Archives for patient-care

4/1/2013 Eugene, Oregon:

At small ceremony held today, Paramedic Christopher Downdike was honored by his ambulance service for having a near 95% against-medical-advice refusal of transport rate. Among other things, Paramedic Downdike was recognized by both his superiors and his peers for being able to sign off nearly 438 patients during calendar year 2012.

“For service far beyond what we could call ‘normal’ we recognize Paramedic Downdike for managing to not transport far more patients than could have been expected.” Said Chief Norberg of the Mountain Orchard EMS department. “Through his inaction, Paramedic Downdike has been able to save Medicare, Medicaid, and a number of other private healthcare insurance companies vast amounts of money that they otherwise would have wasted on paying for ambulance services.”

Displaying little more than his trademark apathy, Paramedic Downdike said that it hadn’t been easy. “First off, I couldn’t sign em’ all off. I mean, these people… they call us at like all hours of the day for stupid reasons. Why are they calling me when they could just as easily take a taxi or just drive themselves. Is it really a heart attack?? Geez… Not this time, buddy.”

Paramedic Downdike continued to deride patients who he felt were beneath his vast array of medical skills and level of competence. He let us know that most patients with “Chest Pain” were really just victims of indigestion that could probably just take some antacids and “be just fine” and that anyone complaining of back pain was “faking it so they can get drugs in the ER.”

“Call me when you’re dying and I’ll come save you. That’s what 911 is for. If you need a lot of my skills, then we’re good. But if you call me because you’re having something stupid like a broken arm, well then you better be able to sign that piece of paper because I ain’t havin’ it.” Said the heroic paramedic.

It wasn’t a perfect record though.

“There’s this stupid state law that says we can’t really tell someone that we’re not going to take them to the ER if they really want to go, so sometimes we’ve got no choice.” Paramedic Downdike explained. “A lot of those cases I was able to just turf to BLS but some of those yahoos actually made me take em’ to the hospital. Hello bench seat… you ain’t messin up my cot today!”

At the end of the ceremony, Paramedic Downdike received a call for a 2 year old having a seizure. He was heard muttering “Stupid parents who can’t give their kid Tylenol” as he sauntered off to “take a leak” before he left.

Posted by Ckemtp on April 1, 2013 • Filed under: Administration & Leadership, ambulance humor, Emergency Medical Services, EMS, EMS Humor, EMS Topics, Fire Rescue Topics, Paramedic, patient care, Uncategorized

A Weighty Protocol Change

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04/01/2013 – Andrew, Illinois

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

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

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

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

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

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

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

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

On the Topic of Ectopics – Ectopic Pregnancy for EMS

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There’s an old adage in emergency medicine that was taught to me by a wise, old physician. It’s not very poetic, but remembering it can save lives. It goes that “Any abdominal pain in a female patient of childbearing age is an ectopic pregnancy until proven otherwise.” It’s wise advice to follow for all EMS providers, but why is that?

In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine lining where it has plenty of room to divide and grow. However, in about 1% of pregnancies the egg implants in an improper or “ectopic” location. An “ectopic pregnancy” (or “eccysis”) is a condition where the embryo implants outside of its normal place within the uterine cavity. Ectopic pregnancies are nearly always non-viable and are extremely dangerous for the mother as they can cause severe internal hemorrhage as they continue to grow. Most ectopic pregnancies occur in the Fallopian tubes, but implantation of the ectopic embryo can occur in the cervix, ovaries, and even inside the abdominal cavity. This is a true medical emergency that can be fatal without rapid diagnosis and treatment.

The biggest risk to the mother from an ectopic pregnancy is internal hemorrhage which can rapidly cause nearly total exsanguination. Since development of the embryo requires a large blood supply, the developing embryo impinges upon the local blood vessels in the tissues in which it has implanted. Growth of the embryo in these ectopic locations can also rupture the structures they’re growing inside such as the fallopian tube. Due to the vascularity of the developing embryo, should a rupture occur the internal bleeding can be very severe. The condition can also cause vaginal bleeding should the blood vessels rupture inside of the birth canal and leak into the uterine space or the lumen of the fallopian tube. In some cases, vaginal bleeding causes the ectopic pregnancy to be flushed out of the reproductive tract and is a common form of miscarriage. A percentage of ectopic pregnancies resolve themselves in this manner. However, should this not happen, prompt medical or surgical intervention is needed.

