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Since sometime in the 1970s the month of April has been recognized as “Autism Awareness Month” with April 2^nd being “World Autism Awareness Day”. It’s a time dedicated to increasing awareness of this disorder that is affecting an increasing amount of the population. While just how many people may be affected is up for debate, the prevalence is growing. So much so that last I heard, 1 in 50 kids are born with a varying degree of the disorder.

You’ll hear different statistics out there than the 1 in 50 I just quoted since there is disagreement between various camps in the Autism Community. Understanding, diagnosing, and much more so treating autism is difficult by the fact that “Autism” is a blanket term covering the many manifestations of “Autism Spectrum Disorder” (ASD). ASD covers a complex array of conditions, symptoms, and behaviors that someone diagnosed as being “Autistic” can display. People “on the spectrum” can be minimally affected, or “high functioning” or can be “low functioning” if they are profoundly affected. I can’t claim to understand it myself and I’ve been as immersed in it as I’ve ever been over the last few years.

Yesterday was “World Autism Awareness Day” and I’m posting this article on April 3^rd. You may be wondering why I didn’t post this up yesterday instead of the recap of the fake “news” stories I posted for April Fools’ Day. I waited for two reasons: one being that while Autism affects my life and my family it is still important to show that life goes on every day. Humor is a big part of our family life out of both fun and necessity. Another reason is that I believe there isn’t anyone reading this that isn’t “aware” that autism is a thing that exists. I can’t imagine there is an EMS professional out there who isn’t aware of autism but if you’re not, here’s a link to the Wikipedia page on it, and here’s a link to the Autism Society of America. Go read and become aware. In fact, it’s probably a good idea to go read and understand more about ASD anyway. There is a lot to know. ASD is challenging and complex and even the so-called (and especially some of the self-proclaimed) “experts” may not know as much about it as they claim to. I’m no expert by far and I want to stay out of the politics of the debate so I’ll just say this. If you’ve seen one person with “autism” you’ve seen one person with autism. Every person is an individual and there is no one right way to think about how every person will manifest their symptoms.

So since you’re all aware of autism now, let’s get to the point of this post: increasing acceptance, understanding, and respect. I’m glad that we’re all aware that autism is a thing, as would most parents of children who are somewhere on the spectrum as well as the people who are on the spectrum themselves. However, I’m sure they would be even happier if they could simply run an errand with their child without having to fear the reaction of other people in public. I’m sure they would really appreciate people not reacting to them or their child out of fear and ignorance should the child manifest typical behaviors or make noise when they go into a restaurant to eat a meal. As a paramedic, I can say that we would really appreciate not having to live in fear of calling 911 and having the responders have absolutely no clue of how to behave towards our son. That’s what I’d say people whose lives are affected by autism really want. While “awareness” is super-neat and all, let’s move on to the next step of making life a little less hard for everyone. Chances are that nobody reading this blog is going to be capable of finding an effective treatment, but everyone reading this can do their part to make the disorder less of a bad thing by working on their own behaviors towards people on the spectrum.

As you may know, my girlfriend Amy has been a huge blessing in my life. Her son, Connor, has some special needs, one of which is being on the autism spectrum, specifically diagnosed as PDD/NOS or Pervasive Developmental Disorder/Non Other Specified. Living with Connor has changed my life in many ways and has taught me more about myself than I thought I could learn. I’m different now, and hopefully it’s for the better. ASD is very complex and I’m as aware of it as I think I can be but I wasn’t always this way.Amy has shown me a lot that I didn’t know I didn’t know. When Amy and I were early in our relationship, she used to come and ride with me on the ambulance on a somewhat regular basis. EMS was as new of a world to her as her world was to me and while never really got anything all that complex while she was riding with me, we did have one call that stands out.

We were the 911 service for a smaller city where everyone knew everyone and the public safety community all hung out together. It was normal for the police, EMS, and firefighters to eat their meals together and we all listened in to each other’s radio frequencies. So one day when I heard the police get called to the local supermarket for “A child wandering the parking lot alone who appears to have autism.” We decided to head over there ourselves with the ambulance to see if we could lend a hand. Amy was with us and she was very interested, and I was the shift officer and approved of us jumping the call.

When we arrived, we found the police out with a male child who couldn’t have been more than 10. He was very afraid of the police, appeared to be non-verbal, and was walking away from them whenever they approached him. When we arrived, he was walking back into the store. I walked up to the police sergeant and offered our assistance. I told them that our ride-along had a child with autism herself. That seemed to be enough for them. They parted like the Red Sea and let Amy take charge without knowing her from anyone. We followed the kid through the store keeping a respectable distance and watched him as he searched the aisles. Finally, the boy walked up to a man who was perusing the frozen foods section and got uncomfortably close to him. Being “official” like I was in my EMS uniform, I stepped between them until Amy grabbed me. “That’s his dad Chris, chill out.”

It was his dad and he was not aware of the fact that two paramedics, three police officers, and a ride-along were very concerned about what his child was doing wandering the aisles and parking lot of a grocery store. The kid hadn’t done anything wrong and neither had his father, but we were all highly aware of the fact that we were uncomfortable dealing with a situation that was normal for the father of the child. Sure, he probably should have been watching the kid more closely, but how often would the parents of a typically developing child let their 10 year old walk alone in a grocery store. I’m not overprotective and I know that my 9yo step-daughter is capable of fending off kidnappers should I let her go pick out a box of cereal while I look for a gallon of milk… should this father be condemned for the same?

This event got me thinking that I really didn’t know as much about autism or the world of special needs children, but an event Amy and I shared later really hit home for me. We were watching Annie, the girl-child, play a little league game in a local park when I saw a man mowing his lawn which was adjacent to the ball field. He mowed row after row of grass all with a teenage boy following him in lock step about 3 feet behind. Back and forth they walked together silently, the man mowing and the boy following. I thought it was odd but Amy’s perspective snapped me into focus, “He must not be able to leave his son alone in the house while he mows his lawn. I used to have to mow my lawn at night when the kids were in bed because I couldn’t leave Connor alone for that long.”

At that moment, I realized that there was a whole world I didn’t know about. Even though I had been a paramedic for years and thought that I knew some things, I was ignorant to how the special needs community lives and gets through daily events that are easy and normal for most. I was ashamed. I realized that the reason the police and both my partner and I were so quick to let Amy handle the little boy with Autism in the grocery store was because we were scared. We didn’t know what to do with something we didn’t understand. Give us a car accident, a robbery, a cardiac arrest and we’d be fine working as a team… but give us a small boy that didn’t understand that we were there to help him and couldn’t communicate back with us and we failed.

As a paramedic, I live in fear of the day that I have to call 911 for my step-son. I know most of the EMS people that would respond to a call for help in most of the jurisdictions that we travel in and while darn near all of them are top-notch, I’m still scared. I’m scared because I would be scared of the medic that I was just two years ago. Sure, I was “aware” of autism as being a thing, but I had absolutely no understanding of what it meant. I had no idea of how to manage behaviors from a person with ASD, and I really didn’t know how to manage my own behavior towards them. I had awareness without understanding. Even though now I’m much more well-versed in my behavior towards people with ASD and other special needs, I’m still not as good as I want to be. The subject is complex and requires a lot of study and personal growth. One day I might be as good as I want to be but today’s not that day. I still have a lot to learn.

As I said before, “Awareness” is super-neat and all and as the step-dad of someone with ASD I thank you for knowing that autism exists. Now I ask you to take the next step and give us all a little acceptance and understanding. Nobody here is probably going to find the next revolutionary therapy but we all can stop being rude when we see someone with ASD having a meltdown in public. We can give a little understanding and courtesy when someone with ASD is being themselves in a way that isn’t quite within the social norm because we understand they cannot help it. As caregivers, we can react with kindness and patience when we realize that someone’s communicative needs and thoughts on the situation at hand aren’t what we may expect them to be.

So you can go blue for autism. You can proudly display your puzzle-pieces. Heck, you might even put a ribbon on your car. However all I’m asking is that you give people a little leeway to be themselves and just be nice to people. Not everyone is the same and we all need your respect and maybe even a little help sometimes. That’s what would be really nice.

So in honor of all of those with Special Needs and also the people who love them, Happy Autism Month y'all.

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If you’re looking for training for your police, fire, or EMS agency on Autism, I recommend this group: http://autismalert.org/

If you’re looking for a window on understanding the world of families with children who have special needs, I recommend the “Imperfect community” at: www.ShutUpAbout.com

Posted by Ckemtp on April 3, 2013 • Filed under: Command & Leadership, Emergency Medical Services, EMS, EMS ethics, EMS Health & Safety, EMS Topics, Fire Rescue Topics, new perspective, News, Paramedic, paramedic education, Patient Management, Training, Training & Development

A Weighty Protocol Change

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04/01/2013 – Andrew, Illinois

Calling the move “A necessary step in the obfuscation of Medical Direction” Dr. Herbert Franzen of the Andrew Clinic EMS system laid out sweeping protocol changes for the EMTs and Paramedics under his medical control.

“I believe that all medication doses should be weight-based.” Says the physician, who wears a calculator watch circa 1985 rather than carrying a smart-phone. “Weight-based medication dosages allow for precise administration of medications to the broadest range of patients in an emergency setting. No longer will we just make blanket statements that call for giving, say, 25 to 50mg of diphenhydramine to patients in anaphylaxis. Now, paramedics will simply administer 0.252345 mg per kg in an emergency, making the dose all the more accurate every time.”

Several of the paramedics working for ambulance services within Dr. Franzen’s EMS system have started picking up math classes at the local community college in order to sharpen their arithmetic skills which are needed to comply with the new protocols. Paramedic Mark Hansen explains:

“I work in the system part-time and work full time under another set of protocols. At my other service, we follow ACLS guidelines and administer 1mg of 1:10,000 epinephrine every 3-5 minutes in a cardiac arrest. Now, according to Dr. Franzen we need to mix up a drip of 1:1000 epi in a bag of 250ml D5W and then administer 1.734mcg per kg per minute. It gives me a headache just thinking about it.”

Even common medication dosages like Zofran (ondansetron) are being changed. Commonly, the anti-nausea drug is given in handy 4mg increments which make dosing a patient easy and quick. Under Dr. Franzen’s system, however, the medication is given at 0.346 mg per kg to increase accuracy. Seizure patients will receive 0.452mg/kg of valium if they are under the age 34.2, 0.431mg/kg if they are age 34.2 to 47.6, and 0.344mg/kg if it’s before the vernal equinox.

“My protocols are enforced by a very proactive team of Quality Assurance personnel which make sure that the medics adhere to a very strict interpretation of the rules. Variances in protocol use will not be tolerated” Dr. Franzen said. He added with a laugh “I prescribe some pretty intense ‘reeducation’ for violations.”

At press time, we received a statement from “Gorgonz the Magnificent” from the Sleeter County, IL county fair who stated that with his experience in guessing people’s weights he is considering a career move to EMS.

Posted by Ckemtp on April 1, 2013 • Filed under: Emergency Medical Services, EMS, EMS Humor, EMS protocols, EMS Topics, EMS training, Fire Rescue Topics, News, Paramedic, paramedic education, patient care, Patient Management

SeekerCenter: An Option for the Pharmaceutically Denied

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Gary, Indiana 04/01/2013

A new service announced today at a small, Gary based company seeks to provide a solution to many thousands of Americans suffering from a growing problem: Repetitive Pharmaceutical Denial.

Gary Lange, Senior Vice President of SeekerCorp announced in a press release dated yesterday that his company “Seeks to aid in the plight of many Americans who keep being denied access to the pharmaceutical enhancement they both need and desire.”

Calling the situation a “Crisis of Epic Proportions” in a subsequent interview, Mr. Lange called attention to the problem.

“Thousands, maybe hundreds of thousands of Americans are denied access to prescription pharmaceuticals in this country every day. These people depend on these prescription drugs to elevate their mood, provide needed relief to the stressors of their life, and avoid facing even another minute without some sort of pharmaceutical enhancement. They are denied access to their needed pharmacological relief by heartless and cruel physicians, nurses, and ambulance crews who cite red-tape regulations, laws, and other procedures for denying these people the prescription medication they desire”

Calling his new system a way to “revitalize and rejuvenate a growing industry”, Mr. Lange has created a website where people who desire pharmaceutical enhancement via prescription medication can get information on how to obtain the controlled substances they want. The site, which does not yet have a web address is entitled “SeekerCenter” and upon its release, will serve as an online information portal for those seeking prescription medications for a number of conditions.

