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Trust… It’s everything

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Any Random Person

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(more…)

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

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

Splashed Sadness – A look at negative emotions in EMS

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WARNING TO NON-EMS PEOPLE: This post is pretty emotional. If you’re not emotionally equipped to handle really sad descriptions of EMS calls, don’t read it.

Here’s a revelation: EMS People are better suited to handling sadness than are laypeople. Of course we are. Not because we are necessarily any emotionally stronger than anyone else but because we have experience in dealing with it. As anyone could see, a good number of the situations we respond to and either assist with or observe are really sad. In my decade or so of riding the ambulances I have come across more situations than I could possibly remember that I wouldn’t want to casually discuss outside of the industry for fear of really making laypeople very uncomfortable. A story that might turn into a running joke among your colleagues might just depress a layperson for weeks.

Like all medics, I have my coping mechanisms and some of them are healthier than the others, they include sarcasm, dark humor, clean humor, Tanqueray martinis dirty and dry up with three olives, blogging, fishing, picking on my soon-to-be wife (9 days till the nuptials as of today!), playing with my boy, fishing, MGD, cigars, and sarcasm. There are a few other things in there too, I’m a rich tapestry.

This blog gets read by mostly EMS people, but there are public people out there that read me too. For both of your benefit, I’m going to relate some stories here of calls that I’ve personally attended to over the years:

A 16yo male takes his 24yo soon-to-be brother in law out into the city for the 24yo’s bachelor party. On the way home, they’re both just obliterated after drinking all night. The 16yo boy is driving home and is going way too fast to notice the semi hauling gravel that pulls into the right hand lane of the 4-lane road they’re driving on. The kid notices it at the last second, swerving just in time to impact the passenger side of the car against the back of the semi trailer. The impact shears off the left side of the 24yo’s skull, popping out the left side of his brain and leaving it, mostly intact, in between the front seats of the car (I almost put my knee into it). The 24yo dies a not-so-immediate death (I don’t want to get into it. Hopefully it was mostly painless). I pronounced the 24yo dead and took care of this very intoxicated 16yo. He was barely able to comprehend the terror of the situation and was covered in blood and brains that formerly belonged to the man his sister was going to marry. He was unhurt but I ran him into the hospital anyway. How could I leave him there immersed in the terror of that scene, in the terror of what he was more or less responsible for?
A 19yo male comes home from the military and his friends throw him a house party. During the party the 19yo takes his 18yo male friend down to the basement of the house to show the friend a new pistol that the 19yo brought home with him. The friend takes the gun to look at it and playfully twirls it around his finger ‘Old West’ style in an attempt to be cool. When he does, the gun fires, shooting the friend from the chin through the top of the skull. When I got to him, he was still breathing and had a strong pulse however it was mostly his brain stem that was controlling the reflex. Most of his brain was splattered on the basement floor. We worked him, transported him to the trauma center, and I believe that they were able to harvest his organs.
A man and his wife of upwards of twenty years are just bumming around the house on a nondescript weekday. It’s about lunch time and they’re going to eat at home before they go to the wife’s doctor appointment. The wife gets up to make sandwiches, gets to the counter, and slumps to the floor. She never woke up. We worked her very hard, but her heart had just decided that it had reached its allotted number of lifetime beats.

The above short summaries of calls that I’ve been to are sad. There’s no joke that can make them not sad. If you read this, there are two reactions I expect from you here:

For non-medical people: You’ve related these stories to yourself. You may be crying. You’ll think about them and your heart will go out to the unfortunate people involved. You’re sad.
For EMS People: Don’t these sound like good calls? They were. Yep, they were sad and I felt very bad for the people that were involved. Good calls though. What’s for lunch?

I think I remember what I did after the above three calls. I think that it was profound although my memory is pretty foggy after all these years. After the first one, I cleaned up the truck and actually got to sleep the rest of the night. After the second I cleared and went to a few more calls and then had lunch. After the third I um, had lunch because it was lunch time.

EMS people can probably know what I’m talking about here. I call it “The Howl”. It’s the sound that a family member makes after you’ve transported their close loved one to the hospital where the patient is pronounced dead by the ER Doc before the family gets there. So there you are, cleaning your equipment while the ER staff makes the sad announcement to the family. Here comes The Howl of anguish that the family member makes when they hear the news. I’ve heard it time after time in hospital after hospital. It’s loud. It’s haunting. It haunts my dreams some nights. I say that The Howl is an example of direct sadness. Direct Sadness is the pain/sorrow/anguish/horror that a person feels when they are a primary person in the situation. In my position of hearing The Howl after working the patient and unsuccessfully trying to save their life I experience Indirect Sadness. For the coworkers that I tell the story to and the readers of this blog, “Splashed Sadness” is the term I use. I think that “Splashes Sadness” is what a person experiences when hearing a terribly sad story like that.

In this business, Splashed Sadness is everywhere. It is one of the hallmarks of professional EMS. Think about it like this, I will always remember a conversation that happened between a group of coworkers and me one nondescript morning some time ago. They told the story of a college age male that overdosed on illegal drugs, stopped breathing, and was resuscitated from asystole (flat-line) by the paramedic that was telling the story. He mentioned that the fiancé of the patient was in the ER with the most-probably brain-dead patient and was holding the patient’s hand and telling anyone that happened by that they were supposed to get married that weekend. He said that she just kept repeating “We’re getting married this weekend” over and over again.

The sadness contained in that story splashed on to me and I’ve remembered it to this day. It will probably be there tomorrow too…

I responded by asking if they recommended that she cancel the caterer. Then there were fart jokes and wrestling (It was an all male crew that day). That’s how I dealt with the splashed sadness. I try not to get any of it on me and I try to psychologically squeegee any of it that I do get on me off as quickly as possible by interjecting humor and sarcasm into the situation. Extreme humor to deal with extreme sadness.

EMS people gain experience in dealing with negative emotions and sadness through all of these routes, direct, indirect, and splashed. While I have dealt with Direct sadness in cases of the deaths of close loved ones including my father, I don’t want to deal with any more. I get indirect sadness a lot of the days that I show up for work, and splashed sadness happens every dang time I talk to a coworker or discuss a bad call with a peer. I’m splashing sadness on you all right now as you read the above stories. If you’re an EMS person, you can deal with the splashing. If you’re a layperson, I’m very sorry for doing that to you but I did warn you before you started reading. My theory is that the more experience you
get with sadness, the better equipped you are to deal with it.

Or you go nuts.

Or you go nuts and start blogging and drinking martinis like I did.

Maybe I’ll get credit in a psychology journal for coining “Splashed Sadness” in EMS.

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

Posted by Ckemtp on February 16, 2010 • Filed under: Ambulance, CISD, EMS, EMS Health & Safety, EMS Topics, EMS ethics, EMS pep talk, EMT, Emergency Medical Services, Fire Rescue Topics, Fire department, Firefighter, Firefighter Safety & Health, In the Line of Duty, Paramedic, bad calls, emotions, inside the mind of a paramedic, paramedic education, psychology, sadness, safety

Why I am Passionate about the Chronicles of EMS

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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.

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

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

Mental Quickness – Do Smart Alecks Make Better EMTs?

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Alright, I admit it. Driving to work this morning was a bit of a challenge. We had two inches of fresh snow and the tires in my car are in desperate need of replacement. Yes, I drive a Subaru and usually it’s all-wheel drive does awesome in the snow… but I cheaped out on the tires, and they’re honestly a bit mismatched size-wise. Therefore driving it in conditions even remotely slick is hard as heck. I would have driven the SUV and had no problems at all but the wife had to drive the kid to school and then had to drive into the city afterwards and I wanted her to have the safe vehicle. Who cares if I go into the ditch? Work can do without me if they have to, but I need my family to be safe.

Since I think of things to write about when I drive, this morning brought my thoughts to how hard I had to concentrate on the road and the minute adjustments of the steering wheel and the accelerator needed in order to keep the car safely on track. Like everyone who knows about driving in slick conditions, I kept my eyes on the road ahead of me in order to “read” the changes in the road surface before I got to them in order to be ready to quickly make the adjustments needed to keep the car heading in the right direction. See a dark shiny patch? Foot off the gas, be ready to steer slightly away from it when the car slides in that direction. See a pile of snow with a frozen rut running through it? Minutely avoid it if possible and steer into the slide with just enough change in the gas to power through the slide. I made it to work, but I had to call in a favor to have a guy stay over for me for ten minutes. I let him know the night before that he might have to, and I did leave early… but I’m not wrecking the car just so I can save a few moments.

I consider myself a pretty good driver in the snow. In a vehicle with good tires I wouldn’t even worry about anything less than 6 inches this far into the winter season, but today was hard. I’m not patting myself on the back here, because if I would have put good tires on the car in the first place I wouldn’t have been in this position, but isn’t that most of what we do in EMS? We end up using our mental prowess to clean up other people’s messes caused by their lack of planning all the time. Today wasn’t much different. The amount of mental power and concentration needed to keep a car moving forward safely in snow-covered conditions is actually quite staggering when you think of it. You have to make quick observations of rapidly evolving conditions, surmise what you think the presentation of the road surface means to vehicle’s path of travel using your limited observations paired with your past experience and knowledge, and come up with a near simultaneous decision on how to handle the situation ahead of you. If you find yourself to be wrong, based upon the car not reacting the way you want it to, you have to instantaneously correct the situation while adjusting for the conditions ahead… or crash.

