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A Shoutout Across the Pond to our British EMS Bretheren

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Mark in his British Paramedic Uniform

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

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

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

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

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

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

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

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

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

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

Wait… What?

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

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

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

Mark (Right) with the rest of the British Team

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

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

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

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

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

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

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

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

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

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

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

Apparently this is British Medical Control

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

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

And you can find Part Two – Here

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

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

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

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

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

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

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

Expanding Our Career Options – Non-Traditional EMS Jobs

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In my decade or so working in EMS, I’ve had the chance to ply my paramedic skills in more places than the back of an ambulance. I’ve been employed as an ER technician, which is of course the usual suspect for a paramedic looking to move their career options from more than just “The back of the truck” and “the front of the truck”, I’ve been employed as a security guard *slash* paramedic for a hospital chain that ran an ambulance service using their security department, and I’ve worked as a paramedic in an urgent care clinic. I think that EMTs and paramedics can and should expand their career options and that to do so, we’ve got to take a few collective steps.

The professional knowledge, skills, and abilities held by a paramedic combined with the unique personal characteristics of successful EMS people makes our profession a valuable resource to a wide variety of potential employers. These employers, beyond the traditional ambulance services, fire departments, and emergency healthcare providers, stand to benefit greatly from opening their hiring processes to paramedics, as does our profession and the general public. Imagine one day that you’ll type in the word “Paramedic” into your favorite job search engine and have more options available to you than you’ve ever thought possible. Imagine that one day when you’ve progressed to a point in your career where the prospect of getting up at all hours of the day and night no longer sounds like a good idea you would be able to get a job that is a better fit to your personality and your unique set of side skills. I say that our ability to improvise, to think quickly on our feet, and to make solid decisions based upon our knowledge base and experiences in the face of limited and evolving information are useful to business in this day and age. 

At the urgent care clinic where I worked, there rarely was a call for my advanced life support skills. Rather we had the run-of-the mill cases that would come into the clinic for immediate-access primary care. My skills at patient history-taking, assessment, triage, and bandaging got a work-out. So did my skills in relating to patients on a personal level and interfacing with patients and their families across the demographic spectrum. I also learned how to prepare, acquire, and process various laboratory tests including point-of-care testing for common conditions and how to properly obtain and prepare samples for advanced labs. Surprisingly perhaps, I got a great deal more practice drawing-up, mixing, and administering medications more so than I ever have in the field. Working with the doctors greatly improved my skills as a diagnostician and has helped me immeasurably in my ambulance practice. (Yes, I said “my ambulance practice”) I highly recommend for both Urgent Care Clinics as well as for paramedics to explore this wonderful partnership. 

What that experience taught me is that I could “fit” into that job description as a paramedic, it also taught me that there was a learning curve in moving out of the ambulance arena and into a clinical one. In my secret squirrel job that I don’t put out here on the blog, I use my healthcare background as a statistician and data management guru of sorts to help make decisions for a large organization assisting a lot of smaller ones and dealing with a lot of people. There was a learning curve there too, but my experience as a paramedic with knowledge of the real-world of healthcare makes a huge difference and brings a lot to the table. Nurses have expanded into this role for quite a while, and a lot of organizations from Education to Public health employ nurses in a lot of capacities apart from their traditional role as a bedside caregiver. Paramedics and EMTs can and should do this as well.

Previously, I had envisioned a certification as a “Clinical Paramedic” to provide paramedics with the knowledge and skills required to function in a physician’s office setting. I still believe that having additional certifications that build upon our initial licensure and education is the way to go. Imagine that once you attain your initial paramedic education there would be multiple educational options for you to choose from that would lead to a wide variety of career paths. You could be a “Public Health” paramedic working in the inner city to improve health standards and access to care, you could be a “Clinical Paramedic” staffing a clinic, working in primary or specialty healthcare, or you could be some type of “Specialty Paramedic” working perhaps as a liaison with children with special healthcare needs for a community organization. The possibilities are literally endless if we dare to explore our options and trumpet our strengths as a profession to the masses.

In order to do this, we’ll have to fall back on the “We Need More Education” answer as well as exploring how our licensing bodies will have to modify our legal scope of practice to allow us to function in these roles. I’m afraid that we’ll have to fight to “own” our licenses like the nurses do (and AmboDriver, you could weigh in on this) but the fight will be worth it.