“Some of these people like to feel relaxed and find that Xanax is their preferred method of relaxation. Some people do not wish to experience discomfort and find that premedication with a prescription narcotic such as Vicodin or Demerol really helps them avoid the unpleasantness of feeling pain during their lives. Some people find that they sleep better on Ambien, or wish to remain alert by taking Adderal or Ritalin as an enhancement device” Mr. Lange said. He continued, making air quotes with his fingers as he talked “These people used to have to try and convince heartless physicians to prescribe them these drugs on their own, we want to help with that. We want to provide a solution for those people who desire pharmaceutical enhancement on a recreational or occasional basis without having to struggle against a system designed to keep them from obtaining these drugs without what the ‘Red-Tape Buzz-Killing Doctors’ say is a ‘real medical need”

SeekerCenter will be an online database, search engine, and message board where people seeking medications can share information regarding such things as which doctors are looser with their prescription pads, the schedules of the local Emergency Room physicians, and which unlicensed Central American Online Pharmacies will ship pills that are not simply filled with talcum powder. Mr. Lange compared the service to that of the popular internet search engines.

“You can log into Google and find every doctor’s office and emergency room in a one hundred mile radius… but can you find out which ones are going to give you a shot of Demerol for your chronic back pain and send you home with a script for three weeks' worth of Darvocet? I think not. Our service will help people get these medications. We also will offer advice on such things as how to fake severe pain from say, a hip displacement on the street, and convince the paramedics to inject you with morphine” Lange said. He added “That pure morphine shit is awesome! You gotta try it!”

Pictured: Just some of the pharmaceutical enhancements needed by most users of SeekerCenter over the course of a week

Mr. Lange is seeking investors for the project, calling the potential “Limitless”. “Soon we plan on adding features such as advertisements for ‘Pain Clinics’ and other doctors who want to help our patients ‘purely out of the goodness of their hearts” he stated, making liberal use of air quotation gestures and flashing a wad of twenties as he said the words “goodness of their hearts.”

SeekerCenter should be online soon and hopes to expand its offerings in every regional market in the United States. Mr. Lange believes that his product will truly help people who believe they have a need.

“Whether it’s a bowl of prescription party favors for your next party, or a way to kick back and relax without worrying that you’re peeing on yourself, now you can find your fix without having to resort to shady, back alley deals from people like I used to be.”

Keep reading this paper for the online address of SeekerCenter. It’s coming soon to a town near you.

Posted by Ckemtp on April 1, 2013 • Filed under: Emergency room, Emergency Room Nurse, EMS, EMS Humor, EMS Topics, Fire Rescue Topics, hospital, News, Paramedic, Uncategorized

Ambulance Roll-Over in Milwaukee – To my friends at MedaCare

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FIregeezer popped up today with this unfortunate story out of Milwaukee, WI: Ambulance Roll-Over in Milwaukee

I read the story and saw that the ambulance was from MedaCare ambulance, which is a good service out that way where a few friends of mine work taking care of the good citizens of the City of Cheddar and Beer.

The story didn't say if anyone was hurt in the incident, so I don't know, but here's hoping that everyone is ok and that any needed recovery happens quickly. We stand with our own here in Wisconsin. The state has an EMS brother/sisterhood that should make other states jealous.

Best wishes to y'all over there at MedaCare. Keep fighting the good fight.

Posted by Ckemtp on March 21, 2013 • Filed under: Emergency Medical Services, EMS Health & Safety, Line of Duty, News

EMS Fights the Flu – The 2013 influenza epidemic

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It’s hitting early, it’s hitting hard, and it’s no joke. This year’s flu season is filling up the nation’s emergency departments, urgent care centers, hospitals, and ambulance run sheets fast. In the US a majority of states are under “widespread” or “intense” flu conditions. No state is currently reporting low levels of flu activity and all states are affected. According to both Google flu trends and the Centers for Disease Control and Prevention (CDC), the US is right in the throes of an intense and widespread flu season that is sickening many people all over our country. The US flu season generally occurs in winter when people tend to congregate indoors, and this year’s locally cold winter is helping the flu spread quickly.

The “flu” is an abbreviation for the disease “Influenza” which is caused by the various incarnations of the influenza virus. The disease has become such a part of our culture that people call almost any minor illness a touch of the “flu.” People say things like “I have the stomach flu” when they have a case of gastroenteritis, or say that they have the flu when they’re feeling a tad under the weather. This causes a lot of misconceptions about what influenza actually is and can cause us to let our guard down about treating the disease and protecting ourselves from it. Make no mistake that the actual flu is a serious illness that can make even an otherwise healthy person incredibly ill. While the symptoms of the disease themselves can seem relatively minor, the intensity of those symptoms and the complications they can lead to are quite serious and can even be fatal.

Influenza is a viral infection that causes symptoms similar to the common cold. However, the symptoms are markedly more severe with the flu than with a cold. The flu brings intense fever, exhaustion, and severe body aches. Influenza is a respiratory illness though it sometimes brings gastrointestinal symptoms like, nausea, vomiting, and diarrhea. The flu can lead to complications such as dehydration, secondary infections, pneumonia, electrolyte imbalances, cardiac symptoms and exacerbations of asthma and COPD. While most influenza-related fatalities are in vulnerable populations such as the very young, older adults, and in those with compromised immune systems, this is not always the case. In the Spanish Flu pandemic of 1918, the Russian Flu pandemic of 1978, and the possible 2009 H1N1 pandemic, most of the fatalities were in the young adult age range.

While modern medical practices do tend to lessen the impact of a flu pandemic in contemporary times, they are still very worrisome as even seasonal influenza epidemics can overwhelm existing medical facilities and cause an estimated 3,000 to 43,000 deaths in this country each year. The CDC cannot accurately count morbidity and mortality from confirmed influenza infections as medical facilities are only required to report deaths from Influenza or “influenza-like-illnesses” (ILIs) in children, however their estimates over the last decade show an average of 30,000 deaths in the US per year. In comparison, in 2009 the CDC estimates that 17,774 people died from HIV/AIDS.

Influenza has caused pandemics, or global infections, throughout human history. While most countries experience epidemics of influenza at regular intervals, the influenza virus occasionally mutates into a particularly virulent strain and spreads quickly throughout the globe. In the 1918 Spanish Flu pandemic it is estimated that between 1% and 3% of the total global population died with an estimated 600,000 deaths in the United States alone. In more remote areas of the country the mortality count was higher with some villages in Alaska being completely decimated. The “Hong Kong Flu” pandemic in 1968-1969 is said to have killed over one million people worldwide with over 33,000 fatalities in the US. The last official pandemic influenza was in 1978-1979, the “Russian Flu” affected mostly the younger population. In the 21^st century, the World Health Organization is attempting to ascertain if the 2009 worldwide outbreak of “H1N1” influenza classifies as a pandemic, with epidemiologists still conducting research. Recently, the CDC has estimated that the 2009 virus killed between 171,000 and 574,000 people worldwide.

Clean your equipment! Don't let your truck be a vector for the spread of disease

The flu is no joke and EMS providers need to practice prevention and infection control. First off, get your flu shot. Ignore the myths about the vaccine and just get it. Immunized healthcare workers are less likely to get sick themselves, are less likely to spread the flu amongst their patients, and are less likely to bring the virus home to their families. EMS providers need to thoroughly clean and sanitize their ambulances and patient care equipment. Hand washing is extremely important, as is the use of proper PPE. All patients exhibiting symptoms of an influenza-like-illness such as a cough, fever, and/or gastrointestinal symptoms should be asked to wear a mask. EMS providers should wear a surgical mask when treating these patients as well. Influenza is spread through droplets that are aerosolized when coughed or sneezed up by an infected person. These droplets settle onto surfaces via gravity and are spread via personal contact or through contact with the droplets while they are airborne. The CDC estimates that the influenza virus can remain viable on external surfaces anywhere from between 2 to 8 hours exposed to the environment. This is more than enough time to cross contaminate your next patient or your coworkers on the next shift. The virus can be killed on surfaces with commonly available disinfectants and regular cleaning and it can be killed on your hands with soap and water or alcohol-based hand sanitizers; However, once a person is infected, the virus cannot be killed with any medical treatment. It can only be slowed down or allowed to run its course.

Protect yourself, protect your patients, and protect your community. Be serious about preventing the spread of the flu. EMS providers are the first line of defense against this insidious disease. Remember that if you are sick, stay home. A person remains infectious for around 7 days after symptoms first appear. Stay home from work until you are at least 24 hours free from fever. Flu prevention is truly an area where EMS is at the intersection of Medicine and Public Health. As with many things, an ounce of prevention can go a long way in the fight against flu.

A comparison of Symptoms between the Common Cold and the Flu

	Common Cold	Flu
Symptoms	Cold symptoms appear gradually and include sneezing, cough, stuffy nose and sore throat. Fevers are very rare and fatigue is mild. Headaches sometimes occur.	Flu symptoms appear quickly (within 3-6 hrs) and include fever, chills, severe aches and chest discomfort.
Severity:	Usually does not cause severe health problems.	Serious health problems, such as pneumonia, bacterial infections, or hospitalizations can occur.
Fever:	Rare	Usually present
Fatigue:	Mild	Moderate to severe
Chills:	Rare	Common
Sneezing:	Common	Rare
Chest pain:	Mild to moderate	Often severe
Coughing:	Hacking, productive cough	Dry, unproductive cough
Headache:	Rare	Common
Stuffy nose:	Common	Rare
Aches:	Slight, but only headaches	Usual and often severe, affects the entire body.
Sore throat:	Common	Rare
Treatment:	There is no cure for the common cold. Cough syrup and other cold medications are available to ease some of the symptoms and make the patient feel a little better. Tea and nasal drops also sometimes help.	Sometimes antiviral medication helps control the flu but often patients simply wait for their body to fight the virus and overcome the disease. Medication is also available to ease patient comfort.
Duration of illness:	Symptoms typically peak two to three days after infection onset, and usually resolve in seven to ten days.	In children, the cough lasts for more than ten days in 35–40% of the cases and continues for more than 25 days in 10%. Adults usually feel better in seven days.
Seasonal?	Not seasonal (occurs throughout the year)	Seasonal (in winter). In the U.S., flu season is generally October to May and peaks in February.
Vaccine?	No	Yes
Causative Organism:	adenoviruses, coronaviruses, rhinoviruses (most common cause), respiratory syncytial virus, parainfluenza virus, influenza virus	Influenza virus

Posted by Ckemtp on January 8, 2013 • Filed under: Emergency Medical Services, EMS, EMS Health & Safety, EMS Topics, Fire Rescue Topics, infection control, News, Patient Management, sanitize, swine flu, Training, Uncategorized

Our Biggest Challenge may be Our Best Opportunity – Medicare Pay for Performance and EMS

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Winding our cot through the hospital hallways, my partner and I we’re trying to efficiently complete the task at hand. It had been a busy morning and this scheduled return trip from the hospital to the nursing home was all that stood between us and a well-deserved lunch. At least, that was what dispatch had assured us as they snagged us out of the report room to take the call. It was simple enough, a short trip from the inpatient Med/Surg unit of BigHospital to a nursing home three miles away. It wouldn’t take us more than a half-hour to get everything all wrapped up.

That is, until we got to the patient’s room.

At the time, I wasn’t the most experienced paramedic in the world, but I knew audible rales when I heard them… from the hallway. The patient was sitting in his bed working as hard as he possibly could in order to breathe. His lungs were full of pulmonary edema and he was obviously in crisis with respiratory distress. I walked over to the nurses’ station, conveniently located directly across the hall from the patient, and asked a nurse about him.

“Oh good, you’re here. He’s going back to NursingHome X. He’s all ready for you to take him. That’s his paperwork on the counter” said Anonymous Nurse. I asked her who his nurse was and if I could speak to her. As it turned out, Anonymous Nurse just so happened to be assigned to our soon-to-be patient.