Now picture yourself managing a challenging patient presentation, one requiring a handful of pharmacological and physical interventions. You’re pretty much doing the same thing as driving in snow. Just like playing a game of chess, you have to be “thinking a few moves ahead” in order to keep up with what the patient’s physiology is going to throw at you. Do you have a fall victim with a broken hip in need of pain control? Did you think that they’re possibly going to drop their blood pressure with a dose of morphine? Well then you better be ready to give fluid to bump it back up to acceptable levels. However, what if you’re treating a CHF patient that would suffer further from the added fluid? What if they were a patient with Chronic Renal Failure? Would that affect your initial dose of morphine based upon the unknown factor of untoward hypotension? In my Northern system, I’d choose to use Fentanyl over Morphine in that case because of the lessened risk of hypotension, but in my Southern system I’d just have to start with a lower dose of Morphine and slowly titrate to an acceptable level of pain control once I gauged the patient’s response to the med.

How about a patient with a large anteriolateral MI? Their Left Ventricular function is soon to be compromised if not treated in a cath-lab. You need to increase blood flow to the Left Ventricle and decrease overall cardiac work by decreasing afterload with use of nitrates, but that’s going to decrease their cardiac output and blood pressure by decreasing their preload as well. You need to stabilize the infarct as best as possible while maintaining the patient’s hemodynamic state, and you may need to consider supporting their left ventricular function with the use of a vasopressor such as dopamine to treat possible cardiogenic shock. In this case, careful observation of the patient’s presentation and all information available to you is of paramount importance in order to make the minute treatment decisions necessary for your patient’s best possible outcome.

It all comes down to “Mental Quickness” or having the mental prowess and state needed to rapidly intake complex information, process it against your knowledge base, and then make reasonable decisions on a course of action in a very short period of time. We call people who are good at this “Quick Witted” and it applies to myriad situations in daily life. People who are good at this are usually funny, are quick to react to new situations, handle change fairly well, and make darn good EMS providers. I practice by trying to have a joke ready for any situation… so you could also call a person who’s mentally quick a “smart ass”.

You can practice your skills at being mentally quick the same way I do. Use humor and try to make good comebacks to the hooks and barbs that your coworkers and friends throw at you. When we’re sitting around busting each other’s chops… we’re actually practicing our EMS skills, right?

Think about it. Exercise your mind through reading, learning new things, and trying to come up with new ways to think of existing information. You’ll be funnier, more popular, will be able to knock your buddies down a peg better, and will improve your patient care.

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

Posted by Ckemtp on February 2, 2010 • Filed under: Administration & Leadership, EMS, EMS Health & Safety, EMS Humor, EMS Topics, EMS paramedics, EMS practice, EMS training, Emergency Medical Services, Fire Rescue Topics, Paramedic, Patient Management, Training & Development, change, ems education, ems scenario based education, inside the mind of a paramedic, mental imagery, paramedic education, patient care, scenario based training, training-fire-rescue-topics

EMS practice

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Did anyone else play a sport (or sports) in high school? I did, actually I played football for a few years. I was on the line, which in my small high school meant that I played every position on the line, both offense and defense, because there just weren’t that many kids out there to play. My graduating class was 83 in my small, small town.

I didn’t touch the ball though. Coach told me just to go out there and hit people. I haven’t touched a football since.

Every day after school we went out there no matter rain, shine, snow, heat, or better things to do and practiced for three hours every night. We did this all season and I hated it. It sucked and sucked bad. However, it did make me a much better football player. It kept my mind focused and kept me in shape. I was a much better “Go out there and hit people” guy than I would have been had I just taken a football class and then played parts of the game every day.

Does anybody do this with EMS? Sure, we all do Continuing Education, but do we really practice as hard as we should as much as we should?

We play parts of the game every day but just as sure as I didn’t intercept a pass and run in a touchdown every game, I don’t perform a pericardiocentesis every shift. I can plink in an IV in my sleep (and do… a lot…) and I probably can treat a STEMI as good as the next guy. Playing the parts of the game that we do more often than the others gets us good practice on what we do most often, and if we don’t allow ourselves to get complacent, that’s just fine. However, how many times have you calculated a dopamine drip lately? Even if you live in the busiest, most dopamine swillingest jurisdiction on the planet you’ve still interpreted Normal Sinus Rhythm a lot more than you’ve shown off your math chops.

The other day I missed a tube. I was caring for a patient who crashed in front of me while heading to the ER. The Pt went from CAOx3 to very obtunded in a matter of a minute or two. The first time I went to tube, (the Pt) was clenched and by the time I got the etomidate ready we were close enough to the hospital that bagging was my best option. When the Pt got sux and sedate juice in the ER I tried again…. and missed.

I freakin hate that! Man, I never miss a tube! At least almost never. I hate it when I do and beat myself up about it. Probably more hard than I should, but that’s just me. I take this stuff seriously if you can tell. The next shift I spent an hour playing with our two intubation dummies and our “Fred the head”. I tubed over and over again every way I could think of. For an hour. Yes, I know that it’s not exactly like the real thing, but it was all that I had access to for practice.

Something cool happened right after I got done with my hour long tubing pennance. I sat down for lunch and immediately got toned out to intercept a code with CPR in progress. I pointed my SUV towards the rural address and hit the gas. When I got on scene, the BLS crew told me over the radio that they were having difficulty with the airway. I walked in, and got the most beautiful tube that I think that I’ve ever gotten. Right in, right through, and right hole.

I think that my football coach would have been proud.

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Posted by Ckemtp on February 1, 2010 • Filed under: ALS Intercept, EMS, EMS Health & Safety, EMS Topics, EMS practice, EMS training, EMT, ET Intubation, Emergency Medical Services, Fire department, Paramedic, Patient Management, ems education, ems scenario based education, intubation, paramedic education

Expanding Our Career Options – Non-Traditional EMS Jobs

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

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

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

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

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

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

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

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

“Like Being on a Carousel” – The NREMT Cert? From TOTWTYTR

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One of my absolute favorite EMS bloggers calls himself “Too Old to Work, Too Young to Retire”. His blog and his writing is witty, insightful… and as the name may suggest, sometimes pretty cantankerous. I missed this post when it came out, but today when I came home from shift and was looking for a good read, I popped over to his blog to have me a look.

I was not disappointed, my friends. Looks like TOTWTYTR is in good form lately and he’s loaded up his torpedoes and aimed them straight at the NREMT, the state licensing agencies, and EMS education in general.

My favorite line from the post? “The entire process of recertification is a fracking farce” Preceeded immediately by a Ron White quote. Classic.

I’ll shut up so you can go read. http://tooldtowork.blogspot.com/2010/01/like-being-on-carousel.html

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Posted by Ckemtp on January 11, 2010 • Filed under: EMS, EMS Topics, EMS rant, Emergency Medical Services, ems education, paramedic education

Uh oh, is it that time again? EMS Recert Time Cometh…

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I’ll betcha that a lot of you reading this are in the same boat that I am… Here’s the reminder!

Yesterday I had the occasion to pull out all of my various certification cards and licenses, photocopy them, and turn them in to one of my departments for verification that I still had them. Much to my chagrin I noticed that it is indeed that time again… the time for me to start gathering up all of my hard-won continuing education hours and credits, compiling them into packets, and begin sending them off to the various places that I hold licensure through.

So let’s see… that’s Illinois, Iowa, Wisconsin, and the National Registry of EMTs. Actually, the Illinois license is on a 4 year schedule, so this is an off period for them. Thank goodness for small favors. Unfortunately though, I also noticed that my ACLS card expires this month and I hadn’t noticed it till now. Now I have to frantically find a class to sit through and get me some learnin’ at. Here’s hoping it’s not like the last time I took the class… It was horrible. Since I had let my card expire by, ahem, a “short amount of time” (3 months) I had to take the full class. Worse yet, the only class I could find happened to be when one of the big hospitals near me was pushing through a bunch of OB/Peds nurses through the class so that they could accept regular med/surg patients on their units. The nurses, suffice to say, were less than thrilled to be there and answered most of the questions with “I don’t know, what does the Doctor order me to do?” The instructor, who was also a nurse, actually accepted that answer for most of the questions. Really. I listened to them give waaay off the wall answers that were accepted as correct by the instructor.

I don’t think any one of them has ever been in charge of a code resuscitation… at least not a successful one. But I digress.

The State of Wisconsin EMS bureau has been changing the rules for renewing your licensure quite a lot this year. Frankly, I don’t quite understand what I have to do as of yet but I’m working on finding it out. As far as I know right now I have to take a “refresher” program. I *think* that by completing a National Registry refresher program I will be fine. Feel free, however, if you’re in the know for Wisconsin EMS renewals, to set me straight on this in the comments section. It’s kinda important for my livelihood.

My Iowa EMS license is much easier. All I do is send them in the exact photocopied packet I send in to the NREMT, fill out a short little form, and a few weeks later I get a shiny new license in the mail. Thank you State of Iowa EMS! Keep Being Awesome!

For the National Registry, I’ve heard faint rumblings about this whole “Computer test based” renewal program. It sounds cool, from what I’ve heard… but I’d have to do the exact same CE for my Wisconsin and Iowa licenses and I wouldn’t get the CE bump I need for the 4 year Illinois license. So much for that, then.

