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GPS in the Ambulance – An overreliance on Ms. Kitty

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

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

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

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

Her:       “It’s what?”

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

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

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

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

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

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

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

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

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

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

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

Ain’t modern technology great?

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

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

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

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

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

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

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

Blood Pressure – Vital Knowledge for EMS

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

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

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

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

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

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

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

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It can diagnose Orthostatic Hypotension

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

What does this mean?

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

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

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It can help diagnose a Thoracic Aneurism

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

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

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 It can help detect increased intrathoacic pressure and other conditions

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

What does this mean?

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

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

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

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

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Want to learn more stuff about stuff? Check out:

 

 

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

EMS Narrative Report – Ckemtp on the MedicCast EMS Podcast

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

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

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

Otherwise, you can view it here.

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

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

 

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

Eight Ways you can Ace your Patient Assessment – EMS

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

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

Take a look at the three general types of assessments:

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

 

 

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

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

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

 

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

                                                    

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

 

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

 

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

 

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

 

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

 

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

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

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Want more information on the patient assessment?

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

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

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

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

EMS 12-lead Case – Ischemia and Failure

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If you haven’t been to www.EMS12Lead.com, Tom Bouthillet’s wonderful EMS educational blog… well then I’m going to just come out and say this:

What are you doing here when you should be over there reading his stuff??

Considering how Tom dwarfs my humble traffic numbers (which is something I always kind of knew he did, but didn’t really know how much until I had a few drinks with him at EMS Today and weaseled his numbers out of him) I’ve figured that I’m going to have to do something. I’m going to straight up steal his shtick and write an “educational” EMS 12-lead EKG post of my very own for your reading enjoyment and educational purposes. Heck, I might even be able to make a point or two. Let’s find out.

I keep an archive of interesting tidbits from my EMS career locked up in a vault in my basement and among the oddities and whatnot I have a binder full of 12-leads. I blew the dust off of the old tome and pulled the EKG that I’m using for this story out of the archives. Oh my, this was a doozy. As always with my stories about patients, I may not have ran this one myself and even if I did, I don’t remember where it was that I ran it nor do I remember the age, location, or even the gender of the patient in question. I also have taken the liberty of lying about all of that stuff just to make it even more confusing and difficult for me to write. So, if you think I’m violating the female Hippo, you’re mistaken.

As I recall, the call was toned out with the dispatch information of a “64yo M Pt unable to breathe”. It wasn’t a long distance away and Our Intrepid Paramedic (OIP) responded in a response vehicle being followed up by an ambulance which arrived shortly after He did. It was a nice, well kept residence and the wife of the Pt let OIP in the door as he entered the home. She indicated that the Pt was in a back bedroom of the house and motioned down the hallway. OIP made the trek and found the Pt sitting upright on his bed, Conscious, Alert, and Oriented times 3 (CAOx3) with somewhat increased work of breathing. The patient stated that he had been experiencing pain that he indicated began at the level of his mandible and continued to his epigastrum (his Jaw to his Gut). He stated that the pain had simply become too much for him this evening and that it became very hard to breathe when he laid down for bed. A good look at him was all it really took for OIP to make a working diagnosis after feeling the patent’s weak and irregular radial pulse and pale, cool, and moist skin. OIP placed the patient on 6-LPM oxygen via Nasal Cannula and told the ambulance medic to break out a 12-lead. The initial rhythm strip showed a sinus bradycardia with an IVCD and lots of multifocal ectopy, including multifocal couplets and triplets. The 12-lead was no better. It showed bad, bad mojo. This poor guy was sick.

EEEEEEEeeeeeeeeeeeek

As the ambulance crew was packaging up on the stretcher to take the Patient to the ambulance, OIP had a few moments to speak with the patient’s wife. She told OIP that the patient had been experiencing pain in his jaw for the last week. She also told OIP that the patient had gone to see his Primary Care physician two days prior and had been told to take advil for the pain in his jaw. She told OIP about how the patient had been very lethargic lately and about how he would become winded when taking out the garbage and walking even shorter distances. She told OIP about how the pain had been getting steadily worse… and also how the doctor said he was fine.

And with a symptom profile of exertional fatigue, difficult breathing, jaw pain,  substernal chest pain, and diaphoresis… what doctor wouldn’t say that… right? Oh wait… hopefully most of them.

The patient wasn’t having a heart attack… he had been having a heart attack for days and now the damage had been done. This was a clear case of the patient not being educated to the symptoms of a heart attack… or of ignoring them in the hopes that they’d just go away. The physician did not obtain a 12-lead nor do lab work and did not diagnose the problem as being cardiac ischemia (Heart attack) when the patient presented for care.

But OIP did… about 2 minutes after meeting the patient he woke up the cardiologist and the cath lab team at a hospital a half-hour’s drive away to help take care of the man. You’ve seen the 12-lead above. It indicates a heart that is in serious trouble. The patient was treated per protocol, which included high-flow o2, bilateral IVs, NTG tablets and paste, and I’m not sure what else the ambulance paramedic did because OIP didn’t accompany the patient to the hospital. That,  and it was too long ago for me to remember what happened… I just know the patient made it there alive to find out whatever his prognosis was going to be from the cardiology team at the ER.

Here’s the deal, once this patient called the ambulance, his care was stellar. OIP and the other EMTs did a fantastic job at rapid recognition, appropriate stabilizing care, and swift transport to an appropriate care facility as none of the local hospitals had the capacity to care for this guy. The EMS people did what they were trained, equipped, and supposed to do. The problem is they were called way too late to make much of a difference in the patient’s continuing quality of life.

I can understand that patients don’t necessarily know when they’re having a heart attack. To a layperson, jaw pain and fatigue could just be the flu. Chest pain could just be heartburn, and exertional dyspnea could just mean that a person has been “pushing themselves too hard lately”. All of those symptom profiles could mean any number of things… but they could also be a heart attack. I can understand how people want to think that they’re not having a heart attack. I get that no one wants to have one. They’re not fun and we as a society may hype them up too much so that people think there is a stigma to the diagnosis. I don’t know if that statement is true, but it sure seems that way sometimes to me.