“Have you checked him recently? He seems to be having some difficulty breathing.” I told her, not really waiting for her to answer my question before I told her why I asked.

“Oh he’s fine, he was having a little earlier but he’s a DNR and the nursing home is ready for him” she retorted.

(Not to get away from the point of this, but the nurse’s statement is why I wrote THIS POST way back in 2009 during an angrier moment in my life, but I digress…)

“Um, I really think you should look in on him. He’s not doing well at all. He’s got rales so bad I can hear them from here. Really, if you listen you can hear them too. <pause for effect> See? I don’t think he’s so ready to go back to NursingHome X yet” I countered.

I’ll spare you the rest of the story because it’s not my main point but as the EMS people in the audience probably know already, the nurse got very angry with me when I refused to take the patient back to the nursing home on the grounds that he was rapidly progressing into respiratory failure and demanded that she call the patient’s attending physician. She was even angrier with me when the doctor had the patient transferred to the ICU based on the phone call. Yeah, she called my boss to complain but luckily there just so happened to be a social worker that overheard our exchange and called my boss as well to commend me on sticking up for good patient care while being just so darn polite about it.

This was the only time I can think of where I stood my ground and refused to take a patient out of a hospital for a discharge transfer because I believed they would die during the transport, but I can think of several times during my career where I have turned around and taken a patient back to an emergency room when they crumped on me during a discharge trip. It seems that it has happened during my career more so than the statistical likelihood should be if the hospitals were always being as conscientious as they could be when discharging patients. And I mean all of the hospitals. I’m not singling out any one of them. Every hospital has occasional times where patients are discharged a little early for a variety of reasons and have to be readmitted back in a very short amount of time.

And today, October 1^st 2012 marks the day where that will become a real problem for all hospitals due to a change in Medicare regulations. Medicare will start fining hospitals that have too many patients readmitted for care within a 30-day period.

I don’t want to get all Chicken Little on you all but Ladies and Gentlemen, we have a problem. As I stated before in a previous post, hospitals are going to start to become very interested in how ambulances take care of their patients. They’re tracking every single scrap of data they can devise a way to get their hands on and in my opinion, they will start tracking the performance of individual ambulance services much more so than they do now. If some ambulance services bring in (or transport back) patients who do better (or are readmitted less) than other services, they’re going to discover that if they don’t know it already. Trust me, they employ an army of people whose only jobs are to devise new ways to track data in preparation for this and other Medicare pay for performance regulations. They have to; there is an unfathomable amount of money on the line.

Read this article for yourself, and read it well. Understand every word because this signifies the coming change that will rock our entire industry: “Medicare Fines Over Hospitals’ Readmitted Patients” (AP)

There are a few quotes I want you to pull out of that and be sure you think about:

“About two-thirds of the hospitals serving Medicare patients, or some 2,200 facilities, will be hit with penalties averaging around $125,000 per facility this coming year, according to government estimates.”

“For the first year, the penalty is capped at 1 percent of a hospital's Medicare payments. The overwhelming majority of penalized facilities will pay less. Also, for now, hospitals are only being measured on three medical conditions: heart attacks, heart failure and pneumonia.

Under the health care law, the penalties gradually will rise until 3 percent of Medicare payments to hospitals are at risk. Medicare is considering holding hospitals accountable on four more measures: joint replacements, stenting, heart bypass and treatment of stroke.”

I am not debating the political ramifications of these regulations. I’m saying that they are here, they’re in effect now, and the amount of money they mean to almost every hospital you can think of is simply staggering. I’m saying that if your ambulance service has a higher rate of patients being readmitted to a hospital due to infection, you have a problem. If your ambulance service has a higher rate of patients who do poorly after being brought in from the field, you have a problem. Also, if you don’t believe me… well then you probably have a problem as well.

EMS needs to be out in front of this! We as an industry have to get up and be out there addressing the problems that these regulations are going to bring! Please tell me that I’m not the only one who sees this… please tell me that I’m just uninformed and there are smart people out there already working on this problem and have already come up with solutions… because if not then we all have a heck of a lot of work to do.

However, this may be the biggest opportunity for our profession that I’ve ever seen.

I believe that the future of EMS lies in community paramedicine. I believe that we have to expand the EMS business model so that we have more ways to serve our patients and generate revenue. To date, the biggest hurdles for community paramedic programs have been finding ways to pay for and generate revenue with them. I assure you that providing post-hospital discharge follow-up care as a way to make patients healthier and avoid subsequent readmissions is very much within the realm of a community paramedic. I also assure you and every hospital person reading these words that paying a community paramedic to perform those services is much, much less expensive than is being fined for having too many readmissions. Trust me, someone could easily pay for a rather expansive community paramedicine system for much less than 1% of their hospital’s total Medicare reimbursement.

I’ll leave you with another quote from the AP article:

"There is a lot of activity at the hospital level to straighten out our internal processes," said Nancy Foster, vice president for quality and safety at the American Hospital Association. "We are also spreading our wings a little and reaching outside the hospital, to the extent that we can, to make sure patients are getting the ongoing treatment they need."

I’ll say it again. We need to be out in front of this issue. Now.

——————————————————-

If you’re interested in what I’ve said on this issue in the past:

Change Medicare, Save EMS

Primary Care Paramedics? I Think it’s Time

Posted by Ckemtp on October 1, 2012 • Filed under: Administration & Leadership, Ambulance, Command & Leadership, Economics, Emergency Medical Services, EMS, ems 2.0, EMS Topics, News, Paramedic, politics

EMS Providers Carrying Guns – A terrible idea

34 comments

Have you ever tried to kill a noxious, invasive weed in your yard? Think of something like bamboo or creeping charlie… something that isn’t serving any purpose and is hurting the growth of the good grass that you want to be in your lawn, something that just keeps popping up no matter what you seem to do.

That, my friends, is how I feel about the recent eruption of posts on Facebook and the blogs lately about how EMS providers should be allowed to carry guns. It’s an annoyance and hurts any constructive growth for our profession.

I’m going to come out right now and say that it is a terrible, awful, no good, very bad idea that needs to be put down the sewer like the turd of an idea it is. EMS providers should not carry guns. Not now, not ever. Never ever never never never. It is a terrible idea fraught with so many perils and pitfalls that it is more than just a slippery slope; it is a death trap that stands to hurt everyone should it come to fruition anywhere.

I didn’t form this opinion lightly. In fact, I strongly support our right as Americans to keep and bear arms. I generally support concealed carry. I don’t take disagreeing with the likes of the venerable Kelly Grayson as anything other than something very serious. I respectfully, yet strenuously, disagree with his opinion and while I know he has reasons for what he believes; I just can’t support his position on this issue.

EMS providers should not carry guns. They should not be issued guns to carry by their agencies; they should not be allowed to carry on-duty even if they have a permit to carry off-duty; they should not be allowed to carry even if they are sworn law enforcement officers working EMS part-time or as a volunteer. I do not say this because I am a bleeding-heart liberal because I am not. I say this, because it is a terrible idea.

Here are some of the reasons why:

1. Using a weapon for defense or as a tool for any other kind of task takes training, experience, and practice. Not only that, it takes lots of training, lots of experience, and lots of practice. Police officers, military heroes, and other professionals who are armed for their occupations receive lots of training, experience, and (hopefully) practice. Without it, any weapon becomes less of a tool and more of a liability. Remember folks, EMS is a profession where members furiously struggle against adding even tiny amounts of time to their initial training classes and can barely be forced to sit through, let alone actively participate in required continuing education classes. Can we ever hope to get them to train, practice, and gain experience in the safe handling and use of a weapon? It’s not possible and won’t happen.

2. Has gun violence against EMS providers spiked recently? Is it really bad out there? I personally know police officers who have been fired upon and hear regularly about police officers who have been shot. It’s terrible for them and I respect the courage they display by simply doing their jobs. While I hear about and have personally experienced physical attacks on EMS providers, the vast majority of them are closed hand attacks perpetrated by mentally impaired, intoxicated, or otherwise disturbed individuals, I rarely if ever have heard of an EMS provider being shot with a gun or stabbed. While I could believe that EMS providers have a higher risk of being shot or stabbed while performing their duties than does the general public, I have never seen data to prove that. I’ll concede though, that it passes the smell test and could be true. However… do you want to know why EMS providers aren’t being shot, stabbed, or assaulted to the extent that police officers are? It’s because we’re not cops. It should never be taken lightly that we are, if not considered neutral in street culture as we are targeted on occasion, largely considered to be non-combatants. We’re not cops. We’re out there to make everyone feel better and are largely being left alone. It’s a finite balance that will be upset the first time that Clint EMStwood pulls out his shootin’ iron and points it at a gang-banger. Once that happens, we lose our neutrality and will be targeted much more often than the comparatively rare times we are now. People will die because of it.

3. More lives have been saved by EMS’s policy of withdrawal from violent situations than could ever be saved by EMS carrying guns. It isn’t cowardly for us to withdraw, it is lifesaving. We do not enter dangerous situations and we do whatever we can to run from them when we find them. Bravado doesn’t figure in to this. We don’t do it because we are cowardly; we do it because it is not our role to face violence. Eventually, people who skirt this rule and do not withdraw run into situations where they must act in a hostile nature to defend themselves or someone else. Eventually, people who do not withdraw injure or kill someone; perhaps they are injured or killed themselves. EMS providers do not have the legal protection, authority, or ability to act in hostile situations. It isn’t our job and it isn’t our job for a reason. That’s what cops do and EMS providers aren’t cops. If you personally want to be a cop, go be a cop. If you wanted to be a cop but found out that it was easier to get a job as an EMT and now hope to bridge the jobs to realize your dreams, then please leave EMS. You’re not helping as much as you think you are. If you just want to strap a gun on your uniform because you think it looks cool, you’re probably not the type of person who reads EMS blogs because of all of the fancy words we tend to use. You may say that we can still withdraw at the same rates that we do now, but I’ll quote my father, who told me that “When you have a gun, every fight is a gun fight.”

Pictured: A possible successor for the IO drill?

You may disagree with me and that’s fine. Please leave your reasoned, courteous debate in the comments section. However I will state that all of the debates on this topic tend to degenerate into shouting matches where the supporters of EMS providers carrying guns prove to me that the state of this country’s educational system could stand to be improved. Do not do that here.

Stay safe out there. If you'd like to read another opinion I agree with, our friend Greg Friese posted this on the same topic.

Posted by Ckemtp on September 20, 2012 • Filed under: Administration & Leadership, ckemtp rants, Command & Leadership, Emergency Medical Services, EMS, EMS Health & Safety, EMS Management, EMS Topics, Fire Rescue Topics, News, safety, Uncategorized

5 tips for beating the summer heat – An EMS and Medical Stock PSA

2 comments

Hey EMS agencies: Looking to help spread the word about staying safe in the heat? Cut and paste this stock PSA to your own site or simply link to this page from your agency's social media page. Here are 5 tips on how to stay cool and healthy that not everyone has heard before.

You probably don’t need us to tell you this, but it’s really hot out there. It’s blazing hot, dangerously hot even. The heat our area is experiencing is affecting everyone, whether we feel it directly or not. While you probably know the basics on how to stay cool and healthy during heat waves such as this one, there are a few things that you may not have thought of yet that can help make this epic heat wave just a little bit more tolerable. Here’s what you need to know:

You’re losing a lot more water than you realize – “Insensible” water loss, or water we lose through breathing, sweating, and keeping our skin, eyes, and mouth from drying out is markedly increased in hot temperatures. Humans lose a shockingly high amount of water this way during a heat wave. You have to proactively replace this loss of water and the fact is that most of us don’t. While the old adage that a person should drink “at least 8 glasses” of water a day may not hold up to scientific study, the Institute of Medicine still recommends that adults consume at least 91 ounces of water on any given day. It doesn’t all have to come from drinking it in, as some of this fluid comes from the foods we eat, and some fruits and vegetables are very high in water content and can hydrate you almost as well as a glass of water can. Drink more water and avoid soda pop and alcoholic beverages, as these can actually contribute to dehydration. The best way to measure hydration level is to monitor your potty breaks. You should be going to the bathroom for a “number one” at least four times per day and the color of the urine should be clear to a faint yellow. When your body is dehydrated it concentrates your urine. The darker your urine is, the more dehydrated you are. Keep it clear.

