Archives for ems-training

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 11^th for the premier of their pilot episode. I wouldn’t miss it for anything. Look out world, EMS is moving forward.

Posted by Ckemtp on February 8, 2010 • Filed under: Administration & Leadership, 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

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

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

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?”
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.
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.
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.
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.
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.
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.
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?”
Explain to the the patient WHAT you are going to do and WHY you are going to do it.
Approach EMS with a servant’s heart. No matter what some EMTs may think, we are here for the patients. It’s not the other way around.

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

Posted by Ckemtp on February 7, 2010 • Filed under: Ambulance, 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?

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

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

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

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

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

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

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

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

Posted by Ckemtp on February 2, 2010 • Filed under: Administration & Leadership, 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

EMS practice

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

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

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

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

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

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

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

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

I think that my football coach would have been proud.

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

Be the Glow Worm – HazMat for EMS.

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I am not a glow worm.

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

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

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

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

1. HazMat’s still scary.

2. Ck’s still not a glow worm.

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

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

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

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

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

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

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

Their patient was in a lot of pain.

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

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

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

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

And once again, Ck is not a glow worm.

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

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

5 comments

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

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

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

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

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

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

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

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

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

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

Education vs Training: The “Professional Ambulance Cleaner”

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Imagine if you will this hypothetical scenario:

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

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

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

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

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

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

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

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

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

Here’s some questions I have:

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

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

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

Cardiocerebral Resuscitation – Change brings Fantastic results

9 comments

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

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

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

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

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

Is that enough incentive for you?

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

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

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

Did you read them? Good.

So here are some things you should know about CCR.

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

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

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

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

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

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

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

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

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

A Motivational EMS Article Geared towards Newer EMTs

5 comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

12 comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What do you think?

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

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

9 comments

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

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

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

Daily Training Topics 10/16/09

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

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

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

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

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

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

- BLS Airway Management knowledge:

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

- The Oropharyngeal and Nasopharyngeal Airways

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

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

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

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

- The Combitube

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

- The Endotracheal Tube

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

- CPAP

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

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

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

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

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

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

- Bag Valve Masks of assorted sizes

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

- A Pocket Mask

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

- The Surgical and Needle Cric kits

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

I’m really liking my new home.

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

Could it be? A Good EMT-B Student?

4 comments

What is with students these days?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Scenarios. A lot of EMS, a little Einstein

2 comments

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

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

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

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

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

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

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

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

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

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

Six Tricks You Can Use Today to Improve Your EMS Narrative Report

11 comments

The EMS narrative report is the most information-rich part of the EMS patient care report. As I've said before, (here and here), the EMS narrative is the part of the EMS report that provides the most information in a way that humans can actually digest. Unfortunately, there are a lot of EMS people out there that still don't quite "get it" when writing their EMS narratives. Here are some useful tips and tricks that you can start using today that will improve your EMS narratives and improve your overall patient care.

You made decisions on the call. Put in the information you used to make them -Every patient's outcome could be directly attributed to your actions and the care that you gave to them. Remember that deciding to give one form of care over another is a decision that you must make with your clinical judgment. Put the information that you used to make the decisions you made in the report. For example, if the patient had Wolf-Parkinson-White syndrome and it was causing a narrow-complex tachyarrhythmia with a ramp-up in the PR interval showing pre-excitation syndrome and you chose to used synchronized cardioversion over adenosine because of it, well then you should probably provide that information in the narrative.
Remember that you're painting a picture with your words – Imagine yourself reading this report several years down the road, perhaps because the patient has sued you and/or your service, or perhaps because your care is being reviewed. In both cases, you won't remember the call clearly because it will have blended in with so many others. You will be held responsible for the content of the report and only the stuff that you wrote in the report will be allowed into court. Be descriptive. Look at the following sentences:
1. "Pt's left lower leg was found to have a fracture below the knee. Fracture splinted in place with pillow splint and tape"
2. "Assessment of Pt's left lower leg showed a probable angulated fracture of the tibia/fibula below the knee. Distal circulation was found to be slowed but present with capillary refill approx. 7 seconds with no palpable pedal pulses and colder skin distally. Unable to straighten Fx due to severe pain and resistance to manipulation. Fracture splinted in place with pillow splint and tape due to the above.
Which one of those sentences tells your medical director more information? Which one of those sentences shows that you're a competent medical provider? Which one of those sentences would you rather base your legal defense off of if the patient decides to sue you for loss of function in their foot? The second one took me 12.4 seconds more to write, but could save years of headaches. It clearly states that you found the injury on assessment (ie, that you didn't cause it) and that you attempted to, but could not restore distal circulation within the scope of field care, and that you did the best you could to take care of it.

