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When God made Paramedics

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Usually I don’t get into emotional fluff or “hero-worship” type stuff… but this one’s an oldie but a goodie. I didn’t write it, I don’t know who did… but as I sit here with my beautiful Gkemtb at my side and my kitty on the other side, I wax poetic…

Maybe it’s the beer?

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When God made paramedics, He was into His sixth day of overtime. An angel appeared and said, “You’re doing a lot of fiddling around on this one.” God said, “Have you read the specs on this order? A Paramedic has to be able to carry an injured person up a wet, grassy hill in the dark, dodge stray bullets to reach a dying child unarmed, enter homes the health inspector wouldn’t touch, and not wrinkle his uniform.”

“He has to be able to lift three times his own weight. Crawl into wrecked cars with barely enough room to move, and console a grieving mother as he is doing CPR on a baby he knows will never breathe again.” “He has to be in top mental condition at all times, running on no sleep, black coffee and half eaten meals, and he has to have six pairs of hands.”

The angel shook her head slowly and said, “Six pairs of hands…no way.”

“It’s not the hands that are causing me problems,” God replied. “It’s the three pairs of eyes a medic has to have.”

“That’s on the standard model?” asked the angel.

God nodded. “One pair that sees open sores as he’s drawing blood, always wondering if the patient is HIV positive.” (When he already knows and wishes he’d taken that accounting job)

“Another pair here in the side of his head for his partner’s safety. And another pair of eyes here in front that can look reassuringly at a bleeding victim and say, “You’ll be alright ma’am when he knows it isn’t so.”

“Lord,” said the angel, touching His sleeve, “rest and work on this tomorrow.”

“I can’t,” God replied. “I already have a model that can talk a 250 pound drunk out from behind a steering wheel without incident and feed a family of five on a private service paycheck.”

The angel circled the model of the Paramedic very slowly. “Can it think?” she asked.

“You bet”, God said. “It can tell you the symptoms of 100 illnesses; recite drug calculations in it’s sleep; intubate, defibrillate, medicate, and continue CPR nonstop over terrain that any doctor would fear… and it still keeps it’s sense of humor.” “This medic also has phenomenal personal control. He can deal with a multi-victim trauma, coax a frightened elderly person to unlock their door, comfort a murder victim’s family, and then read in the daily paper how Paramedics were unable to locate a house quickly enough, allowing the person to die. A house that had no street sign, no house numbers, no phone to call back.”

Finally, the angel bent over and ran her finger across the cheek of the Paramedic. “There’s a leak,” she pronounced. “I told You that You were trying to put too much into this model.”

“That’s not a leak,” God replied, “It’s a tear.”

“What’s the tear for?” asked the angel.

“It’s for bottled up emotions, for patients they’ve tried in vain to save, for commitment to that hope that they will make a difference in a person’s chance to survive, for life.”

“You’re a genius!” said the angel. God looked somber, stiffened, and said “I did not put it there”.

- Author Unknown

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For more on this emotional, fluffy crap read:

“Enough to Make an Old Medic Melt” and,
“Splashed Sadness, a look at Negative Emotions in EMS”

More on EMS Narrative Reporting

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This is a follow-up post to my previous piece on EMS narrative Reporting, EMS narratives, paramedic and EMT narrative reports and the like. I have more, you can see them here:

Soapy Pictures – The EMS Narrative Report

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

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The narrative is the most useful component of the EMS patient care report. It is the part of the report that is actually read, understood quickly, and most useful to the humans who have to act on the information provided in the patient care report. Humans don't process the information gathered by all of the check boxes and drop-down menus very well. If you've ever had to read many patient charts you'll quickly understand why. The check boxes and menus store information in a way that is good for computer processing and statistical analysis, but not for rapid human comprehension. A good EMS Narrative report is a short story that explains the events of the call, the decisions made on the call by the paramedics and/or EMTs, the information available to the paramedics/EMTs that they acted upon to make the decisions they made, and the outcome of those decisions. It should also "Set the scene" for the reader, and explain the circumstances of the call, the events leading up to the call, the way that the call was handled, and provide enough information so that anyone reading it gets a good sense of all of the information gathered by the EMS people who were there. I don't advocate the use of automatic narrative generators as included in some software packages, because computers can't write something that humans usually find useful.

Think about it this way, you're writing your narrative reports for these audiences:

  • Healthcare providers farther down the line who will be taking care of the patient after you transfer patient care – These people are not just the Nurses and Doctors at the ER who you leave your patient with. Your PCR (in most areas and if it isn't this way in your area it should be) is part of the overall patient chart and is the best window to the patient's initial presentation when their condition is in its most acute stage. Remember, EMTs and Paramedics are "The eyes and ears of the physician" at an emergency scene. A good EMS narrative report on your PCR provides that view of the patient to every healthcare provider who takes care of the patient, including the patient's primary care physician and any specialists that care for the patient later. I've seen many times where a quick-thinking paramedic was able to obtain an EKG strip and a good assessment during a patient's undiagnosed episode of tachycardia and write a good narrative explaining their assessment findings which then enabled a cardiologist to immediately make a diagnosis and save the patient weeks of wearing a Holter monitor to try and reproduce the rhythm for a diagnosis.

    In addition to all of the above, you will be judged on the quality of your narrative by the healthcare providers down the line, your service will be judged, and our profession will be judged. If you write a narrative report that is full of poor grammar, misspelled words, nonsensical statements, and other gobbledygook, other healthcare providers will think you're an idiot. If they see your reports as inferior to other service's reports, they'll think your service is a bunch of idiots. They may even think that all EMTs and paramedics are complete nincompoops. I've heard complaints that the ER people never read the patient care reports that ambulance crews leave for them. Maybe it's because they have read too many of them that are complete nonsense. Rite dem gud reports gize!

  • Your Management and Your Medical Director – A good EMS Quality Assurance/Quality Improvement program is impossible without good EMS reporting. It isn't about a game of "Gotcha!". It's about documenting how protocols, procedures, policies, and operations really work in the field. If you have a patient that the medical director follows up on after their care in the ER, the first thing that he or she is going to do is read your narrative to find out what you did, what protocol you followed, and why you did it. If you paint them a good picture, they may find the information useful enough to be able to tweak protocols and fine-tune procedures. Sure, you may get a talking-to occasionally, but a well-documented call that doesn't quite go to plan is always better than a poorly documented call that doesn't go according to plan. You're protecting yourself and your crew. If everyone writes a good narrative, everyone is working to improve patient care.
  • Lawyers – Who didn't see this one coming? It's not my quote, but I've said it before and I'll say it again: "If you didn't write it, you didn't do it… unless it was bad. Then, if you didn't write that you DIDN'T do it, you did do it". EMS people get sued sometimes. Nice, caring, professional, and compassionate people get sued sometimes. It often doesn't make sense why, either. I wouldn't say that there is an epidemic of lawsuits against individual providers or ambulance services, but it can and does happen more often than we want it to. Writing a "LEGALLY DEFENSIBLE" narrative report is key. Always do this, read more on this below. However, it's not just lawyers that want a piece of you that read patient care reports. Lawyers that handle civil cases for our patients read them in order to gather information about lawsuits that our patients file. EMS Patient care reports are a wealth of information for civil attorneys litigating workers' compensation cases, car accidents, accidental injuries, and fraud. By not writing good narratives, we can damage our patients' legal cases. By providing factual, relevant information, we can protect the innocent parties in legal cases. If you're ever called to testify in one of these types of cases, you'll appreciate having written a good narrative. Trust me.
  • Your Own Backside – Remember what I said above about writing a "legally defensible" narrative? This means that you need to write your narrative in such a way that you look like a true professional in the eyes of the court. Even if you did everything exactly right, if you documented the call like a D-minus third-grade book report on "Snuggles the Wonder Kitten", you're an idiot in the eyes of the jury. The jury, or judge, thinks that idiots are probably negligent. Therefore, people who write bad narratives are probably doing other things badly, and people who do things badly are doing them negligently. It's not a good situation and not one that you're likely to win. I've always said that I will make tough decisions when I have to, and will even bend the rules a bit if it is the right thing to do for the patient. However, if and when you have to do this, make sure that you clearly document:

    Document everything. If it was minus-30-degree weather and it was best for the patient to not put them in a KED because they would be frostbitten by the time you were done, that is information that would help you if they had an occult c-spine fracture from an auto accident. If the patient was trying to knock your teeth out and you restrained them, that is also good information. If you withheld a medication indicated by protocol, say adenosine for a Narrow Complex Tachycardia because you saw a ramp-up (delta wave) between the P-wave and the QRS complex indicative of Wolf-Parkinson-White syndrome where adenosine is contra-indicated, you should probably document that well. Good documentation is documentation that gives a full picture of the scene for those that read your report. Document a full assessment (DO A GOOD ASSESSMENT, then document it). Document your working diagnosis and the differential diagnoses that you considered and ruled-out. Document the treatment you gave per protocol and the response that the patient had to the treatments given. Document how you were dispatched to the call and how you responded. Document information that you gathered from people at the scene, and who those people were. Document what you saw when you arrived on scene. Document more than you think that you should. Make sure that its coherent information. I'm going to harp on this again: By all means possible, USE PROPER ENGLISH, SPELLING, GRAMMAR, and PUNCTUATION! Spell check is a great tool. However, it doesn't differentiate between the RIGHT words for the sentence, and the WRONG words. Your going to be wrong if you re-lie only one spell cheque (Yes, those were the wrong words. No, Spell check didn't catch it. Got it?)

    • The reasons you were in the situation where you had to bend the rules and/or make a tough decision

    • The information you had available to you that caused you to make the decision you did

    • The options you considered that were less desirable than the decision you ultimately made, and why
      they were less desirable

    • Why you felt it was best for the patient, even if and especially if the decision went wrong

    • (Make sure it was the best for the patient)

In the previous post, I spoke about the fact that I use the "SOAP" method to write my EMS narratives. I didn't intend to do it this way, and I used to think that I hated it until I realized that it was what I was using when nobody told me to. "SOAP" is an acronym that describes the "SOAP Charting method" I don't know who came up with it, but the letters stand for "Subjective, Objective, Assessment, Plan" (See HERE to go to the other post to read more on it.) These things help you organize the information in a readable format. I think that they help "set the stage" for the short-story that is your narrative.

Here's two examples of "Subjective" information:

  • Ambulance 1-J-26 dispatched emergent through the 911 system to the scene of a two-vehicle MVC with injuries on a two-lane 55mph rural highway. Upon our arrival we found a "head-on" style collision between two late-model pick-up trucks with heavy damage to both vehicles on their front driver's side. Triage was initiated and this Patient (Pt) was identified as critical. There were four injuries on this scene. The Pt in this report was the restrained driver of a late-model pickup truck with heavy front-end damage and intrusion into the passenger compartment. Pt was pinned in the vehicle upon our arrival with his chest set between the steering wheel and the seat. Pt was conscious, alert, and oriented x 2 with labored breathing but no apparent airway compromise. Fire/Rescue notified of the need for heavy extrication and a Med-Pigeon Helicopter was requested for a scene response. Traffic control and the landing zone referred to Anytown Sherrif's Dept already on scene.
  • Ambulance 1 dispatched non-emergent for the routine scheduled transfer of the 59yo F Pt from HOLY BEAGLE HOSPITAL –Rm #223 to ST. BERNARD REGIONAL ICU. Upon our arrival we found the Pt's RN who gave us a passdown report on the Pt. Pt had been admitted to Holy Beagle for treatment of an exacerbation of CHF and had been diagnosed with further respiratory compromise related to pneumonia per her physician. Pt was being transferred for ICU care at St. Bernard. Found the Pt Conscious, Alert, and oriented x 2 with ABCs intact.

These are the first type of sentences that I write into my narrative reports. It is "Subjective" information because it sets the scene. It states who you are, how you were dispatched, what you were dispatched for, where you were dispatched to, and what you found immediately when you got there. The second one states who you received information from: The patient's RN. Notice that I put in statements containing the patient's level of consciousness, airway patency, respiratory effort, and circulatory status. I think that this helps to show that you began your assessment immediately upon laying eyes upon the patient.

Continuing, some examples of "Objective" information, continuing on with the two narratives above:

  • Pt was still located in the driver's seat and was able to understand that he had been in a severe car accident. Pt had strong and rapid radial pulses noted but had shallow respirations. Pt was unable to tell us what time or what day it was. C-spine precautions were initiated in the vehicle with a c-collar and manual stabilization as fire/rescue extricated the patient. Extrication took approx. 10min. Patient was removed via backboard and secured with straps, head blocks, and tape. Pt secured on cot. Due to 10min ETA from ther responding helicopter EMS and an estimated 30min transport time to a trauma center, Pt was taken to the ambulance for stabilization. Patient with CC (Chief Complaint) of chest pain and dyspnea.
  • Pt was sitting upright in her hospital bed. Pt on EKG monitor showing NSR s ectopy. Pt had been given a 20ga IV in her R hand and was receiving an IV drip of 1000ml Normal Saline at 100ml/hr and an IVP drip of Levaquin via that IV site. RN std that Pt had also received an IV bolus of 40mg Lasix approx 20min prior to our arrival as well as 1000ml Tylenol PO for a recurrent fever, last measured at 101.5 degrees. Pt was on o2 at 4-LPM via NC bringing her SpO2 to 98%. Pt had a foley cath in place (thank goodness). Pt was unable to ambulate due to her condition and resultant weakness. Pt secured on cot and taken to rig. Vital signs assessed and per previous in this report (Yes, this is the ONE thing that the check boxes are good for). Pt denied CC other than of being tired.

This is the second section of my EMS narrative report. It is called the "Objective" information because it is information you get through objective observation (think the scientific method). Objective observation is what you observe while you are there when looking at the scene with a trained eye. This could include the initial assessment (or primary assessment, whatever the kids are calling it these days) and a discussion of the life threats or lack thereof that you see. This is information directly gathered by you about the patient.

The "Assessment" portion, and the continued examples from above: (I write "ASSESSMENT" in capital letters in order to differentiate the report. You don't have to, but I just always have)

  1. ASSESSMENT: As above. Skin Pale, cool, diaphoretic. Pupils PERRL. No evidence of head trauma. JVD (Jugular Venous Distention) noted. Trachea midline/mobile. Chest with asymmetrical movement to inspirati
    on, markedly decreased breath sounds in both R upper and R lower chest, bruising, abrasions, and what appeared to be a steering wheel imprint left in Pt's chest with other indications of thoracic trauma. ABD tender to palpation in the RUQ and LUQ, not noticeably distended. Pelvis intact. Extrem c weakening peripheral pulses but good motor and sensation. Pt seemed to be becoming increasingly lethargic, confused, and agitated. Pt was loudly complaining of chest pain and diff. breathing, stating that it "hurt to breathe". Pt's Blood Pressure (BP) taken q 5min showed 1st reading at 134/84, 2nd reading of 128/92, and 3rd of 110/98.
  1. ASSESSMENT: As above. Skin Warm, pink, and moist. Pupils PERRL, no JVD, trachea M/M, Chest equal rise/fall bilaterally c diffuse rhonchi and rubs throughout. ABD SNT. Extrem c good Pulse/motor/sensation/temp x 4. Some pitting edema noted to both lower extremities. Pt was resting comfortably and std that she "felt much better" after the Tylenol. Pt denied other complaints.