I’d love to hear from my readers about how they apply their EMS skills in a manner outside of our traditional role. This is a subject area where I believe our brethren in the volunteer part of our industry can assist us greatly in explaining how their EMS training helps them in their primary occupation. If you are an EMT, Paramedic, jump in and help move us forward. What would do as a medic and what would you like to be doing tomorrow?

Posted by on January 18, 2010 • Filed under: Ambulance, change, Emergency Medical Services, EMS, ems 2.0, EMS Management, EMS Topics, EMT-Intermediate, EMT-Paramedic Specialist, ER, new perspective, Paramedic, paramedic education, physician, potential, profession, salary

Patient Handoffs from EMS to the ER, a Fictional Case Study (not a rant)

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< Rant>

One of the burdens of having a “Popular EMS Blog” is that when someone ticks you off, you have the temptation to come down on them publicly, in blog form. The chance to fire off a scathing criticism of them and everything they stand for in the name of sweet revenge is a siren song that I have resisted up to this point.

And it’s one that I’m resisting today because I’m not that kind of guy. Systems and the way they work? Yea, they’re fair game for my rantings and aren’t spared very often, but people and individuals don’t get picked on here. I just don’t play that way. Everybody has a mother, including me, and my mommy wouldn’t like me behaving like that in the sandbox.

So the following is a completely hypothetical, fictional scenario that didn’t happen. If it happened once to someone I don’t know, then it must have happened a long time ago in an area far far away from anywhere I’ve been. I’m not saying that something like this has never happened to me, but if it did, I’m not writing about it here.

Got that? No picking on individuals here. If you read this and see yourself, then it’s your guilty conscience, not mine. It’s not my job to judge you. You’re the one that has to look at yourself in the mirror my friend. If you’ve done this to someone, have fun shaving and or fixing your hair without having to look yourself in the eyes.

So say someone in EMS gets called to a motor vehicle accident. Imagine that it was a high-speed, head-on MVC and the patient that the EMS person gets called to treat is a middle aged male who is pinned in the vehicle. The patient has multisystem trauma, but is fully conscious and alert. There is one glaring orthopedic injury that looks pretty gnarly, and some other more subtle signs and symptoms of traumatic injuries. Extrication is needed to remove the patient, and it takes about 20-25 minutes to be completed. During that time, the hypothetical EMS person we’re making up here is inside the vehicle, under a blanket, treating the conscious patient. He or She assesses the patient’s injuries, provides stabilizing ALS treatment, packages the patient to protect his injuries, and provides compassion and comfort to him as well. Under the blanket in the car it’s just the hypothetical EMS provider and the scared, injured, fictional trauma patient; During that time, a strong patient/caregiver relationship if forged.

Say that the fictional EMS person takes the fictional patient to Made-Up-Big-Trauma-Center – ER after providing further stabilizing treatment in the ambulance and rapid transport to the made-up trauma center. When the fictional EMS provider wheels the fictional trauma patient into the room where the fictional trauma team is waiting, He or She begins to rattle off the handoff report about the patient to the team. That’s when this happens: One of the fictional nurses on the fictional trauma team talks over the made-up EMS person and starts asking the patient questions that the fictional EMS person had just said. In fact, the fictional EMS person only talked for about 8 seconds before He or She is cut off by the fictional nurse. So, the fictional EMS person shuts up and waits for Who-Does-She-Think-She-Is to ask her questions to the patient, the questions that fictional EMS person was going to answer in just a second or two. Then, the fictional nurse says “Oh, I’m sorry” and let’s fictional EMS person start talking again. Fictional EMS person gets three words out until Ms. Important says “Wrap it up”.

Fictional EMS person wasn’t happy.

Of course, the above story is made up and never happened anywhere in the history of EMS. Trauma Center and ER nurses never treat paramedics like second-class citizens or unpersons. Prehospital assessment findings and patient reports are taken very seriously and are given the respect they deserve. Paramedics and EMTs are treated as respected colleagues by ER staff and work together to provide the best patient care through a productive and respectful working relationship.

Ewww, I think that I just threw up in my mouth a little. Lying does that to me.

So, I figure I’ve probably got a few ER nurses that read this blog thing. How do we fix our relationship in the name of patient care?