Watch your kids too – Kids lose a lot of water in the summertime. Even short bursts of outdoor play can burn a lot of water off of a little one. Push fluids and encourage your kids to drink water, tea, and lemonade. Creative ways to get more water in your kids include supplying popsicles and Jell-O, which are both mostly water with a little flair. You can also have fresh strawberries, celery stalks, and watermelon which both add fruits and veggies to their diets while being an excellent source of quality hydration.

Watch for dehydration and heat-related illness – In this heat you can become dehydrated quickly without realizing it. Dehydration is a serious medical condition that can sneak up on a person and make them sick before they know it’s happening. Mild cases of dehydration show symptoms after about 2% of one’s body water is lost. These symptoms can be a moderate to severe headache (like a hangover), dizziness or fainting when standing up, loss of appetite, dry skin, and constipation. You can also feel fatigued and generally ill. In more serious cases, you may experience a rapid heart rate and flushing of the skin. If you notice any of these symptoms, drink water and cool down. You’ll be amazed at how much better you’ll feel. Watch for confusion, weakness, and an absence of sweating because these could be signs of heat exhaustion or heat stroke, which are serious medical conditions. If you believe that you or someone else is experiencing these symptoms, move the patient to cooler temperatures and encourage them to drink cool fluids to replace what they’ve lost and bring down their body temperature. In serious cases, seek medical attention or call 911.

Wear shoes – Invariably, when the sun blazes down this hard, the emergency rooms start seeing burns to people’s feet caused by walking barefoot on hot concrete. In fact, one ER in the state just had a case of significant burns a patient suffered from walking on hot sand at the beach. When the sun is this strong, resist the urge to go barefoot when you’re walking outside. Burns on the feet are more than just painful, they take a long time to heal and make walking anywhere less than pleasant. Be careful.

Be smart about sunscreen – Most instruction labels on sun-protection products advise that you should apply before you go into the sun, and allow some time for the product to absorb into the skin and start protecting it. Read the label on your favorite sunscreen and follow the directions for the first application as well as the schedule for reapplying it. We’ve all been burned in the past but we can prevent it from happening again if we’re careful. You also should put on a hat and find some shade from time to time. A cherry-red hue isn’t in style this season..

Have fun this summer, but stay cool and be careful. Watch each other and make sure people are taking the heat seriously. It is dangerously hot out there. If you need us, we're here 24 hours per day to take care of any emergency needs. We’ll be here, but we hope that you can avoid us altogether by keeping yourself and your family cool and comfortable. Stay safe

Posted by Ckemtp on July 5, 2012 • Filed under: Administration & Leadership, Emergency Communications, Emergency Medical Services, EMS, EMS Health & Safety, EMS Topics, Fire Prevention & Education, Fire Rescue Topics, News, Public relations

National 911 Education Month – What EMS can do

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If you're an EMS person, you should probably know that April is designated as "National 911 Education Month." It is sponsored by the National Emergency Number Association (NENA) and is dedicated to educating people about the proper care and feeding of the 911 system and the dedicated emergency telecommunicators that make the system run. The month spreads awareness of how to use the 911 system properly and culminates with "National Public Safety Telecommunicators Week." NENA has some great resources, including pre-made radio, web, print, and video PSAs, on their website: here.

I've always said that I am NOT cut out to be a dispatcher. I just don't think that I personally have the mental quickness, ability to multitask, or organizational skills it would take to be good at the job. As an EMS professional, I revere my dispatchers and show them as much love as I can. Dispatchers are the omnipresent bits of sanity in our daily schedules. We need to treat them well and give them equal respect. They do a terribly hard job and I salute them for it. You should too.

EMS professionals should celebrate National 911 Education Month as well as National Public Safety Telecommunicators Week just as much as we celebrate EMS week. We need to do this because well, can you imagine any potential benefits to educating the public about proper use of the 911 system? I think I can. Remember, it's not just about reducing nuisance calls that bog down the system; it's also about educating people when they absolutely need to call 911 because it's better medicine for them or better for society in general. I cringe when I see people who have legitimate medical problems that would benefit from EMS care drive themselves into the ER or even go untreated. It's our mission to help them and the first step is to spend time educating people when it is appropriate to call, without being condescending to those that call inappropriately.

Let's make the message as positive as we can people. We're professionals who care for others. Working EMS is a privilege and we need to remember that. I would rather go to 100 inappropriate calls than miss one single call where we could make a lifesaving difference.

In celebration of the month, I'm going to write a few pieces in honor of those that tell us where to go. I'm going to show some love to the voices in our radios and give you some tools to help spread the message at your own agencies. Tomorrow, look for a piece I've written that you can cut, paste, and send in to your local newspaper as a letter to the editor. Every little bit helps.

Posted by Ckemtp on April 2, 2012 • Filed under: 911, Administration & Leadership, Command & Leadership, Dispatch & Communications, Emergency Communications, Emergency Medical Services, EMS, EMS Dispatch, ems education, EMS Topics, Fire Rescue Topics, News, Technology & Communications

Changing Cardiac Care – Being Suspicious

2 comments

Want another reason to lug the EKG machine out of the ambulance on your next call? A study recently published in the Journal of the American Medical Association and reported on by many national news outlets has found some information that may change EMS care.

From CBSnews.com:

“The study looked at 1.4 million patients who had experienced a heart attack between 1994 and 2006 to investigate the relationship between age and gender and heart attacks, specifically symptoms and death rates. Data revealed that 14.6 percent of women hospitalized with a heart attack died, compared with 10.3 percent of men.

Women were also much more likely to have a heart attack without any chest pain – 42 percent, compared with 30.7 percent of men.”

http://www.cbsnews.com/8301-504763_162-57382624-10391704/heart-attacks-in-women-greater-death-risk-fewer-feel-chest-pain/

Think about how the media represents heart attack symptoms to the public and about how we educate the public to recognize heart attack symptoms. Think about how even our EMS training has prepared us to recognize the signs and symptoms of a heart attack. We all pretty much look for the same thing, chest pain or pressure with radiation down the left arm. However, this study shows that a staggering 42% of women don’t have that symptom and that 30.7% of men don’t either. It tells us that nearly half of the patients who have this deadly condition don’t present with the symptoms we’re classically trained to recognize.

The study’s other finding that more men than women who had myocardial infarctions died after having the condition help illustrate another point: When looking for heart attacks, we all tend to assess everyone like they’re a 45 year-old white male. It is important to remember that age, gender, ethnicity, and culture play a role in how symptoms present. Comorbid conditions such as diabetes can change the way a heart attack presents as well.

This study helps confirm what we pretty much all know, that no two heart attacks are alike. When the heart doesn’t get blood flow to a part of it, it doesn’t work well, and it sends signals to our bodies that we may misinterpret. The classic “Chest Pain” symptom of a heart attack may well present as Jaw Pain, arm pain, weakness, diaphoresis, back or abdominal pain, or even making the patient feel like they have to burp. Unexplained fatigue with exertion, the inability to lie flat, or even dizziness and/or fainting may point to a heart attack.

EMS plays an extremely important role in cardiac care. It could be one of the biggest areas where the appropriate field assessment, working diagnosis, treatment, and transport decisions made by EMS improve the quality of life for the population as a whole. The proper assessment and working diagnosis by EMS can set the patient on the proper path through the healthcare system and make a huge difference in their quality of life.

What does this mean for your care today? It means that should you suspect that a patient has a possibility of having cardiac ischemia or is otherwise presenting with a cluster of symptoms you can’t pin down you should try to perform a 12-lead EKG with your first set of vital signs. While delaying treatment to perform a 12-lead is not anyone’s goal, emerging evidence is suggesting that significant ST elevation can normalize within as little as 4 minutes of common EMS care, including just the placement of a patient on oxygen. If we capture a symptomatic 12-lead at the point where the patient’s symptoms are most acute we can properly make the diagnosis and save the patient precious minutes, hours, and days of diagnostics to pin down the cause. Serial 12-leads, taking multiple 12-lead EKGs at various time intervals can prove beneficial as well. Remember that one 12-lead is a reference, two are a trend.

Gathering the best information we can on all patients in order to help guide their treatment through the healthcare system is one of the most powerful benefits of EMS care. Let’s help all of our patients get the care they need.

Posted by Ckemtp on February 24, 2012 • Filed under: EKG, Emergency Medical Services, EMS, ems education, EMS system, EMS Topics, EMS training, News, Paramedic, paramedic education, Uncategorized

Coming Soon – The Law of Unintended Consequences meets the fire service

3 comments

Remember the post I put up a few days ago entitled “A Predatory Ambulance Fee”? It talked about how the Elgin, IL city council is planning to help recoup their costs for Fire and EMS services by charging for refusals.

(This is the link if you didn’t read it: “A Predatory Ambulance Fee”)

This just in:

Apparently they’re not done proposing new fees in the city. They seem to be very serious about recouping their costs and finding new ways to monetize their services. According to this article posted on Firefighter Nation, they’re planning on adding quite a few new fees to their repertoire.

Here’s the link: “Illinois Department Considers Charging Non-Residents for Fire Services” Read it and see what you think.

The article only mentions two specific fees, a $500 per hour fee for an engine response and $2200 for “a serious car accident where someone has to be transported by helicopter.” These fees are interesting enough, but the article also hints that there are further fees forthcoming.

The chief is quoted as saying that he expects most of these fees to be covered by insurance. After all, he says… that’s what insurance is for.

The chief may be very correct with that statement; insurance exists to pay for the unforeseen costs of bad things that happen to people who pay for it. Insurance companies pay these costs based upon rigid contracts they sign with their customers and charge their customers rates based upon the average risk they assume on behalf of the customer. They will only pay for what they are contractually obligated to pay for. While I have no knowledge of whether or not insurance will actually pay for the charges Elgin is proposing in practice, I’m assuming the city of Elgin doesn’t either and if they don’t seem to care whether the people they are saddling with these kinds of fees are insured for them or not, why should I?

It’s not like these insurance companies aggregate risk across all of their customers and will pass the overall cost of these fees to everyone in the area causing everyone’s insurance rates to go up, right?

Remember, I am not against fire departments, cities, and/or EMS services finding new and innovative revenue streams or ways to defray costs. The City of Elgin is not a villain here. It is very expensive to operate a service and I completely understand wanting to recoup some of those costs. These kinds of fees are somewhat the result of a rigid and over-regulated EMS payment system that chains our entire industry and squashes most hopes of innovation. I believe in EMS payment reform. In fact, I demand it.

But guys? While you’re by far not the only department in the US proposing and implementing things like this… you’re all opening Pandora’s Box. Your citizens are going to fight this, the press won’t be good, and you may end up creating more of a wave of dissatisfaction than you’re really prepared to endure. Think about Moline, IL and what they’re going through right now. Could you imagine their chances of winning their fight if they had implemented these fees?

Then again, perhaps they should implement them in Moline and let the revenue sources balance their budgets… In Moline they say they’re operating at over a $340,000 budget deficit and maybe these kinds of fees would offset that deficit enough that they could make their EMS financially viable.

Or maybe the marketplace will decide and departments that do this kind of thing will be put “out of business” (for lack of a better term) by competitive forces.

I would be willing to bet that there’s someone out there that would only charge $450 an hour for an engine response and only $2100 for a “serious car accident”. There are probably plenty of people and companies that would be happy to do fire response for profit. That’s what happens when governmental services start acting like monopolies in a capitalistic system, they get replaced by free market alternatives. Back in Ben Franklin’s day the fire service was a private endeavor that was only made public when the cost of providing protection wasn’t profitable enough to serve the ends the people wanted it to serve. Make the fire service profitable and private industry may find a way to make a solid business model out of it. Don’t believe me? Think Fed Ex and UPS versus the US Postal service.

I’m not saying it’s a good or bad thing. It’s why private industry exists. If there’s an opportunity to make money doing something, someone will step up to make money doing it. These fees, if they become lucrative, may just be the opportunity for private industry to find a business model that didn’t exist before.

I am able to understand why Elgin wants to implement these fees… but I think that this is a situation ripe for the Law of Unintended Consequences. If I could give cities proposing these kinds of fees some advice I would tell them they should find every single efficiency within their existing budgets before they set about increasing revenue through raising fees. Make no mistake, within the contemporary political climate; citizens are going to scrutinize every aspect of your budget when you start trying to get them in the wallet. You may not like what they find.

