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Trust… It’s everything

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Care to Share My Stuff?? C'mon, Go ahead.

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

Any Random Person

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I love Dave Barry, he has been called the most influential humor writer since Mark Twain. If you haven’t read any of his stuff, you really should. In fact, I’ll even provide a link to his web site here: www.davebarry.com. Yes, I’m providing that before what I’m sure will be my well-written, extremely interesting content below. He’s that good.

I put that up there because I am going to use a quote of his that he put into one of his columns; he asks his readers if they are saying to themselves “Hey, I can do this! *Any* random person can do this!” And he counters that they are wrong, because “It takes a very special kind of random person to do this”.

And that’s how I’m tying this into EMS.

I work with a few EMT-Intermediates (I-99 curriculum) and some EMT-IV Techs (WI has a version of a basic that can start IVs with NS and give a few IV meds) that are very sour on the fact that they aren’t paramedics yet. They’re not sour on the fact that they do not yet wish to sit through the required education to become paramedics, but they’re sour that there are skills that they can’t do that they see their ALS counterparts doing. They see us “paragods” performing ALS skills and say, “Hey, I can do that”.

And it may indeed be true. I see these days that they keep pushing skills that were once only the domain of paramedics down to the BLS providers. Heck, that’s what EMS is entirely built upon. In the far beginnings of our profession (and we’re still really in the beginning phases) the skills that Paramedics and EMTs perform were once only the domain of physicians. If you would have asked a physician in the 70’s whether a non-physician could interpret an EKG and give relevant medications and treatment as well as he could, you probably would have gotten a very incredulous answer. EMS is all about proving to the medical profession that treatments once firmly entrenched as only for use in the hospital have a demonstrated benefit to the patient when used quickly at the patient’s side close to the onset of symptoms. EMS personnel were trained for that most probably because it just isn’t cost effective to have doctors sitting around manning ambulances.

However, the question that has come up in my mind is where the bottom of that lowering of educational requirements for advanced skill performance ends. I have seen in my career a paradoxical movement in educational standards for paramedics and EMTs. There are a smattering of disparate and yet somehow complimentary certifications in some states, but while some educational standards have improved, most of them have decreased. While a good argument can be made for EMS levels between the Paramedic and the EMT-Basic, such as the I-99 and the IV tech in WI or the Iowa Intermediate in Iowa in the sense that they allow rural communities to be able to perform some advanced skills without having to shoulder the full breadth of costs and responsibilities associated with full paramedics, they also don’t take into account that a lot of those skills require a whole heck of education to be safely performed in the outlying patient that can be harmed by inexperienced providers.

The debate that I got into with an EMT-IV Tech over breakfast the other morning went something like this. He brought up the fact that EMT-IVTs could administer Narcan to reverse heroin OD’s or other narcotic overdoses. His statement to that was that they ought to be then able to give Morphine for pain control “since we already carry the reversing agent” (in case they give the patient too much or the patient has a reaction). My thoughts are that they should not be able to, because the administration of a narcotic for anything requires a requisite knowledge of the pharmacologic, physiological, and social actions of the drug. And while yes, that could be covered in a module I could assume, why should it be? I brought up that it takes physicians years of experience to be able to tell how to identify drug seekers who want to get a high from the legal, medically prescribed narcotic. Contemporary medical journals in family practice and emergency medicine have written volumes on the topic, and still physicians can be fooled. The extrapyramidal reactions possible with morphine, including respiratory and other Central-Nervous-System (CNS) depressing features of the drug have other treatments and symptoms that can be hard to recognize for an inexperienced provider. An EMT-IVT just doesn’t have the breadth of background knowledge needed in order to judiciously use the drug safely in all cases. The fact that most of the time it would work out fine does not withstand the certain percentage of patients that could and would be harmed. I ended the argument with him by bringing up something that I’ve always remembered from paramedic school. Our lead instructor told us that our drug bag was nothing but “A big bag full of poison” if you didn’t know how to use it.

Remember, every single time any medical care provider performs any treatment of any kind on a patient they’re making the statement that “Right now, I know better than your body does. I know better than your brain, your nervous system, and better than all of your body’s self healing systems do what you need to keep living and get better”. Any time you put on a bandage, you’re telling that patient that you know better than their body does that they need to stop bleeding. Every time a paramedic or other provider uses an airway management technique they’re saying that they know how to breathe better for the patient than the patient’s own body does. Every time you give a medication to a patient you’re telling them that you know how best to control their body’s systems. Think about it. Every treatment, every time. It is a HUGE deal to be able to do this stuff, and you dang well better know your stuff.

Physicians are rooted in the quest for knowledge. Their reputation as learned individuals goes back to prehistory in one form or another. They’ve earned their vaulted place in society due to their quest for knowledge and reason and their caring for others above all else. EMS people came from physicians. I can think of no other medical profession that has a downward pressure on their educational standards. I’m saying that, because I think that EMS does. We have elements in our own ranks, and external forces that are continuously working to make us into skills monkeys that can be paid very little and know very little.

This is a big statement: Not everyone can be a good paramedic or EMT. It takes a certain intellect, sound ethical reasoning skills, and a level of professionalism that not everyone can attain.

This is another big statement: There are groups in our society that want to make it so that any random idiot can become a basically qualified one. This keeps us all down and lowers the quality of patient care… a lot.

Yet another: Us good EMS people should be really ticked off that educational standards are so dang low these days. Fight for excellence. Respect ourselves.

If you and or your service want to be able to perform advanced skills, earn the requisite knowledge through your studies and earn the level that it takes to do them. Enough is enough. I don’t believe that we should lower any more educational standards. No other group would do this, not the nurses, not the PA’s, and certainly not the physicians. Why should we? Yes, I understand that with the advent of Urban Fire Based EMS the IAFF and IAFC want to put more paramedics on the streets to increase their influence and their revenues, and that in order to do this they need to match the intellectual skills of medics with the intellectual skills needed to be a good grunt firefighter, but EMS is a MEDICAL profession built from the quest for knowledge. It should not be relegated to the technical performance of skills if X equals Y.

Heck, I think that the current level of Paramedic should be the basic level, and that Paramedics should be as independent as Physician Assistants. In fact, I’d like to see that in the future.

Care to Share My Stuff?? C'mon, Go ahead.

Posted by Ckemtp on March 11, 2010 • Filed under: Ambulance, EMS Topics, EMS ethics, EMS rant, EMT, EMT-Intermediate, Emergency Medical Services, Ethics, IV, Paramedic, ckemtp rants, dave barry, edemse, ems 2.0, ems education, everyday ems ethics, paramedic education, physician

Two Cases, One letter – From one Paramedic’s struggles, change can come

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A letter I received from a reader recently has gotten me just as mad as he is, even more so maybe. This letter came in from someone who identifies himself as a paramedic but asks that I protect his identity and location completely. I will do so, only identifying that the letter comes from someone who works out west, somewhere between the Mississippi and Montana but not east as Maine or as far south as Amarillo.

So He comes from somewhere in the US, not the east coast, and not Hawaii. He’s a paramedic and he’s male. That’s all I’ll say. I’m going to work the things he wrote me in his letter with my thoughts and feelings on what he wrote and the situation he wrote about. I’ll rewrite the letter keeping the point of it intact. I’m fairly sure that you’ll be just as angered as I. (Note – This is LONG but it’s good. It will probably tick you off too, enjoy)

(more…)

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Posted by Ckemtp on February 25, 2010 • Filed under: Administration & Leadership, DNR, Do Not Resuscitate Order, EMS, EMS Health & Safety, EMS Management, EMS Topics, EMS ethics, EMS paramedics, EMS system, Emergency Medical Services, Ethics, Line of Duty, PR, Paramedic, Patient Handovers, Patient Management, Public relations, change, ckemtp rants, edemse, ems 2.0, ems education, everyday ems ethics, medical ethics, paramedic education, patient care, politics, potential, pride, profession, professionalism, rant, stories

The Perfect Emergency? Well, almost

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So a while ago, I went to an emergency medical call that was about as perfect as an EMS call could be.

Picture this if you will. Our ambulance was in service. The system was at normal operating levels which are well funded and are adequate for our response loads 90% of the time. I had thoroughly checked and cleaned my ambulance and the equipment inside of it at the beginning of my shift and I had even gotten a chance to have a cup of coffee or two before the call came in. When the call did come out over the radio, it was merely a short walk to the ambulance for my paramedic partner and I. We climbed into our dual paramedic staffed, well maintained, state-of-the-art ambulance, and rolled out to the scene of the emergency which was about 8 blocks away through light traffic. We arrived within 4 minutes of the 911 call and were informed by our dispatcher that the residence was equipped with a “Knox Box” entry system so we could quickly gain entry. We retrieved the key from our ambulance, were able to open the Knox Box, and easily entered the residence using the key inside of it. While entering, we noticed that the resident had a “Vial of Life” sticker on the front door, which signified that the patient was most probably participating in our “Vial of Life” program, meaning that the patient had all of their medical information written down properly on one of our stock forms. In fact, we found the “Vial of Life” right in the refrigerator door, where it was supposed to be. The patient, an elderly person, had used a (Non brand-name specific) home emergency call button to summon assistance, which we also had recommended to him/her during the public outreach that convinced her to have everything else in place for our arrival.

In short, this patient had done almost everything right. He/She had paid taxes throughout his/her long time living in the district and had supported us in order to allow us to have quality, state-of-the-art equipment. He/She had supported us so that we could get good training as well. He/She had listened to us when we suggested that He/She wear an emergency call button as he/she got up there in years, had written down his/her medical information in the “Vial of Life”, had put the Vial of Life in the correct place, and had even installed a Knox Box on the home so we could gain access quickly.

So what wasn’t right with this call? The patient had been experiencing symptoms consistent with a stroke. In fact, it was an easy diagnosis from across the room type of stroke. The patient had noticed that he/she was possibly having stroke-like symptoms and had decided that it would be best to get cleaned up, get dressed, clean up the house a little, and call a neighbor over to see if he would take him/her to the doctor’s office before the neighbor convinced the patient to press the button and call us out to help. By that time… well let’s hope the doctors can work some magic.