< /rant>

Posted by on November 2, 2009 • Filed under: ckemtp rants, Emergency Medical Services, Emergency Nurse, Emergency room, Emergency Room Nurse, EMS, EMS Topics, ER, Ethics, medical ethics, Paramedic, Patient Handovers, Patient Management, rant, RN, Transfer of Care

The Handover Blog Carnival – Funniest. Call. Ever – 9/25/2009

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EMS people are some funny, funny, people. Oh sure, some of our humor is strange to the uninitiated. It’s dark and disturbing sometimes… built from years of bearing witness to the macabre scenes of humanity that play out before us. Sometimes it’s more slapstick, a kick in the groin if you will. Or a psyche patient that’s so attached to the dead squirrel that he’s carrying with him that you just have to put the dead squirrel with you in the ambulance and take it to the hospital. He was starting a cult, he told me. The squirrel had no comment.
But no matter how you look at it, there’s some funny, awesome, and just plain strange stuff that happens to us out there.
And that’s what we’re celebrating here in this edition of The Handover Blog Carnival, the biggest, baddest, and most awesome blog carnival devoted to the Emergency Medical Services, the Emergency Room, and the Accident and Emergency ward. Some of this stuff will only be funny to EMS people. Some of it will make anyone laugh. A lot of it is… well, just don’t read this in church.

Our first post comes in from our friend The Crusty Ambulance Driver.

After him!! He’s having a seejure!! It’s not every day that you get to call in the Fire Department’s helicopter to help you catch your patient.

This was one of those days.

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Ever hear the one about the One Armed Fisherman? He caught a fish that was (holds up arm) “THIS BIG!”

Har. Yea, our friend The Happy Medic chimed in with that one in my comments section a while back ago. He just won the contest :)

Oh, and you can get Swine Flu from Fish, right? Guys? Right?
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Folks, sometimes Life in Manchvegas gets a tad strange. Our buddy Walt T. tells the story of a woman who just was having a bad day.

Then the SWAT team showed up. I’LL KILL YOU!! My love :)

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From the Island Across the Pond, our British Brother Medic999 chimes in with a touching but funny post perfectly memorializing a fallen comarade. He was funny, I can tell that he was one of those guys you just looked forward to working with. EMS is a family.

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Ok, so this is just some gosh darn funny stuff. Prepare yourself for Ambulance Driver’s contribution. Don’t read this in church. You probably should pee before you read it too. I laughed my ever lovin arse off.

“Purty Healthy Sheckshy Titties”, “Find your happy place! Find your happy place!”

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Mack 505 over at Notes from Mosquito Hill discusses those weird things we do with the other social miscreants we work with. I’m sure you’ll know what he means here. EMS is a family. A horribly, horribly dysfunctional family.

 “Hey Partner: “Ice cold Beer?” Yea, you know.
/>
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Lt Michael Morse, or L-T as I call him, over at Rescuing Providence has written this short, punchy, and very, very funny post. It’s everything you need to know about life wrapped up in one, eh, “little package”.

Lord of the Rings

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Happy Medic once told me that I could improve my blog by adding “More Explosions and Bikinis”. I agree. Thanks to EMS Chick and Just Me, Just My Blog I bring you two posts featuring explosions written by female EMS bloggers who empirical evidence has shown, sometimes might wear a bikini.

“So, ya went poof, huh? Weird.” - Just Me

Why do we check our stuff? Because sometimes things blow up and spray you with hazmat. – EMS Chick

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Making up this month’s Handover has allowed me to find this blog from a blogger by the name of Philly Dan. He was doin ambo work when Medics like me may have been in diapers. Great reading over there. Thanks for submitting!

Defib Shocks are for the patients, right? I like this one a lot. Cadillac ambulances wading through floods always get me.

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Lumo, over at My Life in A&E, a UK Medic blog that I read a lot had a late submission that just squeaked in past the deadline. He asked me if it fit the description of a funny call.

Hell yea it does, it’s got wee.

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Thanks heavens for stupid people. Without them, the Emergency Medical Services would be boring. Stupidity makes our world go ’round. As my momma always told me, “If you stick your finger too far up inside there, you’ll poke your brain and get a paulsy!”

Actually , she said “Some people exist just to serve as a warning to others” FireCap5 over at Not Trained, but We Try Hard! put forth a post about a recent canary he had.

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Alright folks! Hope you made it down here. Great job to all of the great bloggers who submitted some funny, funny posts. What follows is some other posts from around the web that I thought needed some attention.