I don’t have the ultimate answer but I’m keeping an eye on this story. You should too.

Soon to be the corporate ladder?

Posted by Ckemtp on November 4, 2011 • Filed under: 911 fail, Administration & Leadership, ckemtp rants, Command & Leadership, Economics, Emergency Medical Services, EMS, ems 2.0, EMS Management, EMS Topics, fire, Fire department, Fire Rescue Topics, Firefighting Operations, Funding & Staffing, News, northern illinois, politics

Issues: I’m Scared of something, Have a Rhythm, and A New Column Up, Too.

2 comments

First off, my newest column is up over at JEMS.com – You might like it. I’m challenging the status quo. Like I do:

“EMS Provider Questions 3-Dose Nitro Rule – JEMS.com”

In the article I use ham as a metaphor for nitroglycerine... it's an admittedly interesting take on things

Did you read that and then come back? Good! But if not, I’ll link it again for you at the bottom. I’ve got a few other things that are on my mind today. Like this:

If you haven’t noticed yet, my posts are back in a rhythm.

I’m really enjoying all of the feedback and participation I’m getting on the blog since I’ve been hitting it regularly lately. I’m trying to do good, solid posts on Mondays and Wednesdays, with something on Friday to carry me through the weekend. On Tuesdays and Thursdays I plan on the occasional link love and mention of some of the other great bloggers out there. I hope y’all like the schedule and what I’ve been putting out lately.

But this week? The schedule is a tad off…

I wrote a detailed, strongly worded, journalistic, researched, and somewhat opinionated piece on a topic I care deeply about. It went long, so I broke it into two parts and planned to run it this week on Monday and Wednesday.

However, you’re probably noticing that you aren’t reading that post right now. That’s because the post scares me.

I am playing with fire with this post. Literally. It involves a burning issue that’s impacting a fire department that I am very familiar with. They, in turn, are very familiar with me. Their city council just voted to end their ambulance service in a move that they deemed purely financial. In the piece, I gave them strong advice and tough love after thoroughly exploring the issue as best as I was able.

But I’m scared to put it up here, honestly.

Any Fire-Based EMS vs. The World issue is a hot issue, fraught with peril for anyone who should so dare offer an opinion that isn’t “FIRE RULES!!! WHAT ARE THOSE IDIOTS WHO DON’T LIKE FIRE DOING!?!?!?!” I didn’t offer that opinion. While I support those firefighters and my good, long-time friends among them, I simply can’t blindly repeat that dogma. This issue is much, much more complex than that and unfortunately for my friends, that dogma isn’t going to work here. It has already failed and it will continue to fail if they continue to use it. The landscape has changed. Down is now up. Dogs and Cats are living together… Mass Hysteria! is happening and they need some new strategies.

Our friend Chief Reason wrote on the topic on his blog over at Fire Engineering and you can read his opinion on the issue I’m talking about here: “City Fires; Chief ‘retires’. (Oh, and Art? We miss you over here at FEblogs)

Chief Reason does a good job of explaining the issue. I respect that man’s opinion a great deal and always have… and I’m not saying he’s wrong at all. I’m just saying that the argument he’s using to defend the position he’s defending is well… dated. The reality has changed as I have said and that kind of argument just isn’t going to work anymore.

Read Art’s post on the subject for more. I’ve written on it but am holding the post for a while. If anyone from Moline cares to talk about my opinion, I’d be happy to speak on it. However, I didn’t just write it for Moline. There is a much, MUCH wider issue at hand.

Here’s the deal: This thing that happened in Moline? It’s coming to your town. It’s coming to where you live and if you defend yourselves the same way I see them defending themselves, you’re probably going to lose your fight. (Not that I want them to. I support quality EMS in the City of Moline. I have a lot of friends and family that live and work there and I want the EMS there to be the absolute best it can be)

I’m going to think about posting the piece. Till then, if you care to read it before I decide, e-mail me at ProEMS1@yahoo.com or hit me up on Facebook and I’ll send it to you.

Also as I mentioned up at the top, my newest monthly column is up over at JEMS.com – Pop by and have a read. I’m challenging beliefs there, too.

“EMS Provider Questions 3-Dose Nitro Rule – JEMS.com”

Posted by Ckemtp on November 2, 2011 • Filed under: Ambulance, ckemtp, ckemtp rants, Emergency Medical Services, EMS, EMS Humor, EMS Topics, EMT, Fire department, Fire Rescue Topics, Funding & Staffing, News, Paramedic

Tripping at the Hospital – A Teachable Moment for EMS

6 comments

Quick: Name the safest place you can think of to have a medical emergency.

Would it be inside of a hospital? Maybe an ambulance base? Perhaps a concert venue with medical staff on site?

Back when I worked in a hospital, we used to have a procedure called a “Code Green.” We’d call one on the occasion of “A medical emergency occurring in a non-patient care area of the property resulting in a need for emergency medical care.” It was implemented in the early 2000’s in response to the disorganized response we had been seeing to on-property medical emergencies in areas such as the parking lot or the hospital lobby. Usually Code Greens would result from someone falling however they occasionally resulted from some other type of medical problem. I even think they even worked a cardiac arrest in the parking lot on a day I wasn’t on-duty. My position at the hospital was a cross between a Security Guard and an EMT as I progressed through Paramedic school. At that chain of hospitals with three campuses and around 500 beds, the Security department operated an ambulance service to do interfacility transports between the ERs and inpatient units. It was an interesting system. As Security/EMTs we naturally became the primary responders to “Code Green” calls, which seemed to happen once or twice a month in my recollection.

I was reminded of our Code Greens when I read this article coming out of Niagra Falls, Ontario (Canada) concerning an elderly woman who fell while walking out of a hospital.

According to the article from The Toronto Star, the 87 year old woman was leaving the facility after visiting her terminally ill husband when she suffered a fall and fractured her hip in the hospital parking lot. The article has a fairly critical tone towards the hospital and its staff; blasting them for having to call an ambulance and for the time it took to get the woman off of the ground. The woman, who in the article is stated to have a previously fractured arm, is reported to have laid on the ground for “Nearly 30 minutes” while waiting for the ambulance to transport her to the ER, which is stated by her son to be “only 50 yards away” from where the fall occurred.

I linked this article today because I believe the opinions expressed show a great deal of information towards the public’s perception of the roles of healthcare workers. The article seems to think that it’s quite ironic that an ambulance was called by hospital staff… to a hospital. When, according to the article there were two nurses on the scene. The article places the orthopedic surgeon who happened by “eventually” and “moved the woman into a wheelchair” as the hero of the story.

My thoughts here are that the nurses who were called to the scene of the fall most probably identified the woman as being at a high risk for further injury from additional movement as evidenced by the fact that she had a previous arm fracture and what I would guess to be an obviously fractured hip. Their concern was probably that further movement of the patient in an incorrect fashion would have aggravated her injuries and could have resulted in further damage. As far as I know, Canadian nurses (like their US counterparts) aren’t trained to move patients with potential spinal injuries and obvious hip fractures who aren’t prepackaged by EMS crews or otherwise immobilized. They also most probably did not have access to the proper equipment needed to do so. In fact, the physician who picked up the patient “with the assistance of an aide” and placed the woman in a wheelchair would have been lambasted if he were a paramedic. While I’m going to assume that an orthopedic surgeon would have extensive knowledge of the human skeleton, it’s not exactly optimal care to bend a hip fracture the 90 degrees to move a patient from a supine (or prone) position to an upright seated one. In this case, packaging the patient on a long spine board with full cervical spinal precautions would have been the best medicine. Everyone has their areas of expertise and as we’ve all observed, or at least became aware of by watching the trial of Dr. Conrad Murray in the MJ death fiasco, doctors aren’t always the best experts in emergency care. That’s what Paramedics and EMTs are for. EMS people are the “Masters of the Acute”. Our specialty is those things that are happening in the here and now. It would have been irresponsible for the nurses to move the patient in this article without having the requisite training and equipment and even the physician that did move her risked causing further injury. While the article lauds him as the hero of the situation, the headline just as easily could have been about how he paralyzed her or lacerated her femoral artery when he moved her obvious fracture 90 degrees.

In my opinion, the statement of the hospital administrator is laughable. It’s doublespeak and must have been given for purely political reasons… I hope.

From the article:

“The supervisor of the Niagara Health System said the incident stemmed from a communication problem among staff.

“We shouldn’t have called the emergency room,” said Dr. Kevin Smith, who was hired on to aid the beleaguered region at the end of August. He said when a person is hurt in hospital, staff should call a “code,” meaning a team — not necessarily in the ER — is paged to help immediately.

When asked why staff felt the need to call for an ambulance, Smith said that may have been an old rule at the hospital. He said staff has now been briefed on the correct policy and a review is underway.

He could have mentioned any of the above things that I mentioned and it would have been just fine. It might have even been a non-issue if Canada’s less-litigious society is taken into account. Instead of stating that nurses aren’t paramedics and aren’t trained to do the same things, he backpedaled and blamed “communication problems” and “old rules”. I can’t say… but maybe this hospital administrator just doesn’t get the difference in emergency healthcare professionals either.

The writer of the article sure doesn’t.

Pictured: Not generally a nurse's thing...

We need to get the word out that EMTs and Paramedics are highly specialized emergency healthcare professionals with expertise in handling acute emergency situations. We are not interchangeable with other healthcare disciplines. Saying that a nurse or even a physician is a good substitute for a paramedic is missing the point that emergency healthcare is different than other specialties. EMS is truly a specialty requiring expertise, practice, and study. A person cannot just be thrown into the position and be expected to perform… no matter what the setting of the emergency happens to be.

This article provides our profession with a teachable moment. I just wish we all had the ability to seize upon it and spread the right message.

The safest place to have a medical emergency? It’s right next to a paramedic. No questions here.

Posted by Ckemtp on October 31, 2011 • Filed under: Ambulance, Emergency Medical Services, Emergency Nurse, Emergency room, Emergency Room Nurse, EMS, ems education, EMS Management, EMS Topics, hospital, News, Paramedic, Patient Management, politics, RN

The Houston Medicare Problem – Formulating Better Instructions on Paying for EMS

1 comment

I’ll admit it. I’m kind of a nerd with Microsoft Excel.

I don’t have the programming skills needed for other database programs and I’m only taking baby-steps in MS Access, but with Excel I’m pretty darn good at making it do cool things. I think Excel is widely underused for being as powerful of a data analysis tool as it is. It’s one of those programs that everybody knows how to use… but nobody *knows* how to use. People learn parts of it and are able to do the kind of work that they do in it without touching the thousands of other tools that it offers them. It’s an insanely powerful system.

See? Excel! It's... not interesting...

I use Excel quite a lot in my various jobs for data aggregation and analysis. Lots of my coworkers do too. Since most everyone knows that I’m an Excel nerd, some people ask me to help troubleshoot their spreadsheets for them. Some problems are quick fixes while others are maddeningly complex. Most problems, however, seem to have a common theme:

Computers always do what we TELL them to do but not necessarily what we WANT them to do.

Computers run programs. They don’t think for themselves. They don’t make their own instructions. They simply look at a list of instructions and run them. They don’t judge the instructions for merit, correctness, or morality (See: 99.9999% of the internet), they just do what they’re told without being able to think about it. When computers appear to be thinking, they’re simply running complex programs with multiple variables. Excel is no different. In fact, excel is very good at doing exactly what we tell it to do with no regard to what we may want it to do.

I sometimes agonize for hours on Excel problems when I can’t get my numbers to add up correctly. Usually these problems involve complex groups of numbers where I know the answers for a certain part of the problem, but want to use Excel to contain and crunch numbers for the parts I don’t know. I’ll write my calculations on what I know already to prove my theory, and then use those theories to expand the spreadsheet. Sometimes the formulas work the first time… and sometimes they don’t. When fixing the problems I have to keep reminding myself that Excel is doing exactly what I told it to do, not what I’m thinking I want it to do. If it’s giving me the wrong answer, it’s because I asked it the wrong question or gave it bad instructions on how to arrive at the answer. It can’t do anything but that.