Organize the order of information – High school Freshman English teaches students that the way to write a proper essay is the "at least three paragraph" method (I think, because I was sleeping by then, mostly). My teacher taught me (and it was an um, not too long time ago? How many reunions has it been?) the "Tell them what you're going to tell them. Tell them. Then tell them what you told them method" this roughly translates into the "Introductory paragraph", the "body paragraph", and the "Conclusion". A Simple, one-page Freshman essay in three easy steps. In EMS reporting we probably won't often go into three paragraphs (even I don't) but we can use the SOAP (Subjective, Objective, Assessment, treatment Plan) or the chronological methods to organize the information. To put the above all simply, if you're going to say: "Patient was found to have a 3 inch laceration above his eye" don't put it right after the sentence "Patient was complaining of pain above his sphincter"…. It could cause confusion.
Take a few moments to plan what you're going to write - Let's just say that if you're an EMT you're probably no Dave Barry when it comes to writing ability. Therefore you probably cannot just sit down and plop out whatever pops into your head onto the computer screen just like that. Heck, I'm a trained EMS blogger and I can't even do it. Reflect upon the call in your mind before you write the narrative, remember important events and observations. Think about how you want to tell the story to your reader.
Think about documentation during the call – There are certain tools, assessment findings, and procedures in EMS, and any medical practice, that exist only for the purpose of providing fodder for documentation. No, I don't believe that the numerical reading on a pulse-ox exists solely for placing within a patient care report, but I give oxygen whenever I think that their clinical presentation warrants it (or if I just feel like it) However, it's great for documenting in your vital sign trends. Think about it this way, when you come across the unconscious/unknown and get a history and physical assessment that points towards hypoglycemia confirmed by a glucometer reading of 20mg/dl and you're a paramedic (or an Intermediate) you "sweeten them up" with an amp or so of D-50. What do you do next? After the med takes affect you probably recheck the glucose reading to confirm that it worked… so you can write it in your narrative report. You probably also state that the patient became alert and oriented x 3, had return of color, and had good vital signs. There are plenty of these data points to remember. Be mindful of them and they will find your way into your reports, creating great documentation.
Do I really have to say it? Really? Still? – Maybe it's because I'm no good at math so English has to be my "thing" by default… but I hammer people for grammar (I rhymed there, see? Grammar is fun!) The first and best way to get people reading you to think that you are an idiot is to pepper your writing with spelling and grammatical errors. It makes you look dumb. There, I said it. Please pay attention and try to do the best you can with your documentation. Really. Spell check and proofreading are your friends. Go back and read what you wrote. If you wouldn't want your doctor documenting your care record like you just documented your patient's, fix it. Enlist the aid of your partner and get them to proofread it too. Who knows, you may find something that you missed altogether.

EMS documentation doesn't have to be hard, It doesn't have to be tedious, and it certainly doesn't have to be done poorly to save time. Build your narrative structure and style and improve it over time. Before too long, with your work and the help of others, you will be writing quality narratives that will serve your legal butt and your patient's health well.

For more information, please read the following information on the EMS narrative report, SOAP charting, EMS Charting, and EMS Patient Care Reports.

Soapy Pictures – The EMS Narrative Report

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EMS reports come in various flavors these days. When I first started in this game back when I was a young, idealistic EMT-Basic (as opposed to a still young idealistic paramedic) all we had were these gosh-awful paper reports. We called them "bubble sheets" and if you've grown up as an Illinois EMT you've probably seen your share of them. Illinois bubble sheets were these multiple carbon copy monstrocities that included two pages just chock full of fun. You had to fill them out for everything the state thought was important, making sure that all of the bubbles were colored in exactly right or the state would kick it back to you however later it was they actually fed it through the machine. It was like taking a test every time you had a patient contact. Nobody read the bubbles but the machine. So if you actually wanted to communicate useful information about the patient to future caregivers or if you wanted to remember details about the call for whatever reason afterwards, the State saw fit to give you a really small box with really small lines for you to write a narrative report.