With all of the bloggers, paramedics, EMTs, and everyone else out there harping about “BS” 911 ambulance calls, one would find it easy to overlook cases like the one above. I for one will come right out and say that I will gladly run 100 nonsense EMS calls rather than miss just one of the above… I don’t want someone to die or suffer further morbidity simply because they were too scared, or polite, or timid to call an ambulance.

I don’t know how to fix the problem, I’d just like to remind you all out there that our job is indeed to take care of people when they’re scared, when they’re sick, and when they’re just plain-ol’ stupid. We’re healthcare providers and it’s our duty. No exceptions.

Remember that.

Care to Share My Stuff?? C'mon, Go ahead.

Posted by Ckemtp on February 22, 2010 • Filed under: 911 fail, EMS, EMS Management, EMS Topics, EMS ethics, EMS system, Emergency Medical Services, Ethics, Fire Prevention & Education, Fire Rescue Topics, Paramedic, Patient Management, everyday ems ethics, patient care, scenario, scenario based training

Equipment Review: Scary Post Ahead

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This was one of my first posts. Since I’m attending an EMS conference, I figured it deserved a bump-up too. Good Luck!

Some of you have been telling me: “Chris, you’re a good paramedic. You should be providing tips and tricks for EMS people so that they can use your hard-won wisdom to improve their patient care. Don’t spend your time ranting about things that bother you in the back of the truck and keep making feeble attempts to make people laugh. Write a serious article, darn it!!”

Actually, I’m really the only one that’s been telling me that, since this blog is only read by like, six people including my mother, fiancé, and my cat… but nonetheless I am going to attempt a serious piece regarding actual patient care issues. As such, I have identified piece of equipment that is carried on my ambulance and is most probably carried on every ambulance in the country. This particular piece of patient care equipment is rarely used, yet critical for patient care when needed. When this piece of equipment is called for, the patient needs it and needs it NOW. Yet, I’m sure that even the most experienced EMTs and Paramedics are struck with horror at the mere thought of its use.

I’m talking here about: The bedpan.

Yes, in my storied career I have been called upon to use a bedpan more often than I would have liked to. The situation is almost always the same, the patient is otherwise stable but the pressures of the bumpy ride on the human bowels are just too much for him or her during the prolonged transport time. Usually in complicated cases like these I prefer to bring along a nurse, since they are eminently more qualified to perform in these critical patient care scenarios. However, as is often the case in EMS, we are called upon to take care of any patient presentation in any patient population and must perform professionally in all situations. I have researched the use of this piece of patient equipment in numerous trade publications and critical care guides and have been struck with the lack of educational materials available for this critical patient care skill.

So, as any EMS writer would do when setting out to write a patient care article, I hit the streets to query other paramedics and EMTs on their secrets for the proper use of the bedpan. I began with the coworkers I have at my two ambulance jobs, one a private, not-for-profit city 911/Specialty Care Transport service and the other a Fire Department based service. Both of them work around 3000 calls per year and run at the ALS level. Here is a sampling of the responses I received:

Question: By a show of hands, how many of you have used a bedpan in the back of an ambulance??

Answer: I raised my hand.

Some of the people there wanted me to clarify the question, they wanted to know if I meant had THEY themselves personally used a bedpan in the back of an ambulance? One guy admitted to using a urinal in the back while transporting a patient. When badgered by the other providers, he clarified by saying that it “was a pretty long trip”. I offered that there have been some situations in my career where I have put the bedpan under a patient who absolutely HAD to go poopie during a trip to the hospital. However, and I just realized that this is the most blessed thing to ever happen to me ever, not one of them has ever been able to “go” with me hovering over them.

Of course, in EMS, I have been covered with every imaginable bodily fluid, including the unholy trinity of urine, vomit, and feces ALL AT THE SAME TIME. And I have plans to erect a statue to the person who came up with the idea of prehospital people administering Zofran (an anti-throw up medication). The other day I spent a few minutes starting a saline lock IV on a lady in her bed inside her apartment just so that I could give her that blessed medication. My fairly new EMT partner wanted to know why I did that, when I usually wait until we’re back in the truck. I let him know that I had been on the foot end of the stair chair going down the stairs before the golden-age of zofran had arrived.

Yes, us “experienced” EMS providers (read: old people who never got real jobs) will tell you that when you can’t let go of the end of the stair chair without letting your patient plummet down a full flight of stairs and the patient chooses THAT EXACT MOMENT to decide that they just *have* to throw up. You well, you just have to close your eyes, close your mouth, lower your face to cover your nostrils, and take it like a true professional. Been there, done that, cleaned the chicken and rice out of my ears with a q-tip. It’s moments like that when you reevaluate your commitment to the profession, and realize that it must be something other than the *interesting* amount of money that they pay you that keeps you coming to work every day. For me, it’s the amount of time that I get to spend typing up articles about bedpans and vomit in my ears… at least it is right now. Has anyone else ever thought that they had been ruined by EMS? I mean, I don’t think that I could ever do an office job. Years of EMS work has left me with the remarkable ability to begin to focus on something like a laser beam for 90minutes tops, then… Hey look!! A Bunny!!

Oh yea, bedpans. So you slide them under the patient and um… Pray that they’re positioned correctly. Wear correct BSI including a pair of gloves, a mask, goggles, and Vick’s Vapo-Rub under your nostrils. Of course, for us old timers, this is required even when you’re making your partner use the bedpan in the back while you drive (heh) Ever So Carefully to your destination. Tell your partner that they need the experience, tell them how professional they are being and tell them that they’re showing true compassion to the patient. Then go out and buy them an ice cream cone filled with Rocky Road. With any luck, you’ll get to eat that too when they suddenly become less than hungry.

In all seriousness, everyone poops. Never let your patient suffer when you can alleviate their suffering with a simple slide of the bedpan under their derriere. Of course, make sure that they REALLY have to go to lessen your risk of contaminating yourself with some really funky pathogens, and also to avoid ticking off the nurses’ lobby by taking their jobs.

Until next time…

Care to Share My Stuff?? C'mon, Go ahead.

Posted by Ckemtp on January 23, 2010 • Filed under: Ambulance, Bed pan, Bed pans, EMS, EMS Health & Safety, EMS Humor, EMS Topics, EMS ethics, EMT, Ethics, Fire Rescue Topics, Fire department, Firefighter, Paramedic, bedpan, everyday ems ethics, odansetron, puke, zofran

Cat Puke Chicken

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Note: This is a repost. I’ve been a busy blogger and this post deserved a bump-up. Also, the “Fiance” in this post is now my lovely wife. Enjoy.

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The other day I got off shift at 8am and had to be to work at my other full-time job at 10am. Since both of the jobs that I work at are about a half hour from my house in opposite directions it worked out that I had about a half hour to go home, perform the personal hygiene ritual, change uniforms, and get on my way to work again. So I did that, got home, fed the cat, and got all prettied up as quickly as I could. Then, without warning, on my way out of the house I noticed it: A pile of cat puke on my rug.

Yes, I like cats. I have one. She’s a keeper, regardless of her regurgitation issues. I think that I’m more of a man because I love my fluffy-wuffy lil’ Kitty-Witty. So cat puke on my rug isn’t the horror of horrors to me that it might be to some people. In EMS, we tend to get puked on by humans more often than does the regular population and that fact may have further desensitized me to the violent act of emesis perpetrated on my rug by my mostly cute little kitty. However, I do like a clean house and the cat puke on my rug is an issue that normally warrants immediate action.

But of course, that’s not what happened. And for those of you in a spousal relationship with another human being you know exactly what I did. You guessed it, I left the cat puke on my carpet and went to work. For those of you who are not in a spousal relationship with another human you may not understand the thought process here. Yes, as I looked down at the cat puke on my otherwise (mostly) spotless rug the thought that it must be immediately cleaned up did in fact occur to me; but the other thought that occurred to me was: “I can leave and go to work and when I get home, my lovely fiancé will have cleaned this up for me. She’ll think that the cat puked on the rug *after* I went to work and I’ll get off scot free!”

And so that’s what I did. Yes, I *could* have taken the five or so minutes it would have taken to clean up the cat puke… but in my defense I’m a model employee and I need those extra five minutes of early arrival time at work to drink coffee and to tell everyone what a model employee I am. So if I would have cleaned it up I would have taken the risk of not being such a model employee. So you see, leaving the cat puke for my lovely, beautiful, and remarkably intelligent fiancé (who will probably read this, btw) to clean up was not something that I did because I’m lazy. It was something I did so I could continue to bring home the bacon for my family in the most productive manor possible.

That’s what I thought anyway, until I came home late that night after a hard day’s 10 hour shift off of a hard fought 24 hour shift spent saving lives and alleviating the suffering of the sick and injured and stepped in the same pile of cat puke on my carpet that I had courageously not cleaned up the morning before. True, she had put in a paltry 12 hour shift at the fire department practicing for the recliner racing 500 and had fed, bathed, and put our son to bed; but that didn’t stop my obviously well-earned righteous indignation to the pile of cat puke permeating my pile covered floor. She had decided (although she swears that she did not in fact see the pile of puke) that I should be the one to clean up the cat puke using some amount of flimsy logic that I have yet to understand.

So, to tie the above 646 words back into the title of the piece, “Cat Puke Chicken” is not the new special at your local Chinese Restaurant. It is the battle of wills that solidified between my fiancé and I as soon as my sock made contact with partially digested Kitty Kibble. We both subconsciously agreed to ignore the cat puke for as long as we could stand it in order to have the other person clean it up first. (See also: “Laundry Chicken”, “Last Sip of Milk in the Carton Chicken”, and “Couples’ Counseling”). This occurs a lot, unfortunately, in most relationships between other perfectly rational human beings. We know that we don’t like having cat puke on our carpeting; we obviously know that the cat puke should be cleaned up at the first available opportunity; and we also have continued doing the other things that we normally do to keep our houses from turning into slovenly hovels. In fact, while this has been going on I have cleaned numerous dishes, laundered, dried, and folded at least four loads of laundry, and have started (but not finished) three household improvement projects. I’m at least as good as a housekeeper as the next guy (Read: Not a good housekeeper) and I do indeed do my best to keep my family and myself from living in squalor.