Early symptoms of an ectopic pregnancy are subtle or even absent with clinical presentation occurring on average of around 7.2 weeks after the last normal menstrual period. The normal range for symptom appearance is 5 to 8 weeks after the last normal menstruation. The presence or absence of proper prenatal care plays a role on when the symptoms are first noticed.

Early signs of an ectopic pregnancy include:

Pain in the lower abdomen that may feel like a strong cramp
Pain while urinating and/or having a bowel movement
Vaginal bleeding that is usually mild. It could be confused with bleeding from an early miscarriage or the “implantation bleed” of normal, early pregnancy

Late signs of an ectopic pregnancy include pain and bleeding. The bleeding will be both external vaginal and internal:

External bleeding is generally due to falling progesterone levels
Internal bleeding or “hematoperitoneum” is due to hemorrhage from the affected tube.

More severe internal bleeding may cause:

Lower back, abdominal, or pelvic pain.
Shoulder pain caused by free blood tracking up inside the abdominal cavity and irritating the diaphragm. This is a late and very ominous sign.
Cramping or tenderness on one side of the pelvis.

Consider ectopic pregnancy in cases where abdominal pain is of sudden onset and is getting worse. Remember that since an ectopic pregnancy may mimic the symptoms of other diseases and also of less serious causes of abdominal pain, such as appendicitis, some gastrointestinal disorders, problems of the urinary system, pelvic inflammatory disease (PID), and other gynecologic problems providers should not quickly dismiss such symptoms as non-life-threatening complaints. Since the condition can rapidly deteriorate into severe internal hemorrhage that can be rapidly fatal, prompt treatment and a high index of suspicion is warranted.

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To see a case review covering Abdominal Pain of another cause for EMS, see: "Appendicitis – An EMS Case Review"

Posted by Ckemtp on November 29, 2012 • Filed under: Emergency Medical Services, ems education, EMS Topics, EMS training, paramedic education, patient care, Patient Management

Prehospital Pain Control

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“We must all die. But that I can save a person from days of torture, that is what I feel is my great and ever-new privilege. Pain is a more terrible lord of mankind than even death itself.’’ - Albert Schweitzer

It has been observed that pain is part of the presenting symptoms of up to 70% of all EMS patients. One study has even suggested that over 20% of EMS patients are experiencing severe to extreme levels of pain. As EMS providers, it is our duty to routinely recognize and aggressively treat our patients’ pain as it is one of the biggest things we fight against in our professional practice.

In the not-too-distant past, pain was not aggressively treated by EMS. This was partially due to lack of training on the part of responders but was also due to a lack of availability of proper measures for pain control. Since then, more medications have been made available for field use and more medical directors have become open to the prospect of allowing providers to aggressively treat pain. Quite a few respected national organizations have weighed in on the subject and it continues to gather a lot of attention. Prehospital pain control is a complex issue with many factors to consider on all levels of the EMS spectrum. Field providers need the tools to effectively manage their patient’s pain as well as the education to recognize and treat it; medical directors need to provide these tools and education to their field providers in a way that allows them to trust their use of them; and our overall attitudes towards pain control need to be changed. Large national studies have shown that rates of pain control measures taken in differing patient populations decrease on some disappointing criteria, including gender and patient income level. While numbers specifically reflecting our area are hard to come by, it can be assumed that our area may loosely follow the wider trends.

The old adage “Pain never killed anybody” used to be thrown around by some people in healthcare. To them it means that any pain patients may suffer in the name of their more expedient care is reasonable. I disagree. Patients may not die due to severe pain but it has lasting effects upon a person’s long-term physical and psychological health. Pain is what our bodies use to teach us lessons on how to avoid noxious stimuli and dangerous injuries. By its very nature, pain makes a lasting impression on us. We need to accept that our patients have more pain than we may realize or expect that they do and provide aggressive and adequate relief for them. While assessing pain is difficult, accepting that people tend to have individualized perceptions of and reactions to pain is important for prehospital providers. It is not acceptable for a healthcare provider to judge a patient’s pain based upon their own personal opinion of how they themselves would tolerate it.

