a like situation.

I like it so much, that I even do it to myself. I’ve mentioned that I come up with most, if not all of my blogging ideas when doing other, mindless tasks. A great deal of my post ideas come while driving. I allow my mind to wander to imaginary concepts and ideas. Since I’m so immersed in EMS on a daily basis, a lot of those thoughts go right back to EMS, and “what if” scenarios come into my mind. Some of them are about patients that I’ve had, the “what if this had happened” kind of questions. Others are completely random scenarios that I wonder what I would do if I happen to be faced with the situation.

Einstein conducted what he called “Thought Experiments” to assess theories that he could not experiment with in a laboratory. One of the ones that I’m most familiar with is his “Flashlight on a Train” thought experiment. In this well documented case, he hypothesized that the speed of light was a constant and was not affected by outside forces. He imagined himself on a long, open railroad train with himself standing at the caboose, or end car of the train. He imagined shining a powerful flashlight from the rear of the train through the cars to the front engine. Using some logic that I am not familiar with because I’m no Einstein, he was able to theorize that the light from the flashlight would hit the train’s engine at the same time and that the light would travel at the same speed no matter how fast the train, and therefore the light source, was travelling. Unlike a missile fired from a jet plane that’s speed would be affected by the speed of the plane that fired it.

So how do Einstein’s thought experiments connect to EMS?

I equate the personal scenarios that I think of and the scenarios that I use to keep my students thinking outside the box to Einstein’s thought experiments. There are things in EMS that we do not do very often. Skills like synchronized cardioversion, surgical airways, and complicated drug administrations aren’t everyday things. Neither are difficult patient presentation with complex layers of comorbid conditions. These are high-risk, low frequency events that trial lawyers dream about. When you need to perform these tasks or think around a list of contraindications when your patient needs action now, having thought about them prior to having to perform is lifesaving.

One of the things I hear the most from paramedics and EMTs is how they run though a list of possible scenarios, patient presentations, and treatment modalities in their heads when dispatched to what sounds like a particularly nasty call. I do that sometimes too, although less now than I used to. Spending the time thinking about these things when you have the time to really ponder the issues is very beneficial and even fun… if you’re an EMS geek like me.

So next time you and your partner are bored sitting in your parking lot waiting for the next call, toss around a few “way out” scenarios. Your care will benefit from it. You might too.

Posted by Ckemtp on September 22, 2009 • Filed under: EMS, EMS Blog, EMS practice, EMS training, Emergency Medical Services, Paramedic, ems education, ems scenario, ems scenario based education, everyday ems ethics, mental imagery, paramedic education, patient care, scenario, scenario based training, whattaya do