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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.

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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

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

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

Guest Post – An Open Letter to Wisconsin Physicians Concerning Do-Not-Resucitate Orders

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This is a guest post written by a local paramedic that has an important message to get out about Physician involvement with Do-Not-Resuscitate (DNR) Orders. I’ve included it in its entirety. It’s an important issue. It takes such an emotional toll on the EMS providers and the families of our patients. Please share this with your colleagues and loved ones.

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An open letter to the Physicians of Wisconsin:

“Medic 1, Engine 7 respond to 123 Anystreet for a male unresponsive. Time out 21:19.”

This simple statement spoken by a dispatcher starts a series of events that will place an EMS crew in a moral dilemma, a family in a confused and angry state, and a personal physician sitting at home, unaffected. As the responding EMTs and Paramedics enter the home in response to this call, they see an elderly female cradling an elderly male in her arms. She is sobbing and distraught. The elderly female holds in her hands the lifeless body of her life long partner and soul mate who seems to have finally given up his long suffering in this world. The lead EMT quickly approaches the patient and finds that the patient is in cardiac arrest. The female states that she always knew that he would die in her arms. She states how long and difficult these last months have been with his terminal illness creeping into their lives and stealing her husband away. The Lead EMT asks if the patient has a DNR (Do Not Resuscitate) order. The wife states that he does. A quick check of wrists and ankles does not produce the state approved DNR bracelet. The EMT’s crew stares at Lead EMT looking for direction. They know that unless there is a valid DNR bracelet on his wrist they must start CPR and perform life saving measures. The Lead EMT knows that the clock is quickly winding down, they must act soon. She asks the spouse again about the DNR and where it might be in the house. The spouse states that there is a copy of the DNR at the hospital. She states that she filled it out at the months ago at the doctor’s office. The spouse says, “I never got a bracelet. The doctor knows that he didn’t want anything does, can’t you call him?”

Meanwhile, a county away, a physician sits at his desk, dictating the notes of the day. He is completely unaware of the drama that is unfolding in the darkness of night and the darkness that is enveloping one spouse’s life. This physician has practiced medicine for years, graduating medical school in the early 1960’s. He has been kind, caring, and concerned for every patient he has seen and is highly regarded within the medical community. When he first started in medicine, ambulances were simply Cadillac station wagons that whisked through the night. They moved the sick and injured from point to point without offering much more than a fast ride. Over the decades the rules changed, medical advances occurred, and now an ambulance is a rolling emergency department with full advanced life support abilities. Unfortunately, unless a physician takes an interest in EMS this change has occurred without notice.

The lead EMT removes the patient from his spouse’s arms. They move him to the floor and start CPR. The crew has no choice, they have no valid DNR order and they have been summoned by a 911 call from the spouse. The spouse screams at and pleads with the crew to stop, she doesn’t understand why this is happening. Her husband has filled out papers; they have them on file at the hospital. She thought this wouldn’t happen. The spouse watches as I.V.’s are started, defibrillator pads applied, and an endotracheal tube is placed into the airway of her spouse. The spouse is now frantic. This was never supposed to happen. Why aren’t the EMT listening to her? She knows what her husband wanted, they were together for over 50 years. Medications are now being given and the EMS crew is trying to coax a pulse out of a tired heart. The crew shoots looks at each other questioning what is right and wrong.

The lack of a DNR order puts EMS crews in a terrible moral and ethical dilemma. They must proceed as the law states; but their hearts are heavy and they are unsure if they are truly doing the best for the patient or the family. They sat in on the trainings years ago about the DNR bracelet. The instructors said it would eliminate these situations, patients would speak to their personal physicians, sign all the necessary forms, and then the patient would be issued a DNR bracelet that would clearly state the patient’s wishes. Yet time and time again, this scenario repeats itself and each time the frustration grows.

After 45 minutes of CPR and three rounds of ACLS medication, medical control is contacted. The ED physician is advised of the situation and advises the crew to terminate all efforts. The crew cleans up and a mournful wife sits by her husband’s side again, holding his hand. This is where she wanted to be all along, just holding his hand and looking for support in this darkest time in her life. Instead, she had to witness the brutality of a full ACLS code. The ribs breaking, the I.V.’s being placed, the monitor screaming out orders in its electronic voice. The peaceful, honorable death she had hoped for has been taken from her, she will now have the visions of CPR and strangers doing procedures to her husband that neither of them ever wanted. These are events that we can never go back in time and change.