So why, as two perfectly rational adults who um, chose to work in EMS, are we locked into this powerful battle of powerful wills? In a word: “politics”. Not the kind of politics that provide the revenue stream for the myriad of cable news networks, but the politics of household supremacy that truly affect our day to day lives. This isn’t Senator So-and-So bloviating about the fact that pork in the stimulus bill is in fact, not pork… it’s me and the woman that I love and want to spend the rest of my life with deciding who shall be the designated Cat-Puke-Cleaner-Upper!! Pulse pounding stuff here.

And as with everything else, this got me thinking about politics in EMS.

Say you’re in a service way far away from anywhere where I work and you have a small volunteer squad that covers the areas that your service is not jurisdictionally bound to cover. Sure, your service would be glad to come if they called you, but somewhere back in history when the powers that be drew the political boundaries they decided that your service was not responsible to respond to the pleas for help that come from that particular geographic area. Suppose that your service just happens to be a small ALS service with two paramedic ambulances and a BLS ambulance on duty 24/7 and the other service was a BLS squad with volunteers coming from home and/or work. These volunteers are dedicated, caring individuals that want to do the best that they can for their friends and neighbors but work in a system where when a call for service comes out it takes about 20 to 25 minutes for the system to get an ambulance to the patient’s side. Say also that the service that you work for has your three ambulances and paramedics about 6 miles from their patients staffed and on duty but you can’t respond because the political system is such that you would be in trouble if you did so.

You may also relate to having that coworker in your EMS or Fire service that just isn’t up to par. They may be a basically qualified EMS provider through the state licensing body, but you still would cringe at the thought of that person responding to take care of anyone in your group of family or friends. They’re a provider that just doesn’t get it. Their care is substandard, their attitude is poor, and you can’t help but feel that the patients being “cared” for by this individual or crew aren’t getting the best medical care possible from your service. You’d want to say something, and normally would, but you’d become an outcast in your agency and would be looked down upon for blowing the whistle. Besides, even if you did the service is short handed and your management wouldn’t fix the problem anyhow because they need to staff the trucks.

Or maybe you can see that EMS in general is underfunded, underappreciated, and undereducated and you can’t shake the feeling that something has to be done to improve patient care industry-wide. You feel powerless to do so, but you’re angered every time you see a representation of bumbling ambulance drivers on TV, or see the local news completely mishandle a news story involving EMS, or especially when you look at your paltry pay check.

In all of the above cases, you’ve got cat puke on your rug and you’re hoping that somebody else is going to clean it up.

As EMS professionals, we know that there are myriad little political games that play out in each and every little jurisdiction a
cross the map. This service may not call this service for mutual aid because someone’s brother once stole a pumpkin from one of the other service member’s brother’s pumpkin patch. “Jim” may not provide good care, but you let it slide because he’s popular with the other crews. Sure, the local fire department gets a kajillion dollars more in funding than your EMS service does and runs like a tenth of the calls that you do, but that’s just the way it’s always been, right?

We need to step up as a profession and clean the cat puke from our carpet. Ignore the politics. Ignore the personal hurt feelings and the power plays. EMS is about the patient. It isn’t about you, or me, or that person down there. We exist solely to save lives and alleviate suffering in the people that we serve in the best possible way that we can. Nothing else matters more than that. So if you can see that cat puke on your rug, and I’m absolutely positive that you know exactly what I’m talking about no matter where you are, you probably have better things to do than be playing chicken. We all need to stand up and say that we are the Cat-Puke-Cleaner-Uppers and that quality EMS is our responsibility, no matter what little political games of chicken are going on. Our patients deserve nothing less.

(Fiance’s note: As of press time, the pile of cat puke on Chris’s floor is still intact solidifying into the fibers of the carpet)

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Posted by Ckemtp on January 22, 2010 • Filed under: Administration & Leadership, Ambulance, Command & Leadership, EMS, EMS Humor, EMS Management, EMS Topics, EMS ethics, EMT, Emergency Medical Services, Ethics, Fire Rescue Topics, Fire department, Firefighter, Paramedic, ambulance humor, cat puke, edemse, everyday ems ethics, politics, relationships

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

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Did I do good?

The Chronicles of EMS, if you’re living under a rock and you haven’t heard, is a cooperative effort between the Great Filmmaker Thaddeus Setla (EMSmedia.tv), the Remarkably Strong Paramedic Mark Glencourse (Medic999), and the “Ruggedly Handsome” firefighter/paramedic Justin Schorr (The Happy Medic). Their cooperative venture has taught me things that I’ve put to use in my own EMS practice that I believe have improved my care. Mark showed me the UK’s “Front Loaded” model and Justin has been talking about EMS providers being a gatekeeper to the emergency healthcare system. It’s a powerful collaboration. (Be sure to follow #CoEMS on twitter and become a fan of Chronicles of EMS on Facebook as well)

So here’s an example of what I mean. I can talk about this now because it’s been long enough that I can sufficiently muddle any possible trace back to the patient and fulfill any patient confidentiality concerns. I work in two very diverse service areas and cover approximately 35 different skilled nursing facilities at any one time. So in the time since the Chronicles of EMS has come out I’ve transported umpteen-hundred patients from those facilities and the patient I’m writing about could be any of those umpteen hundred. So there’s no way to violate confidentiality, Mmmm ‘Kay?

Anyway, some time ago I was dispatched as the ALS response to backup a BLS ambulance for the “unresponsive” patient at a skilled nursing facility. I arrived a few seconds after the ambulance did and carried my drug bag and EKG/Defib into the facility with the ambulance crew following close behind with their jump kit, the cot, and a backboard. After a few seconds in the facility, a staff member directed me to the Physical Therapy area of the facility which was a bit of a walk. When I got there, I saw three other staff members huddled around an elderly female patient who was seated in a reclining chair.

The staff members were fairly excited about the situation, as was the patient, who was very much conscious and alert. The story everyone told me at once was that the patient had finished her physical therapy session on her upper body to strengthen her shoulders and had been sat in the chair by the PT Assistant to rest. After a few minutes, the PT asst. came to check on the patient and found her unresponsive to verbal stimuli, by which I mean that the patient would not awake when spoken to. The PT asst. called the facility’s emergency response team and another staff member activated 911. When one of the nurses arrived, the patient awoke to a sternal rub and was quite surprised to be the subject of so much attention. She had been fully alert and cognitive since that time and when I asked her she denied any chief complaint other than being understandably emotional about the situation.

As I do with every patient after I rule out any immediate life threats I moved into a more detailed assessment. My lady here had skin that was Pink, Warm, and dry. Her pupils were PERRL and her Cincinatti Pre-hospital stroke scale was negative. Her Lungs were clear, her abdomen was soft and non-tender with normoactive bowel sounds, and her extremities were warm and had good pulses, motor, and sensation. Her blood glucose was well within limits, and so were all of her vital signs. All of my other assessment findings were not indicative of any acute abnormalities other than a complaint of slight shoulder pain and weakness which could have been indicative of either an acute MI or of a rigorous PT session. So, to be even more thorough, I hooked her up to my 5-lead EKG which showed normal sinus rhythm with some peaked T-waves. I then ran a 12-lead EKG which was admittedly probably better than mine is.

I asked the nurse “Has she had a potassium level drawn recently?” She looked through the patient’s chart and found out that the patient in fact had been tested for that two days prior and had been found to have a slightly elevated serum potassium level. Since they had been active witnesses to my assessment we agreed that other than for perhaps a bit too much potassium there was little chance of anything being wrong with the patient.

Since we were here in the US and not in the UK like Mark, where he can treat and release (or “Respond, not Convey”) I asked the patient if she wanted us to take her to the hospital. She didn’t want to go and said that she just wanted to go back to bed. When the staff members weren’t completely convinced that we shouldn’t transport her, I suggested that they call the patient’s primary care physician to ask him what his wishes were. The nurse did so, and called from her cell phone in front of us. She did a good job of explaining in detail the events of the call and our collective assessment findings, I provided my interpretation of the 12-lead EKG and chimed in with my assessment findings that I use in my acute care practice.

For his part, the doctor was amenable to treating the patient at the facility and stated that he was comfortable with us not transporting the patient. He ordered a few stat labs and requested that we leave a copy of the 12-lead for the patient’s chart, which I was happy to do. Bottom line: The patient signed a refusal and was happy not to have to go to the hospital; The skilled-nursing-facility staff members were happy that the patient was in no immediate danger; and I was happy that we had made the best possible decision for the patient and that I wasn’t exposing her to unnecessary risk.

What happened here is exactly one of the things that I and others have been talking about with the EMS 2.0 movement: EMS people having the ability to make an educated and sound decision about the best possible healthcare options for our patients and not simply having to activate the full emergency healthcare system for every complaint. This case had every element of that and I believe that the patient being redirected through her normal primary healthcare pathway was a much better choice than taking her to the emergency room.

Heck, since there turned out to be no adverse results to this, and since the patient was probably on Medicare, I would surmise that I’ve ended up saving the taxpayers thousands of dollars in unneccesary costs… Huh? Can educating and empowering paramedics “save” the healthcare system in the US by creating a huge savings in the most expensive form of providing healthcare?

What do you think? Did I do good?

QGE5GE5AAH4W

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Posted by Ckemtp on January 21, 2010 • Filed under: EKG, EMS, EMS Topics, EMS ethics, Emergency Medical Services, Ethics, Patient Management, Skilled Nursing Facility, US economy, change, edemse, ems 2.0, ems education, everyday ems ethics, medical ethics, new perspective, patient care, physician, politics, potential

“CPR Theatre” – Pediatric Deaths, resuscitations, and futility

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This post is a cooperative joint topic with two widely respected EMS bloggers, Steve Whitehead from Http://www.TheEMTspot.com and Greg Friese, from Http://www.EveryDayEMStips.com – Our topic is supposed to be on why it is that EMTs, Paramedics, and other healthcare providers will sometimes “go through the motions” and continue on with futile resuscitations with pediatric cardiac arrest victims. I’m sure that they will have very insightful posts on the topic, as they always do. Here’s my take.

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Can someone say “emotionally charged”?