I hate those things. Notice that the previous isn't a past-tense statement. Some EMS services in the State of Illinois still use those awful things for EMS reporting. Really. Ambulances in Illinois are still required to carry at least ten of them in every ambulance per Illinois Department of Public Health (IDPH) regulations. Honestly, I threatened to go back to using them when one of my services switched to a new EMS reporting software that I'm not sure I like. Let me just say that .html databases are not useful for large data collection projects. They're clunky, prone to losing data, and aren't user friendly.

Here is a little bit of information on data. I am a database specialist of sorts. In one of my positions I work in data management and control. I take huge volumes of aggregate data collected from disparate data sources, mash it together, break it into single data pieces, numbers, and "Yes/No" answers, and then ask questions of it to get back useful reports. I'm not a database genius like some (and real database pros may disagree) but the way that I understand data processing is that data can be computed when it is processed into "Yes" and "No" answers and/or numbers. "Yes" answers are "+1" and "no" answers are "-1" or "0" depending on the question. When data is broken down into these Yes/No questions, it can be processed through a mathematical formula to obtain clear, actionable results. That's why you see categories of data, lots of radio buttons and check boxes, and prewritten answers in the new reporting software that has to be NEMESIS compliant.

(In a later post, I'll analyze data harvesting, structuring, composition, computation, and reporting as it relates to EMS. And, if anyone needs the skills of a Data Ninja, I'm available for EMS data processing. Free for small projects)

Unfortunately for us humans, and especially us humans that work in an almost completely unpredictable and not-easily categorized environment, the type of information that we like to communicate with does not fit well into the structure needed by computers. Us humans communicate in ideas, in words, and in fluid conversational form where ideas are not rigid, and the same information can be quite different when read contextually.

Therefore, my favorite part of the EMS Patient care report or any patient chart is the narrative. If you've had the opportunity to read many patient charts, or even if you've flipped through the paperwork on patient transfers, the parts you probably gravitate to are the narratives. You probably also read the lab results. There's a reason for this. Humans like reading stories which are what narrative reports are. We also like quantifiable numbers, which are what the lab results are. These are pieces of information that we can wrap our brains around, sink out teeth into, and really understand. I would bet that there aren't many people out there who ever even read the canned data areas. I don't.

I write a stock EMS narrative report every time. Not word-for-word, but I follow the exact same formula and use different tools in my reporting as needed to fit the situation.
Here's an example of a patient that I'm completely making up off of the top of my head (really):
Ambulance 1 dispatched emergent through the 911 system for the 42yo F Pt (patient) for the chest pain. UOA (Upon our arrival) we were met by the Pt's family who directed us in to the patient. Found the Pt sitting upright in a chair CAOx3 c ABCs intact (Conscious, Alert, and Oriented with Airway, Breathing and Circulation). Pt c CC of substernal chest pain that she std (stated) began approximately 1hr prior to her calling 911. Pt described the pain as a "deep pressure" that she std began in the inferior sternal area and radiated to the L shoulder and into the L arm. Pt rated the pain at a "7" on a 10 scale and denied any provocative or palliative features. ALS ASSESSMENT (By: Ckemtp): (Note: Billing services want that last part) Skin pale, warm, and moist. Pupils PERRL, no JVD (Jugular Veinous Distention), Trachea Midline/Mobile, Chest Equal Rise/Fall Bilat c Clear Lung Sounds and as described above, ABD Soft/non-tender, Extrem (Extremities) c good PMS (Pulse/motor/sensastion) and Temp. TREATMENT: 12-lead EKG obtained showing NSR (Normal Sinus Rhythm) with occasional PVCs and ST Elevation noted in leads II, III, and aVF with machine and EMT-P interpretation of probable acute MI. o2 applied at 4-LPM via NC (nasal cannula). Pt secured on cot and taken to rig. IV established in R forearm running 1000ml warm NS TKO. Pt given 325mg ASA (Aspirin) PO and 0.4mg SL x 1 bringing her pain to a "5". STEMI alert called to St. Elsewhere with report given via MERCI (Medical Emergency Radio Channel – Illinois). Pt given 0.4mg NTG SL again bringing her pain to a "4" and again bringing her pain to a "3". Pt given 2mg MS04 (Morphine Sulphate) bringing her pain to a "2". Pt transported and transferred to St. Elsewhere ER RN staff s incident or exacerbation.

I've been writing that same report for years with each patient. It's evolved a bit, but I can fit everything I need to fit into it. I would think that any further healthcare providers would be able to discern the patient presentation from that report, and I would be able to recall the events of the call in the event that I had to. When I first started writing narratives, I was told to use tools like "SOAP", "CHART", and other acronymns. I hated them, because I felt overly confined by their rigidity. I decided that I would use the chronological narrative method, and I thought that I was using it for years… until I realized that my narratives reports are just SOAP charts with my spin to them.