Oh, and some shameless self promotion too. Shamless self promotion.

One of my favorite bloggers who seems to be WAY smarter than me, Rogue Medic, has written a post on Correlation and Causation, featuring one of his favorite comic strips. There’s cows, and a lot of the stuff that he’s famous for. Great stuff as always.

Greg, over at Training Success is a buddy of mine who I finally prodded into becoming a blogger. He’s a Haz-Mat wizard. He wrote a good post about role playing in training scenarios from a class that I was in. Check it out.

My cousin is a blogger who I really want to come to Blogger or WordPress. She writes great, but her blog is over at Myspace. She guest posted her funniest medical story on my blog. Here it is. - You can find her Myspace blog on the post. She does a lot of political stuff.

Here’s some shameless self-promotion :) I write on a blog called The Awesome EMS blog - I wrote this here a while back ago and I think that the video is freakin hilarious. I give you Skateboard Fail. Any blogger who wants to co-write on this blog is welcome, I need help on it.

And with that, this edition of The Handover Blog Carnival has come to an end. Y’all rock for coming over and having a read. Be sure to look for the next edition coming out next month over at The Insomniac’s Guide to Ambulances. The theme will be Kids – Seen and Not Hurt. Now, ladies and gentlemen, allow me to play you out.

Posted by on September 25, 2009 • Filed under: ambulance humor, EMS, EMS paramedics, ER, The Handover

EMS Trendsetters Conference 2009

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Are you an EMS Person? Are you involved in Emergency Medicine? Are you an EMT, a Paramedic, a Nurse, a Doctor, a “something medical”? Are you interested in high quality continuing education provided in a fun and cool environment by top quality, national speakers?

You are? I thought so. See, I know my audience pretty well I’d suspect.

Here’s the catch though. I’m plugging an EMS conference that’s being put on by a friend of mine. She’s started a company that provides low-cost CE training in a cool and interesting way for regional EMS people. This is her annual big conference, and there’s a ton of good speakers and educational offerings going on this year. Y’all should come.

But… it’s located in Kenosha County, Wisconsin. If you’re local, come on up! If you’re not, then fly in. The airlines need the money and I’ll promise a beer (a cheap one) to everyone from out of the area who shows up (yes, if you’re over 21 and not afraid to drink Schlitz)

Here’s the website of the conference: http://www.emstrendsetters.org/ – This conference is personally endorsed by Yours Truly, for whatever that means.

Come on out and support one of us doing something for all of us.

This conference is located near: Northern Illinois, Southern Wisconsin, Rockford, Chicago, Kenosha, Milwaukee, Woodstock, Crystal Lake, Fox Lake, Beloit, Janesville, Madison, Wisconsin, Illinois

Posted by on September 3, 2009 • Filed under: Ambulance, EMS, EMS Conference, EMS paramedics, EMT, ER, illinois, northern illinois, southern wisconsin, wisconsin

The Handover is coming! The Handover is coming!

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Coming soon to Life Under the Lights, The Handover Blog Carnival!

Yes, Medic999 has convinced me to put my money where my mouth is and host an edition of the Famous EMS Blog Carnival. Hopefully I can live up to the heavy expectations of the readers and fill the big shoes of the bloggers who have hosted before me. The Handover is the biggest and best blog carnival featuring awesome bloggers from the world of the Emergency Medical Services and The Emergency Room (US) and Accident and Emergency Room (UK).

Yep, it’s an international EMS blog carnival featuring the best in Emergency Medical content from around the world. It is published monthly. There are Paramedics, EMTs, firefighters, Nurses, and Doctors that participate. If you haven’t read it before, you should. In fact, head on over to Medic999′s place – http://medicblog999.wordpress.com/ and check out this month’s edition. The theme for his edition is “My First Call” which promises to pull out the emotional, the macabre, and the flat out hilarious stories that we all share as members of this crazy profession we call EMS and Emergency Medicine.

Oh, and you’ve all been waiting for the announcement, so here it is…. The theme for my edition will be:

“Funniest. Call. Ever.”  The deadline for submissions is Monday, Sept 21st and it goes live on Friday 9/25.

Yes, that’s right. Pull out the best call you’ve ever had, the one that you tell in the coffee shop to other medics that still makes them wet themselves laughing or scratch their head wondering how we could ever make this stuff up. We can’t, and that’s what makes it so funny.