One of the truths about where I’m sitting right now is that I’m chained to a lot of potential responsibility. Today, like a lot of days I’m one of two paramedics on-duty in my service area and the next call is mine. No matter what the next call is, it is my responsibility to get up and answer that call… without regard the horror that fate may be sending me to bear witness to and intervene in. All medics have to accept this inherent part of the job. One of the worst of those possibilities is that it may be a call that involves the significant injury or illness to, or even the death of a child.

Mention the possibility of a child’s death to even the most cynical and seasoned of healthcare providers and you will send a very cold chill down their spine. It’s just horrible. For me, the blessedly rare times that I’ve lost a child have been sentinel events in my life, things that are often thought of but rarely spoken of… almost always spoken of only to comfort the pain of a colleague experiencing the same thing. The loss or suffering of a child just burns into our souls and leaves an indelible scar that only someone who has experienced it can have true empathy for.

And I for one, wish that I didn’t have the empathy that I have for it.

Heaven forbid that I ever have to be one of the parents with pleading eyes at one of those tragic and traumatic scenes. I just can’t imagine what they go through when I’ve said “I’m Sorry”. I can’t imagine their pain, and frankly I don’t want to. As a parent myself the thought is blocked from my conscious mind and relegated only to the deepest recesses of my subconscious fears. Losing an adult patient is one thing, as we humans come to know that our lives are fragile and that our price of admission is to be removed from this existence. It’s a knowledge that we get as we progress through life and gain the experiences, both good and bad, that make us who we are and will become. However, the terrible thought that one could be ripped from us in their age of innocence is an affront to everything that almost everyone holds dear… and it’s more than a lot of us can bear to make the last decision of a child’s life. Instead, we try. We try hard and we keep trying. We hold out hope against thought and fight on, sometimes against futility.

But in my mind, I think I know why it is… because no healthcare person wants to be the person who looks into those pleading eyes and says “I’m sorry”. That decision takes an enormous emotional toll upon the parents and family, of course… but also upon the EMT or Paramedic. It’s ultimately easier on us as EMS people, we reason, to fight on. To race headlong into futility and hold out hope that someone else won’t have to say “I’m sorry”. At least we won’t have to.

There are probably psychological studies out there that I haven’t read that deal with the issue of whether “CPR Theatre” is harmful or helpful to the long-term well being of the surviving family. These studies are probably well-researched. I took a class once that told me that it was better for family members to be in the resuscitation room inside of a hospital to witness the events as healthcare people try to save their loved ones… and I can understand that I guess. Perhaps it is better to witness that “everything possible was done” for your departed loved one. I don’t know.

As healthcare providers, it is our sworn duty to alleviate suffering as best we can using the tools at our disposal. I, like most of my colleagues, realize that the secondary and tertiary patients that we treat are the family members and their grief reactions to the tragic circumstances that resulted in their calling us. I am reasonably comfortable handling their grief reactions and sadness when an adult passes on scene but I am humbly inadequate to be of much comfort to a parent that has just lost their child no matter how I might try.

My guess that futile CPR theatre can be explained as being more for the parents and families of departed children than it is for the slight chance that we might have missed something. We make the effort in the name of showing to the family members that “everything possible” was indeed done, up to and including running their child lights and sirens to a hospital. I’ll even admit that in the back of the ambulance while I’ve done this, I’ve prayed right along with the family that just perhaps this once we would have a miracle. Never once has it happened.

Here’s a mea culpa for you, even though every time I’ve gone through the motions I’ve said it was for the family… It may really have been for my own benefit as I’ve stated it could be above. I am a paramedic and I’ve seen my share of pain, but I don’t think that I can look a parent in the eyes and say “I’m sorry” ever again. I just don’t want to and as I write this, I can’t imagine that I could do that and then come back and look the guy in the mirror in the eyes without wondering if maybe this time would’ve been the miracle. I am probably selfish for this practice… but is that wrong?

From a completely actuarial perspective, no futile resuscitation should be performed due to safety concerns and the unnecessary costs involved. I agree that with adults, transporting cardiac arrest victims is probably deadly. I also understand that no ambulance should risk a lights-and-sirens trip to transport a body to the emergency room. However, I am not an actuary. In those cases I’m a witness to horrible emotional pain and I want someone else to be the one who says “I’m sorry”. It’s human nature, perhaps.

In my career, I have told parents “I’m sorry, there’s nothing I can do” in cases where it was blatantly obvious that the child was long beyond hope of any intervention. I’ve done it more than once and I can see the places where I’ve done it in my mind to this day. Sometimes it’s completely obvious that there is indeed nothing that anyone can do. However, occasionally I have indeed known this and just done it anyway. Perhaps it’s completely subjective. Perhaps it was my level of experience and intuition that guided me at the times I’ve made the decision. I’ll tell you this, it certainly wasn’t a decision made from the pages of a textbook.

I don’t have the answers to this. But I do want to go home and hug my kid. My only advice to the EMS people out there is to realize that we’re all human, and that all you have to do is your best. Be compassionate, and use your best judgment. For that’s all we can ever do.

For more on this powerful topic for EMS, head over to Greg Friese’s page and also to Steve Whitehead’s page. You also may want to read “Splashed Sadness – A look at Negative Emotions in EMS” where I further explore the sad side of EMS and our reactions to it.

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Posted by Ckemtp on January 5, 2010 • Filed under: Ambulance, EMS, EMS Blog, EMS Health & Safety, EMS Topics, EMS ethics, EMT, Emergency Medical Services, Ethics, Fire Rescue Topics, Paramedic, Patient Management, The EMT Spot, Training & Development, bad calls, cpr, emotions, everyday ems ethics, inside the mind of a paramedic, medical ethics, patient care, psychology, sadness

Everyday EMS Ethics – Thoughts on Ethical Behavior in EMS

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Everyday EMS Ethics? Where do I get my authority to talk about anything ethical? I’m definitely not a perfect person. I’ve made some decisions that I’m not proud of in this life, I’m human, and I’m certainly not immune to the mud that life can sling on a person. How then can I talk about ethics with a straight face, knowing that I’ve made some of the very mistakes that I seem to be condemning?

It’s because that just like everyone else, I have the ability to feel good or bad about anything that happens to me and anyone else, I have the ability to introspect and wonder why my gut feels the way it does about something, I also have the ability to want to be a better, more ethical person. As silly as it seems in this world sometimes, striving to be a better person on this journey we call life is what we all must do as we edge closer to “Point B” in our path.

The omnipresent “they” have always told me that “Being a good person means doing the right thing even when nobody’s looking” and I like that phrase. If a lot more people took that view, I think that the world could improve overnight. Imagine if everyone did the “right” thing all the time? We’d have no crime, no “half-assed” jobs, and everyone would get along, right?

Well no, probably not. Of course things would improve and crime would cut down, but since two perfectly ethical people can have logical disagreements on the same issue, we’d still have discord and differences of opinion. We’re all still human and human beings have different thoughts, feelings, emotions, and standards of right and wrong. Therefore, when one throws out the term “Ethics” it seems to draw a lot of shrugs from people who aren’t looking for the conflict it can generate, or who simply aren’t looking to put forth the effort to debate their positions effectively.

Grey areas abound in any discussion involving ethics, but I think that it can be simplified. Even in an area where lives are literally on the line such as in EMS or other healthcare disciplines, the realm of ethics can be summed up in the above phrase about doing the right thing when nobody’s looking and with the application of the Golden Rule, the one about doing unto others as you would have others do unto you.

Of course, that’s not always easy as it sounds, is it? People are motivated by different things and behaving ethically in one situation may justify behavior that may be considered unethical in another. For example, take the case where a family’s breadwinner has to make more income to feed his/her family at home and that need justifies taking more overtime at work than would normally be considered his/her “share” of the OT and the extra income that it brings. The breadwinner’s coworkers may consider the person to be an “overtime hog” and may think that he/she is behaving unethically whereas the breadwinner may feel that the need to feed his family with the extra OT income justifies his taking more OT than is his/her share. Who would be “right” here? If everyone had a family at home that they were supporting with the extra income from the OT, it wouldn’t be ethical for that one person to take more than their proper percentage of the OT… but would it be right if everyone else was a single person with no families to support? Who would decide that?

We have to be unafraid to discuss the grey areas and tailor solutions to fit the unique situations we face. Discussion among rational adults can help guide the actions of the group towards a more ethical and equitable organization, which makes everyone happier in the end. Some organizations discourage this, and instead make overarching rules that discourage the rational adults within those organizations from free thought that would benefit the overall operations, and some are too lax and instead encourage unethical behavior by never sanctioning those who engage in it.

On political topics, I’ve always liked the words of a country song that state “You’ve got to stand for something or you’ll fall for anything” meaning that a person has got to have a set of values and beliefs based upon their own moral compass and introspection in order to guide their decision making when faced with an overwhelming amount of information. And we’re all overwhelmed. I firmly believe that human beings can only process so much information and that there is no possible way for any human being to be well-enough informed on every issue to form a truly solid and rational opinion. Therefore, when we hear something, if we judge it based upon our foundation of core beliefs, we have a way to gauge how we feel about it. For example, I’ll bet that if any, only a small percentage of the people who read this post have ever studied the effects of globalization on the food supply in Micronesia. Sure, we could research the issue, but our core beliefs most probably would tell us that anything that decreases affordable food for the majority of the population is bad. My guess is that this opinion on the issue is perfectly fine and I don’t have the time to put in the requisite study to find out otherwise. This can be applied to EMS almost daily. I believe that a thorough assessment and judicious application of treatment modalities benefits the highest number of patients. I believe that any amount of study time that I put in learning about pathophysiology enables me to better assess my patients and judiciously apply treatment to them. Therefore, I can ethically and logically assume that putting in one hour of study time per day on pathophysiology is a good thing.

Of course, if there were to be a study that came out unequivocally showing that 45 minutes per day is the optimal number and that one hour actually causes degradation in knowledge through um, brain fatigue or something, then my opinion would be wrong… but nobody has studied this topic with enough depth to be sure of that.

Here’s what it comes down to for little ole imperfect me: “Shower Guilt”. I usually say that when I make decisions it’s because I have to look myself in the mirror and shave every morning but that’s honestly not where it gets me. My conscience rears its head during my morning shower. If I’ve done something that I don’t feel deep-down is ethical, my “Shower Guilt” kicks in and I beat myself up for it. I usually can tell how I’m doing by how rough my showers are. It’s been that way for years for me and I’m thankful for it. The introspective time has made me a better, more rounded person.