    The "Assessment" portion of the report is the secondary assessment, the detailed assessment, and/or the focused assessment. At a minimum, it should include what are called "pertinent negatives". These are things that you should always put in every report. Detail a head to toe assessment. The "pertinent negatives" as they are called, are negative assessment findings. Even if you don't find anything, you write that you didn't find anything to prove that you looked at it. I think that you should avoid acronyms such as "normal", or WNL (Within Normal Limits) as they prove only that you didn't really look. Normal is a subjective statement. If the skin is pink, warm, and dry, write that. Don't just write "Skin normal", because a lawyer will pick you apart on what "normal" is for that exact patient, and just how exactly you are qualified to know what "normal limits" are for that patient population. I always break the assessment portion into the same format: Skin signs, head, pupils, trachea, JVD/no JVD, Chest condition and lung sounds, Abdominal findings, pelvis (for trauma), then extremities. After that, I write specific assessment findings that don't fit into the above sentence. Feel free to get as detailed as you need to in writing details about the various organ systems. I also write "as above" in the first part in order to tie in any assessment findings that I may have included in the above two sections. This is a very important part of the narrative, write it well.

Finally, the "Treatment Plan" section: (I always write "TREATMENT" in caps, once again, just 'cuz I do)

  1. TREATMENT: As above. Pt placed on 15-LPM o2 via NRB while still in the vehicle. Bilateral IVs started with a 14ga in L AC and a 16ga started in R AC. Both IVs running 1000ml warm NS fast TKO. Pt placed on 5-lead EKG showing S-tach (Sinus Tachycardia) with occasional PVCs. Pt's abrasions and various superficial bleeding controlled c gauze and tape. Due to Pt's increasing dyspnea, narrowing pulse pressures, JVD, and decreased breath sounds on the R side a needle decompression was performed in the R upper chest (beween 2nd/3rd intercostals) with 14ga IV cath and flutter valve placed. Pressurized air return noted in syringe upon penetration of the pleural space. Note trends of vital signs. Pt's breathing improved markedly and Pt's LOC began to improve. Pt continuously monitored during and after treatment.
  2. TREATMENT: All inpatients treatments continued. Pt maintained on o2. Pt maintained on EKG showing NSR s ectopy. Pt rested comfortably during transport without any additional complaints. VS (vital signs) q 15min without change observed.

As far as the "Treatment" section is concerned, write what you did and how the patient responded. For routine treatments, such as oxygen, bandaging, splinting, and an IV, I usually just write that I did them if the patient condition is such that they would be automatically assumed to be done. For more complex treatments, such as medication given or the pleural decompression described above, I document the rationale and the technique used. A good rule of thumb is: The more invasive the treatment, the more you should write why and how you did it. You should also write how the patient responded to the treatment, and if you considered one treatment over another, write that too.

To end my report, I put the patient's disposition. I also include a statement on how I contacted the receiving hospital (in my case) or medical control:

  1. Receiving hospital notified of incoming level 1 trauma by MedChannel radio. Med-Pigeon Flight crew arrived and our crew assisted in packaging the patient. Handed over Pt care to flight crew and assisted with transporting the Pt to the waiting helicopter. Care transferred.
  2. Pt transported and transferred to St. Bernard ICU RN staff s incident or exacerbation of condition.

    The above statements concern what you ended up doing with the patient. Always show that you passed the patient to an equal or higher level of care. Show that it was an orderly and legal transfer. If you are calling into the base hospital or medical control, state any orders received and who gave them to you ("Formerly St. Hospital contacted via MedChannel with orders received to administer 1 amp D-50 per Dr. Marcus. Order confirmed. 1 amp D-50 given per the order"). If you receive no orders, write that too. I always include the phrase "Pt transported and transferred (to whom) s (which means "without" in case you were wondering) incident or exacerbation (which means, "to get worse") of condition".

Now, let's bring together the reports #1 and #2 so you can read them as a whole:

  1. Ambulance 1-J-26 dispatched emergent through the 911 system to the scene of a two-vehicle MVC with injuries on a two-lane 55mph rural highway. Upon our arrival we found a "head-on" style collision between two late-model pick-up trucks with heavy damage to both vehicles on their front driver's side. Triage was initiated and this Patient (Pt) was identified as critical. There were four injuries on this scene. The Pt in this report was the restrained driver of a late-model pickup truck with heavy front-end damage and intrusion into the passenger compartment. Pt was pinned in the vehicle upon our arrival with his chest set between the steering wheel and the seat. Pt was conscious, alert, and oriented x 2 with labored breathing but no apparent airway compromise. Fire/Rescue notified of the need for heavy extrication and a Med-Pigeon Helicopter was requested for a scene response. Traffic control and the landing zone referred to Anytown Sherrif's Dept already on scene. Pt was still located in the driver's seat and was able to understand that he had been in a severe car accident. Pt had strong and rapid radial pulses noted but had shallow respirations. Pt was unable to tell us what time or what day it was. C-spine precautions were initiated in the vehicle with a c-collar and manual stabilization as fire/rescue extricated the patient. Extrication took approx. 10min. Patient was removed via backboard and secured with straps, head blocks, and tape. Pt secured on cot. Due to 10min ETA from ther responding helicopter EMS and an estimated 30min transport time to a trauma center, Pt was taken to the ambulance for stabilization. Patient with CC (Chief Complaint) of chest pain and dyspnea. ASSESSMENT: As above. Skin Pale, cool, diaphoretic. Pupils PERRL. No evidence of head trauma. JVD (Jugular Venous Distention) noted. Trachea midline/mobile. Chest with asymmetrical movement to inspiration, markedly decreased breath sounds in both R upper and R lower chest, bruising, abrasions, and what appeared to be a steering wheel imprint left in Pt's chest with other indications of thoracic trauma. ABD tender to palpation in the RUQ and LUQ, not noticeably distended. Pelvis intact. Extrem c weakening peripheral pulses but good motor and sensation. Pt seemed to be becoming increasingly lethargic, confused, and agitated. Pt was loudly complaining of chest pain and diff. breathing, stating that it "hurt to breathe". Pt's Blood Pressure (BP) taken q 5min showed 1st reading at 134/84, 2nd reading of 128/92, and 3rd of 110/98. TREATMENT: As above. Pt placed on 15-LPM o2 via NRB while still in the vehicle. Bilateral IVs started with a 14ga in L AC and a 16ga started in R AC. Both IVs running 1000ml warm NS fast TKO. Pt placed on 5-lead EKG showing S-tach (Sinus Tachycardia) with occasional PVCs. Pt's abrasions and various superficial bleeding controlled c gauze and tape. Due to Pt's increasing dyspnea, narrowing pulse pressures, JVD, and decreased breath sounds on the R side a needle decompression was performed in the R upper chest (beween 2nd/3rd intercostals) with 14ga IV cath and flutter valve placed. Pressurized air return noted in syringe upon penetration of the pleural space. Note trends of vital signs. Pt's breathing improved markedly and Pt's LOC began to improve. Pt continuously monitored during and after treatment. Receiving hospital notified of incoming level 1 trauma by MedChannel radio. Med-Pigeon Flight crew arrived and our crew assisted in packaging the patient. Handed over Pt care to flight crew and assisted with transporting the Pt to the waiting helicopter. Care transferred.