Our physician is now walking to his car. Rattling through his pocket looking for keys that he can’t seem to find. He will receive a call later tonight from the county coroner explaining what has happened. He will be honestly horrified to hear of the efforts by the EMS unit and will wonder why this has happened. Ironically, he doesn’t know that he set these events in motion years ago by not securing a DNR order for his patient that EMS crews are able to honor.

“Medic 1 and Engine 7 are clear, no transport, coroner on scene.” This will be another long ride back to the fire house. Emotions are running high, the crew is upset. They can’t figure what is making them angrier, the fact that this happened or the fact they know it will happen again. The cycle continues.

I would ask that each primary care physician look into the laws as they apply to DNR orders and EMS providers in the State of Wisconsin. We do not have the luxury of time. We must make decisions within seconds. We NEED the DNR bracelet. All we need to know is “yes or no” to CPR. We have NO time to read through long winded orders or other legal documents. This is a problem that we must fix and fix fast. You have the power to fix this. Please do so.

Respectfully,

Todd A. Bluhm, Paramedic

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Posted by Ckemtp on December 3, 2009 • Filed under: 911 fail, DNR, Do Not Resuscitate Order, EMS, EMS Topics, EMS ethics, EMS rant, EMT, EMT-Intermediate, EMT-Paramedic Specialist, Emergency Medical Services, Fire Rescue Topics, Paramedic, Patient Management, cpr, cpr fail, crisis, emotions, ems 2.0, medical ethics, patient care, physician, professionalism, rant, southern wisconsin

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?

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

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.

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

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.

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

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

Someone Failed… Is it the System? Everyday EMS Ethics

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A tempestuous night is blowing outside the station walls. The cold night air is stirred wildly, blowing splatterings of rain against the glass window of my bedroom. The wind howls through the trees conjuring up fantastic images of the disturbed environs of the world outside my bunk room. Having gone to bed early, I cannot remember the dreams I must have been having but judging from the fact that my sheets were in such disarray when I awoke, they must have not been pleasant.

I awoke to a familiar but unwelcome voice, the night shift dispatcher coming from my radio. He spoke of a seizure in the next town over. The local ambulance service from that jurisdiction was calling for a paramedic to intercept and assist them with their call. I was due, it was my turn to be ripped from the warmth of my bed and respond to their aid.

I pulled on my clothes and zipped up my shoes. Since whomever controls the seasons in my area has decided to outright skip Fall and move straight to Winter I pulled on a jacket as well. Stepping out into the night air I halfway expected there to be a late September frost on the ground. As I started my truck and keyed the address into my GPS I cranked up the heat to stop my shivering. Hopefully this wouldn’t be too challenging for me in my sleep deprived, freshly woken up state. Hopefully I can wake up enough to safely drive. I shook my head violently to clear the sleep from my bleary eyes and keyed up the mic:

“Dispatch, Medic 84 is enroute to intercept Anytown”

The night shift dispatcher answered me and I switched to Anytown’s frequency:

“Anytown, Medic 84 is enroute to your scene”

With the red lights flashing over my SUV I pointed out into the deserted city streets. Anytown was about ten miles away from my station over country roads. The address was a few miles into their city limits. Curiously, the address they called me to was just a few short minutes from Anytown Hospital and it was strange that the EMT-Intermediate volunteer service had called me to an address where they would usually just scoop and run ILS to the ER. I figured that this must be one of those “Seizures” where the patient seized because of the fact that their heart stopped. People will oftentimes have a seizure when their heart does something funky, like stop, and blood flow is slowed or stopped to their brain. An old paramedic instructor I had once put it this way “Brains need blood flow to be happy, stop the blood even for a second, and the brain gets pissed off”. Everything seemed to get pissed off to that guy. An MI causing arrythmia was a “Pissed off heart”. Diabetes was a pissed off pancreas. A drunk at the bar was pissed off at his liver and so forth.