What I can’t understand is how a patient can present for treatment at a physician’s office with clear symptoms of cardiac ischemia (heart attack) and not be checked for it. I’d like to think that a paramedic would rule it out first and foremost… and I don’t understand why someone wouldn’t.

Then again, I don’t know the information the physician was working with. Perhaps the patient wasn’t honest with his symptoms and tried to minimize what was going on. That’s possible too, as this patient was a proud man who has lived his life like he could handle anything. People do that. Nobody wants to be sick.

The lesson here is to have a high index of suspicion. Patients sometimes minimize their symptoms, and sometimes they over-dramatize them. Some people don’t want to be sick… and some people want to be sicker than they are. I personally will buy into false drama from someone who’s not as sick as they want to be than chance missing the minimized symptoms of someone who’s sicker. I tell my patients that as a paramedic my job is to “Treat for the Worst, and hope for the best.”

But for this guy, OIP never got the chance. This was too late for that. The damage had been done.

This patient’s quality of life was greatly impacted by the fact that he didn’t call 911 at the first signs of his illness. Had he done so, his prognosis would be much different. A quick exam, 12-lead, and appropriate care would have made this guy’s story quite a bit different. Where was the failure? Was it the patient’s fault for not recognizing and/or minimizing his symptoms? Was it the fault of “health education” in general for not reaching the patient in a manner in which he could understand? Does the fault lie with OIP for not spending enough time educating the public about the symptoms and danger of heart attacks? Does the fault lie with this patient’s doctor for missing the diagnosis and/or not providing proper education beforehand?

I don’t know the answer to the above question either. I just know that OIP and the EMS team treated him well once the call came in. I just wish that something different would have happened in the chance of events that lead up to all of this. It would have made the above 12-lead a lot different.

Be vigilant out there.

Posted by on March 15, 2011 • Filed under: EKG, Emergency Medical Services, EMS, EMS Topics, EMS training, Paramedic, paramedic education, patient care, Patient Management, physician, Uncategorized

Does How Your Brain Works Affect Your Patient Care?

8 comments

Hey everyone, before you read the post below, watch this video. This is part of a test:

Now, after you have watched the above video and reacted to it in some way, read the following humorous statement:

“Some helium floats into a bar. The bartender says “We don’t serve noble gasses here!” The helium doesn’t react.”

(Ok, if you’re not a nerd.. The noble gasses (of which helium is one of) are non-reactive. Ha!)

Which one of those two things made you laugh harder, if at all? Did you have a positive or negative reaction to either of them? Both?

The reason I ask this, is because I told my partner that joke about the helium today. His reaction: “Wow… All that knowledge and you still can’t tile your bathroom floor.” He came to EMS after being a contractor and working in the trades. You know, doing stuff that you have to do with your hands. I did too, honestly, since I pretty much grew up on a farm with a father who owned a hardware store. So you’d think I’d be handier than I actually am. I can fix things, sure… but I certainly couldn’t build a house. That’s just not how my brain works.

Years ago, while working in an emergency room I overheard two physicians having a discussion about another ER physician who was very popular with his coworkers and patients. This doctor was friendly, jovial, kind, and nice. I liked him quite a bit and was a little weary of the other two docs talking about him. They talked about how nice this other doctor was to all of his patients and how they wished they could have him follow them around to all of their own patients and be the “nice” doctor who made their patients feel better while they attended simply to the cold, hard realities of their patient’s medical needs. Their solution was that a happy medium could not be reached, and that a healthcare provider was either “too nice and incompetent” or “competent, but a jerk”.

And today, after my coworker brought up the severe need for a new tile floor in my bathroom, I thought back to that conversation. He and I are both paramedics. While I’m more experienced and have been a paramedic for more than a decade longer than he, He and I both take care of the same types of patients with the same types of complaints and make similar results. We follow the same standing medical orders and work under the same medical director in the same ambulances. However, since his brain works so very differently than does mine, how can we possibly achieve the same results?

People choose their physicians based upon their personalities as much as they do anything. They want to develop trust in their doctor, and the interpersonal relationship between doctor and patient on outcomes has been widely speculated upon and researched. I wonder if the same phenomenon exists within EMS. Does the way our personalities, experiences, strengths, weaknesses, and other traits affect our patient outcomes? If my brain is wired so very differently from my partners, how does that affect his patients’ care over my own?

I don’t have the answer to the questions I’ve asked here, but I’ve become pretty curious about this over the last hour or so. To help answer the question of what personality type you think makes the best type of paramedic or EMT, I ask you to write your opinion in the comment section below. I think that we might get some pretty darn interesting answers. 

Be sure to put which humorous thing you most enjoyed above somewhere in the comment.

(Oh, and so two Atoms were walking down the street. One said “Oh no! I’ve lost an electron!” to which the other replies “Are you positive??”)

 (Also, my friend with the Ph D in chemistry said that the helium joke was “A real ARGON-er” – Get it? Ha! Nerd humor is nerdy)

Posted by on January 19, 2011 • Filed under: Emergency Medical Services, EMS, ems education, EMS Humor, EMS Topics, EMS training, Fire Rescue Topics, inside the mind of a paramedic, Paramedic, paramedic education

Assessing Greatness – Catching the stuff you’re supposed to

4 comments

What the heck is wrong with this guy!? You just can’t figure this one out and your patient seems to be crashing before your eyes. You were originally called for the “Unconscious unknown” at a party house frequented by college students and found the 28 or so year-old male unresponsive. Everything you check seems to be a dead end. His heart rate is fine, but slowing… His respirations are adequate but you’re certainly considering getting out the bag-valve-mask… You’re popped your line and given 2 full milligrams of Narcan but that hasn’t had any response. His pupils are PERRL but sluggish. His skin is pale, cool, and moist but not diaphoretic… and there doesn’t seem to be any trauma. Everything with this guy is a dead end treatment wise and you decide that this guy simply needs to be treated with diesel. You have your partner hop up front, turn on the twinkles and the woo-woos and beat feet to the hospital. All the way you check and recheck, trying to figure out if you can fix this guy. Unfortunately, you don’t make any headway before you reach the ER.

