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A Slap in the Face to Paramedics Everywhere?

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As some of you probably know, last weekend I went to the Fire Department Instructors’ Conference (FDIC) in Indianapolis, IN and I spent a great deal of time wandering the convention floor, looking at cool things and talking to cool people. There were plenty of great things to see and great new things to learn about and I immersed myself in doing just that. One of the things I’m always interested in is looking at the new trends in ambulance design and the manufacturers always have their coolest new vehicles on display to feed my interest. However, while walking the conference floor, I came across an ambulance that did more to tick me off than it did to promote their new vehicle design. Seriously, it was like someone slapped me in the face. Here’s the picture I took from my phone:

 Ambulance Staffed by RNs

Does anybody see anything wrong with that picture? I was immediately ticked off…  I’m talking a level 7 hissy fit. I was livid for quite a while and if you follow my twitter feed, you probably saw the three or four times I TwitPic’d it.

I mean really? They had to put “Staffed By Nurses” in six inch high script on three sides of this thing?

I blocked out the name of the service that runs the ambulance and in all fairness to the manufacturer, this truck is awesome. I would be quite happy to work in this truck although being that it has no bench seat, its usefulness as a 911 truck is hampered by its inability to carry more than one patient at a time. However, I would flatly refuse to work in this truck or for the ambulance service that puts it on the street. I happen to know the service that bought it and I’m trying to avoid naming them directly, but they serve a midsize city in Illinois.

Before you go all West Side Story, whip out your switch blade and zip gun, and prepare to have a dance fight with the nurses out there, realize that I’m not mad at them. Sure, mostly they’re well-paid and have climate controlled jobs inside of well-lit buildings, but they didn’t do this to us. My beef is with the management of this particular ambulance service.

So, let’s say that you’re the manager of this particular ambulance service. Obviously, sitting there in your office you must think that your paramedics and EMTs are contemptible morons who live simply to cause you problems. Furthering your view of the world, you probably think that the rest of the medical profession and the members of the general public in your area view them the same way and simply don’t trust them to provide medical care when it’s like *really* complicated and stuff. You probably feel that everyone would feel safer knowing that their patient or loved one is traveling via the companionship of “nurses” whom you must view as actually being like actually *Competent* and stuff.  

And that’s what this rolling billboard to your contempt of your employees and their profession says about you. It’s a slap in the face to the good men and women you have working for you and there is flatly no excuse for it.

Here’s a tip, anonymous ambulance manager person (AAMP). There isn’t a need to have your precious ambulance be “staffed by nurses” when you have sufficiently equipped and prepared paramedics working in it. Paramedics are acute care specialists. We’re also experts in mobile medicine. Our education, training, and experience prepare us for the unique environment that we create when we move patients from one place to another. Critical Care Paramedics have the intensive Care experience, training, and background needed to operate in a critical care ambulance environment, nurses do not. Sure, ICU and ER nurses are great at Critical Care. However you shouldn’t regularly staff a critical care nurse in the transport environment for the same reasons that you wouldn’t put a critical care paramedic inside of the ICU. The professions are like in a lot of ways, but they’re separate for a good reason.

And you, AAMP, don’t respect that. Perhaps it’s because you’re burnt out. Perhaps it’s because you’ve beaten the system you’ve created into such a pulp that nobody wanted to staff your new Critical Care Truck. Perhaps it’s because of a lot of reasons, but it’s certainly not because you wanted the best in patient care or to show that your employees are capable of operating your shiny new “special” ambulance. No, you wanted “nurses” to “staff” that truck… and not only did you want the medical people you’re contracting with to know this, you wanted everyone who saw the truck to know it as the 6 inch high letters stating that fact clearly show. Do you think that the public views your crews as incompetent? If so, do you think that furthering the notion by advertising that your “special” truck is “staffed by nurses” will help that situation?