     

  2. Ambulance 1 dispatched non-emergent for the routine scheduled transfer of the 59yo F Pt from HOLY BEAGLE HOSPITAL –Rm #223 to ST. BERNARD REGIONAL ICU. Upon our arrival we found the Pt's RN who gave us a passdown report on the Pt. Pt had been admitted to Holy Beagle for treatment of an exacerbation of CHF and had been diagnosed with further respiratory compromise related to pneumonia per her physician. Pt was being transferred for ICU care at St. Bernard. Found the Pt Conscious, Alert, and oriented x 2 with ABCs intact. Pt was sitting upright in her hospital bed. Pt on EKG monitor showing NSR s ectopy. Pt had been given a 20ga IV in her R hand and was receiving an IV drip of 1000ml Normal Saline at 100ml/hr and an IVP drip of Levaquin via that IV site. RN std that Pt had also received an IV bolus of 40mg Lasix approx 20min prior to our arrival as well as 1000ml Tylenol PO for a recurrent fever, last measured at 101.5 degrees. Pt was on o2 at 4-LPM via NC bringing her SpO2 to 98%. Pt had a foley cath in place (thank goodness). Pt was unable to ambulate due to her condition and resultant weakness. Pt secured on cot and taken to rig. Vital signs assessed and per previous in this report (Yes, this is the ONE thing that the check boxes are good for). Pt denied CC other than of being tired. ASSESSMENT: As above. Skin Warm, pink, and moist. Pupils PERRL, no JVD, trachea M/M, Chest equal rise/fall bilaterally c diffuse rhonchi and rubs throughout. ABD SNT. Extrem c good Pulse/motor/sensation/temp x 4. Some pitting edema noted to both lower extremities. Pt was resting comfortably and std that she "felt much better" after the Tylenol. Pt denied other complaints. TREATMENT: All inpatients treatments continued. Pt maintained on o2. Pt maintained on EKG showing NSR s ectopy. Pt rested comfortably during transport without any additional complaints. VS (vital signs) q 15min without change observed. Pt transported and transferred to St. Bernard ICU RN staff s incident or exacerbation of condition.

The two reports above could not be much more different, however if you look, they are both written using the same, versatile format. SOAP is a tool for you to use to help organize your information and tell your story of the patient care. Use it as a guide, or a process. Don't use it as a strict format. It will help you as it has me.

Remember, the SOAP chart is just one example of the EMS narrative report, the EMS patient care report, the Paramedic narrative, the EMT narrative, the ambulance report, or the patient chart. Written well, and you are improving your patients' care. Write it poorly, and you're harming your patient and maybe looking like an idiot.

You may print this out and use it with my permission, as long as there's a link: Http://www.LifeUnderTheLights.com – and my e-mail: Proems1@yahoo.com

Till later, all.

 

 

The Insanely long work week – Part 14 2/3

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This has been my shifts so far. One really good save at the start of it, then… well, this.

I was the cat at the end. I envision that there’s an epic fail coming up

Video – Rockford, Illinois – Train derails and explodes during severe thunderstorm

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June 19th, 2009 – Rockford, IL

So last night, I was working my ambulance job in Wisconsin and MISSED THIS. My Illinois Fire Department sent an engine and a chief through the MABAS system who are still there. I don’t have all the details, but apparently a severe thunderstorm washed out railroad tracks which caused a train to derail. The train was carrying haz-mat. It ‘sploded, sending a fire ball 300 feet into the air.

Wow. And I missed it. I slept most of the night. They are reporting that there is one dead and nine injured. Those poor people. God’s blessings to the rescuers and the victims.

You can get more details at: the Rockford Register Star

Update: Here is some more information from RRstar.com

“In Their Eyes” – From Guest Author – Randy Lovelace EMT-B

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Ladies and Gentlemen, Boys and Girls, EMS people and Firefighters,

I bumped this post up, because Randy’s such a darn good guy.

This post is placed with the permission of the author, Randy Lovelace EMT-B. He’s a friend of mine and a firefighter/EMT-B at a department where I work. He wrote this article after a training that our department completed and it was just published in our department’s monthly newsletter. I believe that the post needs more exposure, because it is just great. It exemplifies the camaraderie and community spirit that is embodied in our small-town department (that runs about 3k calls a year). We’re an anomaly, our small-but-proud department. We’ve got a fanatically devoted, passionate group of highly trained volunteer firefighters and EMTs that provide the best possible service to our citizens.

I’ve taken out the references to our department because I try to maintain my anonymity to provide another level of protection of patient confidentiality. It doesn’t detract from the piece.

Thanks Randy, great article.

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In Their Eyes

Last Saturday, May 30th, the Mid-Size Midwestern Fire Department held training for all members at the Greenlee Farm site. Everyone that came was kept busy with all the work of training evolutions, scenario management, fire control, safety, and finally, the actual burning of the house on the property.

Throughout the morning, people started coming out to the site to see what was going on and find out why there was so much activity. Many of those people, however, were family members of the firefighters. There were wives, children and significant others all interested in seeing what we do and how we do it.

For the firefighters, the activities were fairly fast-paced. Most of the training was geared towards fire suppression, which required teams to advance hose lines into the burning structure, identify the source of the fire and its fuel, and correlate the conditions inside with a method of fire attack that would result in the maximum possibility of success while subjecting the firefighters to minimum risk. Some new operators were manning the pump controls on the engines, others were shuttling water from the nearest water source to our site, and dumping it into porta-tanks for use by the firefighting teams.

Instructors, safety personnel, training officers and operations officers all worked throughout the morning, checking everything, verifying that all risks had been mitigated as much as possible, and that all planned training was taking place on time to previously determined standards.
For many of the firefighters running evolutions against the scenarios, this was their first time in a burning structure beyond our training tower. This was their first time fighting fire in scenarios where the fire could get away from them, and their first time in conditions where the heat was a physical entity – attacking you as soon as you entered the house.

Our probies proved that morning that they knew how to properly check their nozzle and hose line before entering a structure. They remembered that you turn the nozzle head to the right (for a stream pattern) to fight the fire, and verify you have water, not air, coming out that hose. They didn’t know that our primary interior training officer was intentionally setting the nozzle for a fog pattern every time a previous team got done, just to test what they did remember. Even our newest firefighters remembered that you position yourself outside the hose line as it turns around a corner, and they all got to experience what it truly meant to back up the nozzle man – that they were his eyes, his guardian angel. They learned how much they could ease the work of aiming the nozzle for the nozzle man, or make it extremely difficult to even hit the fire if they positioned themselves improperly. They demonstrated that although the fire was exciting, it was a known force, and they were to look for the unknown dangers lurking in this burning environment in order to protect themselves and their partner.

Our new firefighters all came to understand the reason for properly wearing all their gear even outside the burning building. They got to feel the immense heat of the fire from 10 yards away, and they felt how much their gear does shield their skin from that heat. They learned that a fog spray from a nozzle can create a magic barrier, insulating them from the heat and allowing them to complete tasks near the fire.