After you finish cleaning and restocking the truck to return to service from the ER you walk past the patient’s room on your way to get a cup of coffee. You’re shocked to see that the patient is sitting up, is alert and talking, and seems to be doing just fine. Incredulously, you ask the nurse what happened. She asks you what the reading you got for the patient’s blood sugar in the field was, and before your mouth can speak, all of the voices in your head seem to scream at you in unison “Holy Flying Pig Tarts!!” you forgot to check the patient’s blood sugar, thinking that it was most probably a narcotic overdose. The ER didn’t however, and found that the patient’s blood glucose was 20.

Have we all been there? Can we just admit that we all have found ourselves in this or a similar situation at least once or twice in our storied careers? As much as I am ashamed to admit it, I have found myself in similar situations where it seems I just messed up and left out an important part of my assessment. Somehow, something important like taking a quick blood glucose reading on an unresponsive is going to slip your mind somewhere in your career and in your adventures in the field and it’s going to bite both you and your patient in the hindquarters. Mistakes, or rather oversights like this are all too common in all branches of medicine because we as the healthcare professionals are simply human beings trying to absorb and process way too many pieces of information at once.

Much has been decried about the practice of “Defensive Medicine” where healthcare providers, mostly physicians, order unnecessary tests simply to avoid missing an obscure case and being sued because of it. People are constantly irradiated for unnecessary X-Rays, CT scans, and other such tests or so say the detractors of these practices. They say that it exposes patients to unnecessary testing, causes a false sense of security, and drives up the costs of healthcare exponentially. Popular culture has even jumped on the bandwagon, with the heroes of popular medical dramas coming out against the practice and being regarded as cowboys or mavericks. The public then eats it up… until they have a headache and don’t get a CT scan to ease their worried nerves.

However, not all practice of defensive medicine is a bad thing and in fact, in EMS I believe that this practice can be a good thing. I have long believed in my career and in my professional paramedic practice that every patient deserves a thorough and standardized assessment. Sure, I am pretty darn good at coming up with my working diagnosis based upon my solid initial assessment with a few secondary and tertiary assessment tricks to narrow in on the diagnosis and get my differentials, but the foundation remains the same. Everybody gets the same head to toe assessment. I’ve standardized it so that I don’t miss anything… or at least that I don’t miss as much as is possible not to miss. Standardizing your assessment and performing the same assessment on every patient every time becomes a security blanket and helps keep your assessment skills sharp with every call. Sure, it may seem silly to listen to lung sounds on a patient with a twisted ankle, or to check pupil reaction on the finger amputation, but you don’t have to let the patient know you’re doing it. Just look at them. Make sure you hit every high point in your standardized assessment with every patient, and you’ll catch a lot more zebras than you’ll miss.

In addition, there are some ground rules that I follow with certain types of patients and those fancy diagnostic tools that they give us to play with. First and foremost, if they say that skin condition, color, temperature, and moisture is the fourth vital sign, then blood-glucose level is the fifth. Sure, not every patient needs a lancet poked into their finger to have the machine read the number, but certainly every patient with an altered level of consciousness does. Even if you think the cause of the patient’s condition is something else, like the patient I had the other shift who was hypotensive and septic with a high fever, check it anyway… because the patient in the above example had a blood glucose of 40mg/dl and responded quite well to some fluid and the D-50 I gave him. Other patients who may not need to be poked can still have hyper of hypoglycemia ruled out by asking them their bladder habits (hyperurination), their last oral intake (Have they eaten enough not to be hypoglycemic) and other sugary questions.

Then, there’s the 12-lead. Can I just say that I see darn near close to zero reason that every patient who gets into an ambulance cannot get a 12-lead EKG done on them? To be sure, I don’t give every patient a 12-lead… but for anything that could be even remotely cardiac related I will perform one. Lethargy? Check. Flu like symptoms? Check. Syncope or near-to-it? Check and Check. It takes only a few minutes to perform and you can really make a difference in a patient’s overall healthcare pathway and well being by taking a symptomatic 12-lead tracing and starting the trend of monitoring. Before we all had the tool (Sorry Chicago… you should be catching up with the rest of the world soon) just how many ischemic cardiac events went undetected?

The crime here lies firmly in the realm of the underassessment, not in overassessing. The patient assessment is the cornerstone of everything we do and takes priority to all but the airway, breathing, and circulatory status of all patients. Making sure to be thorough and methodical in your assessment practices saves not only lives, but your own butt in the process. You cannot over assess just as you cannot overeducate yourself as to what potential findings mean. Just as an EMT basic can ask the same questions as the most seasoned paramedic, they can also ask the same questions as an ER doctor with the proper self education.

EMS needs to see itself as playing a role in the overall healthcare system and in the final care pathways for the patients we treat. Becoming an expert at the patient assessment is a big role in this. Remember, you’re the person who sees the patient in the first stages of their acute illness and in their entry into the healthcare system. Your thorough assessment goes a long way into the wellbeing of every patient you touch. Be great at it.

Posted by on January 13, 2011 • Filed under: Emergency Medical Services, EMS, EMS Topics, EMS training, Paramedic, paramedic education, Patient Management, Training & Development

If you could have anything you wanted…

28 comments

I have a question for all of you out there:

A few recent situations have arisen for me that have essentially… wait for it… Removed almost all of the barriers. The sky is the limit and the future looks amazingly bright. I can’t tell you how good it feels to have my potential back.