If your protocols are so draconian that even critical care certified paramedics cannot be allowed to staff that truck, then your protocol system is in the Stone Age. If your educational system isn’t up to the challenge of preparing your most experienced medics to staff it, then fix that problem. I know that there are great medic/nurse combos out there and I know that flight nurses have garnered quite a bit of respect out there in the world… and heck, I’m not knocking them for doing it. However, this is the time for Paramedics to step up and claim our turf. This ambulance clinched it for me. AAMP, your shortsightedness has caused me to lead a revolution of sorts here. You’re contempt for your staff has indicated to me that now is the time for paramedics and EMTs, such as the ones that work for you, to stand up and start claiming what is rightfully ours. Frankly, AAMP, your ambulance and your attitude is ridiculous and thinking like that must be stamped out right now by the good medics among us.

And I should also say this to the nurses in the audience before you start skewering me for knocking you: Have you looked at the debates in your circles concerning the use of paramedics in the ER and in other hospital units? Have you ever seen the term “Unlicensed Assistive Personnel”? Well I have, and it’s what the upper nursing echelon calls me and my professional colleagues.  It’s offensive, but hey… our jobs are different. You have the hospitals and the fixed facilities. That’s what you do. We have the field. It’s what we do. There’s a line, respect it. If you want to do EMS, go through a real paramedic program. If we want to do nursing, we should go to nursing school. Really, it’s that simple. The transport environment is difficult and requires the use of specialized personnel… which we have, they’re called paramedics. The medical care we provide is close to the care that you provide, except we have autonomy that you do not and we are use to working independently in the environment in which we operate. Your focus is different than mine.  You may be the best transport nurse out there, but even though you personally may be awesome, my profession needs to have people as awesome as you working on our side. That’s what this is about, not to knock your transport nursing skills, but to kick us paramedics in the shorts and get us to step up and maintain ownership of what we should own.

The responses I got back on Twitter show me that there are a lot of like minded individuals out there. Perhaps some of them might work for you, AAMP. You better take that into consideration because if I have my way the paramedics are going to get the notion that we’re not just a bunch of contemptible morons and we’re soon going to take control of our own profession. On that day, managers like you will be obsolete. Perhaps you can get a job managing nurses.

Here is my personal ‘thumbs down’ for the graffiti against my profession that you had someone slather on your shiny new truck, AAMP. My advice? Take it off and reconsider your staffing patterns. What you’re doing is bad for my profession. It affects me negatively, it affects my profession negatively, and it shall not go unanswered.

What do you think?

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Be sure to check out the follow-up to this post “A Slap in the Face? How about a Wake-Up Call?”

Also, for more of my thoughts on the state of EMS in the State of Illinois, check out “Dear Illinois EMS”

Posted by on April 26, 2010 • Filed under: 911 fail, Administration & Leadership, Ambulance, Ambulance Driver, ckemtp rants, Command & Leadership, Emergency Medical Services, Emergency Nurse, EMS, ems 2.0, EMS Management, EMS Motivation, EMS rant, EMS Topics, EMS training, Paramedic, paramedic education, politics, potential, pride, profession, professionalism, Scope of Practice, Vehicle Operation & Ambulances

Advances in Prehospital Analgesia and Conscious Sedation

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Pain is endemic within Emergency Medical Services, whether it’s the pain from a grotesque traumatic injury, the chest pain from a heart attack, or the emotional pain suffered by the local teenage drama queen in response to a minor texting-while-driving incident. EMTs and Paramedics must become better at overall pain management and in conscious sedation. Luckily, there are researchers and pioneers working on new and innovative strategies for just that end.

Researchers at the Plover, WI Polytechnic Institute of Cosmetology and Cheese Making  (PPICCM) have been bringing some cutting edge research to the forefront of Prehospital Pain Management and Prehospital Conscious Sedation and have released some new technologies for use in the field. They have field tested these devices in the dive bars in and around Plover on Friday and Saturday nights and even once or twice on the infamous “TwoFer Tuesdays” down at MoeLarry’s Curly Fries and Cheese Bar. They have come up with compelling data that your agency should consider for your own use.