In our contemporary EMS toolbox we have a number of methods for achieving analgesia, which is the control of pain without causing a loss of consciousness. Analgesia can be achieved by many methods available in the field. While paramedics have medications such as Fentanyl, Dilaudid, Morphine, Ketamine, and Versed available to administer to patients, all levels of EMS providers have effective pain management tools. Proper splinting and patient packaging techniques, ice and/or heat packs, padding and elevating extremities, and even techniques such as guided imagery, breathing exercises, and psychological support have been shown to achieve pain control. It is always a good idea to use a range of techniques when managing a patient in severe pain in order to achieve good control and not just to rely on one technique or medication. For example, no narcotic in any amount will completely control the pain of a badly fractured and angulated extremity if the extremity is allowed to move freely or is improperly splinted. The combination of the splint and the medication must be used in tandem. Paramedics must consider the use of medications together for severe pain, such as by combining a narcotic with a sedative such as a benzodiazepine or Ketamine. While benzodiazepines (Versed, Valium, Ativan, etc) and/or Ketamine do not provide analgesia in of themselves, they work in conjunction with pain medications to potentiate the effect and maximize pain control. Ketamine can also be used to achieve “dissociative analgesia” in higher doses, where the patient’s level of consciousness is decreased to the point where they are no longer conscious of the pain they are experiencing.

Selecting the proper technique or medication for each patient is not always an easy task as no method is a one-size solution. However, it is obvious that fractures should be splinted and supported as appropriate and that patients should be packaged in a position of comfort. For patients requiring spinal immobilization, padding voids on the backboard is appropriate as is the use of a Back-Raft or other approved backboard padding device. Offer ice or heat packs to patients with musculoskeletal injuries and be sure to keep patients warm during care. Talk to them about their pain and provide psychological first-aid as you are able. BLS and ILS providers may consider calling for an ALS intercept for pain control medications in some cases as appropriate.

For ALS providers, choosing the right medication is not always an easy choice. Having knowledge of the characteristics of each medication you carry makes it easier to utilize clinical judgment. Fentanyl is a popular choice for prehospital pain control as it is fast-acting and has a shorter time of duration than other pain medications. Fentanyl also has less risk of hemodynamic instability when compared to other narcotics. Dilaudid, another option in our toolbox is a longer-lasting pain med that is good for patients with chronic breakthrough pain, or for patients with obviously fractured extremities. There is little risk in the prehospital setting of developing dependence in your patients with episodic use of narcotic analgesia for acute pain control.

Perhaps the biggest part of the job of every healthcare provider is alleviate the suffering of the sick and injured and a lot of that is reducing physical pain. Be proactive and aggressive in managing pain for your patient and become comfortable taking with your patients about their pain. We may not be able to eliminate all pain in the prehospital setting, but we can make a big difference in making this world a less painful place.

Posted by Ckemtp on October 3, 2012 • Filed under: Ambulance, Emergency Medical Services, EMS, EMS Topics, EMS training, Paramedic, paramedic education, patient care, Patient Management, Training, Training & Development

EMS 12-Leads – The Standard of Care

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I’m going to make a statement:

Every ambulance in the United States should have the capability to obtain a 12-lead EKG. Regardless of the service’s level of care, be it Basic, Intermediate, or Advanced Life Support, every ambulance should have the ability to get a 12-lead. There are no exceptions in my opinion. It is the standard of care and every ambulance should be able to do it.

In the last few years, the 12-lead EKG has not only revolutionized EMS care, it has influenced the care given throughout the entire healthcare system. Bringing it to the forefront of urgent and emergency care has helped not only save countless lives but also has improved the ongoing quality of life for countless patients. The 12-lead EKG provides invaluable insight into a patient’s true underlying medical complaint and is useful in diagnosing a whole host of potential medical conditions. If you are an EMT or paramedic, you should be able to obtain a 12-lead.

I’m saying this because right now in communities both urban and rural there are ambulances that still do not have this essentially lifesaving capability. The problem crosses all divisions in the level of care and there is no excuse for this fact. Obtaining a 12-lead is an essential piece of the diagnostic puzzle for many patients. It can make the difference between a proper diagnosis and misdiagnosis that can have a lasting detrimental effect on a person’s entire life. There are many solid positive reasons that support EMS agencies expending their critical resources to obtain this capability and few, if any reasons for them not to.

If your agency does not currently have the ability to acquire a 12-lead EKG, here are some reasons that you can take to the powers that be for your service or use as information to show your community for fundraising activities. In my opinion, these things help show the solid reasons why you should begin offering the service as soon as possible.