I use Excel as a metaphor for a lot of systems in life. To be sure, humans have free will (we think) and are very complex in both our actions and motivations, but on the larger scale our systems affect our behaviors in predictable patterns. Just like we predictably follow the lines on the highway when we’re driving most of the time, with the outliers among us creating a need for EMS, our systems affect us predictably. Small changes to the systems we operate within can cause big changes to our behaviors on the large scale. Think of a small change to the width of a highway traffic lane causing more or less accidents, or daylight savings time creating savings in energy costs overall. While there will always be outliers when dealing with humans… the systems we create are instructions that society is given. Society will follow those instructions for both the benefit and detriment of our goals. The overall system will do just what Excel does, by doing what we tell it to do and not necessarily doing what we wanted it to do when we created it.

Here Excel is being used as a metaphor for Awesome

This Headline out of The Houston Chronicle made me think of this. Take a look at it:

“Private ambulances take Medicare, taxpayers for a ride – Companies make millions off the poor, vulnerable – whether passengers need services or not”

I want you to read the article when you have time (it’s a long one – here’s the link) but the salient point they assert is that unscrupulous private EMS organizations, in near criminal collaboration with the operators of unscrupulous “healthcare” organizations, are bilking Medicare for millions via unnecessary ambulance transports. According to the pretty well-written article there does indeed seem to be a problem. While I don’t like the fact that in my opinion, the article unfairly vilifies some of these ambulance services and shows a bias against private EMS providers as a whole, I can’t say if it’s my own stated bias as a proponent of well-ran private EMS that’s causing me to feel that way. However, even the headline “Private ambulance services take Medicare, taxpayers for a ride” shows a bias. My thought is that the headline should read “Medicare Rules allow people to take advantage of the system although most don’t” but I digress…

I would like you to look at the headline of an article I wrote recently that JEMS.com published as my April column, it reads:

“Medic Suggests Reimbursement Change – A different payment model helps EMS & Medicare”

In his article which includes references to Barbecue, I talk about the Medicare reimbursement rules as well, but from a different perspective. (Here’s the link if you haven’t read it). I offer a solution on how a small change to the Medicare rules (think: the instructions) could benefit all involved.

I think that the two extremes here show a poignant contrast. One extreme shows how the Medicare system can be abused due to its rules allowing for abuse and the other shows how the system can disallow beneficial services because of those same rules. It is a good example of how just like excel, the system does what we tell it to do rather than what we want it to do. Other than some unscrupulous people out there, nobody wants patients or ambulance services (*ahem* Private or otherwise) to be able to take advantage and get money in a way that is unfair to the rest of the system. However, I think there are few people out there that would rally against the change that I propose in my article. This is simply a case of the end result being a product of system design. Medicare, like any system, is a set of instructions that produce an end result. The instructions allow for the ambulance services in Texas to bilk the system in compliance with the rules while a different section of those same instructions disallow payment for treating and releasing patients who could clearly benefit. It’s simply a matter of the Medicare system producing results based upon the instructions it’s been given. In both cases, the system isn’t making a judgment, it’s just following the instructions it’s been given. There is no moral value assigned within the system.

Small, efficient changes need to be made here. Just like when troubleshooting an excel spreadsheet the smallest error in a formula can skew the whole result. The companies mentioned in the Houston article aren’t the product of private EMS being evil they’re the unintended result of a system that needs better instructions to act upon. The system is producing what we’ve told it to produce, not what we want it to. These problems wouldn’t exist if we would tweak the parameters of the system to disallow them.

So… what we need are some better instructions. Anyone got any ideas?

Here’s the link to the Houston Chronicle article again

Here’s the link to mine

Also, for more of my column on JEMS.com, here’s my page there with all of my articles listed.

Posted by Ckemtp on October 24, 2011 • Filed under: Administration & Leadership, Command & Leadership, Economics, Emergency Medical Services, EMS Management, EMS Topics, News, newspaper, Paramedic, politics

A Medic Roast in Tennessee

20 comments

Some time ago I worked for a service that had a governing board made up of community members from various walks of life. Most of them were business leaders around the area and only one or two of them had any EMS experience. One day I overheard one of the board members talking about problems he was having with the quality control at a factory his company ran in another area.

I was fascinated.

It seems that the workers at this factory just didn’t seem to care about the quality of the product they created. Products came out with grievous manufacturing errors that turned a lot of their finished products into unsellable junk. He described these errors as things that any reasonable person would notice had they spent more than one day on the job.

Joining in the conversation, I asked him “So, how much does the average worker at that factory get paid?”

He replied with a wage that was actually above my hourly rate as a paramedic. It was significantly more, actually.

It shocked him when I said “So they make that much more than I do, and when I make a mistake someone dies and my career is over? That doesn’t seem right at all”

And no, it doesn’t seem right. Every human being on this planet is going to screw something up on occasion. We’re not perfect. Medical professionals and especially EMS people are constantly challenged to adapt their knowledge to unfamiliar situations with incomplete information. On top of that, the body of our knowledge is constantly changing and it’s up to us to know exactly how to seek it out so we’re consistently doing the best for our patients. It’s not easy to be a good EMT or Paramedic and it’s a responsibility that we’re largely not well-paid for. Top that with the fact that even one simple mistake can be a career ender and…

You get this article that I saw this morning in JEMS: Tennessee Paramedic Demoted after Drug Mistake

If you’ve been a paramedic in the field for any length of time and this article doesn’t scare you, you’ve not been much of a paramedic for any length of time. This is real folks. This is something we all should sit up and take notice to.

The article concerns a paramedic who made a medication error. While it doesn’t state what error he made, it seems that he had mixed a medication in a bag of normal saline and infused it to a patient while intending to give a different medication. The article doesn’t specify the medications given but from the patient’s condition an educated person may be able to infer what they were. It also specifically does not mention the condition of the patient before or after the medication was given, leading me to believe that the patient suffered only minor ill. Yes, I know that I’m assuming… but you can’t tell me that the newspaper wouldn’t have been more than happy to blast the headline “MAN DIES AFTER MEDIC POISONS HIM WITH WRONG MEDICATION” if he had died. My guess is that if they downplayed his condition, there wasn’t much to sensationalize about it.

The medic, who had been with the service for 9 years and who had only been disciplined once in that time for missing something on a rig check, had received “above average performance reviews” and more than one commendation in his tenure.

From reading the article, it looks like an experienced medic made an honest mistake. He was reprimanded for it, suspended for 28 days, and demoted to an EMT.

Yeah, you read that right. They voided 3 years of education that this man had completed and knocked his license all the way to EMT-Basic.

They did this for one mistake. One mistake that even the medic’s chief stated was “… accidental and an oversight on his (the medic’s) part”. An honest mistake that everyone reading this article has already made or will probably make in their career. A mistake that was apparently easy to make, even by an experienced paramedic that most probably did not result in grievous harm to anyone.

If the facts truly are as reported in the article and there are no other unreported wrinkles to this case, I call shenanigans. The discipline this medic received simply does not fit the crime. It’s too heavy-handed. The discipline seems arbitrary, unnecessary, and patently unfair.

The chief was quoted in the article as saying that their agency, which is reported as responding to around 29,000 emergency calls each year, has a “success ratio” of “100%” and that “this is not the norm.”

Pictured: Every Paramedic

So he’s saying that the all of the EMTs and Paramedics that must handle 29,000 emergency calls per year are expected to be 100% perfect 100% of the time or he will negate their education, harm their lifetime income potential, and defame them in the national press? I know that he probably didn’t *intend* to say that… but he very much did say it. I know of no other single profession that has so much at stake every time they go to work. To my knowledge, no other profession has so much risk of long term harm to their lives, their family, and their professional career riding on a very much unrealistic goal of being 100% perfect 100% of the time. It’s shockingly unfair… and terrifying. No human being can maintain those expectations. We’re just not able to always be perfect all of the time for an entire career.

And when you think that the pay for Paramedics and EMTs in this country is by and large pathetically low, you might wonder why anyone would ever consider doing the job at all.

I’ll say again, if the facts in this case are accurate and complete as reported, this is an outrage. It’s an abomination. It’s enough to generate national attention about the unfair working conditions and haphazard disciplinary standards that EMS must endure.

I’ll say this too: I support this paramedic and formally place a letter in the file of the agency responsible for doing this to him.

(This part is for Google) If you work for WRCB TV in Tennessee, please feel free to consider this my opinion.

(You can find the original article HERE: http://www.wrcbtv.com/story/15463233/ems-used-wrong-iv-in-melvin-davis-transport)

Posted by Ckemtp on September 15, 2011 • Filed under: Administration & Leadership, Command & Leadership, Emergency Medical Services, EMS, EMS ethics, EMS Health & Safety, EMS rant, EMS Topics, Ethics, News, Paramedic, patient care, Patient Management

From the #WTF files – AL Fire Chief Flushes Twins down the Toilet?

7 comments

Holy crap! Read this: Odenville, AL Fire Chief Terminated FireLawBlog.com

Did I read that correctly? Did a Fire Chief really FLUSH TWO STILLBORN TWINS DOWN A TOILET!?

No way, that's gotta be a hoax… I mean, that can't happen, right? Please tell me that nobody is that stupid. Please restore at least a little of my faith in humanity…

Nobody? <sigh>

FireLawBlog.com's story on this has a link to the St. Clair Times article on the subject, and it looks like there's a lot more to this story than has been reported. The comments on the article are pretty telling… although I still have very little idea on what actually went on here. At face value, I can't see any possible reason that this would have happened. I just don't understand. Maybe if she miscarried into the commode maybe? I suppose they *could* have missed them… right?

Eww.

Also, the former chief defended himself with this cryptic statement, which I've seen repeated three times in various articles on the story:

"There were two of us there, and we followed protocol,” Davis said. “We followed the state protocol issued by the medic who was in charge at the scene.”

Soooo… Um… The medic… issues state protocol? and he/she ordered this? Aaaannnd… I'm sorry I just don't understand the statement. Maybe it's a bad quote, I don't know.

Anyway, here's the followup story. I just thought I'd call it to your attention.

http://firelawblog.com/2011/06/alabama-fire-chief-sued-over-disposal-of-stillborn-twins/

Posted by Ckemtp on June 8, 2011 • Filed under: Administration & Leadership, Command & Leadership, Emergency Medical Services, EMS Management, EMS Topics, Fire Rescue Topics, News, Paramedic

Colorado CRNAs Vs. Virginia Physicians? An interesting feud for EMS

25 comments

This article came across my Twitter stream this morning. It regards a letter sent to the Centers for Medicare/Medicaid Services by the Governor of Colorado informing them that in some Colorado hospitals it is now acceptable for Certified Registered Nurse Anesthetists to work independently of physician supervision.

The article, which is in the form of a letter written to the editor of The Aspen Times, is written by a Dr. Paul Rein who is the President of the Virginia Anesthesia and Peroperative Care Specialists. He takes issue with the lack of physician oversight and is “quite concerned” about it.

I think that the letter is important for EMS people to read. Especially us EMS people that are looking at how to expand our profession, grow our scope of practice, and expand our skill sets. It shows that there are struggles over these kinds of boundary and oversight issues all over the healthcare arena and that the politics and power struggles aren’t just limited to those of us that ride ‘round in ambulances.

The full text of the letter can be found here at The Aspen Times: http://www.aspentimes.com/article/20101004/LETTER/101009942/1020&ParentProfile=1061

The parallels I can draw from this issue to EMS are striking and enlightening. Here are some of the parts of the letter that I found the most interesting:

“A nurse anesthetist is an advanced practice registered nurse who has received special training to administer anesthesia, usually being supervised by an anesthesiologist. Anesthesiologists are physicians who, after medical school, receive an additional four to five years of specialized training during residency. Not only do anesthesiologists function in the operating room but they are trained to medically evaluate patients prior to surgery and to take care of problems that may arise immediately after surgery. In a few small hospitals a nurse anesthetist may be supervised by the surgeon if there is no anesthesiologist.”