Tradtionally, EMS providers have had a few choices for use in prehospital analgesia and conscious sedation. Advanced providers and paramedics have injectable medications for use, and basic level providers and EMTs have basic splinting and positioning for use in controlling severe pain and the secret weapon for use in putting people to sleep. These medications, including Morphine, Fentanyl, Toradol, Aspirin, and sometimes Nitronox have proven to be very effective, but all of them carry with them side effects and the risk of allergic reactions that can prove fatal in some patients. So can the medications used in Drug Assisted or Rapid Sequence Intubation Techniques: Etomidate, Succynocholine, and the like. To reduce the risk of poor outcomes from these medications, the researchers at PPICCM have developed the following tools:

  • The Open Handed Slap – This is effective as a calming technique for persons who have become hysterical due to superficial trauma to their fingers as well as for family members overcome with emotion due to their loved-one’s bout of indigestion. An example is included below:

 

  • The Mallet Method of Anesthesia Induction – Pioneered by the indomitable Drs Moe, Larry, and Curly (and previously by Dr. Shemp), the use of mallets in induction of conscious sedation is well documented. Simple, yet elegant in it’s use, cranial contact by the fast-moving business end of a mallet is highly effective in reducing any complaints of pain from a patient. In fact, just the visual feedback recieved from opening the case the mallet is stored in and showing the patient that you are preparing to use said mallet is effective in reducing complaints from most alert patients. However, if needed for use, one or two blows in rapid succession is shown to be quite effective in the literature. An example is included below:

 

  • Transcutaneous Oxygen Therapy (TOT-WTYTR) - This method involves pressing the external wall of a “D” sized oxygen cylinder against a bony prominence of a patient in the throws of a violent reaction towards EMS providers. Use of TOT can be handled by both Basic and Advanced providers and it’s effects are determined by the speed and location of the bony prominence that the side wall of the oxygen cylinder is applied to. Lower extremities can be calming while the head and cranium can induce anesthesia and facilitate Rapid Sequence Intubation in most patients. Unfortunately, there is no accompanying video literature for this particular therapy, however it is a simple technique to learn.

Thanks to the brilliant scientists at the PPICCM, prehospital anesthesia and analgesia is in good hands. These simple yet powerful techniques are scheduled to be released for use by my agencies on April Fools Day and should NEVER EVER be used by yours. Ta’ Y’all. Happy Spring.

Posted by on April 1, 2010 • Filed under: 911 fail, Als, Ambulance, crisis, Emergency Medical Services, EMS, EMS Health & Safety, EMS Humor, EMS Topics, Fire Rescue Topics, funny, humor, Paramedic, paramedic education, Uncategorized

Trust… It’s everything

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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.

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

Any Random Person

560 comments

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.

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

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

17 comments

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…)

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

 

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

Why I am Passionate about the Chronicles of EMS

15 comments

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

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

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

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

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

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

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

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

Mental Quickness – Do Smart Alecks Make Better EMTs?

8 comments

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.

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

EMS practice

8 comments

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.

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

Expanding Our Career Options – Non-Traditional EMS Jobs

16 comments

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?

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

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

2 comments

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

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

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

5 comments

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…

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

Education vs Training: The “Professional Ambulance Cleaner”

22 comments

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:

  1. Which ambulance service do you think will have cleaner ambulances in the long run?
  2. Which employee do you think will do an overall better job in cleaning the ambulances?
  3. Which employer, “YOUR Ambulance” or “HIS Ambulance” do you think has the better philosophy?
  4. 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?

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

Cardiocerebral Resuscitation – Change brings Fantastic results

9 comments

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

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

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

13 comments

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:

  1. A.      Be supportive and consolatory, understanding that you’ve just been through an intense, traumatic experience.
  2. 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.
  3. 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:

  1. 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.
  2. B.      Administer a fluid bolus in the hope that you can slow the imminent delivery.
  3. 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:

  1. 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.
  2. 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.
  3. 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.