I wondered what this patient had that was pissed off for her.

The roads were open but the night was pitch black. The wind was blowing my small SUV in all directions but straight. Thinking that this was probably a bad call, I pushed the gas as hard as I felt was prudent with the driving conditions. I didn’t meet any traffic to get in my way. Just as I was coming into their town, a familiar voice crackled over Anytown EMS’s frequency:

“Medic 84. We still need you to respond but you can slow it down to non-emergent. We’re short an “I” and it’s going to be you”.

Ohhhh, so they couldn’t staff the truck fully and responded using me to make their full crew. Now I understood. Anytown EMS is a good service with dedicated people, but sometimes even the best volunteer service needs a hand. That’s what mutual aid is for. We have an arrangement with them in such circumstances so that our intercepting paramedic can make up a full crew for them by partnering with one of their EMTs.

I turned off the lights and just cruised silently through their deserted town. Yes, I popped the lights on momentarily to get through a couple of stop lights, but who’s counting, right? Arriving on their scene the EMT came out to me and said:

“You don’t need to bring anything. This is her third ambulance ride in 24 hours. She spilled a glass of water and (a family member) called because she thought she was “having a seizure” and needed to go back to the hospital”

Oh, now I remember this address. I don’t even work for this town and I’ve been here like umpteen times this year. The patient is one of their frequent fliers. Every community has them. I swear, without our frequent fliers we’d be short like a thousand annual calls. Think of the sleep time I could get.

Climbing up into the ambulance, I met the patient for the umpteenth time this year. She was in no distress and this is where her part in the story ends. My question isn’t about her. Honestly, the question here could be about any frequent flier in any community that has an ambulance response.

Why do we have them? Why do they depend on us so much?

The patient in this example had been to the ER twice already in the previous twenty four hour period, both times being transported by EMS and both times being taken home in a private car by family. Both previous times she had called her General Practitioner physician and had been referred to the ER because she said the word “seizure”. I can hardly blame the GP for recommending she call 911 rather than phone triaging her and suggesting she come into the office. But remember, it’s not about her. I can think of probably ten patients right now that I would consider to be among my personal roster of repetitive patients (I only have ten fingers) and their use of the emergency healthcare system for management of their chronic complaints is staggering in comparison to the use of it by the general population. Last year, every shift for two months we would respond to the same gentleman’s house to wake him up by popping in an IV line and giving him some D-50. We got pretty tired of it, as you can imagine. Most people with diabetes manage their illness pretty well and only occasionally need the assistance of an ambulance crew. This guy chose to manage it by drinking hard alcohol. I swear that I wanted to just leave the IV in place so that I wouldn’t have to start one the next day.
We fixed it by refusing to treat him on scene and release him anymore. It is common practice in my area to “sweeten up” a comatose diabetic with low blood sugar by popping in an IV and giving IV sugar (D-50), or in milder cases, by giving them high-sugar foods and making them eat until they regain full mental faculties. Once they regain their senses, all but a few of these patients sign a refusal of treatment form and do not wish transport to the ER. However, for this patient, we would find him unresponsive, so we would pack him up, move him into the ambulance, start the line and sugar him up while enroute to the ER. Once we were transporting, he couldn’t refuse to go and would end up at the ER for hours. Finally, he started managing his diabetes better because it was more convenient than waiting at the busy, urban ER we would take him to (yes, it was the closest. I work in many different jurisdictions).

However, the above solution just passed our problem we were having with the ambulance response onto the already overburdened Emergency Room. Yes, it “solved” the problem by increasing the patient’s level of personal inconvenience (although we still go to this guy about once or twice a month), but at what cost?
Who or what is causing the failure for these people? Who or what is causing the failure for this whole patient population? Is it the system that fails to adequately educate them on how to properly care for themselves or cure their ailment? Or is it the patient who is unwilling, or incapable of caring for themselves?

For both of the above named patients, socialized medicine already exists for them. They’re wards of the state as far as healthcare is concerned. One of them owns a house, one of them is in a free, government subsidized apartment, one
is in one state, the other is in another. You and I pay for their healthcare and almost their every need.

Is this the system’s fault? Is it their fault? Who should pay for the failure?