I guess what I’m saying with this post, and with my whole Everyday EMS Ethics series is that ethical issues must be discussed in a positive, adult manner for progress to be made. When people look at problems or violations in ethical standards in a rational and objective manner, solutions come out that go beyond heavy-handed rule spewing and approach the realm of positive resolution and healthy growth. By maintaining an open dialogue, others participating and observing the dialogue can glean lessons that will allow them to make more ethical decisions in their own lives and professional situations. Ethical behavior encourages others to behave ethically. Discussing the ethical standards of a group in a positive and uplifting manner makes people within the group feel good about doing the “right” thing.

Paramedics and EMTs face heavy ethical questions in our day to day work. It’s in our job description.

What does your organization do to encourage ethical behavior?

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Posted by Ckemtp on December 2, 2009 • Filed under: Administration & Leadership, Command & Leadership, EMS, EMS Topics, EMS ethics, Emergency Medical Services, Ethics, Fire Rescue Topics, Paramedic, Training & Development, edemse, everyday ems ethics, medical ethics, professionalism

Everyday EMS Ethics – Social Media and “Smart” phones?

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Today I finally joined The Future™ and got up to speed with the latest technology 2006 has to offer by purchasing myself a shiny new BlackBerry Curve™ “Smart” phone. This thing is SO COOL! I can access my tweets, my facey page, and all of my other online stuff right through it AT ALL TIMES. It’s not an overload, really… I like carrying on 14 conversations at once… at all times. Really I do.

This new addition to my arsenal of cool tech gadgets got me thinking about a story I heard somewhere about a young firefighter/EMT that ran into a bit of trouble with one of these things. Incidentally, this story could have come from any public safety agency anywhere these days, so you probably don’t know whom I’m speaking of here, but if you think you do then go kick that person in the butt for me.

Anyway, this young firefighter/EMT was a full-fledged, “smart” phone carryin’ member of The Future™. Like any good young member, he was fully invested in Social Media. This firefighter/EMT responded to an incident scene and thought that a picture of the incident would make excellent fodder to post on one of the social media sites that he participated in. So, he snapped the picture with his “smart” phone and immediately posted it on the social media site. Appended to the photo he put what undoubtedly was an especially witty and thoughtful comment related to the person(s) who caused the incident.

Thus ensued “all hell” being brought down upon this young firefighter/EMT by the upper echelons of his fire department. Turns out that the Chief, the Assistant Chief, and a number of his coworkers were “friends” of this young firefighter/EMT and were immediately notified of what he’d posted on the social media site. They were not amused in the least and did not find the humor in the especially witty comment that he’d posted with the picture.

I agree with the Chief on this one. Let me be the first one to expound upon the virtues of social media in EMS and Fire. The fact that you’re here reading this is a testament to its potential to positively influence our profession and our interactions with the public and each other. However, its potential to tarnish our image if used irresponsibly is there as well. This case was an example of that.

I never did get a chance to see the picture, but from what I heard of the case the picture did not involve any personally identifiable information. Locals could have seen the picture and identified it, so could those involved of course, but it didn’t violate any laws that I know of.

What it did violate, are the ethical standards in which we operate under. Public safety people respond to incident scenes where we see things not meant for public viewing every day. We’re all familiar, I hope, with HIPAA and the various other privacy laws that we operate under, but we also need to be aware of the ethical standards that guide our interactions with private information.

When I got into this business, the metaphor that we used was “The Coffee Shop”. We were told to keep our shop talk behind closed doors within the service, and not go down to the local coffee shop where people could hear us talk. In the small town I lived in, everybody knew everybody and everybody had a scanner. Even if one of our guys was talking about “This Person” who had had some type of medical condition or had injured themselves in a spectacular way, everyone would know whom he was speaking of. Thusly, we didn’t go talking about what we saw out in the public. It wasn’t a legally mandated standard, it was an ethical standard of behavior that allowed the public to trust us and feel comfortable calling us in their hour of need. People won’t call us when they need us if they fear public embarrassment. Most people, that is.

Nowadays, it’s gotten complicated. With social media sites more popular than ever and showing no signs of slowing down, the impulse for some of our ranks to post information of an ethically non-public nature up there on the interwebz can be irresistible. With my “smart” phone in my pocket at all times, I have an express lane to career ruin right there at my fingertips. All I have to do is act irresponsibly one time with a photo, comment, or post and my career is finished.
And I remember and respect that.

Professionally Ethical behavior requires that we separate our professional lives from our personal ones. While it would have been no big deal for Joe-Public-Came-Across-An-Accident-Scene to snap a quick pic and send it off, it is a huge deal for a Professional Rescuer to do the same. We were called to the scene to help the people involved. Professional Ethics mandate we leave our personal feelings and personal lives at the station. If the public gets the perception that their personal business is going to be splashed across the interwebz by one of the people who came to help them, then I’ll bet that the public is going to be mad at that.

Just remember, folks. Friends and families of public safety people have always been interested in what we do out there. They always will be. With today’s ultra access into our personal lives that social media can bring, it’s easy for youngins to get carried away and violate the ethical standards on spreading private information. There’s a rule for this and technology hasn’t changed that rule. You don’t use your position of public trust to gain access to and spread private information.

Just don’t do it. Resist the urge and keep your career, and honor, intact.

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Posted by Ckemtp on December 1, 2009 • Filed under: Administration & Leadership, EMS, EMS Topics, EMS ethics, Emergency Medical Services, Ethics, Fire Rescue Topics, Fire department, Firefighter, PR, Technology & Communications, edemse, everyday ems ethics, medical ethics, professionalism, technology-communications-ems-topics, whattaya do

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>

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

The Drunk Responder

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Greg Friese, over at Everday EMS Tips, has written a post in observance of Drug Free Work Week – Oct 19-25th, 2009 entitled “When a Coworker is Intoxicated” In it, he asks what we would do as EMS professionals and Firefighters in cases where we suspect that a coworker is under the influence. This originally started as a comment to his post, but it went long enough that I thought I could get a post out of it. Here it is:

Ewww, I hate these situations. I’ve worked full-time EMS for a long time, but I’ve volunteered for longer than that. One would think that this is a problem that I’ve encountered more often in the volunteer services, however I’d have to say that the few times I’ve actually noticed it are about equally distributed.

Thankfully, these situations have been few and far between. However, EMS and Fire people like to drink sometimes (ahem) and the potential exists for this to happen more often than you’d think.

In a volunteer service, the classic example is someone showing up for an emergency call after consuming alcohol. Often, these people sincerely did not want to “show up drunk” but thought that the need was great enough for them to show up after having “Just one or two”.

For the paid services, aside from the absolute taboo of consuming alcohol while on duty, the classic example would be spending a late night out at the bar and then showing up for work in too short of a time for the alcohol to be removed from the person’s system. If you’ve ever had a coworker show up complaining of a hangover, this may indeed be the case.

Both are unacceptable. Personally, I know that my career depends on never doing this. I also know that my patients deserve a caregiver who is on top of his (or her) game. I subscribe to the FAA’s rule governing pilots, or the “8 hour from Bottle to Throttle” rule. I take myself out of the response roster for at least 8 hours if I have had one sip of ETOH and I stop drinking a minimum of 8 hours before having to go on duty.

There’s no excuse for a provider having any amount of alcohol on board while performing any aspect of EMS. If the patient smells even a whiff of ETOH on their provider, that provider is drunk until proven otherwise. Even if the provider is under the legal limit the patient loses confidence. Our patients deserve better. If you had EMS come for a family member and smelled alcohol on the responding ambulance crew, you’d think the same thing and would probably become very angry or fearful for the actions of the responding crew.

Remember, each “drink” defined as one ounce of alcohol, raises your BAC (Blood Alcohol Content) by roughly 0.02%. That amount of alcohol takes approximately one hour to be removed from your system by your liver. Each person is different, and other factors come into play… however if you’ve been drinking you need to leave hours between your personal fun and your professional care.

The problem here, of course, is the percieved effect on the person who reports a coworker for possibly being under the influence. In some agencies there may be fear on the part of the coworker who notices the smell of ETOH or other intoxicant that they will be ostracized by the group for blowing the whistle and turning the offender in. In reality, it is your duty to your future patients and the reputation of your agency to turn someone in no matter the percieved ill effects. However, to make this easier I have some tips:

Act immediately – If this person gets activated for a call or otherwise interacts with a patient, they could cause that patient harm. This is unacceptable.
Enlist the aid of a coworker if you’re uncomfortable immediately going to a supervisor – Get someone else to nonchalantly speak to the person or linger in their vicinity to see if they notice what you do. Go together to report the suspicions even if the other person doesn’t notice what you do. It’s that important.
Remember that someone’s life may very well depend on your actions – Friendship among coworkers is one thing, but a drunk firefighter or EMS provider may very well kill someone. You or another coworker may be injured or killed by their actions on the fireground or emergency scene. Your patients may suffer at their hands because their decision making ability and reaction times are impaired. Can you stand that on your hands for not reporting it?
You may be helping the person through a real problem – Is the coworker an alcoholic? Could they be? Being at work drunk, especially in such an important job as EMS and firefighting is indicative of a real problem with alcohol. Turning them in may be the first, and biggest influence in getting that person help or in allowing them to help themselves.

This is a tough situation, but is an easy call. Keep alcohol and other drugs out of the emergency services. Keep yourself sober and sharp while on-duty or responding. It’s just not worth losing everything over a couple of beers. Have your fun and enjoy yourself while off duty but remember, alcohol can be a wonderful servant but is a terrible master. Do yourself, your career, and your patients a favor and leave ETOH in your personal life, far away from your station.

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Posted by Ckemtp on October 22, 2009 • Filed under: Administration & Leadership, Command & Leadership, EMS, EMS Health & Safety, EMS Topics, EMS ethics, EMS safety, Emergency Medical Services, Ethics, Fire Rescue Topics, Firefighter Safety & Health, edemse, everyday ems ethics, medical ethics, professionalism, safety

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What do you think?