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

EMS 2.0 – What are our Core Beliefs?

23 comments

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

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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.

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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?

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

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

12 comments

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?

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

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

9 comments

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 

You may be interested in this part:

“RESULTS: In the 3 years preceding the change in protocol, there were 92 witnessed arrests with an initially shockable rhythm. Eighteen patients survived (20%) and 14 (15%) were neurologically intact. During the 3 years after implementation of the new protocol, there were 89 such patients. Forty-two (47%) survived and 35 (39%) were neurologically intact. CONCLUSION: In adult patients with a witnessed cardiac arrest and an initially shockable rhythm, implementation of an out-of-hospital treatment protocol based on the principles of cardiocerebral resuscitation was associated with a dramatic improvement in neurologically intact survival.”

This is good stuff. Remember, the above is only reflective of those included in the study, who are “Witnessed arrest(s) with an initially shockable rhythm”. Anecdotally, I’ve personally attended those that were not in a shockable rhythm and witnessed greater effectiveness as well.

Here’s the short version of our protocols for Witnessed V-Fib Arrest: (and for those of you who want more, email me at: proems1@yahoo.com and I will be happy to send you a copy of the protocols)

We follow an acronym called MCMAID in our resuscitation protocols, it stands for:

Metronome – We carry a metronome in our monitor/defibrillator bags that clicks out at 100 beats per minute. We are to compress at 100bpm. No more, no less. This metronome keeps us on rhythm and reminds us to be on the chest.

Compressions – 100 compressions per minute. Do not stop. Initially, we are to administer 200 compressions (2 minutes) before our first shock. We are to limit any interruptions in compressions absolutely as much as possible, charging our defibrillators while compressions are ongoing, and recognizing V-fib through the compressions if possible. Compress hard and deep, completely releasing tension on the chest upon recoil to maximize the compression and decompression of the chest.

Monitor – Place the monitor on the patient using fast patches. Do not stop the 200 compression cycles to determine the rhythm. Shock at max joules biphasic. If you can anticipate V-Fib, charge the defib during the compressions and only stop long enough to clear for the shock. Don’t check the pulse, get right back to compressions.

Airway – Initially, a BLS airway will be placed in the patient and a non-rebreather oxygen mask will be placed on the patient. If the airway must be controlled by more advanced means to protect and ensure a patent airway, now is the time to do so.

Intravenous Access – Most of the time, this is accomplished through the means of the Ez-IO drill that we carry and love. (See: Alternative Circulatory Access Strategies – Hi Ho IO) This can also be obtained through peripheral or EJ IV access.

Drugs – Epinephrine 1:10,000 1mg IVasopression 40 IU, Amiodarone 300mg, then Epinephrine 1:10,000 1mg q 3-5min. If refractory, we may give an additional 150mg Amiodarone IV.

To see the full MCMAID protocol (I put it up in a post) you can see it by clicking here.

Today Dr. Kellum came down again for our monthly training and let us know the latest breakthroughs and orders in the project. He is stressing the importance of End-Tidal CO2 (ETCO2) monitoring and states that no pulse check is necessary without a spontaneous increase in ETCO2. He expects every intubated (or combitubed) patient to have ETCO2 monitoring in place.

He also expects that we will monitor ETCO2 readings as a way to prove effectiveness of compressions. Rescuers who cannot get ETCO2 readings consistent with other personnel when providing compressions shouldn’t be doing compressions.

Rescuers should switch off compressions EVERY ONE MINUTE whenever possible. This is providing some fantastic results in preliminary trials.

He also stated that the effectiveness of the CCR protocols are showing a marked increase in refractory V-fib. He hinted that the protocols might soon show a need for thrombolytic use in treatment of refractory V-Fib.

Stay tuned folks, I am happy as heck to be included in this. I will bring updates, with permission, as many times as I get them.