Can’t wait to see this month’s edition and I can’t wait to get started on the submissions for my edition next month. Stay Safe, everyone.

Oh, and in case you haven’t seen (and I hid it when I posted it) Here’s the story of my first that I submitted for this Month’s Handover:

http://proems.blogspot.com/2009/06/my-first.html

Posted by on August 27, 2009 • Filed under: Ambulance, blog, blogger, EMS paramedics, EMT, ER, Fire department, The Handover

The DNT Order??

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Tonight I would like to take a few moments to hit on what is one of my top-ten all-time use-a-lot-of-dashes-in-between pet-peeves in EMS and probably in health care in general. It’s the “DNT” or “Do not Treat” order. It might just as well be called the “DNC” or “Do Not Care” order, or “Do Not Comfort”, or “Do Not Be Humane”, “DNBH” Order.

Yes, I’m talking about DNRs here. They’re “Do Not Resuscitate” orders and if you’ve been in EMS for longer than a minute or two you’ve heard about them.

DNRs serve a good, humane purpose in a lot of cases. We all know that even though we’re improving (GO CCR!!) CPR and ACLS are largely rituals that we perform for the dead in our society. They rarely bring people back if they happened to be sick enough to die in the first place. They’re also very traumatic things to do to a body. DNR Orders are a humane way for patients and families to say “Enough. When God or whom/whatever I may or may not believe in says it is my time, it is indeed my time”. I can respect that. I happen to be a Christian and I believe that we go to a better place once God decides that it’s time to punch our clocks. If I had a hopelessly terminal disease I would probably be pretty ticked off if some young kid with a shiny new EMT card brought me back to face more of the disease progression with a couple of broken ribs for the trouble. I get it.

What I don’t get, and what just drives me crazy is people who treat DNR orders like they’re “DO NOT TREAT THIS PATIENT BECAUSE THEY’RE JUST A DNR” Orders. I know that I will hear this again, and probably tomorrow because I heard it three times today and I’m on a 48hr shift here, but I think that I might say something unkind to the next person that says, “well.. They’re a DNR” when I ask them why they’ve let their patient suffer in agony for hours before they decided to send them to the ER. Yes, I um… occasionally go to “Skilled Nursing Facilities”, can you tell?

Here’s what a DNR order does NOT mean:

  • It does NOT mean: Let your patient be Hypoxic – Yep, I can see that they probably don’t want you sticking an ET tube down their throat. BUT PUT THEM ON OXYGEN IF THEY ARE HAVING TROUBLE BREATHING!! HELLO!!?! WOULD YOU WANT TO LAY THERE WITH A PULSE OX OF 80 SOMETHING!?! IT’S CALLED COMFORT CARE!!!! ; Ahem, sorry… but good patient care is one of my highest goals. Please, on behalf of everyone who does not want to go through the agony of suffocating in their own body, please do things to maintain a patent airway and good oxygenation. Please.
  • It does NOT mean: Wait until a simple medical problem is something critical before you seek a higher level of care – For the EMTs/Medics in the audience (if I ever get one.. Tell your friends!! J) how many times have you walked into a patient’s room at a “Skilled Nursing Facility” and found that only when a patient’s family member came to visit and found grandma gorked out did the staff think to maybe do an assessment on them. Treat every patient the same, give them all the same level of care, just don’t pump on the chests of the ones with the DNRs! Simple, right?? Don’t let them get septic from a UTI. Don’t let them get pneumonia from a simple cough. Don’t… forget that we’re all deserving of human comfort.

  • It does NOT mean: Let your patient die of dehydration and/or starvation – This goes back to being humane. Really… Yes, I have see this, treated it, and taken care of it but I don’t see the point in saying why or where. (Remember, I’ve been a lot of places in the ten odd years I’ve been in the back of a bus). Every human being needs to eat and drink some way, somehow to keep from dying a horribly painful death. Don’t neglect people because they happen to have made a decision to not have CPR done on them.

Don’t think that I’m just picking on the nursing homes here.