I was curious as to the educational standards of a Certified Registered Nurse Anesthetist and so I went to their National Association’s web site: Http://www.AANA.com – It says this:

“The requirements for becoming a Certified Registered Nurse Anesthetist (CRNA) mainly include having a bachelor’s degree in nursing, or other appropriate baccalaureate degree, Registered Nurse licensure, a minimum of 1 year acute care experience (ICU, ER for example), and the successful completion of both an accredited nurse anesthesia educational program and the certification examination.”

(Source: http://www.aana.com/BecomingCRNA.aspx?id=98&linkidentifier=id&itemid=98)

Huh.

Actually, I wasn’t familiar with the requirements for a CRNA before I read that, but it says that they have to have:

A four year degree in Something
Licensure as a Registered Nurse
A minimum of One Year Acute care experience
Completed an Accredited training program
A passing grade on the certification exam

I was curious, so I popped on over to Salary.com and typed in “Registered Nurse Anesthetist” in my own zip code for a base salary search. I found that they start out at $131,000 and top out at over $170,000 in my local area.

Then, after giving serious consideration to changing this blog from “Life Under the Lights” of Fire Trucks and Ambulances to “Life Under the Lights” of an Operating Room, I decided to point something else out about the differences and similarities of a Paramedic and a CRNA.

“The didactic curricula of nurse anesthesia programs are governed by COA standards and provide students the scientific, clinical, and professional foundation upon which to build sound and safe clinical practice. The basic nurse anesthesia academic curriculum and prerequisite courses focus on coursework in anesthesia practice: pharmacology of anesthetic agents and adjuvant drugs including concepts in chemistry and biochemistry (105 contact hours); anatomy, physiology, and pathophysiology (135 contact hours); professional aspects of nurse anesthesia practice (45 contact hours); basic and advanced principles (sic) of anesthesia practice including physics, equipment, technology (sic) and pain management (105 contact hours); research (30 contact hours); and clinical correlation conferences (45 contact hours).

Most programs exceed these minimum requirements. In addition, many require study in methods of scientific inquiry and statistics, as well as active participation in student-generated and faculty-sponsored research.

Clinical residencies afford supervised experiences for students during which time they are able to learn anesthesia techniques, test theory, and apply knowledge to clinical problems. Students gain experience with patients of all ages who require medical, surgical, obstetrical, dental, and pediatric interventions. The results of a 1998 survey of program directors show that nurse anesthesia programs provide an average of 1,595 hours of clinical experience for each student.”

(Again, from http://www.AANA.com – the emphasis is mine)

Remember that the CRNA’s have a Bachelor’s Degree and a RN license prior to beginning their training. This is different from the Paramedic curriculum. We have hour requirements as well:

“The emphasis of paramedic education should be competence of the graduate, not the amount of education that they receive. The time involved in educating a paramedic to an acceptable level of competence depends on many variables. Based on the experience in the pilot and field testing of this curriculum, it is expected that the average program, with average students, will achieve average results in approximately 1000-1200 hours of instruction. The length of this course will vary according to a number of factors, including, but not limited to:

-student’s basic academic skills competence

-faculty to student ratio

-student motivation

-the student’s prior emergency/health care experience

-prior academic achievements

-clinical and academic resources available

-quality of the overall educational program”

(Source: Http://www.EMS.gov – Thanks to Chris Webster, Sam Bradley, Greg Friese and Kevin Reiter)

Not that the above is related to the article I read, I mean it’s saying that people with a BS degree in something, a medical license, and what amounts to a little more than an EMT-B class plus an EMT-P class from an accredited school make an average of $150k… but I digress.

Back to the article, Dr Rein has this to say about CRNAs:

“It is interesting to note that the United States is the only westernized country in the world that allows nurses to administer anesthesia unsupervised. Countries such as Canada, Australia, New Zealand, Japan and Israel, just to name a few, have no nurses administering anesthesia. In some European countries there are a few nurse anesthetists who work under the strict supervision of a physician.”

He continues and says this:

“So what’s up with us? Well, it seems that the American Association of Nurse Anesthetists have convinced our government in Washington that unsupervised nurses are just as safe as a physician. They point to the fact that there are no comparative studies to show they are not. The reason there are no studies is that it would be unethical to perform such a study in which some people get a physician and some do not. Can you imagine a patient agreeing to participate in such a study?”

Can you imagine indeed?

Dr Rein is right when he says in the letter that Anesthesia is a Medical profession and is a specialty of physicians for a reason. When he says “Just because we have made it safe is no reason to take it for granted”, he’s right as well. Anesthesia is dangerous for the untrained and inexperienced provider and it is a specialty not to be taken lightly. However, where’s the line? Is this an attempt by the”Virginia Anesthesia and Peroperative Care Specialists” to fire a shot at the “American Association of Nurse Anesthetists?” Are Doctor Anesthesiologists afraid of losing jobs to the nurses? Where is the line where patient safety is best maintained while being most cost-effective and efficient?

If this doesn’t provide incentive to you to think about requiring a degree for Paramedics, I don’t quite know what will. I’m not doing this job for the money and neither are you, but does that make us any more or less moral than a CRNA who “Isn’t doing his/her job for the money” either, but still makes a ton more of it than any paramedic I know?

You could change the names of the players in this argument, fiddle just a bit with some of the details, and change this into one of a thousand other feuds going on under the healthcare umbrella. This is the same story that paramedics face when we’re trying to get new skills, new techniques, more money, and more responsibility. While I’m not taking a stand on the CRNA/MD issue because it’s not my specialty, I’m offering up this debate as a study in professional growth and conflict between two of the myriad of medical camps out there. As we push EMS forward, grow as a profession, and promote the EMS 2.0 agenda, learning from things like this will be of value to us all.

————————————————–

Thanks to the following for their contributions:

The Aspen times – Http://www.AspenTimes.com
The American Association of Nurse Anesthetists – Http://www.AANA.com
www.EMS.gov

Posted by Ckemtp on October 4, 2010 • Filed under: ckemtp rants, Emergency Medical Services, EMS, ems 2.0, ems education, EMS pay sucks, EMS pep talk, EMS Topics, EMS training, medical ethics, News, Paramedic, paramedic education, Patient Management, physician, politics, potential, profession, Training & Development, Uncategorized

I don’t usually talk about Political things…

4 comments

But when I do, they’re usually of the macro-local type and have something directly to do with EMS.

This is one of those things.

The village of Schaumburg bucked the national trend of raising taxes and fees to cover rising expenses when its board unanimously approved a 4.4 percent reduction to the 2010 property tax levy

You read that right: reduction.

But that’s not all. Village officials also did away with vehicle sticker fees and moved to have property taxes cover garbage removal.

Just for the record, Schaumburg is in Illinois, folks. The same state that sent our senator up to the White House last election cycle. Lowering taxes isn’t exactly the modus operandi for an Illinois municipality. In fact:

Schaumburg is an anomaly among Illinois municipalities. Others like Gurnee and Orland Park raising taxes and fees where ever they can. Northbrook, which has seen an increase in sales tax revenue stood pat.

Schaumburg is one of the larger municipalities in the sprawling conglomeration of suburbs surrounding Chicago. It faces the exact same economic challenges that other municipalities in the area face, but it seems to be doing much better, economy wise.

The measure, if you read the article, isn’t final, but it looks like it will pass. Schaumburg has a full-time Fire/EMS dept and pays their firefighters extremely well, they also seem to have great city services and every time I’ve been in the city I’ve liked what I’ve seen.

In fact, the recent NAEMSE conference was held in a hotel in Schaumburg, and they played a small part in paying the hotel tax.

As I’ve said before, I’m not one to wax too poltical on this blog. This is an EMS and Fire blog and you come here to read about things related to Fire and EMS. I understand that. I don’t want to hijack the discussion to the miasma that is our national political scene and end up alienating a different percentage of my readership every time I post something of an opinionated political nature. However, local politics affect EMS and Fire, and I speak on the politics of EMS quite a bit. This is one of those issues.

I have to ask the question here:

Businesses pay taxes, residents pay taxes, Visitors pay taxes… It goes to say that the more businesses, residents, and visitors a locality gets, the more taxes they’ll pay by sheer volume. People have a choice on where they locate their business, where they visit, and where they choose to live. If you were in the position to do any of these things, knowing that Schaumburg is lowering their taxes, and plans on removing their property tax entirely - just like they said they would – would you choose to do so in Schaumburg, or in the other towns mentioned in this article?

In additon, removing the stupid municipal car stickers, which are really just a massive inconvenience and hassle to the residents of a city, and covering garbage disposal fees through what’s left of the property tax?

Well, Schaumburg… you may just be an island of sanity in an insane state. May word get out and people flock to your borders. It’s called “competition” and usually only successful businesses are the groups that think of lowering their prices to become more attractive to the customer. Bravo.

Source: http://www.nbcchicago.com/news/local-beat/Schaumburg-Officials-May-Lower-Property-Taxes-103947993.html?dr#ixzz10vUpO9PP

Posted by Ckemtp on September 29, 2010 • Filed under: Administration & Leadership, Economics, Emergency Medical Services, EMS, EMS Management, EMS Topics, fire, Fire Rescue Topics, Funding & Staffing, News, newspaper, Paramedic, Uncategorized

A Weighted Issue – The Fire Service Helping Private EMS

112 comments

There has been quite a bit of buzz lately over a story that happened pretty close to my generic neck of the woods. It’s been featured on www.JEMS.com as well as www.EMS1.com and has blown up the twitter streams. I was made aware of it by the JEMS Facebook fan page posting the link two days ago.

Before I link to the article, I’d like to say that I was immediately on the side of the private ambulance company and I jumped right on the JEMS facebook comments thread to state my case. I figured that there would be some dissention, but that most people would share my view.

But that’s not exactly what happened…

Apparently there is a vast chasm in opinions out there on this issue, and it’s not just the Firefighters vs. the non-firefighters like I thought it would be. The comments section is up to 61 comments as I write this and the discussion is poignant and well reasoned. I still believe in what I said… but I’m willing to revisit the issue

Here’s the article: http://www.jems.com/article/news/illinois-fire-department-refus

So… do you see the discord there?

The private ambulance service, which is a pretty new company that runs only one or two ambulances was started by a paramedic with a dream (yea, really). It took the patient from a rehab hospital to a private residence in Springfield, IL. I don’t know the exact road mileage, but I do know that Springfield, IL is a good 4 to 5 hours away from where the rehabilitation hospital is located. The patient was reported to have been on Medicare and Medicaid and weighed approximately 700lbs.

Yep, this ambulance crew had to take a 700 pound patient on a long distance transfer. I feel their pain.

The crew couldn’t get the patient from their ambulance into the residence when they got there and called the Springfield FD (SFD) for assistance moving the patient. SFD refused to assist them.

Ultimately, the private ambulance crew arranged for another private ambulance from a Springfield area company to come and help them. The job got done and everyone was happy, right?

Well, no… of course that’s not what happened. Someone alerted the media and the story popped up on the wire. Now there’s debate flying all over the interwebs and I for one want to keep it going. Viva debate. Viva discussion.

Here’s my comment from the JEMS Facebook Page:alled “community service” which I guess is something they don’t understand in Springfield.

There is nothing wrong with private ambulances and even the staunchest fire service EMS person would agree that no fire department would accept a long distance transfer (in this case, probably a good 5hrs) discharging a Pt from a rehab hospital to home. Some service has to exist to do this type of work, and Mercy Ambulance stepped up to do it. The patient was a TAXPAYING CITIZEN of Springfield FD’s area and Mercy was returning that taxpaying citizen to his or her home. This person has already paid for Springfield FD’s services and they refused to provide them.

I would guess that SFD regularly responds to other so-called “Nusaince calls” all the time, or have they stopped responding to Activated Fire Alarms, dumpster fires, and CO alarms as well?

Mercy Ambulance wasn’t doing this for the money. The reimbursement from Medicare is laughable and the “reimbursement” from IL medicaid is pretty much non-existant. They did this because the patient needed to get home. The reimbursement system is such that they would have had to eat the cost of additional crew and making the assumption that the SFD would respond for the “Public Assist” of one of it’s tax-paying constituents is reasonable.

SFD gets a letter in the file for this one.

I’m actually familiar with the ambulance service in question. In the area that it mainly operates within, the Fire service is always happy to help out the private ambulances with these types of cases. It has to do with providing something called “community service” which I guess is something they don’t understand in Springfield.