Posted by on October 17, 2009 • Filed under: CCC, CCR, cpr, cpr save, DNR, Do Not Resuscitate Order, EKG, Emergency Medical Services, EMS, ems 2.0, ems education, EMS practice, EMS protocols, EMS Topics, EMS training, ET Intubation, ez-io, intraosseous, IO, IV, new perspective, Paramedic, paramedic education, patient care, Patient Management, save, SMG, SMO, southern wisconsin, STEMI, technology-communications-ems-topics, Training & Development • Tagged: , , , ,

MCMAID Resuscitation Protocol

4 comments

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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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 1st  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)

  1. Hypovolemia (Infuse Normal Saline wide open)
  2. 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])
  3. Hydrogen Ion, i.e. acidosis (Perform ventilation [1])
  4. 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
  5. Hypokalemia (not treated in the field.)
  6. Hypothermia (See Hypothermia & Frostbite Guidelines)

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

  1. Tablets (See Toxic Exposure/Overdose Guidelines)
  2. Tamponade (EMT-P: Perform Pericardiocentesis)
  3. Tension pneumothorax (Perform needle decompression)
  4. Thrombosis, cardiac i.e. myocardial infarction (See Chest Pain Guidelines)
  5. 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.

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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”

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

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.

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

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.

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

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.

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

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.

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.

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

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

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The EMS narrative report is the most information-rich part of the EMS patient care report. As I've said before, (here and here), the EMS narrative is the part of the EMS report that provides the most information in a way that humans can actually digest. Unfortunately, there are a lot of EMS people out there that still don't quite "get it" when writing their EMS narratives. Here are some useful tips and tricks that you can start using today that will improve your EMS narratives and improve your overall patient care.

 
  1. You made decisions on the call. Put in the information you used to make them -Every patient's outcome could be directly attributed to your actions and the care that you gave to them. Remember that deciding to give one form of care over another is a decision that you must make with your clinical judgment. Put the information that you used to make the decisions you made in the report. For example, if the patient had Wolf-Parkinson-White syndrome and it was causing a narrow-complex tachyarrhythmia with a ramp-up in the PR interval showing pre-excitation syndrome and you chose to used synchronized cardioversion over adenosine because of it, well then you should probably provide that information in the narrative.
  2. Remember that you're painting a picture with your words – Imagine yourself reading this report several years down the road, perhaps because the patient has sued you and/or your service, or perhaps because your care is being reviewed. In both cases, you won't remember the call clearly because it will have blended in with so many others. You will be held responsible for the content of the report and only the stuff that you wrote in the report will be allowed into court. Be descriptive. Look at the following sentences:

     

    1. "Pt's left lower leg was found to have a fracture below the knee. Fracture splinted in place with pillow splint and tape"

       

    2. "Assessment of Pt's left lower leg showed a probable angulated fracture of the tibia/fibula below the knee. Distal circulation was found to be slowed but present with capillary refill approx. 7 seconds with no palpable pedal pulses and colder skin distally. Unable to straighten Fx due to severe pain and resistance to manipulation. Fracture splinted in place with pillow splint and tape due to the above.

     

    Which one of those sentences tells your medical director more information? Which one of those sentences shows that you're a competent medical provider? Which one of those sentences would you rather base your legal defense off of if the patient decides to sue you for loss of function in their foot? The second one took me 12.4 seconds more to write, but could save years of headaches. It clearly states that you found the injury on assessment (ie, that you didn't cause it) and that you attempted to, but could not restore distal circulation within the scope of field care, and that you did the best you could to take care of it.