And for one of those things, I’ve got a question for all of you out there.

In December, my EMS system is reviewing their protocols. We have a lot now and the protocols are extremely liberal. However, I’ll be expected to ask for new things like I always do, and right now I haven’t really given it as much serious thought as I need to in order to argue my case. Because of that, I’m kicking it out to you with this question.

Within the boundaries of what we can do legally within the regulations of the Wisconsin EMS system and within the realities of the current economy, if you were me and could ask for whatever you wanted from your amazingly progressive Medical Director and your amazingly energetic and supportive EMS coordinator…

What would you ask for? Toradol for pain control? Induced hypothermia (already have it), RSI? (got it too), CCR? (yep, we started it),  Mag Sulfate drips for anaphylaxis? (Have it), Glucagon IV for beta blocker ODs? (uh huh). Cardiazem? (yep)…

and Etcetera, etcetera, etc…

So I’m in a progressive system. The question is… what do I ask them for now?

What do you think?

Posted by on November 23, 2010 • Filed under: Administration & Leadership, Emergency Medical Services, EMS, ems 2.0, EMS protocols, EMS Topics, EMS training

Those Darn Kids!

16 comments

These darn kids and their new-fangled toys!

Hey, at least I aint @FossilMedic 's Age yet.

Call me old fashioned if you want to, but allow me to hike my EMS pants way up higher than my belly button and talk in my Old Grizzled Medic ™ voice for a second here. You see, the kids these days are doing something that just tans my hide. What, with their iPhones, and their iPods, and their iPads, and me with my iGlasses and the Etch-a-Sketch… Confound it! I just don’t understand.

You see, Youngins… back in my day we didn’t have all of these fancy techno-toys that we do now. When it came to running on the ambulance, we made do with what we had and that was the way we liked it. What, with all of the trudging 20 miles to work in the feet of snow uphill with the both ways and whatnot we earned our measly pittances and then trudged back home to our coal-heated shacks to jitterbug away the three hours we got off of work in between our 120 hour shifts. We didn’t need all the pansy stuff you enjoy now.

We did our medical care to the best of our abilities then. We actually had to LIFT our patients into the ambulances on the cot, rather than having the little button lift 700lbs with one finger. We had to look at actual paper maps to find addresses, rather than having the nice lady in the GPS tell us where to go. Heck, we even had to write paper reports on our EMS calls BY HAND USING A PEN.

Paper reports written by hand do one thing and only one thing very well. They suck. They are simply awesome at sucking. They stink on ice. They are medieval torture devices left over from the Monty Python version of the Spanish Inquisition and honestly, the day we switched over to computerized reporting I stabbed a wooden stake through a stack of the dreaded Illinois “Bubble Sheet” EMS report forms. Then I poured gasoline on them, turned around and flicked a match behind my back as I walked away in slow motion without looking back at the explosion and flames. I was wearing sunglasses. It was epic.

It was Just Like This! Only with more geekery and no little girl and I was shirtless...

Paper reports could be documented at the patient’s side but it just always seemed so darn inconvenient to do so. I did it occasionally during long transports, or when we were running back-to-back calls and I wanted to jot down the high-points of each call on the report form so I could accurately remember them when I got the chance to catch up on my paperwork. It wasn’t uncommon to be “down” four or five reports in those days because we were just so dad-gum busy and the reports took so blasted long to `complete. A stack of those paper reports could give you writers’ cramp for days. Especially the Illinois “Bubble Sheet” forms which I used for years, they were awful monstrosities constructed to worship the demon “ScAnTr0nn” who mandated that little bubbles be filled out perfectly for every name, address, and number you scrawled on the form. Those evil little dots cost me hours of my life, a good amount of my hair, and most of my sanity. After using the awful bubble sheets for years, I switched systems to a place that utilized a somewhat less-evil paper report form, and then back to a place that still used the hated bubble sheets, and then Huzzah! To a place that had computers.

Although I must admit that the hand-strength I developed from writing those awful things made my one-handed beer can crushing trick a hit at parties.

The first report I wrote on a computer was a simple little form written on a then state of the art laptop that weighed approximately 17523lbs. It took forever to load, locked up and lost reports frequently, and was an absolute gift from God. Then, the regional EMS system stepped in and put computers in the EMS report rooms at the hospitals because nobody could ever figure out how to hook up their ambulance laptops to the ancient dot-matrix printers they’d provided for us. Those programs were sweet! I hate switching my hand between a mouse and a keyboard 15 times per second to enter data and the reports we used on the desktop were forms I could simply use the keyboard with the whole time. I actually typed faster than the program could keep up and knew just how many times I had to tab through a list to mark the correct spot on the form without seeing it on the screen. I’d end up having the report typed out a few seconds before the machine caught up and put the words on the screen. It. Was. Awesome.

Still, those reports were something that could only be done away from the patient’s side. We all had note pads to jot down info we wanted to put on the report while we were treating the patient and we took those notes to the computer to enter into the report. Nowadays, them kids with their fancy technology have Toughbooks with touch-screens that they use to write their EMS reports and since their invention, I’ve noticed a trend.

It first started when I noticed my medic protégé Chad had a habit of bringing the toughbook in with him to emergency calls. He’d grab the jump kit, the o2 bag, and the computer. Then, while he was interviewing and assessing the patient, he’d be starting their report.

This dismayed me. Again, call me a crazy old coot and an old-fogey… but I believe that we should not only focus 100% on the events of the call and upon what the patient is telling us, but also that we should give the appearance that we are doing so. You just can’t make me believe that a patient is going to feel that we are listening to that which ails them and are paying attention to their needs when we have our nose in a lap-top. Sure, it may save time on the overall reporting process by allowing the EMT to get an early start on the documentation, but it also ends up taking more time on scene to wait for the computer to enter in information. I also think that it takes away the EMTs ability to fully observe everything that is going on with the patient and the scene around them. It robs one of their situational awareness and of the nuances of the patient assessment.