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

Soapy Demons – Ckemtp is a geek

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Washing Machine Sta 1 Ok, so this post really proves just how much of a geek I really am. Just bear with me for a bit.

This subject causes me a lot of personal grief. I know that it probably shouldn’t and that I am indeed a geek for worrying about this issue because seemingly no one else does, however this issue has plagued me for years and I need to get it off of my chest.

This is about the washing machine at the main fire station where I work. I’m at this station a lot, whether I’m working one of my three weekly scheduled paid shifts, hanging around with my wife who works there three scheduled paid shifts as well, or volunteering my time for call response, training, or work projects. So I have the opportunity to use this particular large, commercial, washing machine quite a bit.

It’s a nice machine. It handles the huge loads that we generate on a daily and nightly basis. It cleans the stuff pretty well and runs pretty quickly and quietly.

The problem is, the soap. It does not rinse the soap out of the clothes, bed sheets, blankets, turnout gear, or anything else that we put in there. The “rinse” water is always white with suds and everything comes out soapier than when we put it in there.

I am well aware that this is not a sexy problem. It’s not a big issue and castles will not fall because of it. It just drives me nuts.

When it comes to be my time to use the machine, I run two full cycles at a minimum to rinse out the machine. The third cycle usually has at least some soap in the water but I use it anyway because all of the residual soap that is left in the stuff that we constantly wash in there. The stuff is full of soap! Our sheets, our towels, our turnout gear… everything. After you run a load in there, even after a second full cycle, the water is white with suds on the final rinse phase.

For a few years, I begged, pleaded, cajoled, and bargained to get people to use less soap in the machine. I tried to get the purchasing division to get us a different type of soap that might rinse cleaner. I even went so far as to post up a few memos in the washing room and write a couple of written requests to the purchasing division and the officer above them.

Predictably, nobody cared those times and still nobody cares about the issue now. Everybody still dumps the same big glob of soap into the machine when they start it and then promptly forgets about it. Whomever comes in and removes the stuff from the washer just puts the stuff right in the dryer, still soapy as all get out, and throws another load in the washer. Then, they dump a big glob of soap in the machine and the cycle perpetuates. Honestly, it’s a losing battle for me and I know that I’m the only geek who cares out of the 100 other people on the department. Nowadays I’ve resorted to trying not to care about it so much and also by surreptitiously watering down the soap that we use. I’ve been doing that for years and nobody seems to ever have noticed (until they read this). It helps a bit, but still our stuff is soapy as heck.

Am I crazy? Probably, but consider this: This small issue is hurting my department and the way we function. Really. We spend hours per week cleaning and polishing our apparatus. To do that, we need towels. Lots of them. Now that they’re all full of soap, they don’t soak up water anymore and we have to constantly replace them with new towels that promptly get full of soap and don’t absorb water and leave our trucks streaked with laundry soap and water spots. Then, we replace the towels again and the cycle perpetuates. How much money do we spend on new towels?

Consider this also: Our guys sleep on linens that get washed every day after they’re used. These linens are full of soap and are against our guys’ skin every night. What happens when one of them develops an allergy? Occasionally, some of this linen goes for use on an ambulance… when will we get a patient with an allergy to our soap?

Consider this as well: How much does it degrade our turnout gear to be full of regular laundry soap? Sure, we bought the expensive specialized turnout gear cleaner, but it doesn’t matter because the water we’re using to wash the gear is full of the soap from everything else? Does that degrade our protection? How much are we harming our very expensive protective clothing by filling it with soap? When will the gear fail and someone get burned because of this? Will it happen? When someone gets burned will it be my fault because I didn’t try hard enough to fix an issue that I saw?

Yes, I’m a geek for caring about this issue so much. I feel like an OCD Chicken Little. However, this small, nothing issue is costing the department money overall and could get someone hurt out there on the fireground. After that, I’m sure people will wonder how this could have been prevented. I’m sure also that they’re looking for ways to cut costs now that the economy tanked and tax revenues are down.

And there sits the washing machine, quietly driving me crazy.

How many issues out there do people know about like this? Issues that are small enough so that nobody else cares but that snowball into big problems for the organizations. How many of these issues affect EMS and the fire service industry-wide. How many of them affect everything?

One day I’ll conquer my soapy demon. For now, I have to keep watering down the soap in secret… but as crazy as it seems, I feel that I’m making some small difference. You can too. Be it the way your equipment is checked in the morning, the way you package your lifesaving gear, the way you make sure that the gas tank is full, or the way you do whatever it is you do to make your service the best it can be.

Now get out there and water down your soap. You might just save a life.

Care to Share My Stuff?? C'mon, Go ahead.

Posted by Ckemtp on October 10, 2009 • Filed under: EMS, EMS ethics, EMS safety, EMT, Emergency Medical Services, Ethics, Fire department, Firefighter, Paramedic, edemse, ems 2.0, everyday ems ethics, fire, new perspective, pride, professionalism, soap

Everyday Ethics for EMS Providers

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Mike left a comment on the last post I wrote “EMS Politics, Medical Ethics, and… What would you do?” with a good quote that I’d like to bring the forefront of discussion: “Your next call could be your last call”.

That sentence sums up something that I’ve always said about EMS quite nicely. Bravo to you and your old partner, Mike.

I firmly believe that EMS professionals face “No Win” scenarios several times in their careers. There are things that come up and situations we face that would test the most knowledgeable medical ethicist. Often times we have to make terrifyingly difficult split second decisions using woefully inadequate information that will not only affect the very life of a patient but also our careers and our livelihoods. It’s not fair, and it’s not fun. Paramedics are entrusted with huge responsibility for clinical judgment but can be quickly chastised and sanctioned for even stepping a little bit outside of the box. No, we’re not physicians and No, we’re not licensed to perform everything that a patient may need. I understand that there are some things that are just too dangerous to do in the field, and that yes, patients sometimes die in front of us and we are powerless to stop it.

However, in the scenario presented in the abovementioned post, that was not the case. In the case presented, the patient needed a surgical cricothyrotomy and needed it NOW. The paramedic described in the scenario had been trained in the procedure, had the tools available to him to perform the procedure, and the patient was going to die quickly without the procedure. The catch was that the protocol system he was working in did not allow him to perform the procedure.

The scenario gives two choices:

Don’t perform the cric. Use your full airway bag o’ tricks such as first trying BLS techniques (Heimlich Maneuver, abdominal thrusts) attempting to remove the object with Magill forceps under direct laryngoscopy, attempting to intubate the patient with an ET tube and push the blockage into the right main stem bronchus with the tube allowing the left lung to be ventilated (It’s better than nothing), and scooping the patient up and running really fast to the hospital. If all that takes more than 5 minutes from the time the airway got blocked, including the time from incident to the 911 call, the dispatch time, and your travel time, expect brain damage at the very least. If it’s much longer than that, expect the patient to die.
Perform the cric. You’ve got the knowledge, you’ve been trained on the procedure, and you have the equipment available to perform the procedure. The procedure is in the standard scope of practice for paramedics all across the country. Unfortunately, even if the patient makes a full recovery, you’re in deep trouble. The Medical Director in the scenario has not authorized the procedure for paramedics under his/her direction and therefore you’re practicing medicine without a license which is a violation of the letter of the law. It may very well be the only thing that will save the patient’s life, but you’re likely to face severe penalties for violating your protocols.

So what do you do?

I firmly believe that medical direction should not hold paramedics back and that there has to be some leeway in the standard operating procedures that paramedics function under to allow for these situations. Every protocol system and EMS service that disallows such procedures that are allowed under national accepted scope of practice can have situations where patients have poor outcomes up to and including death. In these systems, the EMS provider bears the brunt of the negative result. If he allows the patient to die, it could be argued that he withheld lifesaving care and violated a duty to act. If he was protected legally by the letter of his protocols and the fact that he followed them, he at least could be committing a moral and ethical violation that will haunt him for the rest of his life. I would suspect that the medical director and/or the authorizing body would not be sanctioned in this case… if they were even aware of it. By performing the procedure and saving the patient, the paramedic will be punished quite severely. Even if the patient survives but has residual morbidity resulting from the prolonged anoxia, the medic could be sued for and be held liable for the damages.

In any case, the paramedic carries the burden. It’s a no-win situation.

For the record, I didn’t actually have this happen to me, but I have worked in two systems simultaneously where one is more progressive than the other. In fact, I do right now. Fortunately, both of these systems allow surgical cricothyrotomies, but they carry different medications and have different dosages. One of my services uses CCR (Cardiocerebral Resuscitation – http://www.callandpump.org/) and the other follows an older version of the AHA guidelines. While both are acceptable and I follow the protocols for the system that I am working at when I am working there, I can see the potential for ethical conflict. I’ve been a full-time paramedic for a long time and I’ve flexed the rules occasionally when it was in the best interest of the patient. Luckily (and yes, I know I’ve been lucky) the patient has always had a good outcome when I’ve had to do this.

Here are my rules for “bending” the rules:

Above all, always act in the best interest of the patient – If you can show that you acted in the best interest of the patient, disregarding any other potential motives, you’re well on your way to vindication. However, remember that ‘rule bending’ must be for the patient’s best interest, not your own. Something like not placing the shoulder straps on the patient during transport because it makes it more comfortable to care for them is in your own best interest, not necessarily in the best interest of the patient. Taking a patient to a hospital closest to your next errand and not to the most medically appropriate is also in your best interest and not in the patient’s. The cric scenario regards whether the patient will live or die at great peril to the paramedic.
Know what your protocols are and why they are the way they are – Knowing your protocols inside and out is essential to being a good professional provider. Knowing WHY they are the way they are, i.e. the reasoning behind them is essential as well. Be able to show that you know them inside out when you’re questioned, to show that you’re not negligently ignorant of the rules you have to function under.
Be able to prove what information you had available for you to consider – In these situations, you’re working with incomplete information. However it is your professional obligation to gather as much information as possible as quickly as you can gather it. Do a thorough assessment, and talk to the patient and any bystanders, if possible. When questioned about the incident later, you need to be able to present the information that you were presented with to the people who are going to play armchair quarterback. Be able to put them inside of your shoes.
Be able to prove what options you had available to you, how you considered them, and why they did not or would not have
worked – In the previous airway control scenario, I laid out possible options that the paramedic in the scenario considered. I also laid out why they would not work as the situation unfolded. Be able to show your thought process and how you ruled out options that were within the letter of the rule book.
Be able to prove why you thought that the option you chose was absolutely necessary – If it was a “do or die” call, be able to prove it as best you can. You should be
able to show why it was necessary that you chose the option you did. In the cric scenario, transporting the patient to the hospital so that a physician could perform the procedure would most likely have resulted in the death of the patient. In that case, the best interest of the patient, obviously, would be to continue living… which he would not have done without the paramedic violating the rules. BE THAT SURE of yourself.