 
 
 
  1. Organize the order of information – High school Freshman English teaches students that the way to write a proper essay is the "at least three paragraph" method (I think, because I was sleeping by then, mostly). My teacher taught me (and it was an um, not too long time ago? How many reunions has it been?) the "Tell them what you're going to tell them. Tell them. Then tell them what you told them method" this roughly translates into the "Introductory paragraph", the "body paragraph", and the "Conclusion". A Simple, one-page Freshman essay in three easy steps. In EMS reporting we probably won't often go into three paragraphs (even I don't) but we can use the SOAP (Subjective, Objective, Assessment, treatment Plan) or the chronological methods to organize the information. To put the above all simply, if you're going to say: "Patient was found to have a 3 inch laceration above his eye" don't put it right after the sentence "Patient was complaining of pain above his sphincter"…. It could cause confusion.
  2. Take a few moments to plan what you're going to write - Let's just say that if you're an EMT you're probably no Dave Barry when it comes to writing ability. Therefore you probably cannot just sit down and plop out whatever pops into your head onto the computer screen just like that. Heck, I'm a trained EMS blogger and I can't even do it. Reflect upon the call in your mind before you write the narrative, remember important events and observations. Think about how you want to tell the story to your reader.
  3. Think about documentation during the call – There are certain tools, assessment findings, and procedures in EMS, and any medical practice, that exist only for the purpose of providing fodder for documentation. No, I don't believe that the numerical reading on a pulse-ox exists solely for placing within a patient care report, but I give oxygen whenever I think that their clinical presentation warrants it (or if I just feel like it) However, it's great for documenting in your vital sign trends. Think about it this way, when you come across the unconscious/unknown and get a history and physical assessment that points towards hypoglycemia confirmed by a glucometer reading of 20mg/dl and you're a paramedic (or an Intermediate) you "sweeten them up" with an amp or so of D-50. What do you do next? After the med takes affect you probably recheck the glucose reading to confirm that it worked… so you can write it in your narrative report. You probably also state that the patient became alert and oriented x 3, had return of color, and had good vital signs. There are plenty of these data points to remember. Be mindful of them and they will find your way into your reports, creating great documentation.
  4. Do I really have to say it? Really? Still? – Maybe it's because I'm no good at math so English has to be my "thing" by default… but I hammer people for grammar (I rhymed there, see? Grammar is fun!) The first and best way to get people reading you to think that you are an idiot is to pepper your writing with spelling and grammatical errors. It makes you look dumb. There, I said it. Please pay attention and try to do the best you can with your documentation. Really. Spell check and proofreading are your friends. Go back and read what you wrote. If you wouldn't want your doctor documenting your care record like you just documented your patient's, fix it. Enlist the aid of your partner and get them to proofread it too. Who knows, you may find something that you missed altogether.

EMS documentation doesn't have to be hard, It doesn't have to be tedious, and it certainly doesn't have to be done poorly to save time. Build your narrative structure and style and improve it over time. Before too long, with your work and the help of others, you will be writing quality narratives that will serve your legal butt and your patient's health well.

For more information, please read the following information on the EMS narrative report, SOAP charting, EMS Charting, and EMS Patient Care Reports.

Soapy Pictures – The EMS Narrative Report

More on EMS narrative reporting

Posted by on July 12, 2009 • Filed under: Ambulance, chart, Emergency Medical Services, EMS, ems narrative, EMS narrative report, EMS paramedics, ems patient care report, ems pcr, EMS Topics, EMS training, emt narrative, Fire Rescue Topics, Paramedic, paramedic education, paramedic narrative, Patient Management, soap, Training & Development, training-fire-rescue-topics

Soapy Pictures – The EMS Narrative Report

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EMS reports come in various flavors these days. When I first started in this game back when I was a young, idealistic EMT-Basic (as opposed to a still young idealistic paramedic) all we had were these gosh-awful paper reports. We called them "bubble sheets" and if you've grown up as an Illinois EMT you've probably seen your share of them. Illinois bubble sheets were these multiple carbon copy monstrocities that included two pages just chock full of fun. You had to fill them out for everything the state thought was important, making sure that all of the bubbles were colored in exactly right or the state would kick it back to you however later it was they actually fed it through the machine. It was like taking a test every time you had a patient contact. Nobody read the bubbles but the machine. So if you actually wanted to communicate useful information about the patient to future caregivers or if you wanted to remember details about the call for whatever reason afterwards, the State saw fit to give you a really small box with really small lines for you to write a narrative report.