At the end of the day, we had probies and rookies saying they’d never been this hot, they didn’t remember a time when they were this tired. Firefighters of all levels of experience were drenched in sweat, looking for any place at all to sit down, rest and cool off. This day, everyone worked their tails off, everyone was tired, and most had aches of one sort or another.
It’s days like this when we could have been mowing our lawns or napping in a hammock that each of us asks, “Why do I do this? Why do I give up my free time to train so hard?”
The answer to those questions could go in many directions. We could say there’s nothing better to do, it’s for the adrenaline rush, it’s for the camaraderie, it’s to get far away from the Wife’s Honey-Do list. But, reflecting honestly, I think we work and train like this for a different reason. I believe a small piece of each of us wants to be a hero. I’m not talking about saving the world all by ourselves, and I’m not talking about the rush to disaster when all others rush the other direction. I’m simply talking about doing something that needs to be done, when it needs to be done, and doing it well enough that we end up making things better, not worse, for all involved parties. I’m talking about doing the right thing, serving our community doing things that others will not or cannot do.

The belief I’ve just stated, however, was modified on Sunday, the day after our training burn and all that hard work. I got a phone call from my daughter, relating something that happened between my son-in-law (a firefighter) and his son, Austin.

Austin was at the fire on Saturday, and he watched everything he could. His eyes were flashing in every direction, seeing what was going on, where the fire was, what the firefighters did to contain it, watching pump operators, watching hose line tasks, listening to the commander give instructions over the radio. He looked for his father, wanting to see what Dad was doing. When his father sat down, Austin joined him, assuming the same posture. And Austin had the biggest smile I’ve ever seen on a child’s face during that entire time.

When he got home, Austin wrote his father a letter, and drew a picture for him. The letter, transcribed exactly, read:

To Daddy,

Dear daddy I loved waching the fire. It was one of the most coolest things I ever sean. I sean a fan fall that was fun. When I get older I hope I am going to be a firefiter. Just like you.

From Austin

(transcribed with permission from Austin and his Dad)

After my son-in-law read this letter, he was quoted as saying “Aw Buddy, that’s great. Thank you. I love you, too!”

When this story was related to me, tears began to form in my eyes, and I started to understand that I just might be wrong about this entire process. These people I trained with on Saturday, they’re not probies and rookies and veterans and officers, these people are family. I don’t train with them, and go to calls with them. I work with them. I work to protect them. I work to accomplish things together that we could never finish alone. And they all do the very same for me. We nurture each other, we care for each other, we make each other better people that any of us thought we could be.

This firefighting family isn’t a replacement for my own kin. But they’re a perfect model of our families at home. We do the same things at the department as we do at home. We protect and nur
ture, we prepare, we train, we work at home just as we do with the fire department.
I realized that we say we have many reasons for being volunteer firefighters, but in the end, we do it for our families. We do this because we have a need to teach our own how important it is to do good things. We teach them that rewards aren’t always monetary, quite often, they’re heartfelt. We teach them that hard work can be its own reward. In this process, we get benefits as well. We raise children that aspire to be like us, children that are excited for what we do, even when they see how hard we work and sweat to accomplish our tasks. We’re teaching future members of society to love the work we love, and we are preparing them to replace us when we’re too old to continue the exhausting pace that firefighting demands. We’re teaching our children that success exacts a toll – exhaustion, aches, sweat, time. Success demands that we first be ready for a challenge before we can tackle that challenge. And we teach them the sweet taste of victory when we’ve done all that work. We provide them with functional families, homes with love and caring, places to be safe from the rest of the world.

As you prepare for Father’s Day on the 21st, take time to reflect on what you’ve just read, as well as the following concepts. Please note, the phrase “father figure” implies gender, but there’s no gender requirement to be a father figure.

1. If you mentor, you’re a father figure to the one benefiting from your tutelage.
2. If you lead, you’re a father figure to those you command.
3. If you’re the Fire Chief, you’re a father figure to the entire department.
4. If you have children, you’ve already met at least 2 of the previous tests.

For each of us, there’s one more benefit. Austin said it in his letter and all of our children have said the same at one time or another. We’ve already done what we’re still hoping to accomplish. In their eyes, we’re already heroes.

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Comments on this post will be read by the author. He deserves kudos.

Good Post on "Rescuing Providence"

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The good Lieutenant over at “Rescuing Providence” has written a good and touching post on one of the simple pleasures in EMS.

http://rescuing-providence.blogspot.com/2009/06/difference.html

Since the wedding (OMG! Today is my 1 week anniversary and I haven’t gotten Gkemtb a gift yet!) (Awwww, I think I’m gonna get a cavity) (Cuz I’m so sweet)

Where was I? Oh yea. Since the wedding I haven’t had time to write any long posts. I’m going to work on it today because I’m on fire shift and so far have been practicing for the recliner racing 500. That’s one of the reasons that I’ve been putting up so many short posts and have been linking to the other great EMS bloggers. The other reasons involve the fact that the EMS blogosphere has been getting really, really good lately and every darn EMS person in the world could benefit from the knowledge and wisdome being put out there every day by my peers in the EMS blogosphere.

Have a great day folks, stay tuned.

A warning to the EMS Blogosphere

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http://www.iemta.com/KEMSA%20Chronicle%20Article.pdf

The above link is to an essay written by a Paramedic from the State of Kansas who got into a very large amount of trouble by being less than flattering in a blog post that he wrote about a specific patient. There is no link to the actual blog that I know of, but in the above letter he stated that he broke patient confidentiality.

The hit he took was huge. He lost two jobs, lost his license for 90 days, and was almost barred from practice indefinitely. Two of his coworkers were suspended for writing comments as well.

Just a note for us EMS bloggers. Do not do not do not violate patient confidentiality, ever. Change any and all details. Not only is it good for your patients, it’s good for your career. I like the EMS blogosphere, and I do not wish for it to disappear because of any like incidents.

A post worth reading

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Kelly Grayson over at http://ambulancedriverfiles.blogspot.com has written a great article on a patient he had exhibiting Wolf Parkinson White syndrome.

http://ambulancedriverfiles.blogspot.com/2009/05/little-cardiology-geekery.html

His “Cardiology Geekery” was one of the best written and most educational articles on the topic that I’ve ever read. I learned something, and so should you.

Please come back though :)

Clean EMS – Lifesaving practices in Ambulance Cleaning

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Here is a shocking statistic: According to the United States Centers for Disease Control and Prevention (CDC) Nosocomial Infections (or Healthcare Associated Infections – “HAIs”) defined as “… infections which are a result of treatment in a hospital or a healthcare service unit, but secondary to the patient’s original condition” are the 4th leading cause of death in the United States. The CDC estimates that nosocomial infections sicken 1.7million patients and are responsible for 99,000 associated deaths each year in US hospitals alone.

Let me repeat those above statements. HAIs KILL almost 100,000 people and make around 1.7 MILLION patients sick and/or sicker PER YEAR in the US. If you don’t believe me, here is the page from the CDC website where I got those facts. I’m inclined to believe the CDC, however I question how many people are weakened from their newly acquired HAI which allows their original condition to worsen and kill them? This means that in the United States of America, healthcare people kill all of those patients every year because we’re not doing things like washing our hands well enough?

My grandmother always told me that a hospital is no place for sick people, looks like she might be right.

Every person spews bacteria, viruses, fungi, and a host of other things everywhere they go. Our skin crawls with Staphylococcus Aureus, microscopic mites, cold and flu viruses, and hosts of other microbes that flake off with our skin and hair. Our fecal matter is full of E. Coli which gets on our hands when we *ahem* clean ourselves. Our coughs and sneezes spew droplets full of germs in a wide radius. Pretty much every time we touch anything our hands pick up thousands (if not millions) of germs that spread to everything else we touch. We are walking, talking Petri dishes being used by all kinds of nasty germs as unwitting patsies to help them breed, move, spread, and infect. Put a bunch of people together and you have an infection control problem. Put a bunch of sick people together and throw in people with all kinds of weakened immune systems and virulent infections and you have a healthcare organization.