That, and it’s just plain rude.

It bothers me enough that I launched a whole ridicule-based diatribe against my young protégé and shamed him into no longer bringing the computer into calls with him. I have no problem if he begins the report at the patient’s side during transport as long as he has completed everything that needs to be done and he makes sure to monitor the patient thoroughly. That’s cool, I guess. I am glad that he won’t have to suffer the pain of hand-written EMS reporting. That’s a cross us Grizzled Old Medics™ bore for you with honor.

You’re welcome. Now get off my lawn, and STOP USING THE COMPUTER IN FRONT OF THE PATIENT!!

Posted by on October 29, 2010 • Filed under: ambulance humor, ckemtp rants, Emergency Medical Services, EMS, EMS Humor, EMS Topics, EMS training, Fire Rescue Topics, Paramedic, paramedic education, paramedic narrative, patient care, Patient Management, stories, technology-communications-ems-topics, Uncategorized

Back in the Saddle Again!

4 comments

Back when I was a high-school student I was completely enamored with EMS. I just couldn’t wait to slip into a uniform and get out on the streets of an ambulance. While in retrospect maybe I could have refocused the energy I spent researching the EMS gig into something a little more profitable, the sheer amount of stuff I read about EMS in my formative years helps me in my job to this day.

One of the earliest EMS blogs I ever read was one that I found back in High School. I forget the name of it now and I would guess that it isn’t even still up there on the interwebs anymore. However, the writer’s acerbic descriptions of his own life under the lights of an ambulance were hilarious and fascinating to me. I’ve never forgotten the words he wrote.

I was reminded again of one of his stories this morning when I was getting off shift. I’m finally back in the back of an ambulance after spending some time at my secret-squirrel job and I’m loving it. While I wish I got paid more to do what I love, I do truly love what I do. This morning was no different. Again, the EMS gods had me laughing until I cried while an elderly lady screamed in sheer terror.

Yes, I said that. No, I’m not a monster. You would probably have laughed too. Hard.

This morning the radio decided to wake me up around 0430 for the tip-up of the uninjured fall victim. I went, assessed, found nothing, and tipped the poor guy up back into bed. It was a simple call. He signed off on a refusal form, and all was right with the world again. I went back to the station to write the report and after some time spent in between dozing and typing on the Toughbook, I finished my report around 0600. By then it was too late to go back to bed and sleep for an hour, so I stayed up to wash the ambulance and make sure the shift chores were done. It’s the custom at our company to leave the quarters pristine for the oncoming shift, so we do a full cleaning in the morning before shift change. It works for us.

Around 0630, my partner and protégé Chadwick sauntered in to the station. The poor kid had been ran hard and put away wet the day before and looked unapologetically fresh in contrast to as haggard as I looked. Darn Kids. As he helped me dry the trucks and sweep the floor, I was teasing him about catching a late call.

“Can you feel it, Chad?” I would ask. “Right now, there’s some guy that’s waking up and walking up to the toilet for his morning dump who’s gonna vasovagal out and seize on the bathroom floor. It’s your call so when you kneel down, try to avoid the skid marks.”

I kept razzing him as time went on, and when we finished washing the trucks we walked outside to enjoy the crisp, bratwurst-and-cheese-scented Wisconsin morning.

“Did you hear that?” I asked, “that was someone hitting the floor”.

And amazingly, right then the tones went off. It was for a medical alarm that had been activated at a non-medical senior-living high-rise in town. Coincidentally, it was for a fall victim in the bathroom.

Nice.

Chadwick mumbled something that might have been profane I’d think if he wasn’t such a Bible-Thumper and hopped in the truck. I drove because it was his call. On went the lights before I opened the bay door. I think it’s more dramatic if I turn the lights on before I open the door. It just looks cooler that way. Johnny and Roy did it, so I can too. I also wear my helmet like they did. Yay me.

We arrived on scene right before the less-than-optimally-caffeinated police officer who was responding with us. He was able to finagle the key out of the knox box and let us into the building. Apparently last week one of our crew had gotten fed up with the key not being in the box at this building and had opened the lock in a gentle, professional way using his foot. Apparently the building management wasn’t happy with them for doing that, especially since it was for a call that turned out to be a false-trip of a medical alarm. Today we found the key in the box… weird how that happens.

Chadwick and I deftly navigated the long hallway and the small elevator up to the third floor with our stretcher and all equipment in tow. Hypo-caffeine Copper tagged along, and we found the door to the apartment locked up tight. Luckily for the maintenance man, he had the key right handy for us to use.

We entered the apartment with us yelling “Ambulance!” and him yelling “Police Department!”  I thought it was redundant, but hey… he needed to wake up and yelling something helps that. We heard the sound of a running shower and walked towards the bathroom yelling our respective titles.

The patient heard us, no doubt, and did her best Wicked Witch of the West impression as she yelled “Ohhh Myyyy GAAaaawwwd!” We explained again about the whole “Ambulance!” and “Police Department!” thing, but she was having none of it. We told her that somehow her button had gotten pressed and that the machine had called us, but that didn’t seem to ease her fright at having three strapping young men in uniform show up to help her shower, apparently.

After much consternation on her part, and my starting to laugh the tears out of my eyeballs we thanked the lady, apologized for her fright, and cleared the scene to head to the police department for the fresh pot of coffee the officer said he was dreaming about. We hung out, and since I’m a renaissance Medic I tweeted in a HIPAA friendly manner about the call.

Some of the responses included such things as:

 “So I guess the Medical Alarm button is now the ‘Bring Someone to Wash My Back Button??”