Lucky for me, there’s an awesome NREMT recert class they put on in Davenport, IA. I’m heading out that way to get me some high-quality learning and have me a little bit of fun as well. Thanks EICC and MEDIC EMS!

This post doesn’t have much of a message to it other than for me to gripe about having to yet again put all of this stuff through. I am all for education, and I research EMS stuff nearly every day, but unfortunately I haven’t thought of a way yet to translate stuff I learn from my colleagues on the EMS blogosphere and the other sites on the interwebz into hard Continuing Education credits. Maybe I’ll spearhead that issue too once I get time. Maybe…

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

Posted by Ckemtp on November 20, 2009 • Filed under: AHA, EMS, EMS Health & Safety, EMS Topics, EMS training, EMT, EMT-Intermediate, EMT-Paramedic Specialist, Emergency Medical Services, Iowa, Iowa EMS, Paramedic, Training & Development, ems education, paramedic education, wisconsin

Education vs Training: The “Professional Ambulance Cleaner”

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Imagine if you will this hypothetical scenario:

You and your roommate have just graduated EMT school together and go to work at competing ambulance companies in the same city. He works for HIS ambulance service, and you work for YOUR ambulance service. Both services have similar fleets, similar deployment patterns, and similar call-volumes. In fact, there’s really no way to tell them apart other than the fact that the HIS ambulance service uniforms are sickly green jumpsuits, and YOUR ambulance uniforms are Macho Blue Shirts with navy blue pants.

You both go off for your first day on the job which understandably includes several hours of training on company policies. For both of you, the whole day turns out to be a long class on how to clean the inside of ambulances.

Here’s the differences, though. At YOUR ambulance, you learn about the biological functions of bacteria and viruses. You learn their strengths, their weaknesses, how they reproduce on inanimate environmental surfaces, how they create biofilms to increase their reproductive capabilities and life span, and how pervasive they are in randomized samples from real-life ambulances. You learn how grime collects in the ambulances, how it adheres to the surfaces that you will be cleaning, and what the various types of substances are that you will most commonly find in real-world applications. The whole first day is spent on nothing but learning about dirt, grime, and germs and how they contaminate ambulance interiors. They even threw in the types of materials that the ambulance interior is made from and what the specific dirt-holding and germ-breeding properties of each material are. You see samples and scenarios pertaining to germ and dirt proliferation on ambulance interiors.

Not only that, there’s homework, reading material, and a report due the next day.

The second day that you report to YOUR ambulance service, you learn all about different types of cleaning products, tools, and disinfectants. You learn how to properly choose the detergent needed for optimum dirt-dissolving power on what type of surfaces you may have to clean; You learn the proper disinfectant to choose for each type of commonly encountered bacteria, virus, and fungi spore; and you learn the proper contact times to leave each product on for optimal disinfection and/or dirt dissolving power. Then you learn about every different type of sponge, mop, rag, fabric, and tool used to clean the ambulances. You spend a few hours in the laboratory they have testing out the material and performing experiments in the name of learning.

Oh, and after that day too, there’s a lot of homework and reading material.

Your roommate, on the other hand, went to work and found out that he too had to learn about ambulance cleaning. He learned that they also expect clean ambulances, however his choices and training are much simpler. He is told to clean the ambulance using two bottles: One marked “Cleaner” and the other marked “Germ Killer”. He is given ten rags and is told to clean the ambulance for inspection by the owner of the company using the tools given in the time allowed. He does so and is told “Good, now do it again tomorrow”. The next day, he again cleans the ambulances using the tools and training provided, and is again told “You did a good job”

In the above scenario, the first ambulance service, “YOUR Ambulance, uses a form of advanced education to teach their people how properly to clean the ambulances to their specifications. The education is rigorous and in-depth.

At “HIS Ambulance” they use training, and vocational experience to teach their employees how to properly clean the ambulances.

Here’s some questions I have:

Which ambulance service do you think will have cleaner ambulances in the long run?
Which employee do you think will do an overall better job in cleaning the ambulances?
Which employer, “YOUR Ambulance” or “HIS Ambulance” do you think has the better philosophy?
Which ambulance cleaning class will result in the better, more motivated, happier employee?

Anyone else see the relationship to EMS training/education here? Which one results in a more “Professional Ambulance Cleaner” that is better equipped to handle the job?

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

Posted by Ckemtp on November 12, 2009 • Filed under: Ambulance cleaning, Ambulance maintenance, EMS Management, EMS Topics, EMS training, Emergency Medical Services, Management, Paramedic, Training & Development, disinfection, ems 2.0, ems education, ems scenario, ems scenario based education, paramedic education, profession, professionalism, sanitize, scenario based training, training-fire-rescue-topics

Cardiocerebral Resuscitation – Change brings Fantastic results

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Hold on to your brains here people, because I’m about to blow your mind.

With new research comes new treatment modalities, and with new treatment modalities comes a change in our profession’s very foundation. This change is hard to accept and hard to convince others to implement, but it is necessary for us to do so.

I’m talking here about CCR, or Cardiocerebral Resuscitation. Hold on, because it’s coming, it’s fantastic, and it will shake the very timbers of our profession.

First off, if you don’t know what I’m talking about, here are some things you should read first. Go ahead and read them, then come back and read this. I’ll give you a teaser on why you should read forward:

40% – 60% resuscitation rates are possible in witnessed V-Fib cardiac arrests.

Is that enough incentive for you?

First, go visit: Http://www.CallandPump.org to read about the ongoing research project.

Then, read my first post on CCR: “Advances in Resuscitation – CCR, if you’re not doing it now, you will be”

Follow the links on that post to see the article outlining the research project and the subsequent article published in the Annals of Emergency Medicine.

Did you read them? Good.

So here are some things you should know about CCR.

It’s about moving blood – Good compressions make all the difference. Press hard, press fast (100 compressions per minute) and switch out compressors every 1 minute. Yes, do this even though you’re going to complain that I “don’t know how it goes in the field”. Yes, I do because I’m a practicing paramedic with a decade or so of experience and two full-time EMS jobs. I know it’s hard and unwieldy, but the results are almost magical.

When I first became a CPR instructor for AHA some years ago, I taught my students, incorrectly, that chest compressions were all about compressing the heart between the sternum and the spine. It turns out that I was wrong. The point of effective compressions is to vary total intrathorascic pressure creating both a positive total pressure that forces blood out of every vascular space and organ in the chest including the heart and aorta and also then creating a negative total pressure to pull blood back inside. The more blood you can get flowing, the higher pressure you create in the arteries moving blood through the vascular system and perfusing the heart and the brain. By continuing compressions, you boost the arterial pressure higher to the point where it will perfuse the heart and the brain adequately to maintain some amount of metabolism and prevent some cellular necrosis. When you stop, even for a few seconds, the pressure falls to almost nothing and must be worked back up to the level needed to provide some perfusion of the critical organs. 100 compressions per minute isn’t a request, it’s a mandate if you wish your patient to survive. Switch out compressors every one minute. We’re human beings and we’re fallible. It’s been shown that we cannot maintain adequate compressions for more than a minute. Pop on your ETCo2 monitor and watch the number fall after one person does compressions for longer than that and you’ll believe me.

Transport is deadly – One of the tenants of CCR is that every intervention that interrupts compressions must be proven to be of more benefit than continued perfusion of the heart and brain. If we are to maintain adequate compressions to continue this perfusion until the heart restarts and begins moving blood on its own, we must not move the patient from a hard, level surface. One of the biggest interruptions of compressions is the act of moving and readying the patient for transport. We jostle them around, put them on a narrow cot, bounce them from wherever they fell, load them into the ambulance, and then bounce them along the road to the ER. All of this decreases arterial pressures by negatively impacting our ability to adequately compress and also by limiting our ability to effectively compress and increase intrathorascic pressures to the extent possible. Therefore, transporting the patient is deadly because it harms our ability to resuscitate our patients.

Of course I want you to take them to the hospital eventually (hopefully once they’re resuscitated) just don’t be so eager to get them there. Work the patient where you find them. You’ll do your best work on scene and will be pleased with the results.

Be prepared to use more and less common medications – How many medications do you carry on your trucks? One service I work for that doesn’t use the new CCR protocols carries 6 prefilled syringes of Epinephrine 1:10000 on the trucks. Let’s see… One Epi every 3-5minutes x 6 syringes equals 18-30 minutes of epinephrine for the arrests we run. I put the officers on notice that I will be needing a second truck to respond to codes that I attend. In addition, since more patients are being resuscitated, the need to practice post-resuscitative care is increased. Be prepared to hang antiarrythmic drips. Be prepared to hang dopamine. Practice caring for patients post resuscitation. You may want to consider researching induced hypothermia to mitigate reperfusion injury to the heart and brain.

Also, remember that Vasopressin and Amiodarone are in the AHA ACLS protocols. Does your service use them?

Approach cardiac arrest with a clear game plan – If you’re in the emergency services, you should be familiar with the Incident Command System, or ICS. Resuscitations should be no different. One person is the “Code Commander”, one person is the “CPR Sector Officer” and so forth. Train on these like you would train for any other major incident and watch your success rates climb.