Now imagine that every movement inside that organization collects, incubates, breeds, and spreads bacteria. You’re in the hospital and the dietary tray comes by? It left germs. The nurse comes in and holds your hand? She left germs. You take a pen from the registration person? You spread germs. You sneeze? You spread airborne germs. Hospitals are one of the most effective tools that germs have in their arsenal of spreading themselves and causing the diseases that they do and while no exact statistics exist that I’ve been able to find to back up my next statement, Ambulances are probably worse. It makes sense to me because we’re in a smallish enclosed environment that goes all around town to lots of private homes, nursing homes, hospitals, and who knows where collecting various bodily fluids and other types of DNA samples from every person we put in the back (and/or the front). Factor in high call volumes that leave little time for proper decontamination, EMS personnel that have little understanding of proper disinfection practices and that are already overworked, overtired, and under-motivated to properly clean and you have a Mobile Infection Causing Unit (MICU? Cute)

Bottom line: Hour for hour, time spent cleaning your ambulances and your equipment may ultimately save more lives than time spent training.

Before I launch myself into a full-fledged rant on my obsessive-compulsive ambulance cleaning techniques, I think that I should tell you the point of this article. I want to lay out a few simple steps that you can put in to place on your next shift that will keep you, your coworkers, and your patients much healthier and happier. With a little bit of information on proper cleaning practices, you have the potential to make a very large difference in the long-term outcomes of your patients.

Here are some terms you should know:

  • Sterilization: (Also known as Terminal Sterilization): This is a term used to describe the total and complete removal of all forms of microbial life including bacteria, viruses, fungi, and other organisms in all phases of their lifecycle. Sterilization is accomplished by a few methods, two of the most popular being the heat and steam pressure used in an autoclave device and ethylene oxide gas however a long soak in a glutaraldehyde solution may be used. Sterilization is used for “Critical Devices” defined as tools or equipment that come into direct contact with the bloodstream or other normally sterile areas of the body such as IV needles, scalpels, and surgical tools.

  • High-Level Disinfection: This is a term used to describe a very broad-spectrum disinfection process that destroys almost all microbial life but may not completely remove all possible bacteria, viruses, or spores. It is usually accomplished by a prolonged soak in a liquid chemical sterilant but not for the contact time needed for terminal sterilization. This process is used for “semi-critical devices” that come into contact with mucous membranes but for which sterilization is not completely attainable or would damage the equipment. Examples of semi-critical devices in the EMS field include laryngoscope blades, Magill Forceps, and oropharyngeal airways (that thank goodness are now almost always disposable!)

  • Disinfection: This term is used to describe a process in which an environmental surface is first cleaned and then processed in a manner that kills a defined amount of known microbial organisms. There are two further loose classifications of disinfection practices below the above: “Intermediate” which is used for patient care equipment and surfaces such as EKG monitors, Ambulance cots, sphygmomanometers (OMG! I spelled that right the first time!! – It’s a bp cuff), stethoscopes, and other like equipment. “Low” level disinfection would be appropriate for environmental surfaces such as walls, floors, and countertops.

  • Sanitization: This process is defined as a chemical substance or process that kills 99.999% of a specific bacterial sample within 30 seconds but when compared to a normal use concentration a disinfecting agent will kill a broader spectrum of microbial life.

  • Antiseptic agent: This is a term used to describe a process that kills microbial life on living tissue, such as antiseptic soap or alcohol hand sanitizer.

  • Cleaning (or Pre-Cleaning): This is a process used with a detergent and a cloth or other friction-causing device that removes dirt and other gross contaminants from a surface. By removing the gross contaminants, you remove the food that microbes eat, the dirt particles that they hide in, and the biofilms that they create and thrive in. Most disinfectants and sanitizers require a pre-cleaning process in order to be effective.

  • Contact Time: The length of time that a surface must remain saturated with a sanitizer or disinfectant in order to kill the specified number and type of microbes desired.

Why did I go to the lengths that I just did to define such boring terms? Because it gives you an idea of how hard you should work to kill germs in the back of your ambulance. Bacteria and other like microbes grow, adapt, and change in response to various stimuli. There is scientific debate on the next statement but some of these changes may include developing resistance to the chemicals that we use to kill them. Remember, microbes are the ultimate adaptation machines capable of surviving almost anything anywhere. It takes a process to kill them all and to n
ot just kill the slower, weaker members of the microbial “herd”. Think about it, natural selection favors the strong organisms capable of resisting environmental change. Introduce a disinfectant improperly and all you’re really doing is killing the weak microbes and leaving the strong to survive and thrive on the added food source made of the microscopic corpses of their dead comrades.

Eww.

I may be nuts, but I clean hard. When I do my dishes at home by hand because on a medic’s pay I can’t afford a dishwasher (actually I’m just too lazy to install one) I thoroughly rinse my dish sponge, saturate it with water, and then microwave it for two minutes. I do this because a sponge is the perfect environment for bacteria to survive. It’s wet, dark, and warm. The heat and radiation generated by the microwave kill most of the bacteria that grow inside the sponge. Otherwise, all I’m doing is spreading new germs on my dishes. The same goes for cleaning my kitchen counters. Actual scientific studies (That I’ve learned about by reading this awesome column by Dave Barry) state that people who regularly clean their kitchens actually have more bacteria in them than people who don’t clean them much at all. It makes sense. With all of the wiping of surfaces and ineffective disinfection practices done in the home, microbes simply hitch a ride on the sponge or the cloth being used to “clean” and redeposit and breed on another surface. I’m sure they appreciate it.

Unfortunately, what happens in your kitchen also happens in your ambulance. Even more unfortunate for us and our patients, is that your kitchen usually isn’t exposed to MRSA, C. Diff, or Tuberculosis… or HIV, or Hepatitis B, or VRE… or hundreds more other microbes that I can’t spell properly. Start spreading those around and you’ve got yourself a rather deadly situation.

Needless to say, pretty much no matter how good you think you are cleaning your ambulance now you could be doing better. First of all, you should spend some time selecting the proper product for the job and pay attention to how it’s properly used. Fortunately, the good bureaucrats at the EPA, CDC, and a whole alphabet soup bowl of organizations have left you a trail. Always read the product label and instructions and look for the sentence that says “Using this product in a manner not consistent with its label instructions is a violation of federal law”. This is because it is the job of the Environmental Protection Agency (EPA) to regulate and test “Hospital-level Disinfectants” which are appropriate for use in EMS. The EPA tests these disinfectants which contain a wide variety of chemicals or combination of chemicals of varied efficacy against known bacterial cultures. It then measures the length of time that it takes the chemical(s) to kill specific organisms and the amount of the sample that is killed. It is important to remember that the disinfecting agent is only proven to be effective in specific concentrations in specific lengths of time. Any less than that and who knows what will or will not be killed. Also important to remember is that in the lab, they’re testing bacterial cultures without the presence of any dirt, proteins, or any other soil. Microbes hide in the pores of dirt particles, hide under proteins, and create “biofilms” that protect them against noxious stimuli. They’re the ultimate survivors, remember? Heck, even cockroaches get the sniffles.