"SOAP" is an acronym that stands for "Subjective, Objective, Assessment, and treatment Plan". As it goes, the "Subjective" information is the information regarding the call, the events that you found when you got there, and a bit of history regarding the subject of the report. The "Objective" information is the information that you found through objective observation of the subjective information. The "Assessment" is just that, and to signify it in the report I write "ASSESSMENT" in capital letters. In the assessment portion of my report, I include "pertinent negatives" or a full sentence regarding my secondary assessment findings. In this section, I put in the findings such as the skin condition, the lung sounds, and the abdominal condition. While the old adage is that if you didn't write it, you didn't do it. I say that if you didn't write it, you didn't do it… unless it was bad. Then if you didn't write that you didn't do it, you did do it. (G'head an
d read that last sentence again until it makes sense) Including the pertinent negatives in the report shows that you did a thorough secondary assessment which is helpful for defense in case there is a bad patient outcome. Finally, the treatment plan shows the treatment that you performed and the response that you got from that treatment. Be thorough. At the end of the report, I put in the stock information that I passed the patient to the facility staff after calling in a report.

A good EMS Narrative report does a few things. First and foremost, it presents information about the patient's condition and the care that they recieved. The information that EMS gathers is important to their further care. The observations we make and the assessments we take are a view of the patient when their illness or injury is most acute. Our information can set the stage for the entirety of the patient's care down the line. The EMS Narrative also serves to refresh our memory for when we get called in to the office for an unknown reason a year or so down the road. Remember, you're always writing the report for your own legal defense. I also like the narrative because since I write it the same every way and always try to make it as detailed as possible, I can catch when I didn't do as thorough of an assessment as I would have liked to.
The EMS narrative report is the best way we have to tell the story of our patient care. Make it good, make it detailed, and for goodness sake, use proper spelling, grammar, and punctuation. You will be judged by other healthcare professionals on the quality of your narratives, make them good and not only will you look good, but your patients will get better care.

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I'd love to see some report styles used by different providers. So I'm asking y'all if in the comments section you would make up a narrative report and post it so that we all could see examples of other EMS Narrative reporting. I think that it'd be educational, and maybe if you're a geek like me… fun.

This post is part of a group of posts on EMS narrative reporting:

For more information, please read the following information on the EMS narrative report, SOAP charting, EMS Charting, and EMS Patient Care Reports.

EMS Documentation – EMS Narrative Reporting – Paramedic – EMT – ReportPage

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Somehow I've become the go-to site for information on the EMS Narrative Report. I'm very much OK with that. I believe that the Narrative Report and the EMS Report is the most important information-sharing tool for the Paramedic or EMT.

Here are some of the things I've written concerning the EMS Narrative Report, and for EMS Charting general.

Soapy Pictures – The EMS Narrative Report

This article is about the evolution of my narrative style, and shows how I went from just writing something into actually charting about the patient in the best way that I can. It shows how I fuse the "Chronological Narrative" reporting style with "SOAP Charting" (using the SOAP method to write the EMS narrative) – There's a lot of tips in here.

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Why I am Passionate about the Chronicles of EMS

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

Mental Quickness – Do Smart Alecks Make Better EMTs?

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Be the Glow Worm – HazMat for EMS.

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Education vs Training: The “Professional Ambulance Cleaner”

Cardiocerebral Resuscitation – Change brings Fantastic results

A Motivational EMS Article Geared towards Newer EMTs

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

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

Daily Training Topics 10/16/09

Could it be? A Good EMT-B Student?

Scenarios. A lot of EMS, a little Einstein

Six Tricks You Can Use Today to Improve Your EMS Narrative Report

Soapy Pictures – The EMS Narrative Report

EMS Documentation – EMS Narrative Reporting – Paramedic – EMT – ReportPage

Connect with Ckemtp and LUTL

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Featured from across Fire/EMS

In a totally unrelated note……

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Archives for ems-training

Connect with Ckemtp and LUTL

Get your Daily Life, Under the Lights

Care to Search the Blog?

Random EMS Articles from LUTL

My Most Recent Posts

Comments – Recently Recieved from the Field

Oldies but Goodies

The EMS Blogosphere - and others

Tags Across FireEMSBlogs.com

FireEMSBlogs.com Community

Featured from across Fire/EMS