And,

“If she pressed the button and got three young public safety types to show up and help her in the shower, is there a way that I, personally could get the button for my own use? We’d have to have a gender setting, of course… As I require attractive young members of the other gender to help me with my showering endeavors”

And,

(something that was absolutely HILARIOUS regarding “Old Lady Boob” that I have redacted from my blog site, you’ll just have to get on to Twitter to see humor of that caliber)

So after this morning’s antics and activities, I can safely say that I absolutely love my job again. I never stopped, but I’m happy that I came back refreshed from my hiatus. I missed the people we see, their twisted humor, and their acerbic personalities. It’s just like the first EMS blog I read said it would be and I praise whomever he was for his accurate description.

Sorry about the lapse in posting, y’all. I’m back and am loving it. Hope you are all too.

Posted by on October 21, 2010 • Filed under: ambulance humor, Emergency Medical Services, EMS, EMS Humor, EMS Motivation, EMS Topics, EMS training, Fire Rescue Topics, humor, In the Line of Duty, Paramedic, stories

Colorado CRNAs Vs. Virginia Physicians? An interesting feud for EMS

24 comments

This article came across my Twitter stream this morning. It regards a letter sent to the Centers for Medicare/Medicaid Services by the Governor of Colorado informing them that in some Colorado hospitals it is now acceptable for Certified Registered Nurse Anesthetists to work independently of physician supervision.

The article, which is in the form of a letter written to the editor of The Aspen Times, is written by a Dr. Paul Rein who is the President of the Virginia Anesthesia and Peroperative Care Specialists. He takes issue with the lack of physician oversight and is “quite concerned” about it.

I think that the letter is important for EMS people to read. Especially us EMS people that are looking at how to expand our profession, grow our scope of practice, and expand our skill sets. It shows that there are struggles over these kinds of boundary and oversight issues all over the healthcare arena and that the politics and power struggles aren’t just limited to those of us that ride ‘round in ambulances.

The full text of the letter can be found here at The Aspen Times: http://www.aspentimes.com/article/20101004/LETTER/101009942/1020&ParentProfile=1061

The parallels I can draw from this issue to EMS are striking and enlightening. Here are some of the parts of the letter that I found the most interesting:

“A nurse anesthetist is an advanced practice registered nurse who has received special training to administer anesthesia, usually being supervised by an anesthesiologist. Anesthesiologists are physicians who, after medical school, receive an additional four to five years of specialized training during residency. Not only do anesthesiologists function in the operating room but they are trained to medically evaluate patients prior to surgery and to take care of problems that may arise immediately after surgery. In a few small hospitals a nurse anesthetist may be supervised by the surgeon if there is no anesthesiologist.”

I was curious as to the educational standards of a Certified Registered Nurse Anesthetist and so I went to their National Association’s web site: Http://www.AANA.com – It says this:

“The requirements for becoming a Certified Registered Nurse Anesthetist (CRNA) mainly include having a bachelor’s degree in nursing, or other appropriate baccalaureate degree, Registered Nurse licensure, a minimum of 1 year acute care experience (ICU, ER for example), and the successful completion of both an accredited nurse anesthesia educational program and the certification examination.”

(Source: http://www.aana.com/BecomingCRNA.aspx?id=98&linkidentifier=id&itemid=98)

Huh.

Actually, I wasn’t familiar with the requirements for a CRNA before I read that, but it says that they have to have:

  • A four year degree in Something
  • Licensure as a Registered Nurse
  • A minimum of One Year Acute care experience
  • Completed an Accredited training program
  • A passing grade on the certification exam

I was curious, so I popped on over to Salary.com and typed in “Registered Nurse Anesthetist” in my own zip code for a base salary search. I found that they start out at $131,000 and top out at over $170,000 in my local area.

Then, after giving serious consideration to changing this blog from “Life Under the Lights” of Fire Trucks and Ambulances to “Life Under the Lights” of an Operating Room, I decided to point something else out about the differences and similarities of a Paramedic and a CRNA.

 “The didactic curricula of nurse anesthesia programs are governed by COA standards and provide students the scientific, clinical, and professional foundation upon which to build sound and safe clinical practice. The basic nurse anesthesia academic curriculum and prerequisite courses focus on coursework in anesthesia practice: pharmacology of anesthetic agents and adjuvant drugs including concepts in chemistry and biochemistry (105 contact hours); anatomy, physiology, and pathophysiology (135 contact hours); professional aspects of nurse anesthesia practice (45 contact hours); basic and advanced principles (sic) of anesthesia practice including physics, equipment, technology (sic)  and pain management (105 contact hours); research (30 contact hours); and clinical correlation conferences (45 contact hours).

Most programs exceed these minimum requirements. In addition, many require study in methods of scientific inquiry and statistics, as well as active participation in student-generated and faculty-sponsored research.

Clinical residencies afford supervised experiences for students during which time they are able to learn anesthesia techniques, test theory, and apply knowledge to clinical problems. Students gain experience with patients of all ages who require medical, surgical, obstetrical, dental, and pediatric interventions. The results of a 1998 survey of program directors show that nurse anesthesia programs provide an average of 1,595 hours of clinical experience for each student.”

(Again, from http://www.AANA.com – the emphasis is mine)

Remember that the CRNA’s have a Bachelor’s Degree and a RN license prior to beginning their training. This is different from the Paramedic curriculum. We have hour requirements as well:

“The emphasis of paramedic education should be competence of the graduate, not the amount of education that they receive. The time involved in educating a paramedic to an acceptable level of competence depends on many variables. Based on the experience in the pilot and field testing of this curriculum, it is expected that the average program, with average students, will achieve average results in approximately 1000-1200 hours of instruction. The length of this course will vary according to a number of factors, including, but not limited to:

-student’s basic academic skills competence

-faculty to student ratio

-student motivation

-the student’s prior emergency/health care experience

-prior academic achievements

-clinical and academic resources available

-quality of the overall educational program”

 (Source: Http://www.EMS.gov – Thanks to Chris Webster, Sam Bradley, Greg Friese and Kevin Reiter)

Not that the above is related to the article I read, I mean it’s saying that people with a BS degree in something, a medical license, and what amounts to a little more than an EMT-B class plus an EMT-P class from an accredited school make an average of $150k… but I digress.