So how do we translate this little bit of microbiology class into EMS? More importantly, how do we protect our patients’ and our own health by integrating proper cleaning and disinfection procedures into our shifts while still getting time for lunch? By arming yourself with a little more knowledge, and taking the steps that I’m putting forth below, that’s how. Proper ambulance disinfection doesn’t have to be a daunting task. It just has to be done properly. We also need to look over the volumes of cleaning and disinfecting products available as well and learn how to deploy them properly against our pathogenic enemies.

I can’t recommend any one cleaning product. (Although I would review them if they sent me a free case and paid me a lot of money to do so! Proems1@yahoo.com) However I have used a lot of them. My EMT textbook recommended bleach back when I went through my initial training. While common household bleach, which is a solution of the oxidizing agent sodium hypochlorite and some inert ingredients, is very effective in 1:10 bleach/water concentrations as a hospital disinfectant and in 1:30 concentrations as a sanitizer, it is fairly uncomfortable to use in the back of an ambulance. It can damage equipment and clothing and also can cause severe mucous membrane irritation and damage in humans. Bleach solutions are particularly affected by the presence of organic soil and require very thorough pre-cleaning for proper effect. I prefer to use commercially available hospital-level disinfectants that have a short-to-medium contact time against most pathogenic bacteria, viruses, pseudomonas, and fungi and also contain a detergent that can be used in the pre-cleaning steps. It is important to look at the contact time that it takes for the disinfecting agent to work against the microbes it is able to kill. Some products will advertise claims such as “Kills 99.999% of germs in 30seconds!” which is the definition of a sanitizer. However, if you look at the label directions, it kills 2 or 3 germs in 30 seconds but takes a full 10 minutes to be effective against HIV, Hep C, and pneumonia. Look for a chemical that is easy to apply, thoroughly wets the surfaces you’re disinfecting, and doesn’t dry too quickly in your environment. Lysol IC spray®, a popular commercial product, contains isopropyl alcohol and a benzyamoniumchloride compound. The isopropyl alcohol makes up the majority of the formulation and can sometimes dry too quickly to maintain effective saturation of the surface and therefore effective disinfection. If the disinfection product your agency uses dries too quickly, you should reapply it to keep up the proper contact time, or switch products.

My research in to the effectiveness of the popular pre-moistened disinfecting towelettes makes me cringe to think that they’re commonly used as the only cleaning and disinfecting procedure in a lot of places I’ve been to. I have yet to find one of these products that are soil tolerant enough to not require a pre-cleaning step prior to disinfection and I’ve never seen one that leaves behind enough moist product to maintain saturation to the contact time without drying too early. This may be an effective way to pre-clean and maybe sanitize, but I’ve not found one that can be an effective disinfectant with the ineffective contact time. They simply don’t do a good enough job as a disinfectant. However, their big advantage is that by using multiple towlettes on multiple surfaces you’re preventing cross contamination by simply throwing away a dry towlette and using a new wet one on the new surface. It’s the same principle as the people who don’t clean their kitchens often having less infected surfaces than those who continuously spread the germs around. Be careful though, how many times have you seen someone in the ER give the bed a quick wipe, not even wet 100% of the surface area, and then hastily throw on another sheet so they can get another body on the cart?

In the ambulance, I recommend bringing good cloth towels. Use at least 6 or 8 of them. You have to do a pre-cleaning step to remove gross contamination and eliminate the soils that will cause whatever disinfectant you use to lose effectiveness. If you use a combination cleaner/disinfectant you can use it for both a pre-cleaning and then a thorough wetting soak. However for the cost conscious I recommend using a good regular detergent for pre-cleaning because they tend to be cheaper and more effective at dissolving grease and removing soils. Be sure
to change towels often and use proper Body-Substance-Isolation (BSI) to protect yourself from the germs back there. After pre-cleaning, thoroughly saturate each surface in the ambulance with a proper hospital-level disinfectant and watch to make sure that each surface stays thoroughly saturated for the full contact time. Reapply it if necessary. Remember, if you’re not leaving the product on there to do its job, you’re not really doing anything but making the microbes angry. Pay special attention to commonly touched surfaces in the ambulance, such as door handles, radio microphones, the handles on the ceiling, o2 connections, drawer and cabinet handles, and the steering wheel. I even disinfect the handle that’s on our hand sanitizer dispenser. It gets touched a lot with filthy hands. My biggest tip? Take a vacuum into the back of the rig with you to suck the big garbage and dust out of the cracks and crevasses before you pre-clean. It works great and makes it simple to do a great job.

Patient care equipment should be disinfected after every use. Remember to clean and sanitize monitor cables, stethoscopes, BP cuffs, splints, backboards, head blocks, spider straps, cot straps, and anything and everything else we use. Your patients’ lives depend on it. So could yours.

Remember: Be sure to take the time to wait for the disinfectant to do its job. Pay attention to contact time. Always remember a pre-cleaning step. While some minimal soil can be ok, anything that is visibly dirty or that hasn’t been cleaned all shift should probably be pre-cleaned.

Whew! This was a long one. If you got this far, be proud. Remember. Plumbers have saved countless more lives than doctors. Doctors treat disease, plumbers carry it away to prevent it altogether. Next time you see an “Environmental Services” person in the hospital, thank them for being the life savers that they are. Every bit helps.

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Related Posts:

“The Shine Factor” – One of my first, and best, articles.

Reference Material:

http://en.wikipedia.org/wiki/Disinfection, http://www.wcponline.com/column.cfm?T=T&ID=1482&AT=T, http://firechief.com/ems/ambulance_transports_0301/, http://en.wikipedia.org/wiki/Nosocomial_infection, http://www.opticide.com/tb111503.htm, http://www.cdc.gov/ncidod/dhqp/hai.html, http://www.futurehealthcareus.com/?mc=appropriate-selection%20&page=ps-viewresearch, http://www.miamiherald.com/living/columnists/dave-barry/story/861087.html

EMS Week 2009 – Letter to the Editor

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*** Note!! – I’m getting a lot of traffic sent by Google looking for EMS Week thank you letters. There are more than one on this site. This is just the one that was indexed first and pops up first. Look at the home page to see more.

Here is a letter to the editor that I sent to a local paper in honor of EMS week. You may change the name of the service and the geographic location and use it for your service if you wish. EMS Week is May 17th through the 23rd 2009.

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You may never give it a second thought but we’re here for you. When the unthinkable happens Emergency Medical Professionals are standing ready to swoop in and help you and your loved ones. Whether it’s a serious medical condition or accident, EMTs and Paramedics are quietly and heroically performing lifesaving tasks in our communities every day.

EMS Week 2009 will be celebrated this year the week of May 17th to the 23rd. It is a national awareness week highlighting the vital services provided every day by the Emergency Medical Services professionals throughout every community in the United States. Here in (GEOGRAPHIC AREA) we are lucky to be served by dedicated EMTs and Paramedics who give of themselves in many capacities to ensure that our lives are protected.

The (is the 911 ambulance provider for the (GEOGRAPHIC AREA). In addition, we provide (SOME OTHER SERVICES IN SOME AREAS). We would like to thank the citizens in our service area for all of the support that they have given us in the past and would like to take this opportunity to express our continued passion for health in our community. We pledge to continue providing the highest quality Emergency Medical Services and Medical Transportation and to continuously find new and innovative ways to improve our quality and service to our community.

In order to do this we are calling on our citizens to support us by taking a few steps of their own. First, everyone should learn CPR. It is a simple and easy way to make a big impact in the lives of your neighbors and loved ones. With the odds of surviving sudden cardiac arrest decreasing roughly 10% per minute without adequate CPR and Defibrillation, good early CPR saves lives. If everyone knew this lifesaving skill just think of what we could do and who we could save. Please contact our office or your local hospital to find out about upcoming classes.