I hate those things. Notice that the previous isn't a past-tense statement. Some EMS services in the State of Illinois still use those awful things for EMS reporting. Really. Ambulances in Illinois are still required to carry at least ten of them in every ambulance per Illinois Department of Public Health (IDPH) regulations. Honestly, I threatened to go back to using them when one of my services switched to a new EMS reporting software that I'm not sure I like. Let me just say that .html databases are not useful for large data collection projects. They're clunky, prone to losing data, and aren't user friendly.

Here is a little bit of information on data. I am a database specialist of sorts. In one of my positions I work in data management and control. I take huge volumes of aggregate data collected from disparate data sources, mash it together, break it into single data pieces, numbers, and "Yes/No" answers, and then ask questions of it to get back useful reports. I'm not a database genius like some (and real database pros may disagree) but the way that I understand data processing is that data can be computed when it is processed into "Yes" and "No" answers and/or numbers. "Yes" answers are "+1" and "no" answers are "-1" or "0" depending on the question. When data is broken down into these Yes/No questions, it can be processed through a mathematical formula to obtain clear, actionable results. That's why you see categories of data, lots of radio buttons and check boxes, and prewritten answers in the new reporting software that has to be NEMESIS compliant.

(In a later post, I'll analyze data harvesting, structuring, composition, computation, and reporting as it relates to EMS. And, if anyone needs the skills of a Data Ninja, I'm available for EMS data processing. Free for small projects)

Unfortunately for us humans, and especially us humans that work in an almost completely unpredictable and not-easily categorized environment, the type of information that we like to communicate with does not fit well into the structure needed by computers. Us humans communicate in ideas, in words, and in fluid conversational form where ideas are not rigid, and the same information can be quite different when read contextually.

Therefore, my favorite part of the EMS Patient care report or any patient chart is the narrative. If you've had the opportunity to read many patient charts, or even if you've flipped through the paperwork on patient transfers, the parts you probably gravitate to are the narratives. You probably also read the lab results. There's a reason for this. Humans like reading stories which are what narrative reports are. We also like quantifiable numbers, which are what the lab results are. These are pieces of information that we can wrap our brains around, sink out teeth into, and really understand. I would bet that there aren't many people out there who ever even read the canned data areas. I don't.

I write a stock EMS narrative report every time. Not word-for-word, but I follow the exact same formula and use different tools in my reporting as needed to fit the situation.
Here's an example of a patient that I'm completely making up off of the top of my head (really):
Ambulance 1 dispatched emergent through the 911 system for the 42yo F Pt (patient) for the chest pain. UOA (Upon our arrival) we were met by the Pt's family who directed us in to the patient. Found the Pt sitting upright in a chair CAOx3 c ABCs intact (Conscious, Alert, and Oriented with Airway, Breathing and Circulation). Pt c CC of substernal chest pain that she std (stated) began approximately 1hr prior to her calling 911. Pt described the pain as a "deep pressure" that she std began in the inferior sternal area and radiated to the L shoulder and into the L arm. Pt rated the pain at a "7" on a 10 scale and denied any provocative or palliative features. ALS ASSESSMENT (By: Ckemtp): (Note: Billing services want that last part) Skin pale, warm, and moist. Pupils PERRL, no JVD (Jugular Veinous Distention), Trachea Midline/Mobile, Chest Equal Rise/Fall Bilat c Clear Lung Sounds and as described above, ABD Soft/non-tender, Extrem (Extremities) c good PMS (Pulse/motor/sensastion) and Temp. TREATMENT: 12-lead EKG obtained showing NSR (Normal Sinus Rhythm) with occasional PVCs and ST Elevation noted in leads II, III, and aVF with machine and EMT-P interpretation of probable acute MI. o2 applied at 4-LPM via NC (nasal cannula). Pt secured on cot and taken to rig. IV established in R forearm running 1000ml warm NS TKO. Pt given 325mg ASA (Aspirin) PO and 0.4mg SL x 1 bringing her pain to a "5". STEMI alert called to St. Elsewhere with report given via MERCI (Medical Emergency Radio Channel – Illinois). Pt given 0.4mg NTG SL again bringing her pain to a "4" and again bringing her pain to a "3". Pt given 2mg MS04 (Morphine Sulphate) bringing her pain to a "2". Pt transported and transferred to St. Elsewhere ER RN staff s incident or exacerbation.