Back to the article, Dr Rein has this to say about CRNAs:

“It is interesting to note that the United States is the only westernized country in the world that allows nurses to administer anesthesia unsupervised. Countries such as Canada, Australia, New Zealand, Japan and Israel, just to name a few, have no nurses administering anesthesia. In some European countries there are a few nurse anesthetists who work under the strict supervision of a physician.”

He continues and says this:

“So what’s up with us? Well, it seems that the American Association of Nurse Anesthetists have convinced our government in Washington that unsupervised nurses are just as safe as a physician. They point to the fact that there are no comparative studies to show they are not. The reason there are no studies is that it would be unethical to perform such a study in which some people get a physician and some do not. Can you imagine a patient agreeing to participate in such a study?”

Can you imagine indeed?

Dr Rein is right when he says in the letter that Anesthesia is a Medical profession and is a specialty of physicians for a reason. When he says “Just because we have made it safe is no reason to take it for granted”, he’s right as well. Anesthesia is dangerous for the untrained and inexperienced provider and it is a specialty not to be taken lightly. However, where’s the line? Is this an attempt by the”Virginia Anesthesia and Peroperative Care Specialists” to fire a shot at the “American Association of Nurse Anesthetists?” Are Doctor Anesthesiologists afraid of losing jobs to the nurses? Where is the line where patient safety is best maintained while being most cost-effective and efficient?

If this doesn’t provide incentive to you to think about requiring a degree for Paramedics, I don’t quite know what will. I’m not doing this job for the money and neither are you, but does that make us any more or less moral than a CRNA who “Isn’t doing his/her job for the money” either, but still makes a ton more of it than any paramedic I know?

You could change the names of the players in this argument, fiddle just a bit with some of the details, and change this into one of a thousand other feuds going on under the healthcare umbrella. This is the same story that paramedics face when we’re trying to get new skills, new techniques, more money, and more responsibility. While I’m not taking a stand on the CRNA/MD issue because it’s not my specialty, I’m offering up this debate as a study in professional growth and conflict between two of the myriad of medical camps out there. As we push EMS forward, grow as a profession, and promote the EMS 2.0 agenda, learning from things like this will be of value to us all.

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Thanks to the following for their contributions:

Posted by on October 4, 2010 • Filed under: ckemtp rants, Emergency Medical Services, EMS, ems 2.0, ems education, EMS pay sucks, EMS pep talk, EMS Topics, EMS training, medical ethics, News, Paramedic, paramedic education, Patient Management, physician, politics, potential, profession, Training & Development, Uncategorized

EMS case law? AMA Refusals, Death, and Documentation

18 comments

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

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

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

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

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

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

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

So do you see a problem there?

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

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

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

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

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

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

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

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

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

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For more tips on EMS documentation:

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

What Difference Does EMS Make? Choose Your Own Ending

17 comments

John didn’t need his alarm clock this morning. In fact, he was wide awake just a few minutes before it went off. He turned it off so as to not wake up his wife and got up quietly to start the day. Today was going to be great. It was huge. Months of work at the office were finally going to be recognized today in the biggest project meeting he’d had in a year. Today’s meeting would launch his career faster than almost anything he’d done before. He was excited. He was ready.

John showered, shaved, and got dressed up in his new suit that he’d bought the day before. He wanted to look his best for this meeting. Everything was counting on it. His wife Joanne had coffee and a quick breakfast ready for him when he came down the stairs. He sipped on his coffee for a bit as he ate his breakfast. It was really sweet of her to do that, He thought and he told her so with an extra hug and kiss as he left for his commute. He wanted to be to work early today to make sure that he was there to answer any pre-meeting questions. This was the day.

Traffic was light on the interstate that morning and John was moving at a good clip. It was strange, he thought, for traffic to be this kind to him on a Monday morning but he figured it was a good omen. His phone buzzed with an e-mail and he glanced at it. It wasn’t anything that couldn’t wait until he was in the office, he thought. Then a great song came on the radio. John reached down to turn up the volume so he could get pumped up for the drive…

He never saw the cars stopped just in front of him.

Mary took care of herself pretty well for a type one diabetic. Her doctor had told her that. She stuck to her diet, maintained her sugar levels meticulously, and took her insulin on a sliding scale that seemed to be working perfectly. Her blood sugar readings were always right where her doctor said they should be. Mary was proud of that. She worked out and tried to get out walking or jogging the trail at the park at least 3 or 4 times a week. She felt good, looked good, and thought that she was doing all she could to take charge of her health.

It was a beautiful Saturday morning and Mary thought that she should take her dog Patches out for a walk around the pond. Patches was a 1 year old Golden Retriever and loved jumping in the lake to fetch sticks. Mary had taken her morning dose of insulin, popped a multivitamin tablet from her new bottle that she’d bought the day before, and ate a quick bit of breakfast before she put Patches on his leash and started walking to the park. It was about five blocks away and patches knew the route well. Everything was great, until the nausea hit… Mary tried to fight it but knew that she was going to throw up when she started salivating and breathing heavily. She ended up throwing up in some bushes next to the sidewalk. She thought that she was lucky. Nobody saw her hurl up her breakfast and she immediately felt better. It must have just been the new vitamins that made her stomach upset, she thought as she continued walking to the park. She figured that she just wouldn’t take them again.

Mary never felt sick. She just thought that she should take a nap. The rock over there looked like a good place. Why was she so sleepy? Never mind… Just lay down and nap. Nap good.

Luckily, another jogger happened by to find Mary unresponsive.