I’ll be posting more on this in the coming days. I’m really excited about CCR and the possibilities that it holds for our patients and our profession. You will be too, trust me

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

Posted by Ckemtp on November 11, 2009 • Filed under: CCC, CCR, EMS Topics, EMS training, Paramedic, Patient Management, Protocol development, Training & Development, cpr, cpr save, ems education, paramedic education, save

Will your career survive a decade or more in full-time EMS? Take this three question quiz!

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This is a simple test that you can use to see if you have the proper mindset to make it a decade or longer in this insane profession we call EMS.

NOTE TO NON-EMS PEOPLE: This post is geared especially to those in the industry. It explores humor that we employ to keep us with a healthy degree of insanity. If you’re not in the industry and you find this to be disagreeable in some way… well then in the words of Motorcop: “You’ve got the wrong frikkin’ blog pal!” Go read about scrapbooking or something.

This is a simple three question blog based quiz that you can use to determine if you have the right mindset needed to make it more than a few years in this crazy, wild profession we call EMS. If you fail this quiz, um… well then you should tear up your EMT card immediately or not. Nevertheless, if you find this at all funny, you’ve come to the right place. Howsabout that?

Question #1:

You’re working a service that employs two paramedics per day to support BLS ambulance crews in your jurisdiction and beyond. The other paramedic on duty with you that day responds to a neighboring jurisdiction and manages to resuscitate a patient in cardiac arrest. He transports the patient on-board the BLS ambulance to the local community hospital that does not have ICU admitting capabilities on site. Shortly after he transports the patient to the small ER he contacts you asking you to respond down with the ambulance to stat-transfer the patient to a tertiary ICU approx 1.5hrs away lights and sirens. The patient’s got three drips going, is receiving bolus cardiac meds, is on a ventilator, and is not doing well. The ER doc wants the patient outta there as soon as he can get him reasonably stabilized for emergent transport. Oh, and before you ask, the helicopter’s not flying due to weather. You’re it, Buddy.

You arrive at the ER with your EMT-Basic partner and um, you’re “enthused” about the “challenge” you’re about to face. Walking into the ER you hear more than the expected commotion coming from the patient’s room. You enter the room to find the ER staff performing CPR and attempting to resuscitate the patient after he went into cardiac arrest again. You and your partner assist, but despite everyone’s best efforts, the patient unfortunately expires.

When you return to service and get back to quarters, you expect your coworkers to:

A. Be supportive and consolatory, understanding that you’ve just been through an intense, traumatic experience.
B. Make fun of you and suggest that you’re an incompetent paramedic because, after all, the other paramedic “saved” the patient… then you showed up and killed him.
C. Insist that you’re an agent of the grim reaper and pin up another chalk outline with a line through it on your “Bulletin Board of Death” they’ve got going.

Question #2:

Your rural ambulance responds to a local community health clinic for a “Woman in Labor”. Upon your arrival you find a 36 week pregnant female Gravita 3 Para 3 (3 Pregnancies, 3 live births) with contractions 5 minutes apart. The physician wants the patient transported to the local OB unit that is 45minutes away lights and sirens. You load the patient in the ambulance after assessing the patient and find that she is an otherwise healthy pregnant patient possibly in early labor. You initiate ALS care including o2, an IV, and an ECG monitor for good measure. Your partner points the ambulance towards the hospital and you take off lights and sirens. Ten minutes into the transport, the patient’s bag of waters ruptures and the patient states that she urgently feels the need to push.

Do you:

A. Tell your partner to pull the ambulance over to the side of the road in a safe area so that he can come back and assist while you pull out and open up the OB kit, preparing for imminent birth.
B. Administer a fluid bolus in the hope that you can slow the imminent delivery.
C. Calmly tell your partner to “Drive it like he stole it” and coach the patient in “trying not to push” while you try answer “B” and hold her legs firmly closed because hey, who wants to clean up afterbirth all over their ambulance?

Question #3:

You’ve just returned your ambulance to service after a mundane call on a particularly busy day. The other ambulance in the jurisdiction has not had a rough of a day as you’ve had and was out getting lunch when you returned to the station. Before you have the chance to radio dispatch and let them know that you’ve restocked and are back in service from the previous call, the tones drop for an unresponsive male patient that sounds like he has a severe lower GI bleed. Although you’re probably two blocks closer to the call than the other truck, they are dispatched because you haven’t gone in service yet. Their most direct route to the scene puts them right past the front of the station where they’re sure to see you on their way by.

Do you:

A. Call dispatch on the radio and inform them that you are indeed in service and will respond to the call if they wish you to do so.
B. Quick, hide! Close the station door and pretend that you’re not yet back in quarters. They deserve to get the call, they’re only out two blocks farther than you are, and you don’t want them to see you and know that you’re ducking it.
C. Run out to the front apron of the station and smile and wave as they drive by! Hiiiiieeey!! Enjoy the butt bleeder! Don’t forget to write!

Extra Credit Question:

How many fingers do you think that the other crew will wave back at you with when they pass you in the previous question?

Answers:

If you answered mostly “A’s” – Congratulations, you’re a new, competent, caring EMT. Feel proud of yourself, but you’re probably not going to retire from this job. I could be wrong… but you’re pretty straight laced. Have fun with that.

If you answered mostly “B’s” – You’ve been in the business a while, haven’t you? You’re well on your way to developing the hard outer shell you’ll need to survive for a while in this business. Just don’t lose your gooey center.

If you answered mostly “C’s” – Um, you’re one of my coworkers, right?? Guys, come on… Why’d you go and dump a bucket of water on me last night while I was sleeping? If you’re not one of my coworkers, e-mail me and I’ll send you an application. You’ll fit right in.

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

Posted by Ckemtp on November 6, 2009 • Filed under: ALS Intercept, EMS, EMS Health & Safety, EMS Humor, EMS Motivation, EMS Topics, Emergency Medical Services, Paramedic, ambulance humor, camaraderie, emotions, ems scenario, ems scenario based education, inside the mind of a paramedic, mental illness, paramedic education, scenario, scenario based training

EMS 2.0 – What are our Core Beliefs?

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Building a foundation.

A comment I got on my last post – EMS 2.0 – Momentum Building – from Timothy Clemans has inspired me to write this post. He stated that EMS should develop our set of core beliefs. Click over to go read it, and then please come back because this is a participatory event.

Second Edit: I didn’t finish writing this as soon as I wanted to, and Ambulance Driver got out a post I want to answer, but yesterday and most of today have been blogging days off. So expect my answers to the issues raised by our respected friend AD

—————————————————————

What should we state are the core beliefs of the “EMS 2.0 Movement” as it’s being called now on Twitter, Google Groups, and as I’m sure by the time I get this finished, all over the interwebs? What are our core beliefs, the truths we hold to be self evident? What are our virtues and our rallying cry to fend off the slings and arrows that are sure to be launched at our group as we sally forth to set right what we see wrong in EMS today?

Here’s the deal, I’m from the country. I love country music (Yea? So?) and one of the songs I like is from INSERT NAME OF ARTIST HERE. In it, the HE sings “You’ve got to stand for something or you’ll fall for anything”. I believe in that. It actually shapes my political beliefs quite a bit. Here’s why, there is so much happening out there that one single human being cannot possibly keep up with it and form a coherent opinion on everything. Even if you tried, you’d still be basing some opinions on some shoddy reasoning and incomplete information. This is why I pay more attention to what I believe as a person. I have tried to develop my sense of right and wrong, and use that as a filter to determine whether a belief is good or bad.

That’s what we should do with EMS 2.0, in my opinion as someone who writes about it as a concept and yearns for change in my profession. We should develop our core beliefs and possibly a statement of our mission and use them as a filter to determine our stance and actions to take as we move forward. They must be general, universally acceptable, and applicable to a broad range of circumstance.

They should be the ethical standards that guide our progress.

And no, they cannot come directly from me and they will not be easy to implement. They must be collaborative and engaging to as many people as possible in order to have broad appeal and effectiveness.

So here’s what I’m going to do:

I’m going to write my thoughts on them, and my recommendations on what I think they should be. I ask you to comment on what I’ve written and add your own thoughts. If you have a blog, please link to any posts you’ve posted. Please join the Google Groups and follow EMS2Movement, (and ME too!) on Twitter. Participate and grow this. If we can harness the thoughts, feelings, and ideas of the multitude of EMS people out there from across the nation and the world, we’ve really got something here.

EMS is truly on the brink of something very exciting. Yes, I know you’ve heard that before and you have your doubts about whether anyone can actually do anything to fix what you see as being wrong with the profession. I say that EMS has never had what it has now, we have never had the EMS blogosphere and online communities bringing forth cooperative and collaborative voices in such a powerful way as now. Through our efforts we can bring positive change. We can set the tone and the direction for our profession to follow and set forth to improve emergency care for everyone.

It will be a long road, but through cooperation and collaboration, we can start the journey together.

And that’s powerful stuff.

—————————————-

Proposed Mission Statement for EMS 2.0 – By: Chris Kaiser (Ckemtp)

“EMS 2.0 is the common name for a group of interested professionals within the Emergency Medical Services that strive for excellent and ever improving patient care within our communities. We will work to establish guidelines for EMS professional education, common licensure and certification standards, evidenced based medical care protocols, and professional ownership of EMS by paramedics and Emergency Medical Technicians. We will establish strategies for improving compensation and working conditions for our fellow professionals as well as strategies for increasing our service level to individual communities in the face of dwindling resources and revenue by developing new services and revenue streams for our industry. Our focus will be intentionally broad and collaborative and will serve to encompass the spectrum of well thought and tested ideas through research, communication, and self-regulation of our profession.”