Better knowledge drives better medical care – The most common EMS treatments for chest pain can mask essential diagnostic signs and symptoms that help pinpoint cardiac causes of the complaint. Things like Nitroglycerine, Oxygen, narcotic analgesics, and aspirin can normalize the waveform complexes on an EKG tracing after only a few minutes. EMS providers used to begin treating the symptoms of chest pain before acquiring a 12-lead when the technology was not widely available. This caused a broad cross section of patients who were truly experiencing a heart attack that needed to be treated emergently to have 12-lead tracings that were normal upon their acquisition in the ER. The ERs then needed to rely on the laboratory values of the patient’s cardiac enzyme markers to make a diagnosis. This often times added 12 to 24 hours to a patient’s time to proper diagnosis and sometimes resulted in a heart attack that was missed entirely. EMS 12-lead EKG acquisition helps change that. EMS providers can obtain a symptomatic 12-lead EKG at a patient’s first point of entry to the healthcare system when their symptoms are at their worst which will oftentimes show diagnostic information that 12-leads obtained later in their care will not. This exponentially increases the diagnostic sensitivity of the overall assessment of a patient and can change their entire path of care, resulting in more appropriate treatment being given sooner. This can save more of the patient’s heart tissue and increase their quality of life for the rest of their life. In addition, proper care can decrease a patient’s length of hospital stay, saving millions in healthcare costs when viewed as a sum total.

12-lead EKGs increase the safety of EMS care – Certain types of heart attacks such as ones occurring on the front, underside, and the right side of the heart can cause nitroglycerine administration to be dangerous. EMS providers of all levels give nitroglycerine for chest pain. However, when given to a patient experiencing a right-sided, inferior, or anterior heart attack that affects the right ventricle of the heart, nitroglycerine can cause a severe drop in a patient’s blood pressure that can prove detrimental or even fatal for some patients. A 12-lead EKG can pinpoint these types of heart attacks with a fairly high degree of sensitivity and can help prevent the harmful drop in blood pressure. Heart attack victims need nitroglycerine and like all medicines that can be harmful when not properly used, EMS providers need to be able to see the 12-lead and share it with physicians at the receiving hospital to increase patient safety. Increased safety equals better patient care, decreased liability, and better patient outcomes overall.

If you can provide oxygen, you can take a 12-lead – All paramedic ambulances should be able to obtain a 12-lead EKG with no exceptions, however so should all ambulances of any level. EMT-Basics and EMT intermediates functioning on an ambulance service of any level should be able to get a 12-lead. The first arriving care providers who will be beginning treatment on a potential heart attack victim need to be able to obtain a symptomatic 12-lead. While BLS and ILS providers cannot and should not interpret the 12-lead EKG and should not change their care based upon it (unless ILS protocols allow), they may transmit the information to the receiving hospital and/or responding ALS intercept and may act upon the orders they receive from their medical control. Obtaining the symptomatic 12-lead is essential for proper diagnosis of heart attacks. The first arriving care provider needs to get one, regardless of their level of care.

It can determine the proper hospital to take a patient – Patients having heart attacks need hospitals that can take care of them. The current gold standard of heart attack care is generally agreed upon by physicians to be “Percutaneous Coronary Intervention” (PCI), also known as a “Cardiac Cath.” This is a surgical procedure where an interventional cardiologist threads a tool into the arteries that feed a patient’s heart through the vessels in their leg. The cardiologist can then open a blocked coronary artery and allow the area of the heart being damaged by the heart attack to receive blood flow again. The sooner this is done, the better. A symptomatic 12-lead EKG obtained by EMS can make the difference between a patient being transported to a patient where this surgery can be immediately performed rather than to a hospital that may not have this capability or does not have it immediately available. This makes the difference between immediately appropriate treatment that saves both lives and heart tissue and treatment that may not be the best for the patient. Inappropriate treatment costs a lot more money when it results in a patient needing transport from a facility that cannot properly care for them to one that does.

These are just some of the reasons that all ambulance services of any level should be able to obtain 12-lead EKGs in the field. It is an essentially lifesaving tool and is the standard of care. There are few, if any dangers or drawbacks to using the tool and multiple strongly supported reasons to do so. EMTs and Paramedics that do not currently have the capability should get it as soon as possible, and the communities that they serve should support them with the funding and resources to do so. The medical directors of communities where EMS 12-lead acquisition is not currently possible should write protocols for the practice and should support development of a system of care that properly uses the critical information obtained to make the most positive impact in patient care.