I would guess that SFD regularly responds to other so-called “Nusaince calls” all the time, or have they stopped responding to Activated Fire Alarms, dumpster fires, and CO alarms as well?

SFD gets a letter in the file for this one

That has been “liked” six times since I wrote it.

The rub here for the Defenders of the Fire Service™ is that they say that the “Medical Transportation Industry” is an “Industry” and therefore should have their own plans in place to deal with this type of case. They say that they shouldn’t diminish their ability to respond to emergency requests in order to help out a private business with a client. They say that they would expose themselves to liability, expose themselves to potential injuries of their employees, and that they would be providing this service for free. They say that this isn’t their job and that they shouldn’t be spending taxpayer dollars to help out a private entity.

And… I might concede that to them if I thought it was genuine. I mean, does the fire service help out the towing and recovery industry with cleaning up car wrecks? Do they help out the private fire alarm business by responding to and resetting false alarms? Do they provide private residences with smoke and carbon monoxide alarms?

Yes, of course they do all that. They do other things too. They help out all kinds of community entities, both public and private, for-profit and not-for-profit all the time. The Defenders of the Fire Service™ keep trumpeting their statement that they are an “All-Hazards” emergency response agency that is constantly adapting to meet “the needs that the public are demanding from them”.

All of those community entities the fire service assists have one thing in common, they pay taxes. Some of them pay property taxes, some of them pay rent that goes in-part to pay property taxes, and some of the straight not-for-profits provide services that help the people paying property taxes.

And last time I checked, the SFD does receive property taxes.

Here’s one thing with what I said though… The “All-Hazards response” idea is for responding to “hazards” and I can see where a private ambulance needing a hand isn’t exactly a hazard or an emergent need.

Would any of the Fire Departments I’ve worked on have done it? Yes, absolutely. A citizen needed an assist and we would have marked it as a “Public Assist”. We would have responded non-emergent, helped, and it would have been a non-issue. The person pays tax dollars and we would have looked at it as the same as responding with an engine for a 911 lift assist.

However, I will concede that the Private ambulance service would have been more proactive if they would have called the SFD and asked them if they would help them before they loaded the patient. If the SFD told them “no” at that time, they could have arranged for alternate methods at that time. Instead, they just assumed. They transported the patient to someone else’s sandbox and just hoped that they would play nicely.

And the SFD doesn’t play the way that Mercy Ambulance is used to playing.

If you can’t tell, I’m on the side of Mercy Ambulance here. Although I say that they should have dropped the dime and rang the SFD to ask them before they just assumed they’d help.

One thing’s for sure though, this issue isn’t going away and it will probably become more common. There’s a ton of differing opinions out there as shown by the comments that news story received and it shows that there are EMS professionals on both sides of the fence that have strong and reasoned opinions. This is an issue that would benefit from some discourse and that’s why I’m bringing it up.

What are your thoughts?

Posted by Ckemtp on September 17, 2010 • Filed under: Administration & Leadership, ckemtp, ckemtp rants, edemse, Emergency Medical Services, EMS, EMS ethics, EMS Health & Safety, EMS Topics, Fire department, Fire Rescue Topics, Firefighter Safety & Health, News, Paramedic, Patient Management, politics

Modern (f)Art

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Howdy Everyone!! It’s Ckemtp, your friendly neighborhood EMS and Fire blogger with a few things I’d like to bring to your attention. I’d like to talk to you today about politicians. Not the politicians that are doing such a great job at managing our collective money on the national level… I want to talk to you today about the local ones, the ones who do the important work of making sure our traffic lights aren’t burnt out, that our roads are pot-hole free, and that our sewer systems don’t back up and discharge raw sewage into lakes and rivers and stuff.

Specifically, I’d like to talk about Local Politicians and public art.

My favorite writer, the legendary Humorist Mr. Dave Barry, wrote a piece about public art a few years back that you just have to read before continuing on with this post. It’s actually one of many of his articles that include things about public art, which he defines as “Art that is purchased by experts who are not spending their own personal money” it also involves the phrase “a naked man the size of an oil derrick” and has references to nuclear weapons and alcohol. I love Dave Barry, I really do.

Read this: “Does Public Art Make Sense” – Then come back once you stop ROFL’ing

This is "Art" I think... Oh I know! It's a bus stop

Then, g’head and read THIS ARTICLE from Michigan Capitol Confidential which talks about the REALLY SMART city of Ann Arbor, Michigan… which is planning an $850,000 piece of public art. It’s really interesting to me that they’re planning this… and I really hope it isn’t made of flammable material because the city is “Facing a multimillion dollar budget deficit” and is planning on laying off firefighters to handle the budget crisis.

Here’s that article again: http://www.michigancapitolconfidential.com/13219

Yes, Ann Arbor, MI, the REALLY SMART city that it is, is laying off firefighters while spending $850,000 (That’s EIGHT HUNDRED FIFTY THOUSAND DOLLARS) on a “three piece public fountain”.

Oh, right… if it’s a fountain, it probably won’t burn down. That makes sense. Of course it might get filled with trash, since they’re laying off the city’s “Solid Waste Coordinator”. Y’know… the guy who oversees the trash pickup for the city. On the other hand though, they are hiring an “Art Coordinator” to, I don’t know… look at the art maybe? Maybe he’ll pick up the trash from the fountain.

Taxpayers, I’m talking to you here. Inefficiencies and, in this case, abject stupidity in local governments are killing us. If I was having trouble keeping up with the maintenance and mortgage in my own house, the first thing that I would do would not be to buy new paintings to hang on the walls. I certainly wouldn’t buy paintings at the expense of paying for trash pick-up, sewer service, or portable fire extinguishers. I think that I would pay for necessities first and niceties second. Responsible people take care of the whole Maslow’s Hierarchy of Needs thing; Food, clothing, and Shelter first and buy pretty things after that. You do the things you HAVE to do well before the things you’d like to do.

At least responsible, SMART people do that… and apparently that’s not the kind of people that the voters in Ann Arbor, MI think would make good city council members.

Or do they?

Maybe they can call this "Art"

Posted by Ckemtp on July 27, 2010 • Filed under: Administration & Leadership, Command & Leadership, dave barry, Emergency Medical Services, EMS, EMS Management, EMS Topics, Fire department, Fire Rescue Topics, Funding & Staffing, News, politics, Uncategorized

Why I am Passionate about the Chronicles of EMS

15 comments

If you’re an EMS professional, you should be paying attention to the Chronicles of EMS.

I think every person involved in EMS on any level needs to pay attention to the work of three of the profession’s upcoming giants, Mark Glencourse, Justin Schorr, and Thaddeus Setla. Their collective project is a warp-leap forward for how our profession is presented to, judged by, and thought about by our internal and external observers, customers, and colleagues. With their efforts come Hope… Hope that one day soon EMS will take its rightful place as a true profession; Hope that our profession will get the paid the attention that it deserves; Hope that our educational standards, resource needs, and compensation will finally be improved; and Hope that we will be able to improve our total service to our patients and our community through shedding a new light on our profession.

If this works… everything could change. Everything could change quickly, incredibly, and wonderfully. Imagine if EMS became “cool” and the public finally thought about who we are, what we are, and what it is that we do for them. Imagine if people demanded that their community leaders pay as much attention to EMS as we need them too… Just Imagine.

EMS needs a strong, unified message. The Chronicles of EMS can be that message. It is a professional, smart, and uber-cool message aimed straight at where we want to be going. It is not lip service, it is not Hollywood glamour, and it is certainly not dramatized for profit. It is being prepared by industry-experts who are still working the same streets that we are everyday. Everyone involved is one of us. Everyone involved is passionate. Everyone involved wants this, and they want it as bad as you do.

The reason I write about EMS is because I want to improve our profession and our service to others. I want to make this better so bad that I can taste it and I’m willing to work as hard as I have to. Our patients and our communities deserve the best we can give them and I believe that key to fixing EMS is communication and the spreading of our message. This blog exists for that reason and so do the other blogs in this genre. The other bloggers, authors, speakers, and writers I’ve met have all spoken to me of the same goals. Our profession exists to save lives and alleviate suffering and improving our profession help us save more lives and alleviate more suffering in our communities. EMS does indeed make a difference out there in the world and we’re the ones doing it. The Chronicles of EMS is a great beacon of hope in our collective quest.

EMS Deserves More. Our Patients deserve more; Our Families deserve more; and yes… We deserve more. Mark, Justin, Ted, and everyone involved in the Chronicles of EMS are working hard to give us just that. They deserve our support and our attention.

I’ll be in San Francisco on March 11^th for the premier of their pilot episode. I wouldn’t miss it for anything. Look out world, EMS is moving forward.

Posted by Ckemtp on February 8, 2010 • Filed under: Administration & Leadership, change, Command & Leadership, Emergency Medical Services, EMS, ems 2.0, EMS Blog, EMS blogosphere, ems education, EMS Health & Safety, EMS Management, EMS Topics, EMS training, EMT, Fire Rescue Topics, Firefighter Safety & Health, Happy Medic, humor, Line of Duty, medicblog999, News, Paramedic, paramedic education, Patient Management, pride, profession, professionalism, Public relations

Thanking Those who REALLY Deserve it – Merry Christmas

4 comments

I originally meant to post this during Thanksgiving, but this season seems appropriate enough. I love Christmas. It’s my most favorite time of year. I love family, friends, cooking, and giving gifts. I love Christmas parties, I love the fellowship, and I love being kind to everyone and having them not look at me strangely… ok *as* strangely as they do other times of the year.

And also, I tell people “Merry Christmas”. I don’t say “Happy Holidays”, “Happy Winder Holiday”, or “My lawyer sez to tell you ‘good luck”. If someone responds with “Happy Chanukah”, or “Happy Kwanza”, or “Happy MishMash Shaloob” I’m not offended by it and I’m happy that they wished me the sentiment so there ya go.

Oh, and to my UK friends, Merry Frumpydumples to ye’

So what’s my Christmas post going to be? Well, it’s about thanking who’s really important to thank. As you all know, I’m a volunteer paramedic and firefighter as well as being a career paramedic and firefighter. This time of year in the small towns, it’s pretty common to have people stop by and offer up sweet treats and tell us “Thank you” for what we do for them. Let me make the blanket statement that I really appreciate it folks, even if my waist line and my pending diabetes doesn’t. However, I don’t think that I deserve your thanks.

I have always gotten more from my service to others than I could ever hope to give back to it. I love EMS and I love the Fire Department and I love helping people. I identify with it and I couldn’t imagine my life without it. Even after a solid decade of running my “Life Under the Lights” I can’t imagine doing anything else. I am rewarded a thousand times over by every smile I get, every person I comfort, and every person that I am privileged enough to come into contact with as a caregiver.

So who should the people that wish to thank us actually be thanking?

Well , first thank my wife for every time that I’ve had to get up and leave for a volunteer call in the middle of a family dinner. Thank my kid for every time that I’ve missed out on play time, or story time, or nap time because the pager called me away. Thank my family for all of the times that they’ve had to do without me because I was working mandatory overtime. Thank my wife too for all the nights she sleeps alone because I’m on a 24 and am sleeping at the station. Thank my friends for all the times that I’ve stood them up on plans because I’ve gotten stuck running calls. Thank everyone who cares that I spend time with them, because a lot of the time I could be doing that I’m off caring for everybody else.

Thank the same people for every volunteer or public safety person you know… because without the caring and understanding of the people that truly matter in life for us, we couldn’t be out there doing it for you. They’re the heroes here.

That, and one more thing. I was never in the Military and I probably should have been. This may not be much, but Thank You to all of our Military Men and Women out there serving for me and my family. I can’t write enough to say how much I deeply, and truly appreciate your sacrifice… but from the most humble part of my heart, Thank You for everything you do. The same thanks goes to your families and loved ones as well.

Merry Christmas, Every one.

Posted by Ckemtp on December 24, 2009 • Filed under: 2009, Ambulance, appreciation, Emergency Medical Services, EMS, EMS ethics, EMS Health & Safety, EMS Motivation, EMS pep talk, EMS Topics, fire, Fire Rescue Topics, Firefighter, Firefighter Safety & Health, In the Line of Duty, Line of Duty, News, Paramedic, pride, profession, professionalism

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