Proposed “Core Beliefs” for EMS 2.0 – By Chris Kaiser (Ckemtp)

Emergency Medical Care is a right, not a privilege for those members of our society truly experiencing a life threatening emergency. Communities must fund EMS as they would fund any other essential public service.
EMTs and Paramedics are members of a profession serving the most basic of human needs and the most diverse of all patient populations. We must attain the tools necessary to serve our mission through education and flexibility.
EMS providers must seek out new educational opportunities and work within regulatory systems to allow new knowledge to be translated to our care.

I’ll add more later. What are your ideas?

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Posted by Ckemtp on October 24, 2009 • Filed under: Ambulance Driver, EMS, EMS Blog, EMS Topics, EMS ethics, Emergency Medical Services, Paramedic, blogosphere, ems 2.0, ems education, new perspective, paramedic education

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What do you think?

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

Advances in Resuscitation – CCR If you’re not doing it now, you will be

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Visitors to my old blog probably know that at my ambulance service we tend to bring back a lot of codes. I talk about it a lot. Back in 2004 our medical director, Dr. Michael Kellum, got us involved in a “Demonstration Project” to bring Continuous Compression CPR or Cardiocerebral resuscitation to a rural area. Since that time, the results have been more than dramatic. Depending on what statistics you look at, we may be “Saving” almost 50% of witnessed arrests found to be in ventricular fibrillation.

It’s all explained at Http://www.callandpump.org But if you want to go right to the whitepaper that explains what we do, why we do it, and how it’s done then you want to go here: http://callandpump.org/assets/Proposal_Current.pdf – This link is explains the demonstration project initiated by Dr. Kellum et al. in the two county area that I work in. This paper was published in 2004 at the beginning of the project.

This is a link to the results published in the Annals of Emergenc Medicine in 2008 – http://www.ncbi.nlm.nih.gov/pubmed/18374452?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

MCMAID Resuscitation Protocol

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This post is a stub, and is a supplement to “Advances in Resuscitation – CCR, if you’re not doing it now you will be”

——————

EMERGENCY MEDICAL RESPONDER/EMT

A CODE COMMANDER should assign duties according to MCMAID prior to arrival

Establish that the patient is unresponsive, and not breathing normally
Rule out DNR status, dependent lividity, rigor mortis

First Priority: M-(metronome) Quality Chest Compressions

Turn on Metronome, ensuring a rate of 100/minute
Initiate 2 minutes of chest compressions, pediatric-follow AHA 2005 Guidelines

Second Priority: C-(compressions) Quality Chest Compressions

Assign two compressors switching every minute, checking each others quality
Depth should be at least 2 inches
The heal of the compressor’s hand should come off the chest, ensuring full recoil

Third Priority: M-(monitor) Defibrillate

AED, push analyze (pediatric patient >1 yr , use peds pads up to 8 yrs if available if not use adult pads)
Manual, charge max joules during CPR, analyzing for no more than 5 sec (EMT-I/P) – (pediatric 4 joules/kg)
Immediately resume 2 more minutes of compressions

Fourth Priority: A-(airway)

Oropharyngeal airway and 10 liters O2 via NRB mask
Check patency if chocking is suspected
No ventilations until after 3 cycles - (unless pediatric-follow AHA 2005 Guidelines)
CombiTube/ET after 3 cycles of compressions, unless 1^st rhythm is nonshockable, then as soon as possible, ventilate at 6/minute only enough volume to just make chest rise

If ROSC, acquire 12-Lead EKG, ***ACUTE MI SUSPECTED*** see STEMI Guidelines.

Give a status report to the ambulance crew by radio ASAP and ensure ALS has been dispatched.

AEMT

Fourth Priority: I-(IV) Establish venous access

Initiate IO 0.9% Normal Saline unless IV is assured and quick, run wide open (20ml/kg boluses for pediatric patients)
Consider second IV and chilling both for unresponsive ROSC. Refer to Therapeutic Hypothermia Procedure

INTERMEDIATE

Monitor basic rescuer interventions closely, ensure quality, uninterrupted chest compressions

Fifth Priority: D-(drugs) Proceed to ACLS resuscitation medications

Obtain venous access, if not already done
Epinephrine 1:10,000 1 mg IV/IO every other cycle of compressions (4 minutes)
Vasopressin 40 units IV/IO, repeat dose in 10 minutes if no ROSC
If multiple shocks have been given, Amiodarone (Cordarone) 300 mg IV/IO, followed by another 150 mg if still refractory (shocks being delivered)
After 3 cycles of compressions, (unless first rhythm in non shockable) place advanced airway without interrupting compressions and begin ventilations at 6/minute, using only the volume to just make the chest rise.
If initially non-shockable, Identify and correct reversible causes: The Five H’s and the Five T’s This applies mostly to PEA, but to a lesser extent, Asystole, as well.
If rate is <60, Atropine Sulfate 1 mg IV. Repeat every 3 – 5 min to a maximum of 3 mg

“The Five H’s” (treatment orders are in parentheses)

Hypovolemia (Infuse Normal Saline wide open)
Hypoxia (Place an advanced airway and administer high-flow oxygen at a ventilation rate of 6/minute with only enough volume to make chest rise. [1])
Hydrogen Ion, i.e. acidosis (Perform ventilation [1])
Hyperkalemia [2]
1. Give Calcium Chloride (10%) 1000mg IV over 2 – 5 minutes. May repeat X 1
2. Give Sodium Bicarbonate (8.4%) 50 mEq IV
3. Give Albuterol Sulfate 2.5 mg HHN may repeat X 1
Hypokalemia (not treated in the field.)
Hypothermia (See Hypothermia & Frostbite Guidelines)

“The Five T’s” (treatment orders are in parentheses)

Tablets (See Toxic Exposure/Overdose Guidelines)
Tamponade (EMT-P: Perform Pericardiocentesis)
Tension pneumothorax (Perform needle decompression)
Thrombosis, cardiac i.e. myocardial infarction (See Chest Pain Guidelines)
Thrombosis, pulmonary i.e. pulmonary embolism (No specific pre-hospital treatment available)

Paramedic

If there is ROSC, as seen as a sudden large increase in EtCO2 and/or patient movement

Give Amiodarone (Cordarone) 150 mg IV/IO over 10 minutes, if multiple shocks given
Reassess the need for airway devices
Maintain advanced airway, if the patient remains unconscious
If the patient wakes up, the airway may be removed. Use the procedures for removing advanced airway devices in the Respiratory Distress Guidelines.
Monitor patient’s EtCO2 and ventilate accordingly (12-20 per minute to maintain EtCO2 around 35 mmHg)
Maintain SBP >80 mmHg, Consider Dopamine Hydrochloride 10-20mcg/kg/minute IV infusion
Consider inducing hypothermia, See Therapeutic Hypothermic Guidelines
Consider RSI See Respiratory Distress Guidelines
If post-resuscitation 12-lead EKG shows STEMI refer to STEMI Guidelines
Contact Medical Control for the following:
- To discuss termination of resuscitation in the absence of a valid Wisconsin DNR Bracelet
- Additional medication orders

FOOTNOTES:

1. Do not hyperventilate during cardiac arrest, even if hypoxia and acidosis are suspected causes. Strictly follow the ventilation guidelines described above.

2. Suspect Hyperkalemia when patients with a history of chronic renal failure (dialysis patients) develop cardiac arrest. Pre-arrest history may include weakness, missed dialysis appointment(s), vomiting, concurrent illness, and T waves that are peaked and as large as the R wave.

—————————-

This post is a stub, and is a supplement to “Advances in Resuscitation – CCR, if you’re not doing it now you will be”

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Posted by Ckemtp on October 17, 2009 • Filed under: CCC, CCR, DNR, Do Not Resuscitate Order, EMS Topics, EMS paramedics, EMS practice, EMS protocols, IO, Paramedic, Patient Management, SMG, SMO, Uncategorized, cpr, cpr save, intraosseous, intubation, paramedic education, patient care

Daily Training Topics 10/16/09

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Just about every 24 hour shift that I work up in my Northern job I put together a little impromptu training session. It’s a way for me to address things that I think are important for the crews to refresh on as well as a way for me to read up on some things and make sure I remember the stuff I should know. I try to learn the latest things on the chosen topic with a bit of research before I present the class as well. It keeps me sharp, which is good.

Also, (and let’s talk about the important things here) it gives me a cheap and easy blog post which I like because I’m really trying to bump up my posting frequency with this Fancy New Blog and all that.

Today’s training topics were a refresher class on intravenous access as well as BLS Airway Management Skills. We have a good number of EMT-Basics, EMT-IV Techs (here in Wisconsin) and even an EMT-Intermediate ‘99 that are on-duty today. My partner and myself (incidentally, both named Chris) are the duty medics.

So, without further ado, here’s what I taught them. Remember, this was a BLS class, and is geared to newer providers.

- IV Skills: I didn’t do anything on my own here. One of the benefits of the EMS blogosphere is that I have a wealth of training information at my fingertips. A lot of the time, I’ll pop on over to see what Greg Friese is doing on Http://www.everydayEMStips.com – And if I’d like some in-depth EMS knowledge, I’ll head over to Http://paramedicine101.blogspot.com.