This is an area where EMS truly makes a documented, lasting impact in quality care and where EMS development is driving the healthcare system as a whole. Make sure your service and your practice is a part of it. Do the best by your patients and communities. Save more lives. Help more people get better.

If you have questions, I offer myself for any information you may need. My e-mail is proems1(at)yahoo(dot)com.

Posted by Ckemtp on April 23, 2012 • Filed under: Administration & Leadership, change, Command & Leadership, EKG, Emergency Medical Services, EMS, ems 2.0, EMS system, EMS Topics, new perspective, Paramedic, Patient Assessment, patient care, Patient Management, Scope of Practice, STEMI, Technology & Communications, Uncategorized

12-lead EKG tips for EMS – Making the most of the squiggly lines

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The 12-lead EKG is one of the most fantastic advances in EMS treatment since the invention of the bandage. The movement of this powerful diagnostic tool from the confines of the hospital to the streets has been nothing short of revolutionary. It has given EMS professionals a wealth of information on how to best care for our patients and has driven hospital care and the development of medical care practices by providing clear and critical data that physicians had rarely before seen.

Did you realize that by moving this tool to the field, EMS has almost made heart attacks into a minor medical complaint that can be effectively treated if caught early? EMS has changed healthcare with that. We’re catching things that used to go uncaught and have vastly improved the lives and qualities of life for countless patients who pass through our care. Kudos to the visionaries that helped drive this change. No matter the level of the service, be it ALS, ILS, or BLS, a 12-lead EKG is an essential EMS tool and should be the standard of care.

Proper acquisition of the 12-lead EKG is paramount to getting the most out of this tool. An improperly acquired 12-lead does not provide diagnostic quality information and can render the tracing mostly useless. Here are a few tips to making sure that you get it done right:

Lead Placement

Traditionally, the limb leads go on the limbs, and while it’s acceptable to move them closer if you have to, try to avoid placing the leads over bony prominences or overly fatty areas. Look for a generally flat, clean, intact area of skin with muscle generally underneath.

The V-Leads go on the chest in a specific pattern. Leads V1 and V2 go in the 4^th intercostal spaces (between the ribs) on either side of the sternum. To find these, go about 3 finger widths up from the xyphoid process, or bottom of the sternum. V1 is on the patient’s right, V2 is on the left.

V4 should be placed next, it goes one rib down in the 5^th intercostal space, on the mid clavicular line. Place V3 in between V2 and V4.

V5 goes in the anterior axillary line (front of the arm pit) and V6 goes in the mid-axillary line. They go in the same horizontal line as V4.

Skin preparation

It is important to prepare the skin by cleaning it with an alcohol prep and by abrading it with a cloth towel to remove dead skin cells. You may need to wash the area with saline and dry it. Remove excess body hair by shaving. For females, place the leads under the breast tissue. You may need to lift and clean the skin underneath the breast to get a clear tracing.

Baseline

A quality 12-lead EKG has a smooth, flat baseline (called the isoelectric line). Baseline wander, or the vertical motion of the EKG line can mask important findings in the EKG tracing and result in a non-diagnostic EKG. The patient should remain motionless and lay as close to supine as possible for the acquisition of the tracing and the ambulance should be stopped and not moving during the process. It sometimes takes a few minutes for the EKG tracing to normalize and you should wait for it to do so. The goal is to be able to see the entire cardiac waveform clearly and be able to measure accurate ST segment levels. Skin prep is important to reduce artifact. A tracing with artifact or baseline wander can mask serious EKG findings and may cause a patient to be misdiagnosed.

Multiple EKGs

One EKG is a spot-check of the patient’s heart. Two EKGs are a trend of their condition. Try to obtain a symptomatic tracing of the patient before treatments like oxygen, nitroglycerine, or aspirin are given. While you shouldn’t delay treatment, it has been shown that ST segment elevation can normalize quickly with EMS treatment and an EKG obtained afterwards that does not show ST segment changes can mask a STEMI that should be emergently treated by a cath lab. The 2 or 3 minutes you spend taking the symptomatic EKG can save the patient hours or days going without definitive treatment for their underlying condition.

A good rule of thumb is to capture a 12-lead EKG tracing at the patient’s side where you find them symptomatic, then again when you load them in the truck, and then before you arrive at the ER.