I've been writing that same report for years with each patient. It's evolved a bit, but I can fit everything I need to fit into it. I would think that any further healthcare providers would be able to discern the patient presentation from that report, and I would be able to recall the events of the call in the event that I had to. When I first started writing narratives, I was told to use tools like "SOAP", "CHART", and other acronymns. I hated them, because I felt overly confined by their rigidity. I decided that I would use the chronological narrative method, and I thought that I was using it for years… until I realized that my narratives reports are just SOAP charts with my spin to them.

"SOAP" is an acronym that stands for "Subjective, Objective, Assessment, and treatment Plan". As it goes, the "Subjective" information is the information regarding the call, the events that you found when you got there, and a bit of history regarding the subject of the report. The "Objective" information is the information that you found through objective observation of the subjective information. The "Assessment" is just that, and to signify it in the report I write "ASSESSMENT" in capital letters. In the assessment portion of my report, I include "pertinent negatives" or a full sentence regarding my secondary assessment findings. In this section, I put in the findings such as the skin condition, the lung sounds, and the abdominal condition. While the old adage is that if you didn't write it, you didn't do it. I say that if you didn't write it, you didn't do it… unless it was bad. Then if you didn't write that you didn't do it, you did do it. (G'head an
d read that last sentence again until it makes sense) Including the pertinent negatives in the report shows that you did a thorough secondary assessment which is helpful for defense in case there is a bad patient outcome. Finally, the treatment plan shows the treatment that you performed and the response that you got from that treatment. Be thorough. At the end of the report, I put in the stock information that I passed the patient to the facility staff after calling in a report.

A good EMS Narrative report does a few things. First and foremost, it presents information about the patient's condition and the care that they recieved. The information that EMS gathers is important to their further care. The observations we make and the assessments we take are a view of the patient when their illness or injury is most acute. Our information can set the stage for the entirety of the patient's care down the line. The EMS Narrative also serves to refresh our memory for when we get called in to the office for an unknown reason a year or so down the road. Remember, you're always writing the report for your own legal defense. I also like the narrative because since I write it the same every way and always try to make it as detailed as possible, I can catch when I didn't do as thorough of an assessment as I would have liked to.
The EMS narrative report is the best way we have to tell the story of our patient care. Make it good, make it detailed, and for goodness sake, use proper spelling, grammar, and punctuation. You will be judged by other healthcare professionals on the quality of your narratives, make them good and not only will you look good, but your patients will get better care.

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I'd love to see some report styles used by different providers. So I'm asking y'all if in the comments section you would make up a narrative report and post it so that we all could see examples of other EMS Narrative reporting. I think that it'd be educational, and maybe if you're a geek like me… fun.

This post is part of a group of posts on EMS narrative reporting:

For more information, please read the following information on the EMS narrative report, SOAP charting, EMS Charting, and EMS Patient Care Reports.

More on EMS narrative reporting

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

Posted by on June 13, 2009 • Filed under: Ambulance, ambulance report, Emergency Medical Services, EMS, ems education, EMS Health & Safety, ems patient care report, ems report, EMS Topics, EMS training, EMT, Fire Rescue Topics, idph, illinois, narrative, Paramedic, paramedic education, paramedic narrative, patient care, Patient Management
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