For this training, however, I took the tips laid out by Steve over at Http://www.theEMTspot.com – where he wrote “Six Techniques to Nail the IV Every Time” I put it up on the projector and wrote down the bullet points on the white board. (and I gave him the credit for the easy and valuable training both in the class and on here)

- BLS Airway Management knowledge:

For this one, I pulled out every airway and oxygenation management tool we carry in the truck, which in my service includes:

- The Oropharyngeal and Nasopharyngeal Airways

Do you know when to use one over the other? Here’s some tips. First, if the patient is unresponsive enough to take an oropharyngeal airway without triggering a massive gag reflex, the patient NEEDS an oropharyngeal airway. (or an ET tube/Combitube/King LT for that matter)

Nasopharyngeal airways are used for patients unresponsive enough to need an airway adjunct but that still have an intact gag reflex. DO NOT USE nasopharyngeal airways in cases of head or facial trauma. (Why? Because the nasopharynx is separated from the rest of the cranial vault by the Cribiform plate, which is a very thin piece of bone that can be fractured very easily with significant head trauma. If it is fractured, you run the risk of placing the nasopharyngeal airway – or the nasogastric tube for that matter – right into the cranial vault… which is bad.

The oropharyngeal airway is measured from the corner of the mouth to the angle of the jaw. The Nasopharyngeal airway is measured from the nare (nasal opening) to the earlobe.

On a side note, do you know how to check for a gag reflex? My almost never-fail method is to use the eyes. If the patient is unresponsive, running your finger lightly through their eyelash should elicit a response (i.e. wiggling) if the patient has an intact gag reflex. Further, a variation on the theme is to lightly open their eyelids with your gloved fingers and lightly blow into their eye. Don’t do it hard, and certainly don’t blow hard or use any pressure with your fingers, but if a person isn’t unresponsive and can tolerate that without flinching… they aren’t human.

- The Combitube

Honestly, I’ve not had a good track record with the combitube. I prefer the King LT. (Sorry Happy)

- The Endotracheal Tube

For this part of the training I looked at the various parts of this procedure that an EMT-Basic might be asked to participate in, such as preoxygenation with a BVM before the procedure, setting up the equipment for the ALS provider before he/she needs it, choosing the various adjuncts to assist the ALS provider in confirming tube placement, and various methods to secure the tube.

- CPAP

This is a miracle treatment. CPAP, or Continuous Positive Airway Pressure has revolutionized the management of congestive heart failure and pulmonary edema. Every EMT should know how to use this, when to use this, and how to properly apply this wonderful thing.

- Non-Rebreather O2 mask, Nasal Cannula (Adult and Peds)

If you don’t know how to use this, you probably should.

- The Nebulizer set up (We use Albuterol (Proventil) and Ipatropium Bromide (Atrovent)

We covered the proper set-up of the nebulizer and the various differing ways that it can be employed. Sure, you can use the duckbill for the patient to hold, but you can also pull the reservoir bag off of a Nonrebreather mask, insert the nebulizer chamber where the bag went and you’ve got yourself a handy mask neb.

We also went over the proper way to connect the nebulizer to the Bag Valve Mask. Depending on your equipment this setup could vary. Ours did like 3 ways. Check yours.

- Bag Valve Masks of assorted sizes

Learn how to properly seal the masks, the proper ventilatory rate (8-10 per minute) and the proper size for each variation in patient population.

- A Pocket Mask

Haven’t used one of these in a while, have you?

- The Surgical and Needle Cric kits

The basics don’t need to know how to use these, but it’s good to practice. Three of us had to hold the student down to do it, but we got it in on the second try!

I’m really liking my new home.

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Posted by Ckemtp on October 17, 2009 • Filed under: EMS, EMS Topics, EMS training, ET Intubation, Emergency Medical Services, Patient Management, ems scenario based education, intubation, paramedic education, patient care

Could it be? A Good EMT-B Student?

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What is with students these days?

I precept and mentor quite a few students these days. Maybe it’s because I’m old and my memory is going south on me, but I don’t think that I acted quite like this current crop does when I was a student. I think that I took it seriously. I think that I respected the elder members of my profession and did what they told me to, right?

I always tell students that I’m a real jerk when I’m precepting them. I’m not… but I like the whole Mr. Myagi (old reference, look it up youngins) thing. You know, “Wax on Wax off” equates to something EMS related or what not. I try to reinforce the things I think that are important for them to know to be a good provider at whatever level they’re currently working on. Everyone has to work on their assessment and patient communication skills. Everyone has to get good at MANUAL BPs, listening to Lung Sounds, Abdominal Sounds, and their patient’s stories. Everyone has to get good at not being afraid to assess the patient in a competent, professional way. I figure that once they get the assessment and the friendly, professional communication thing down, the rest can be reinforced pretty easily.

Recently I’ve been adopting the “Dr. Cox” school of mentoring students. I love the TV show Scrubs. On the show, Dr. Cox torments his young protoge’ relentlessly and calls him a different girl’s name every time he addresses him. I think that it’s funny as heck and I’ve been doing that lately. The first student I did it to left the program after a week (Not my fault! He was running with another medic a lot more than he was running with me!) and the second, well… the second student I pulled this on really surprised me.

He was an EMT-B already, but was fresh out of class and was working for a fairly slow volunteer service that one of our part-timers volunteers for. She had brought him over to get some experience on a busy service and since I was her partner for the day, he got to be subjected to my whims as a preceptor. I think his name was Stacy, Jennifer, or something.

We had two calls right off the bat. A refusal at a “Nursing Home” that called us for a patient with pink eye, and a “Elderly Man out of Control” at a farm house way out in the country where the County Sheriff ended up transporting on. This kid seemed to be good luck, considering that we weren’t having to go to any coffeeless hospitals that early in the morning. Our streak of luck ended when we caught a tranfer from an ER to a secondary admitting hospital for an elderly lady with a GI bleed.

This was perfect for the kid. It was about an hour-long ride with the patient. Plenty of time to teach the kid “friendly banter” skills with the patient and also to have him do a reassessment q 15min while I sat back, cracked jokes, and worked on the three reports. Win win. We picked up the patient at FavoriteSmall Hospital ER and got her in the truck. He was quiet at first, as all students are, but I made a deal with the patient. I asked her if she could help me get the student over his shyness. Oh boy, she did. She talked his ear off the whole way and he participated in the conversation like a champ.

Yes, I think that it’s important to connect with your patients on a human level. He did that pretty well, actually.

The only thing that I thought he needed work on was how he took blood pressures in a moving truck. Admittedly, that’s a hard skill to master. One of my cardinal sins is to make up a BP and tell me the made-up number you “think” it is. He may have done that.. but I didn’t call him on it right away. Instead I waited until after the trip because the patient was very stable.

“So Denise, how sure are you on those BPs you took? Because… I didn’t know if you could really hear them or not..” I asked him.

“Uhhh, well I was pretty sure… mostly… a little I think” he stammered.

“Stacy, just make sure that you tell me you’re not sure if you’re not sure. I’d rather use incomplete information than fictional information anytime. I’m not accusing you, just curious here.”

After we got back to quarters, the calls died. The other truck ran a DOA but we didn’t get anything for hours. Knowing me, I sat down and worked on the blog for a while and ended up putting a couple of hours into the new site design. After two hours, in walks the student and takes a BP on me. Apparently the kid had spent the last few hours taking Blood Pressure readings on every person at the base!

I think that his name was Joe. He can ride with me anytime.

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Posted by Ckemtp on October 16, 2009 • Filed under: Administration & Leadership, EMS, EMS Humor, EMS Topics, EMS training, Emergency Medical Services, Paramedic, Patient Management, ems education, paramedic education, training-fire-rescue-topics • Tagged: EMT-B, EMT-Basic, preceptor, student

Scenarios. A lot of EMS, a little Einstein

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A while back ago I had a kick where I did a scenario-based EMS ethics piece that took a look at a possible situation that could be faced by some Paramedics and asked readers what they would do in that case.

The response was pretty good. You should add your opinion here.

I use a lot of scenario based training for the EMS people that I teach. I teach a lot. Being the old, grizzled veteran that I am (shameless self plug but looking at the kids these days entering the profession sometimes I feel like shaking my fist at them, hiking my jeans up to my navel, and yelling at them to “Get off my lawn!”) I have the opportunity to mentor a lot of newer providers and precept a fair amount of students. During our slow periods, I find that giving the students an informal scenario helps them to step outside their thought processes and really think about what they would do when faced with a like situation.

I like it so much, that I even do it to myself. I’ve mentioned that I come up with most, if not all of my blogging ideas when doing other, mindless tasks. A great deal of my post ideas come while driving. I allow my mind to wander to imaginary concepts and ideas. Since I’m so immersed in EMS on a daily basis, a lot of those thoughts go right back to EMS, and “what if” scenarios come into my mind. Some of them are about patients that I’ve had, the “what if this had happened” kind of questions. Others are completely random scenarios that I wonder what I would do if I happen to be faced with the situation.