Conditions Requiring an EKG

A 12-lead isn’t just for chest pain.Acquiring one never hurts any patient and may help catch the odd presentation of a serious but vague condition. Obtain a 12-lead for possible strokes, altered levels of consciousness, weakness, dizziness, fatigue, palpitations, and otherwise vague medical complaints. Remember that diabetic patients, younger women, and various ethnicities often have atypical presnetations and may have “Silent MIs.” Be vigilant. You may just save a life.

Posted by Ckemtp on April 9, 2012 • Filed under: Emergency Medical Services, EMS, ems education, EMS Topics, EMS training, Paramedic, paramedic education, Patient Assessment, patient care, Patient Management, STEMI, Technology & Communications, Training, Training & Development, Uncategorized

A Medic Roast in Tennessee

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

I was fascinated.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Pictured: Every Paramedic

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

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

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

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

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

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

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

Blood Pressure – Vital Knowledge for EMS

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The blood pressure is one of the most ubiquitous diagnostic tools used in medicine and has a sacred role in EMS. Every EMT and Paramedic needs to be able to get an accurate blood pressure from every patient, every time. It is so widely regarded throughout medicine as a useful diagnostic tool that it’s considered to be one of the “Vital Signs” and pretty much everyone reading this has either taken someone’s blood pressure, and/or has had theirs taken many times.

Of course we know that the blood pressure is the measure of the heart’s ability to pump blood throughout the body. It’s simple, right: Cardiac Output – Vascular resistance = BP. The blood pressure is represented as a number *slash* number, or “Something *over* something” measured in “mmHg” (millimeters of mercury). These numbers represent the “Systolic” and the “Diastolic” pressures, with the Systolic blood pressure meaning the peak fluid pressure of blood flowing through the arteries at “systole”, or the heart’s peak contractile force; and the Diastolic blood pressure measuring the pressure of blood in the arteries when the heart is at “diastole”, or at rest. EMS people use the blood pressure to see how well the patient is “Perfusing” or circulating blood and the oxygen and nutrients it carries to the end tissues it supplies. “Hypotension” is too low of a blood pressure and can result in tissue damage, tissue death, and/or Shock; and “Hypertension” is too high of a blood pressure and can result in all kinds of short and long-term damage to the body, including heart disease, kidney disease, stroke, and many other chronic conditions. In EMS, we use the blood pressure as an important diagnostic tool in such things as trauma to measure blood loss, and also in medical care to determine shock or cardiac compromise.

But we all know the basics, right? Good, if you’re an EMT, you probably should know all that. However, you may not have heard these terms:

Pulse Pressure: The difference between the Systolic Blood Pressure and the Diastolic blood pressure. For example, a patient with a BP of 120/80 has a Pulse Pressure of 40mmhg.
Stroke Volume: A measure of the volume of blood ejected with each beat. (Stroke volume + Pulse rate = Cardiac Output)
Preload: A measurement of the pressure left in the vascular system during Diastole (Or “Left Ventricular End Diastolic Pressure” I’m just going to call it preload)
Afterload: The pressure that chambers of the heart must generate in order to pump blood. In the case of the Left Ventricle, it’s the pressure it must create through contraction in order to pump blood into the aorta.

(For everything else you’ve ever wanted to know about blood pressure, read this: “Overview of Blood Pressure” by John Ross)

What if there were more things that taking a patient’s blood pressure could tell you about them?

There are, of course. The blood pressure is way more useful as a diagnostic tool than most EMTs and Paramedics realize. Here are some of the things that the simple blood pressure can help you learn about your patients and the care they need:

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It can diagnose Orthostatic Hypotension

Have you ever seen a medical provider take “Orthostatic Blood Pressures?” These are taken as three consecutive blood pressure measurements taken with the patient in the Supine (laying down), Sitting upright, and Standing position. To properly perform this, have the patient lay supine for five minutes and take a baseline blood pressure measurement. Then have the patient sit upright, wait two minutes then take their blood pressure. Repeat with the patient in a standing position. If the patient gets dizzy for more than a minute with positional changes, that’s a positive sign for orthostatic hypotension, as is a drop in systolic blood pressure by 20mmhg between readings.

What does this mean?

Well, it can mean that the patient is dehydrated, is experiencing hypovolemic shock, has some type of cardiac compromise or an arrythmia, is anemic, has a problem regulating their blood pressure, has an electrolyte imbalance, and a few other conditions. It can also be caused by medications such as Beta Blockers or even Viagra. Orthostatic Hypotension is also a common cause of Syncope, or fainting. It’s an important assessment finding to record in your patient care report and to pass on to the receiving facility.