I’m writing this after coming back into my bunkroom and finding my sheets and blankets twisted into a ball. Everyone else in the house is snoring because of the abrupt weather change. (and DDex, if you read this YOU FREAKING SNORE WORSE THAN NACHO!) Whatever dreams I was having before this call came out must have been strange.

Until the next…

—————————————-
Update:

My blogger buddies Happy Medic and Medic999 took off from this post and wrote their point of view on their respective blogs. Here they are. Join the discussion.

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

Posted by Ckemtp on September 29, 2009 • Filed under: 911 fail, ALS Intercept, Ambulance, EMS, EMS ethics, Paramedic, edemse, emotions, medical ethics, politics, socialized medicine, universal healthcare

Still more Everyday EMS Ethics – Gkemtp(it) is born

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I’ve been on this kick lately for medical ethics in EMS. So, I’ve decided that “Everyday EMS Ethics” is going to be a featured area on my blog. I think that It’s annoying my wife Gkemtb who, by the way, is starting Paramedic school today and is now becoming Gkemtp(it). The (it) means, “in training”.

The unfortunate thing is that she’s now reading her paramedic textbook and she’s asking me ethical questions as she’s studying medical legal aspects of paramedicine. Tonight, she asked me this question:

Imagine you’re in the back of an ambulance with a patient on a long-distance transfer. During the transfer, the patient states to you: “I think that I’m ready for my life to end. I’ve had a good run and I’m just comfortable with the idea of the end of my life. If I die, don’t do anything to bring me back. I’m ready to go”.

I said, “Well… it depends. Is the patient in his right mind?”, “How old is the patient?”, “is this a suicidal ideation? Or is this someone who might be getting ready to sign a DNR but hasn’t yet?”. She indicated that in her mind, it was an elderly person with a long medical history. If it was someone that was possibly mentally ill… the likelihood of which increases with decreasing age and better long-term prognosis, then I wouldn’t honor it just the same as you wouldn’t kill someone who asked you to kill them because they wanted to commit suicide. However, if it was, say, a long term brain cancer patient that had metastasized and was causing great pain… then it’s a different question. Ultimately, if I was the only person that the patient said it to, I would try to get them to say it in front of other witnesses. If that couldn’t happen, and the patient did in fact go into cardiac arrest… well then I would probably resuscitate them because I would never be able to prove that I acted in accordance with the patient’s wishes. But I wouldn’t like it. Please tell me what you would do, because heck, I don’t know…

The other thing she brought up was if I knew about the “Oath of Geneva” and um… I didn’t know about it.
A quick Google search brought it right up for me, so here it is:

Physician’s Oath

At the time of being admitted as a member of the medical profession:

I solemnly pledge myself to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude which is their due;
I will practice my profession with conscience and dignity; the health of my patient will be my first consideration;
I will maintain by all the means in my power, the honor and the noble traditions of the medical profession; my colleagues will be my brothers;
I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;
I will maintain the utmost respect for human life from the time of conception, even under threat, I will not use my medical knowledge contrary to the laws of humanity;
I make these promises solemnly, freely and upon my honor.

According to the article I read on it, which surprisingly wasn’t from Wikipedia this time, and is located at (http://www.cirp.org/library/ethics/geneva/) this oath was adopted by the World Medical Association (A group made up of National Medical Associations… well, read it yourself:

The World Medical Association is an association of national medical associations. This oath seems to be a response to the atrocities committed by doctors in Nazi Germany. Notably, this oath requires the physician to “not use [his] medical knowledge contrary to the laws of humanity.” This document was adopted by the World Medical Association only three months before the United Nations General Assembly adopted the Universal Declaration of Human Rights (1948) which provides for the security of the person.

Paramedics come from physicians. Therefore, I believe that we are to honor much of the same ethical standards as they are. Healthcare is an honorable profession. We have the obligation to carry it on that way.

Sorry about the serious posts lately guys J I’ll go back to posting about driving fast and kneeling in poo soon.

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

Posted by Ckemtp on August 27, 2009 • Filed under: Ambulance, EMS ethics, EMS paramedics, edemse, medical ethics, scenario, whattaya do

Everyday Ethics for EMS Providers

Comments

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

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