Einstein conducted what he called “Thought Experiments” to assess theories that he could not experiment with in a laboratory. One of the ones that I’m most familiar with is his “Flashlight on a Train” thought experiment. In this well documented case, he hypothesized that the speed of light was a constant and was not affected by outside forces. He imagined himself on a long, open railroad train with himself standing at the caboose, or end car of the train. He imagined shining a powerful flashlight from the rear of the train through the cars to the front engine. Using some logic that I am not familiar with because I’m no Einstein, he was able to theorize that the light from the flashlight would hit the train’s engine at the same time and that the light would travel at the same speed no matter how fast the train, and therefore the light source, was travelling. Unlike a missile fired from a jet plane that’s speed would be affected by the speed of the plane that fired it.

So how do Einstein’s thought experiments connect to EMS?

I equate the personal scenarios that I think of and the scenarios that I use to keep my students thinking outside the box to Einstein’s thought experiments. There are things in EMS that we do not do very often. Skills like synchronized cardioversion, surgical airways, and complicated drug administrations aren’t everyday things. Neither are difficult patient presentation with complex layers of comorbid conditions. These are high-risk, low frequency events that trial lawyers dream about. When you need to perform these tasks or think around a list of contraindications when your patient needs action now, having thought about them prior to having to perform is lifesaving.

One of the things I hear the most from paramedics and EMTs is how they run though a list of possible scenarios, patient presentations, and treatment modalities in their heads when dispatched to what sounds like a particularly nasty call. I do that sometimes too, although less now than I used to. Spending the time thinking about these things when you have the time to really ponder the issues is very beneficial and even fun… if you’re an EMS geek like me.

So next time you and your partner are bored sitting in your parking lot waiting for the next call, toss around a few “way out” scenarios. Your care will benefit from it. You might too.

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Posted by Ckemtp on September 22, 2009 • Filed under: EMS, EMS Blog, EMS practice, EMS training, Emergency Medical Services, Paramedic, ems education, ems scenario, ems scenario based education, everyday ems ethics, mental imagery, paramedic education, patient care, scenario, scenario based training, whattaya do

Alternative Circulatory Access Strategies – Hi Ho IO

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A while back ago, Steve over at http://theemtspot.com wrote a great post on Gaining IV Access. In the post, he’s got some great strategies for getting your IV starts every time.

But, as we all know, sometimes you just can’t get the darn catheter to go into that tiny vein for whatever reason. Try as you might, it seems like you’re going to be turning the patient into a pincushion before you establish your IV access. Sometimes that’s fine, when the patient is pretty much stable and you just need access. But when the fit’s hitting the shan, you’ve got to step it up. Luckily, our friends in the medical product industry have been working hard to beef up our firepower.

My favorite alternative way to make holes in people’s circulatory system is this:

[youtube=http://www.youtube.com/watch?v=3pZxOqfB3YA&hl=en&fs=1&]

The EZ-IO or, the intraosseous Drill, is a great way to get a big circulatory access point in a hurry. It’s stable, it’s reliable, and works in a hurry. I’ve used it and we carry it on every ambulance that I work on. I don’t do paid endorsements, but if the company that made this wanted to offer me a ridiculous sum of money to endorse this product, I would.

Intraosseous infusion was just for pediatrics when I first got into the game. We carried the Illinois bone marrow aspiration needle and used it for bad peds. We still do, and the thought of jamming that big ol’ needle into a baby’s tibia still gives me a touch of the heebie jeebies. However, I have to say that it’s one of those things that is absolutely needed when it is indeed needed. Adult patients weren’t so lucky. Before the EZ-IO came about if we couldn’t get a vein in the field with an IV cath on a critical patient, chances are the patient would have to wait for a central line in the hospital. Sure, we can attempt access in the external jugular vein one time and we can always give endotracheal doses down an ET tube in cardiac arrest situations, but I don’t really like any of those methods. The EJ because of the risks involved, and the ETT method because I’ve never really seen it be effective nor read any really positive research on the method.

Now, with the EZ-IO that’s changed. For our service, with cardiac arrest save rates between 40 and 60% depending on the literature you’re reading (Really. www.callandpump.org) most of our medics don’t attempt an IV on a code. If they, or I, am the only advanced level provider, the patient is “drilled” right off and that is our only circulatory access point during the initial resuscitation effort. If there is an EMT-IV tech, EMT-Intermediate, or an additional paramedic present, I will attempt one AC IV placement or direct it to be attempted, however I will most likely drill the patient for secondary access. For most truly critical patients, I place two IV sites. One is capped and acts as a backup site unless aggressive fluid resuscitation is needed or another provider takes over the medication part of the resuscitative team.

There’s been only one study that I’ve found on the effectiveness of the EZ-IO… and yes, this comes from the manufacturer’s web site… but I give them a modicum of credibility because they’re not selling something that hasn’t been around for quite some time as a viable method.

Q. Is IO better or just equal to IV for fluid, drug delivery?

A. The only human IO pharmacokinetic trial reported that IO flow levels are equal to that of IV as supported in the ACLS guidelines issues in December 2005. Drugs injected into the IO space of the tibia, sternum and humeral head all reach the central venous circulation within one second which is faster than drugs given through IV in a low flow perfusion state

and this:

Q. What are the risks with this product – infection, leakage, bone not healing?

A. The documented overall complication rate associated with intraosseous insertion and infusion is less than 1 percent. Potential complications include extravasation (leakage), dislodgement of the needle, compartment syndrome, bone fracture, pain related to infusion of medications/fluids and infection. To date, there have been no reported complications from use the EZ-IO® product system. Overall IO experience in thousands of children and 4,000 adults show the infection rate to be less than 0.6 percent and those are usually not serious and can be treated as outpatients.

Medical mumbo jumbo, I know. I just love this tool. You should have it and use it too. I’ve seen it save lives, save outcomes, and make life much easier on poor, overworked paramedics.

Of course, that’s not to say that there aren’t alternative IO tools out there. I’ve been through a class on the BIG: Bone Injection Gun, and while I’ve heard generally positive things about it, I’ve never used it personally. I also have not had the chance to use the sternal IO access device (I believe it’s called the FAST Sternal IO) however, I found this video on it that came from the military medics that do use it.

[youtube=http://www.youtube.com/watch?v=9eDaA-4WHfs&hl=en&fs=1&]

Yes, that guy is CONSCIOUS.

Yes, it gives me the heebie jeebies to watch that. I’ll let students practice their IV skills on me… but A FREAKING STERNAL IO!? Those military guys have my respect, because they’re crazy. He didn’t even whimper when another guy was JABBING 6 NEEDLES INTO HIS BONE!

Although, I did get tazed for love one time. I guess I’m crazy too.

Thanks for reading, y’all.

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

Posted by Ckemtp on September 20, 2009 • Filed under: ALS Intercept, CCC, CCR, EMS, Emergency Medical Services, IO, Paramedic, ems education, ez-io, intraosseous, paramedic education

To Kneel or not to Kneel

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“Muungh… What the heck was that!?” I thought to myself as I looked around the darkened room. “Where am I? Why am I awake? What IS that awful noise?” I thought. Something had awoken me from a not-so-good sleep on a not-so-comfy sofa. Slowly, I realized where I was. “I must have fallen asleep in the day room at the station” I thought. “Why am I awake?”. I heard commotion outside and realized that it must have been the radio that woke me up. Somewhere in the dark subconscious recesses of my brain it came to me that the pager said “Person not breathing, CPR in progress”. I pulled on my shoes and thought the most important thought that any EMS provider can have when being jolted from a deep sleep at 0′ dark 30 to try and wake the dead: “I have to pee!”

Once the bathroom duty was completed I slid into the passenger seat of the ambulance and pulled up the address on the map program. My partner pointed the ambulance South while I clicked on the siren. Wailing into the night we went, lights flashing, adrenaline pumping, morning breath so bad I could slay a walrus. “Where did I put that mouthwash?” was my thought. So focused on the job were we.

Arriving at the address just behind the engine company from the first due station we hurried to gather up our gear for the battle ahead. Monitor? Check. Airway and drug bags? Check and Check. Backboard? Check that too. We hurry up to the front door and are met by a middle aged female saying “I couldn’t wake him up! He was fine when we went to bed!” We enter the bedroom and I see the middle aged male on the bed. His lifeless eyes were fixed and unseeing as we approached him. His mottled skin was cool to the touch. Long gone was any fighting chance at life. I knelt on the bed next to his torso to check a pulse and apply pads to get a strip and immediately know what is going to happen next.

“I’m freakin going to have freakin dead guy pee on my freakin knees for the rest of the freakin shift! Dang it! Dang it! Dang it!”

EMS people kneel a lot, and not just when we want a raise or need to get state-to-state reciprocity from an EMS office. At one of the departments I work at we did a big action photo spread of all of the EMTs and Medics in action. EVERY SHOT was me kneeling. Kneeling at a patient’s head working on the airway, kneeling at the patient’s chest starting an IV, kneeling next to a patient to assess them after an injury, I kneel so much that you’d think I have a promotion by now. We all do.

But you’d think that by now I’d know enough not to kneel in poo, pee, blood, vomit, or whatever vile substance is on the bed, floor, or surface that I have to kneel on. I mean come on. I’ve been doing this over a decade now. I have thousands of calls under my belt. I live, sleep, eat, breathe, blog, and study EMS as much as I can stand to (and that’s a lot) and I *still* am stupid enough to put my knees in poo on a somewhat regular basis?