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It can help diagnose a Thoracic Aneurism

The arms are the most common places where the blood pressure is measured. The blood pressure cuff aka a “Sphygmomanometer” is wrapped around the arm at the bicep and applies pressure to occlude the brachial artery. The brachial artery is supplied by the subclavian artery, of which there are the Right and the Left subclavian arteries respectively. It has been shown that there may be a normal 10 to 20mmHg difference in blood pressure between the arms in a small minority of patients. Therefore it is important to take blood pressure readings from both arms when diagnosing hypertension. It is also useful to note when there is a difference in readings above 20mmHg from one arm to another. This can be a sign of Increased intra-thoracic pressure, a Thoracic Aneurism, or something called “Subclavian Steal Syndrome”.

In a thoracic aneurism, a condition with a mortality rate reaching up to 80%, the aortic arch in the chest is compromised. This results in severe pain (usually described as “ripping” or “tearing”), hypotension, and usually death if it ruptures. As the aneurism tears, it compromises the entrance to the right subclavian artery before the left, causing the blood pressure in the right arm to drop. This is an important diagnostic tool to use in diagnosing chest pain and should be documented.

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It can help detect increased intrathoacic pressure and other conditions

The thoracic cavity is the area commonly called the chest and is the area above the diaphragm protected by and enclosed in the rib cage. As we know, there are a lot of important things in there that humans need functioning properly in order to, you know, live. Pulsus Paradoxus is a condition where the heart’s pumping capacity is compromised by the thoracic pressure and the blood pressure rises and falls with inspiration and exhalation. The blood pressure drops (and sometimes even the radial pulse disappears) with inspiration and rises again with exhalation based upon the volume/pressure of air in the chest. The “paradox” results from the fact that you can hear cardiac beats on auscultation of (listening to) the chest, but cannot detect them with the blood pressure and/or pulse.

What does this mean?

Lots of conditions can cause Pulsus Paradoxus and roughly they can be broken down into three groups: Cardiac causes, Pulmonary Causes, and Other causes.

First, let’s give a nod to the other causes, the non-cardiac and non-pulmonary causes, which are Anaphylaptic Shock and an obstruction of the superior vena cava.

The cardiac causes can be: (and THANK YOU Wikipedia for being smarter than me and very accessible)

cardiac tamponade – A “bruise” of the heart resulting in the pericardial sac filling with blood that cannot escape and compromises cardiac function. (Treated with a pericardiocentesis, which some EMS providers can do in the field. I can).
constrictive pericarditis – Inflammation or purulent (puss-filled) infection of the heart which compromises pumping ability.
pericardial effusion – Fluid around the heart
pulmonary embolism – A blockage in the pulmonary artery or vein
cardiogenic shock – Impaired pumping ability of the heart due to cardiac damage or other compromise. Commonly seen in severe myocardial infarctions. (Heart attacks)

It can also be caused by pulmonary (lung) conditions, such as a tension pnuemothorax, COPD, and sometimes in severe and acute asthma, where the patient traps so much inhaled air in the lungs that they cannot exhale the excess pressure due to the inflammation of the air passages.

When you see these signs, make sure to take multiple blood pressure measurements to trend the patient’s progression. Calculate their Pulse Pressures, as cardiac tamponade, tension pneumothorax, and other conditions are characterized by narrowing of pulse pressure and compromised cardiac output also resulting in hypotension.

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It can help detect a closed head injury, stroke, or Intracranial Hemorrhage (<– that’s an excellent link)

Cushing’s Triad, aka Cushing’s reflex, is a group of symptoms that has been shown to reveal increased intracranial pressure (ICP), the pressure within the cranial vault around the brain. This reflex shows three distinct signs which are predictive of Stroke (both ischemic and hemorrhagic), intracranial bleeding, head trauma, and some other conditions that raise ICP. These signs are:

Slowed pulse rate
Markedly increased systolic pressure (high BP) with widened pulse pressure, as the diastolic pressure usually stays normal, and:
Irregular breathing (Cheyne-Stokes pattern respirations)

Any time you suspect an injury or condition that may raise ICP, check the blood pressure and look for Cushing’s Reflex. It can help you zero in on the patient’s condition.