I once had a transport where I took a young infant with a horrible medical condition from a small ER to a tertiary Childrens’ Hospital. (A different one from the one in a previous post). This poor little baby was now living with a set of very nice foster parents but just didn’t seem to have much chance in the world due to his/her terrible start in life. The child was on oxygen, needed regular suctioning, and was being sent to this tertiary facility to replace his/her feeding tube, which had become dislodged. Because of that, the patient was having some increased breathing difficulty and was actually pretty challenging to take care of for the hour long transport. The foster mother had brought the baby into the pediatrician’s office for this condition, and the pediatrician had set up the direct admit to the tertiary facility after sending the kid to the ER close to his office.

The foster mother was a very nice lady who seemed genuinely concerned and caring about the kid. I asked her why if the kid was in that bad of shape did she not call 911. Her answer? “I thought I couldn’t call 911 because he has a DNR order”. Someone, and I don’t know whom… but someone had told this wonderful foster mother that this child was NOT WORTH EMERGENCY CARE because he had a DNR order! Yea, not in so many words I don’t think… but that’s the general idea she had. I corrected it. Told her to call 911 whenever she felt she needed to and let her know that the ambulance crew where she lived would love to come visit her to learn about and help take care of the child. I cannot believe that someone would lead a person to believe that… I just can’t.

Oh, and yes, today I had a SNF patient that fit my whole DNR/DNT pet peeve thing… and yes, an ER staff person may or may not have given the “Just a DNR” comment. In fact the whole healthcare system may have failed someone today that chose to have a DNR order and neither he/she nor his/her family knew about it. But I did, and I fixed it.

And I just ranted about it.

Someday soon I may turn this blog post into a coherent article, got any rants you’d like to post? I like comments. As always: ProEMS1@yahoo.com

Posted by on February 13, 2009 • Filed under: Ambulance, ckemtp rants, cpr fail, DNR, Do Not Resuscitate Order, edemse, EMS, ems education, EMS ethics, EMS rant, EMS Topics, EMT, ER, Ethics, everyday ems ethics, nursing home, Paramedic, Skilled Nursing Facility

Why am I doing this??

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So the other day I was taking this cute little 9 month old to a tertiary specialty childrens’ hospital. It was a nice place, big, clean, bright, state of the art equipment, people scurrying about looking busy, cute nurses, etc.. It was a class act. The patient was stable and quite pleasant actually. We had been playing in the back for the last hour to the extent that a 9 month old can play while in a papoose restraint. Yes, he was papoosed, but only because he had a fractured femur and needed the tight immobilization. I happen to like kids thankyouverymuch.

What got me about this is that when I got the patient into the ER room, a bunch of slightly older kids walked in wearing scrubs. My first thought was that they had a new crop of ED techs that were in training… however, much to my horror they identified themselves as surgical residents. Oops. Looks like the last ten years or so that I spent driving fast and breaking things could have been spent in a cramped room looking at books and developing my student loan debt. It got me to thinking that if new doctors were starting to look young, and if I was starting to feel grandfatherly in the ambulance, maybe I should consider advancing my career.

The problem with this is that I’m an EMS addict. Really. No I don’t have 25 warning lights in my personal vehicle and my physique is free from star-of-life tattoos… But I just have always liked getting up every morning and being plum lucky enough to be a paramedic. I can’t imagine doing anything else for a living. It has struck me that whenever I hear coworkers talk about career advancement it usually involves leaving the streets and taking time away from patient care. If you’re on the fire side, you can become a lieutenant or captain and get off the “box” away from the “gomers”, or if you’re not you can become a nurse and increase your income while diminishing your clinical decision making skills (Yes, I pick on most nurses here). However, I’ve been thinking about what I could do to “advance” my career while feeding my addiction to making sick people feel better in the way that only medics can.

So here it is, after a shift or two of kicking it around, I have decided to decrease the amount of my time that I used to spend sitting around on duty watching Internet videos of people hurting themselves and looking up pictures of cats with funny captions (Yes, I’m more of a man because I love my fluffy-wuffy lil’ Kitty-Witty) and spend some time writing useful tidbits of ambulance crap that I have garnered through the last ten years or so of riding under the lights and being smacked around by what the streets have served me up. What follows on this blog is one of my first pieces for the enjoyment of a wide audience. If you like it, I’d love feedback here or at: proems1@yahoo.com.

Oh, and for the web crawlers: Paramedic, Firefighter, EMT, Boobies, ambulance, fire, medic, EMS.

Posted by on February 9, 2009 • Filed under: Ambulance, EMS, EMT, ER, Fire department, Firefighter, hospital, Introduction, Paramedic, show tunes
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