Right now, I’m on the 2^nd day of a 48hr shift a half hour away from my home. Last night, around late evening I knelt in a poo/pee mixture. I was really trying not to here, but the patient began to vomit after we got (the Pt) on the backboard in the cramped, carpeted bathroom (the Pt) was in. I couldn’t log roll (the Pt) without kneeling and the carpet was just saturated with a vile mixture of hours old poo/pee. My knees got soaked in it. And no, if you are asking, I ran out of the house late and didn’t think to bring an extra pair of pants and the pants that I had kept at the station had been taken home for laundering after another like incident.

For times like these, I recommend the “Ckemtp” method of knee disinfection. It applies for those times where call volumes don’t allow you to actually take your pants off to clean them:

Put on gloves. No sense in contaminating your hands. Chances are your knees won’t have broken skin on them unless you’ve been trying to get that promotion (Enough with the “on your knees” jokes! – This is serious!)
Take and put a towel or washcloth (a smaller wash cloth works better) in between your knees and your pants.
Spray the ever-loving bejeebus out of your pants, saturating your knees with disinfectant spray. DO NOT use bleach-based spray. The milder the better. (see “Clean EMS” for advice on contact times)
Press another towel on the outside of your pants, soaking up as much poo/pee laced disinfectant into the towels as you can. Rub them together a bit.
Re spray with disinfectant and let it air dry.
Remove the towels from your pants.
Call your wife and beg her to drive you up a new pair. Beg. Hard.

Just for the record, my lovely wife was unable to drive me up some new pants. Awesome…..

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

Posted by Ckemtp on May 26, 2009 • Filed under: Ambulance, EMS, EMS Health & Safety, EMS Humor, EMS Topics, EMS rant, EMT, Emergency Medical Services, Fire Rescue Topics, Fire department, Firefighter Safety & Health, In the Line of Duty, Paramedic, Patient Management, ambulance humor, ems pants, ems uniforms, infection control, inside the mind of a paramedic, kneeling, paramedic education, paramedic pants, puke

The Profession that is EMS

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(Attention: I edited this post heavily. I think that my ADD was in full effect when I wrote it. It’s better now, I think)

The results are in: the bloggers, posters, commentators, columnists, partners, colleagues, and other people even passively involved in EMS have spoken. It seems that EMS ain’t much of a profession these days.

Dang it. I wanted this to turn out to be a real career. I thought that it would. I needed it to.

You see, I have wanted to be a paramedic since I was about 14 years old and didn’t really know what a paramedic truly was. It’s my father’s fault. He was the volunteer fire chief in the small town where I grew up. And I mean really small here. There were (and still are) about 400 people on a good day if everyone was home with their families and there were a couple tour busses rolling though. The town was Edgington, IL and dad was the chief of the Andalusia/Edgington Vol. Fire Prot. Dist. I’d say that there is where I got my passion for this stuff. It was the kind of department where everyone was a farmer and I got pulled up into a truck to go to my first house fire when I was only 14 years old. I was a body and they needed all the bodies they could get. I was hooked and had to continue. It made me want to know more. I wanted to be a firefighter and EMT so bad when I was a young teenager that I tried to get the state to let me challenge the EMT class before I was 18. I worked very hard to get them to bend the rules for me, but they didn’t let me. I know now that they were right. I should have spent those formulative years doing something productive like learning math or biology or picking stocks or something. Instead, I spent those days carrying around a copy of “Emergency Care and Transportation of the Sick and Injured” that my dad gave me from when he took his first EMT course. I treasured that book. It was my bible. I was a young EMS Geek.

When I turned 18 I signed up for my first EMT-B class and joined the local vollie squad. It was a very rural service with a huge area. We covered 275 square miles of rural territory providing only Basic Life Support (BLS) care. Not much has changed there since then. They’re still an all BLS squad. After a few years I became a paramedic at the age of 20. With that, I became an Advanced Life Support (ALS) provider and was licensed to do all these cool new things but the vollie squad didn’t change for me and I couldn’t do all those cool things with them. This disconnect between my licensure level and my career path lead me to obtain employment at an ALS service. It was interesting being a Medic at 20… I could give complete strangers schedule “A” narcotics but I couldn’t go have a beer after a hard day’s work spent scraping up humanity. Man was I young and dumb. I had no idea what I was getting myself into. There was quite a few times where my bravado got smashed into my face. Luckily I had many, many mentors along the way who took the time to give me their best and train me in the arts and sciences that are the Emergency Medical Services. Without those dynamic individuals, I shudder to think of how some of the calls that I’ve had would have turned out.

Thanks to everyone who has helped me along the way.

However now as I reflect upon the decade or so that has passed since then it brings some things to mind. It is debatable whether this next statement deserves a “fortunately” or an “unfortunately” in front of it. I wrote it both ways but neither word seemed to fit the statement. So here it is stripped of any adjective. Most of those people who mentored me are still on the street with me or have moved out of EMS altogether. While this could seem almost normal in some other professions it could go both ways in EMS. A lot of those people were veterans in the service at the time I met them and were where I am now in the profession. They had around ten years on the job and were at the top of their game as far as providing care was concerned. I don’t want to have such gaul as to say that I am as good as my mentors were even though I have worked very hard to be so… but I have given my all so that I can say I can hold my own with dang near any medic out there. The problem is, I feel like I peaked at 20… as some of my mentors may have peaked when they got their licensure. The ones that are still on the street are getting tired. It’s extremely hard on the body to do this emergency stuff every day for twenty or thirty years. It tears you up. But they’re still doing it. They’re still in the thick of things with me in the same job. They’re still slogging through the blood and the mud and the tears fighting for their pay checks and living their lives working multiple jobs being a slave to overtime shifts. They’ve proven that there is precious little career advancement. The others who left the profession, well they’ve gone on to other jobs taking their lifesaving experience with them. Teaching those of us that are left in the trucks that our income potential is limited if we stay here in the field. We may be saving lives, but we’re hurting our families by working jobs that don’t pay squat.

Sure, there are some good EMS jobs out there. There are EMS jobs that pay well, have great hours, and have a well defined career path. Unfortunately that’s not even close to being the norm. We need every EMS job to be like that but most aren’t.

I don’t say the names or exact locations of where I work on here for a few reasons, like I never want to cross patient privacy guidelines or HIPPA laws. That and I don’t want my comments to be associated with my employers. My opinions are my own and nobody else’s. With that said, some time ago I took advantage of the family package being offered by a member of the opposite sex. This changed my life in ways that I couldn’t imagine. (as a matter of fact, I have to take a “read me a story” break in the middle of writing this) One of the ways that I couldn’t have imagined was that one of my jobs became nearly incompatible with family life. I work for an agency that responds to disasters in a governmental way that I won’t name here in the hopes that google won’t pick it up. With that job I had been making enough money to support a house, a couple of cars, and a good existence. However, being gone 6 months out of the year isn’t good when one has a 4 year old. Because of that, I decided to stay closer to home most of the time and make my fortunes solely as a paramedic again, after spending a few years splitting my time between my busy ALS-Providing Volunteer Fire Department (around 3k calls per year) and travelling around the country for my other job.

With that decision I’m back to being a wage slave and an overtime hog. I work three jobs and I’m gone a lot. I make the same exact pay rate as do the new medics right out of the school. While I’m expected to help mentor the others I’ve found that the program is really only lip service at the full-time place where I work. I do my best because I really, truly care about the patients, the people I work with, the community, and the service (in that order). But I fear that I’m going to end up like my mentors have… still stuck in a truck making very little pay while being so concerned about the patients who need me that I can’t leave them for the sake of my family. Or in an entirely new profession that I don’t love and am not passionate about.

It’s precisely that dilemma that prompted me to start writing about EMS.

I want EMS to be a profession that I can be proud of. Not a job that anyone can do with a moderate amount of education, but a career that spawns true professionals that can make a living doing this and progress up a true career ladder.

Here are two suggestions I have on to do this:

First, we need to make the educational requirements hard. The more we learn and master, the more useful we are. While I don’t want to leave my mentors behind, I don’t think that any idiot out of high school should be able to take an EMT class and hav
e my position… like I did to my mentors. The volunteer services won’t like this statement, and neither will the IAFF or the IAFC or the ENA or the (insert acronym here)… but I believe that the MINIMUM STANDARD to become a PARAMEDIC should be an associate’s degree. Perhaps even a Bachelors degree should be required for a PARAMEDIC.

Secondly, EMS needs new revenue streams. The fee for service model doesn’t work. Neither really does taxation (and I’ll get into both of those in another post). We need to capitalize upon and monetize our current skill sets while developing additional skill sets that will bring new sources of revenue into our services. I believe that the cost of an ambulance shouldn’t be a barrier for someone to call 911 for a life-or-death situation… however I also believe that I deserve a fair wage. With additional revenue streams, both of my ideals could be optimized.

For further consideration, read these:

http://medicscribe.blogspot.com/2009/04/profession.html#comments – Peter Canning’s Blog on the same topic

http://tooldtowork.blogspot.com/2009/04/rant.html – Too Old to Work, Too Young to Retire’s blog on the same topic

http://www.communityparamedic.org/ – A new program that I really think shows promise

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

Posted by Ckemtp on April 19, 2009 • Filed under: Ambulance, EMS, EMT, Paramedic, paramedic education, profession, professionalism

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