I would love for people to jump in and offer their takes on this topic. Please comment away. If you haven’t read the great comments on the previous post, left by such people as Medic999, HappyMedic, and TOTWTYTR you can find it here.

I use scenarios like the one that I wrote out in the previous post as a teaching tool for new EMS people and students that I precept. I think that scenario-based teaching is a great way to promote critical thinking skills and to evaluate what a person would do when faced with the situation presented. In the future, I’m going to be featuring scenarios that challenge ethical standards as a way to educate ‘Everyday EMS Ethics’. Look for the “Featured Areas” to showcase these and other interesting articles.
And thank you for reading.

Care to Share My Stuff?? C'mon, Go ahead.

Posted by Ckemtp on August 26, 2009 • Filed under: EMS ethics, EMS paramedics, Ethics, edemse, everyday ems ethics, medical ethics, scenario, whattaya do

Follow up to The Shine Factor: What makes a great Ambulance Service

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This is part 2 of a 3 part series on “The Shine Factor”

Part 1 of this series can be found here – The Shine Factor

Part 2 of this series can be found here – What Makes a Great Ambulance Service

Part 3 of this series can be found here – The Shine Factor – Grunts

——————————————————–

Perhaps I really am an EMS geek. I do EMS tourism. No, I don’t find new and interesting ways to hurt myself enough to require emergency services but when I’m travelling I usually stop in to EMS and Fire Stations along my way and go look over the service. This has been a lot of fun some times (Thanks MAST in Kansas City and Sedgwick Co. EMS in Wichita! I had a great time) and has been somewhat less fun in other areas. If you’ve ever done this, you’ve probably noticed some things like I have.

First, there are services out there that are average. They run ok equipment, they have an ok group of people working there, and they appear generally competent.

Then there are services that are not so good, the kind that leave you shaking your head at in the car when you leave after politely pretending to be impressed.

And finally, there are services that really, truly do impress you. They’ve got this stuff down to a science. Their rigs are clean, well taken care of, and in great shape. Their equipment is top of the line and well stocked, their uniforms are cool, their people are really friendly and seem more intelligent than your coworkers, and their facilities make yours look like a single-wide trailer. Heck, the place even smells like freshly squeezed awesome. These services are so much of a class act that you find yourself wondering why exactly you work where you do and aren’t working there with them.

I’ve seen these services along my path and I have noticed a few things that seem to characterize all of them. Sure, some do these things better than the others to different extents however you will find a healthy mix of these things at all of these services. I’d like to share some of these things with you.

Things I’ve found out about awesome EMS Services:

Their people are proud of the organization: You’ll find that the people who work at awesome services sincerely have pride in where they work. They’re there for a reason. They enjoy working for a service that has a good reputation in the community and the wider region. They think that their service is cool; they think that working for their service is cool; and they are respected by people from other agencies because of the position with the agency that they have. There’s a general feeling among the people that work for the service that it takes hard work and performance to earn a position within the agency. A service earns self respect the same way a person does, by having high standards and meeting their own challenges. A service that earns the respect of its people earns the respect of the wider community. Their Shine Factor is high.
Their people truly care: “Apathetic” is not an adjective you would use to describe these people. The culture that they’re in allows them to know that they make a difference in everything the service does, not only in the lives of their patients. They know that they are an important part of their service and that they would be missed if they were gone. They care about their coworkers and are as much friends as they are colleagues. There is mutual respect and a feeling that everyone there has to pull their weight in order for the service to meet its goals and thrive. Have you ever seen something wrong in a truck and haven’t spoken up because it was someone else’s fault or someone else’s job to take care of it? These people care enough not to do that.
Their community cares about and supports them: Community support is absolutely essential if an EMS agency is going to thrive. The best services have proven their worth to their communities and constantly work to prove why they need, deserve, and responsibly use the support they receive. The community supports them because they see the benefit in supporting them. You can see the community’s support in the newness and quality of their equipment and facilities as well as in the salaries that the employees are paid. You can see how responsible the service is with the support they get in how well they treat the equipment and the community in return.
The culture of the service just ‘feels good’: The culture of the organization defines the way everything runs. Bad organizational cultures breed discontent and apathy in everyone over time. Good organizational cultures breed people who feel comfortable coming to work and handing the responsibility of being an employee. People that work in a bad culture form cliques and get angry a lot. People that work in good cultures come up with ideas that get judged on their merits. People that work in bad cultures fear mistakes because of the punitive measures that will come down from on high. People that work in good cultures acknowledge their mistakes and are allowed to learn from them so that they grow as a provider and as a person. People that work in bad cultures hate coming in to work. People that work in good cultures have friends at work and feel comfortable, if not happy, with being there. I think that you can get what I’m talking about.
Their people are experts in what they do: Paramedics and EMTs are experts in Pre-Hospital medical care. They have to be, there is nobody else who could or should be. The people in awesome EMS systems have great protocols that are challenging to learn and require advanced skills to perform. Their protocols evolve with emerging science and keep on the progressive edge of medicine. The training, quality review, and quality improvement programs are tough and demanding. People take pride in being the best at what they do and earn their own self respect by doing it well. They respect themselves for their efforts and respect their coworkers for earning their respect every bit as much as they do. Ever been scared that you or a family member or friend would get hurt while so and so’s on? These people don’t have to be.
The organization respects and supports the employees: This relates to the organizational culture but deserves its own point. Employees will not respect the employer unless the employer respects the employees. In awesome EMS services, the employees and management function in an atmosphere of mutual respect. The management provides the employees with adequate, functional equipment and facilities even when asking them to do more with less. They strive to promote fairness in corrective actions and policies, knowing when to cut someone slack when appropriate. The employees are treated like adults and are encouraged to innovate and take ownership of their areas.

I’ve been to these services and I can honestly say that I left their station with the feeling that I wanted to be a part of their organization. Then, I’ve gone back to my service and taken an inventory on what we needed to do to emulate them. It’s all about being able to enjoy coming to work for the right reasons where you work with people who care, respect, and strive for the same things that you do. EMS people who are passionate about EMS who are allowed to shine build great organizations no matter where they happen to land. EMS people who aren’t build organizations that fall into the other two categories. I suggest that you take some of the suggestions below to help get your service to where you want it to be:

Read “The Shine Factor” – One of my previous posts and the predecessor to this one.
Realize that your community won’t care about you u
nless you tell them why they should – EMS organizations need to market themselves just as any other business. No matter what your classification is, you need to market yourself to your community every day. Your constituents are your customers and they won’t think about you unless they either need you or you put your message in front of their faces. Tell them what you do, tell them why you do things the way that you do, and tell them what you need to do what they do. Let them know how you strive for quality. Let them know how well you are stewards of their hard-earned dollars. Let them know who you are and what you stand for. Trust me, PR saves lives and EMS budgets.

Right now, resolve to treat everyone else in your organization like a professional. Try to earn their respect. Someone has to take the first step here, it should be you.

End any secrecy in your organization – Sure, direct personnel actions are one thing, but unwritten policies and issues directly affecting all employees are quite another. Allow people to become involved in the organization in any role they want to. Organizational secrecy builds “Silos” where people tend to stratify themselves based upon their own perception of what is most important to the group and allows individuals to worry that anyone with a new idea is there to steal their position within the silo. Allow people to participate and collaborate on decisions affecting the organization.

Encourage innovation. Encourage participation and new ideas – No idea is a bad idea. Business these days thrives on the economics of ideas. Don’t shoot down any idea without a collaborative review of its merit. Employees come up with new and better ways to do things every day, let them develop those ideas and test their effectiveness. If those ideas are repressed in an organizational culture that resists change, the whole organization will suffer when people begin to feel that their contributions never matter.

Encourage people to take ownership of their roles and responsibilities – I work for my ambulance service because it would miss me if I was gone. Why would anyone ever go to a place where it didn’t matter if they were there or not? When people begin to feel that their time isn’t valued or their efforts aren’t appreciated, they stop putting forth any time or effort above what it takes to avoid being fired. That’s it.

Never let anything stagnate – If you haven’t reviewed a system in over a year, you’re lagging behind. If your protocols haven’t changed in over a year, you’re not keeping pace with medical science. Even if something is working very well, that doesn’t mean it shouldn’t be reviewed and measured regularly. Make systems prove their worth. Don’t let anything get stagnant. Pull ineffective policies or programs and replace them with another idea. Review those ideas and see if they’re better suited to your goals. Set lofty goals and try hard to reach them.

Reevaluate why you do what you do – Why are you in the organization? Are you there because you care about what you do? Are you passionate about it? Once you remember what it was that brought you to EMS and to the organization where you’ve happened to land, evaluate if you still see your organization fires your passion. If it doesn’t, work diligently to make it meet your design. Earn your own respect. Forgive and forget past grievances and collaborate on new solutions. Bust silos and build bridges, not fences.

As always, I welcome comments and e-mails: ProEMS1@yahoo.com

——————————————————

This is part 2 of a 3 part series on “The Shine Factor”

Part 1 of this series can be found here – The Shine Factor

Part 2 of this series can be found here – What Makes a Great Ambulance Service

Part 3 of this series can be found here – The Shine Factor – Grunts

Care to Share My Stuff?? C'mon, Go ahead.

Posted by Ckemtp on April 17, 2009 • Filed under: Administration & Leadership, Ambulance, Command & Leadership, EMS, EMS Health & Safety, EMS Management, EMS Topics, EMS ethics, EMS rant, EMT, Ethics, Fire department, Firefighter, Paramedic, The Shine Factor, edemse, ems 2.0, everyday ems ethics, new perspective, professionalism, technology-communications-ems-topics

Oh no you didn’t…

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Really? Did you just?? Oh come on now… you don’t really think??