Work had been scarce lately and Steve was happy to get his truck back on the road. He drove a live-bottom trailer hauling asphalt for a big local paving company and they hadn’t had many big projects come their way lately. Driveway work was steady, but rarely did the company need Steve to drive a big truck out to a site for a driveway job. Steve made his best money and hours when the company had highway work and today was the first day of a big job they’d just gotten. He’d been in line with the other trucks waiting his turn to dump his load into the paver for hours and even though he was happy to be working, he had to pee. Minutes turned into hours and finally it was his turn to drop his blacktop and head back for a new load. He couldn’t wait to be done. He really had to pee by this time and he knew exactly where his next opportunity would be. He backed his trailer up to the paver and raised the bed. Then through his rear-view mirror he saw the people scramble and jump off of the paver. He felt his truck lurch forward as the paver machine was pushed into it from the impact of a car travelling too fast in the construction zone. When he jumped out of his truck after looking to make sure there was nobody coming at him, he saw his friend Luke laying on the ground. Luke was bleeding, bad. The car and the paver were a tangled mess of metal and there was someone screaming at an unmoving figure in the passenger seat of the car.

Steve no longer had to pee…

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Note to blog readers:     I can’t quite decide on what I should do from this point on. I can take two paths, one is a rallying call to community members asking them to put themselves in the place of the people in the above cases and get out there and support their local EMS. The other, is a rallying call to us EMS people… I’ve written it both ways. You can see what you like best.

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Option #1

Every day, Paramedics and EMTs put on their uniforms, fire up their ambulances, and get ready to face the onslaught of whatever mayhem the streets produce for them during their shift. They do a job that is unpredictable, complicated, and vital to the community. These three stories could happen to you or someone you love tomorrow and each of them will require the response of a highly trained, expert Emergency Medical Services (EMS) provider. There are times when your local ambulance service makes the difference between life and death but there are far more times when they make a big difference in a person’s continuing quality of life. By interceding in the first few moments of a medical emergency with highly trained experts, EMS makes a difference for us all. Communities that support their local Emergency Medical Services have better services and community members that are more educated about what makes quality EMS are better suited to support their local services.

You may not think about the people who respond to your call when you dial 911, but all we do is think about you. Get informed, get involved, and support your local Emergency Medical Services.

We’re there for you. We need you to return the favor.

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Option #2

As you come in to work today, lace up your boots, or turn on your pager, think about the patients in the above cases. They’re people just like anyone you see in your day to day life. They and others like them didn’t intend to be placed in the situations they’re facing and to them; theirs is one of the most intense situations of their life. Their very life and the continuing quality of their lives could rest in your hands today. They are depending on you. Their families are depending on you. Your knowledge, skill, and preparation to perform your best are paramount to these people. Their care rests on you. You owe them your best and there is no excuse they’ll accept for poor performance.

EMS providers transcend their self when they lace up their boots and sign on for duty. Society needs us. Our patients need us. We need us. We will never know the impact we’ll have on the lives of our patients, their families, and their communities… but it’s huge. We as EMS providers play a pivotal role in our communities. They’ll never acknowledge it en masse… but that doesn’t diminish its importance. Recognition for our skills isn’t necessary for our skills to be vital. EMS people do their jobs because they’re important. We do our jobs because our guts tell us that what we’re doing is right… and even when we stumble and find ways to improve ourselves and our care, it doesn’t diminish the importance of what we’ve done. We have acted, and we continue to act in the best interest of humanity.

Today you can make a choice. You can make the choice to seek out and become the best EMS provider you can be or you can choose not to. I suggest that you make the right choice but no one will ever be able to force you. Your care is an art and a science. Your performance is based upon hard science and soft intuition. There can never be a book that will tell you exactly what is right for every situation… you simply have to learn it and learn how to make the right decisions to fit the situations you find yourself in.

My advice to all EMS providers is to take the high road. Err on the side of what you truly feel is best for your patient. Do your best. Study hard and learn from those you consider the best among us. As an EMS provider, you bear the burden of an overloaded system that pays poorly and garners little respect. I feel it too. I say that it doesn’t diminish the importance of what we do and it isn’t the individual patient’s fault. They deserve our best no matter what the system is doing to us. It’s our responsibility and our calling. It has been said that the definition of a “Professional” is one who can perform their duty adequately in conditions that would cause the amateur to turn back. I’d say that we’re living in those conditions today, but we still have to perform. Do your best and know your stuff. Lives depend on your commitment.

It is our job to promote ourselves. It is our job to elevate EMS. It is our job to speak out and optimize the system. The fault for its failings lies within our profession and it is our job to change it. All of us, individually and collectively have the responsibility.

Will you answer?

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So I got a little philosophical in this one. Which ending do you like better?

Posted by on September 7, 2010 • Filed under: 911, edemse, Emergency Medical Services, EMS, ems 2.0, ems education, EMS Motivation, EMS pep talk, ems scenario, ems scenario based education, EMS Topics, EMS training, Ethics, everyday ems ethics, Fire Rescue Topics, In the Line of Duty, inside the mind of a paramedic, letter to the editor, Line of Duty, Paramedic, paramedic education, Patient Management, pride, profession, professionalism, Public relations, scenario, scenario based training, stories, Training & Development, training-fire-rescue-topics

Too Much Information For a Paramedic?

19 comments

 

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

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

11 comments

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

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

29 comments

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

Police Car Drivers, Ambulance Drivers, and their responsibilities

12 comments

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

A Slap in the Face to Paramedics Everywhere?

89 comments

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

Saved by the Bell? High School Student EMS

61 comments

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

Trust… It’s everything

4 comments

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

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

3 comments

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

Guest Post – From JDmedic on Two Cases, One Letter

5 comments

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

Why I am Passionate about the Chronicles of EMS

15 comments

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

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

9 comments

 

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

Mental Quickness – Do Smart Alecks Make Better EMTs?

8 comments

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