Second, everyone should learn the warning signs for heart attack and stroke. Studies have shown that 60% of people call a friend or family member when they realize that they may be having a serious medical problem. You should know that approximately 1% of cardiac tissue dies per minute in an untreated heart attack. Paramedic ambulances provide lifesaving medications that can stop or slow down this damage and can be at your side within minutes of a call to 911. This treatment is not only lifesaving, it also can greatly improve your quality of life after the attack.

Again, thank you to our citizens for their support. We encourage the public to say hello to our EMTs and Paramedics as they see them around town and also to contact our office for more information on any of the above topics. Please also see our website at Http://proems.blogspot.com

Sincerely,

Ckemtp NREMT-Paramedic

Anytown Ambulance Service and Malt Shop, Inc

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

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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

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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

 

Follow Up to the Shine Factor – Grunts: Part 1

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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

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The other day I determined the most important piece of equipment in my ambulance for the day. It varies from shift to shift, you see. Sometimes it’s one of the sexier tools we carry, like the IO (intraosseous – Into bone marrow) drill or the $25k cardiac monitor. That day, it was definitely NOT sexy but nonetheless it attained the status of the most important piece of equipment of the day. It was (drum roll please): The emesis basin.

For my non-EMS audience (Yes!! I’m getting one!! Keep telling your friends!!) “Emesis” is a medical term for “Raalllpfffegh” or, more technically, “barf”. It’s puke, vomit, throw-up, and the like. It’s something that, (apologetically) has been mentioned a few times in my writings. For EMS people, as I keep saying, it tends to be an integral part of our careers. The “Emesis basin” is a polite, professional term for a puke bucket; A portable version of the Porcelain Goddess that people pray to on hungover mornings if you will. Having one on the ambulance is necessary for a lot of reasons, none the least of which is to keep the puke out of your shoes. If you ever want to see a medical person scramble, and I mean any medical person, yell that you’re going to need an emesis basin quick like.

Quick sidebar story: The other day I was working the clinic when a patient asked for someone to come into his room. He said “I think I’m gonna throw up!” and he definitely looked like he wasn’t kidding. The problem was, when calculating his probable trajectory; I saw that he was aiming for the exact ground level cabinet where the emesis basin was stored. I had to act fast. I sprung into action, diving commando style towards the cabinet. Seconds ticked like hours. Quickly I opened the door and grabbed for the basin, cursing myself in my head for the lack of dexterity I had in getting the basin out the door. If only I had more time! I could…

Yes, he puked on me… Only a little bit though… He just peppered my scrubs a bit with splatter off the floor.

So anyways, the emesis basin was the most important piece of equipment on the ambulance the other day. The patient needed it and needed it right then and there and I got it for her. Luckily for me we had one. Yep, we had ONE; Just ONE bucket that I used ten minutes into my hour long transfer. It was my fault too, because it was my ambulance for the day and therefore the responsibility to check the stock levels and functionality of the equipment was mine and mine alone. The fact is, though, that the emesis basin just isn’t on my mental list of things that I absolutely have to check. I check the biggies really well every shift. I make sure that there’s plenty of EKG electrodes because I really like 12-lead EKGs and I’ll do the fancy right sided ones when I think that they’re necessary. I check to see that we have a good supply of all sizes of IV caths just in case I need to turn multiple people into pin cushions. I check the airway stuff religiously, and even do a monthly op check on my monitor every shift just to make sure it works. That, and I follow our check list to the letter every time.

But I took the emesis basin count for granted, and it almost cost me another vomit bath.

Now, I’m not shying away from my responsibility to check out every piece of equipment on my truck before I head out the door every morning, but really if I was down to my last basin, so probably was the crew before. Since I don’t think that they had to use one, so probably was the crew before them. Then it goes right back to me, when I probably didn’t check it that shift either. More of my fault there then.

Luckily I had the one that I did.

I would wager that one of the most annoying things that can happen to an ambulance person is to find out that you’ve run out of something you need at the worst possible time. Everyone hates that. If it happens a lot it can really tear down The Shine Factor of your organization a lot. It makes the EMT that it happens to blame themselves a bit, but also blame their coworkers a lot more. Nobody likes to bear the blame entirely on themselves so they rationalize that while they may have not exactly checked that exact piece of equipment, the previous crew obviously didn’t either. Then anger starts, and eventually apathy blooms.

Here’s what a grunt like me can do to put an end to this: (Yes, very very simple, I know) Check your freaking truck!

I don’t mean check it like you are told to do per the rule book, I mean check it out thoroughly every single shift. Pull everything out. Make sure that it works. Make sure you know how to use it (couldn’t we all use a refresher on the traction splint?) Make a production of it to whomever happens to be around to see you do it. While you’re doing it, take the extra minute or two to spray something on the surfaces and wipe them off with a towel. It may not be a full decon, but it at least make things cleaner and more sanitary.

A strange thing will happen here, I guarantee it.

First, you will KNOW for sure that your truck is in tip-top response readiness. You can’t fix the fact that it may have 200k+ miles on it, but you sure can make sure that you’ve done your part. It’s a good feeling. Trust me.

Second, you’ve now just picked up a big part of the responsibility for increasing the shine factor in your organization by taking away a big potential aggravation spot for your other crews. They may not deserve it all the time… but at least you’re doing your part to keep everyone happier and to make sure that every patient in that ambulance doesn’t have to suffer additionally from the lack of needed equipment.

Third, by making this a production, and even by turning this into a game, you’ve single-handedly improved the overall care that your organization provides and therefore the pride that your coworkers have in the service. If you do your best truck check, and then challenge another crew to find something that you may have missed, you’re pulling their pride into it too. Make it a bet. Put breakfast or something like it on the challenge. Their pride is on the line too, and that will get them invested.

At a service I worked for in times past, we always stayed with the same truck day in and day out. Since I’m pretty much OCD on truck cleanliness, I got into a competition with another medic from a different station that was riddled with the same OCD that I was. We polished, shined, cleaned, vacuumed, and tried to generally outdo the other with how brightly our truck shone in the sunlight. If I would have had the ability, I’m sure that we would have taken surface cultures to see how sanitary our trucks were (and THAT would be a great topic for an upcoming piece!). That competition put our personal pride into making our trucks the cleanest and shiniest they could be. Once we were invested personally, our pride inspired us to clean the trucks better than any management policy ever could. In fact, management’s best option to further motivate us would probably have been to offer prizes and recognition for the competition. Positive reinforcement other than negative sanctions that there would have been. It works.

Here are some things that I resolve to check each shift:

  • The batteries in my ear thermometer
    • And I’ll make sure that we have the little cover things too
  • I want at least two of every size ET tube in case the first one gets all mucked up
  • Every blade too.
  • I’m actually going to get out the test solutions and calibrate my glucometer. (Yea, when was the last time you did THAT)
  • The child car seat.
  • The portable suction unit, both manual and mechanical.
  • The cot. I’ll bet that the one you’ve got needs at least ONE thing tightened and has at least ONE speck of blood on it.
  • The number of towels in the cabinet. Does anyone else put one on their knee when they
    kneel down at the side of the cot and put the patient’s arm on their knee to cushion the bumps? How many times have you had blood run down on your pants? Now, be honest, how many times have you just felt it easier to walk around that way for the rest of your shift? (Guilty. Ewww)
  • Every other little thing, too.

As always, “Get out there and polish some chrome”

 

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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

Why am I doing this??

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

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

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

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

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


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