Seriously…

Did you really just call me an “Ambulance Driver”?

An Ambulance Driver? Oh come on… Four years of college level classes, hundreds upon hundreds of hours of continuing educations, a veritable alphabet soup of certification acronyms behind my name, and this nifty Star of Life disco ball patch on my arm and you STILL just called me an Ambulance Driver? Really? Oh come now, do you know that calling me an ambulance driver is like calling a High School Teacher a “Nanny”, or calling a Police Officer a “Police Car Driver” or calling a Nurse a “Bedpan Jockey”, or calling a Firefighter a “Fire Truck Driver”, or calling a scientist a “Microscope Looker-Inner” or calling a Congressman a “Pork spewing bloviator” (I could go on, but I won’t… although that last one might be right)

EMS is an acronym for “Emergency Medical Services”. EMT stands for “Emergency Medical Technician”. Nationally, there are three levels of EMS professionals. Each level signifies to the public that the person holding the Title and the requisite license or certification has met stringent educational and training standards that allow them to take care of people. These levels are EMT-Basic, EMT-Intermediate, and EMT-Paramedic. Some of the states have expanded on this by offering additional levels of certifications between the levels, such as the EMT-IV Tech in Wisconsin (an EMT-Basic that can start IVs and give some limited IV meds), or the EMT-Paramedic Specialist in Iowa that is above the NREMT-P a bit but still below their Critical Care paramedic.

A paramedic these days has a college level education, takes over 1000 hours of didactic (classroom) time and can spend anywhere from 6 months to a year in clinical rotations. We can poke, prod, cut, inject, bandage, stabilize, evacuate, and care for you sixteen ways from Sunday. In my ambulance I carry 48 different emergency medications that I have to know how to use REALLY well or I can kill you. (I do know how to use them really well, trust me, so do my peers). I can intubate your trachea so you can breathe, reinflate your collapsed lung with a needle, surgically open your airway if I need to in order to save your life, and do a whole host of other things that you wish that you never ever need. My ambulance is a critical care unit on wheels that can be at your curbside in under 8minutes flat twenty four hours a day seven days a week. Today’s ambulances bring the emergency room right to you and begin advanced medical care right away. This care saves lives and improves your medical outcome greatly for a whole host of medical complaints.

And you, Joe public, still call me an “Ambulance Driver”. Which, if you hadn’t noticed, somehow irks me a bit.

Unfortunately for me, and for the members of my profession, it’s not your fault that you call me that, dear Joe Public. It’s my fault. It’s the fault of each and every EMS professional out there that you know so little about our profession and our industry that you resort to calling us that detestable term. It is our responsibility to get the word out. It is our responsibility to educate you about our life saving services, and our responsibility to let you know just how and when to use us properly. If we don’t do it, and therefore let the responsibility fall to others, we EMS people aren’t going to be happy with the job they do. We’re not going to be happy with the popular representations of paramedics in the popular media. We’re not going to be happy with the results of our public health education campaigns.

The American Heart Association has recently released a campaign entitled “Mission: Lifeline”. It’s a marketing campaign aimed at increasing public awareness of heart attack symptoms so that Joe Public calls us first when they start having the big one. If you’ve been reading this, you know that my all time biggest pet-peeve is when the people having conditions where they need us and need us now but aren’t dramatic like a car accident or cardiac arrest don’t call us. I can’t make a direct quote, but I read a study once where like 60% of people call a friend or family member first when they think they’re having symptoms of a heart attack. Calling EMS for these 60% or so of potential patients whose lives may very well depend on the early interventions we can provide them seems to be an afterthought. I can’t tell you how many people I’ve transported from small hospitals to big hospitals that were having the big one and DROVE THEMSELVES INTO THE ER without calling us.

Please, Joe Public, know that the VERY FIRST CALL you should make when you have pains in your chest is 911. Do NOT hesitate. Do NOT worry about the cost. JUST CALL US!! Do you know that approximately 1% of cardiac muscle tissue DIES AND CANNOT BE SAVED per MINUTE in a bad heart attack (myocardial infarction)? The difference is simple. You call 911 and usually (depending on where you are located) an ambulance arrives within 10minutes and starts lifesaving interventions and gives you medications to help slow or stop the damage in progress and salvage heart tissue that is being damaged. Please remember that “Time is Muscle” and that the extra expense of an ambulance is more than covered by the quality of life that we’re keeping for you. Really. Please call. Don’t wait. You can call your family AFTER you call 911. Please, I’m begging.

I’m also telling you EMS people out there to get the word out. Go market yourselves! If you want people to know what we do, it is YOUR PERSONAL RESPONSIBILITY to tell them. Go, do it now. If you want my help to write something, e-mail me and I’ll help. For free even. It’s that important.

Ambulance driver….. Seriously.

Care to Share My Stuff?? C'mon, Go ahead.

Posted by Ckemtp on March 31, 2009 • Filed under: AHA, Ambulance, Ambulance Driver, American Heart Association, Command & Leadership, EKG, EMS, EMS Humor, EMS Management, EMS Topics, EMS ethics, EMS rant, EMT, Emergency Medical Services, Ethics, Mission Lifeline, Paramedic, Public relations, STEMI, ckemtp rants, edemse, ems 2.0, everyday ems ethics, funny, grumblemedics, inside the mind of a paramedic, new perspective, rant, technology-communications-ems-topics

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

Care to Share My Stuff?? C'mon, Go ahead.

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

Professing EMS

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Some time ago I was working a shift in a clinic on a particularly busy day when I had a few moments to sit down, have a cup of coffee, and talk with my coworkers. It was the usual stuff, talk about the day, tidbits about personal lives, and since most of the people I was working with were women, talk about things that I didn’t really need to hear about. After a few minutes we all had to get back up and head back onto the floor to keep up with the constant tide of flu-season sniffles.

It was all pretty mundane for me until the doc that we were working with who hadn’t been there much before, made a statement. As we were walking out, he said “Man, I really hate this! This isn’t my love, it’s not my passion!” I was taken aback. I asked him what he meant. He went on to say that he really wanted to be a concert pianist and that he only did medicine now because he didn’t know how to do anything else.

Now, I’m not you… but even though this guy was a pretty good Doctor, I immediately felt sorry for all of the patients that day. I mean, would you want this guy to be your doctor? Who in their right mind would want someone who hated taking care of you taking care of you?

It did, however, get me to thinking… Is that where we are in EMS today? I mean our profession. The profession of EMS, our careers and our industry. Are we made up of people like this doctor? Now during the day that I worked with him, he never made any egregious errors in patient care, nor did I see him do anything illegal, immoral, or fattening. However, if providers aren’t *in* to providing to care, would you want to have them providing care to you or your family? What about your service? Sure, we all know providers who love EMS, love their patients, and can’t wait to take care of any patient that calls for their help, but while I would hope that they are the majority… are they?

EMS is a profession in its infancy, we’ve only been around since sideburns were popular, but in that time we’ve gone from dedicated but untrained people rocketing around in hearses to professional providers practicing curbside critical care. It’s a great profession to be in and I’m proud to be a part of it. As a group we’re a pretty dynamic fast paced lot. I would like to ask our group though, do we have the love of providing care to the breadth of society who call us when they think that the life or health of their themselves or their loved ones are in danger? Or have we fallen short of the lofty goals set forth by Johnny and Roy?

Yep, I’m asking a lot of questions here. I just would like to open up a dialogue among the EMS professionals out there. Ask yourselves if the EMS providers in your area are advancing the profession of EMS to the place where you think it should be heading. Ask yourselves if you work with people who have the love of the profession enough so that if they were strangers and you were a patient would you want them making decisions about your life? I think that it’s high time that EMS is taken over by EMS professionals who care about advancing our profession into the future, not by people who don’t care enough to understand the vast array of issues that face our industry today. I would like EMS people to take ownership and drive our industry where we believe it should go. It’s our profession, and our responsibility to strengthen our service to meet the challenges that are facing our communities. And that responsibility starts with you, the individual EMS provider.

You, as a caring EMS professional actually have the tools to do this. First off, realize that EMS is a profession all its own, truly a dynamic industry that has earned a place in the very fabric of country. Think about it, our generation and the generations to come have grown up with the notion of 911. They know that when the unthinkable happens, all they have to do is call the magic three numbers and someone will come and help them. It’s a powerful piece of the American psyche that people rarely give second thought to… but they all know what they’re going to do the next time they find Grandpa unresponsive. I think that if EMS ceased to exist (and contrary to what it may look like from the dashboard of your ambulance some days, it’s not all that likely) our society would look a lot different than it does now. People need to have the notion of EMS. And make no mistake, we’re darn privileged to have the role in society that we do. It is, however, up to us to awaken the public to what it is that we do, to educate ourselves to our own potential, and to show the medical establishment what we’re capable of. Ask yourself, really ask, if you want some other group to decide where we’re going for us, oh… say like the nurses’ lobby, or the IAFF, or the DOT, or the (insert non-EMS acronym here). You are sitting right now in an industry on the cusp of a watershed change, and it’s up to you to take ownership and steer EMS where you want it to go.

Here’s what I’m doing, and what I would like to suggest to you all. First, recognize that EMS is indeed a profession; and a good one at that. Second, evangelize EMS to all you meet. You can’t complain about the system abusers (or worse, the people who truly need us and yet don’t call us) if you aren’t out there educating them about what we’re here for. Third, realize that “PR Saves lives” and make sure that the information out there about EMS in your community is projecting the message that you think it should, and if it isn’t, write something up and get the word out to change that. Talk with everyone you can and let them know just what it is that we do, who we are, and what we’re capable of. Take ownership of EMS, because if we don’t, someone else out there will.

As always, post publicly if you want public discussion, or contact me at: ProEMS1@yahoo.com

Care to Share My Stuff?? C'mon, Go ahead.

Posted by Ckemtp on February 10, 2009 • Filed under: Ambulance, EMS, EMS Topics, EMT, Ethics, Firefighter, Paramedic, Public relations, ems 2.0, everyday ems ethics, fire

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