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Here are some tips for making sure your blood pressures count:

Automatic BP cuffs do an ok job of measuring the blood pressure in a routine setting, but they have weaknesses. They cannot detect pulsus paradoxus, they give wildly inaccurate readings in bradycardia (slow heart rate), and they’re very much affected by the bumps in the road felt in the back of an ambulance. TAKE AT LEAST ONE OR TWO MANUAL BLOOD PRESSURES.

Can’t hear the systolic pressure? Take a palpated blood pressure by feeling the radial pulse while you deflate the cuff. The first pulse you feel = a reasonably accurate systolic pressure.

As with a lot of diagnostic tools, the first blood pressure measurement is a spot-check. The second reading creates a trend and reveals a lot more information. Take them every 5-10 minutes on critical patients, and every 10-15 on stable ones, keep mindful of the pattern.

This is by no means an exhaustive list, but it should give you some more respect for the humble blood pressure. As always, follow your local protocols and medical orders and this article isn’t meant as medical advice. Keep learning out there.

Also, feel free to add things in the comments section. I’d love to see what I missed.

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Want to learn more stuff about stuff? Check out:

Links to my articles on everything you’ve ever wanted to know about writing the perfect EMS Narrative Report.

EMS Practice – Practice makes perfect – Comparing High School football to EMS skills

Assessing Greatness: Catching the stuff you’re supposed to

Posted by Ckemtp on June 20, 2011 • Filed under: Ambulance, Emergency Medical Services, ems education, ems narrative, ems patient care report, EMS Topics, EMS training, Fire Rescue Topics, Paramedic, paramedic education, Patient Assessment, patient care, Patient Management, Training & Development, training-fire-rescue-topics

Eight Ways you can Ace your Patient Assessment – EMS

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The patient assessment is probably the most important skill every EMS person should master in order to be a truly exceptional EMT. No matter the call, no matter the patient, the EMS provider needs to be able to rapidly zero in on a complaint, make a working diagnosis, and provide adequate treatment for the patient’s condition. This skill is more important than any other simply because if you don’t know what is going on with the patient, you can’t know how to treat them.

Patient assessment has been taught many ways over the years by different versions of the EMT curriculum. I was taught that each patient gets three different types of assessment during the course of an encounter with EMS. These are: The Primary Assessment, the Secondary Assessment, and the Ongoing Assessment. Each of these three types of assessments is valuable to the EMT or Paramedic in determining what is really wrong with the patient. They’re designed to function in concert, each giving more information to the EMS provider that they can use in formulating an effective treatment plan. The more detailed they are, the better treatment decisions they allow and the better the patient’s overall progression through the healthcare system will be. Every patient should get all three of these assessments. EVERY PATIENT, EVERY CALL, EVERY TIME. Whether the call is a 911 emergency fall off of a cliff or a simple discharge back to a nursing home, every patient you come into contact with in your entire career should get your best assessment. It’s something you just can’t skip.

Take a look at the three general types of assessments:

The PRIMARY ASSESSMENT: The quickest assessment in the EMS toolkit, it is the first impression you make of your patient. It is intended to rapidly identify life-threatening conditions and facilitate immediate stabilizing treatment. In this assessment you should check for Airway Patency (openness), Breathing (Rate, quality, presence), and Circulation (Pulse, blood pressure, and Skin perfusion – Color, temperature, and moisture). You should also check for gross deformity, major trauma and/or blood loss, or anything else that may cause the patient to crash. If found, you should act immediately to provide stabilizing treatment. This is also where you should determine the chief complaint, the need for spinal immobilization, and form your general impression of the overall patient condition.

The SECONDARY ASSESSMENT: Also known as the “Head to Toe Assessment”, this is a detailed physical examination of the patient, literally from head to toe. A secondary assessment should check a minimum of the following: Skin perfusion (again), Pupil and eye condition (using the acronym PERRL “Pupils Equal, Round, and Reactive to Light), Jugular Venous Distention (JVD), condition of the Trachea/neck (is it Midline? Is it mobile? Tugging to one side? Trauma?), Chest Rise and Fall/condition (Equal bilaterally? Normal?) Lung sounds? Abdomen (Pain? Tenderness? Soft, Firm, or Rigid? What quadrant? Any Pulsatile Mass? Any Rebound Tenderness?) Extremities (distal pulse/perfusion, deformity, Motor/Sensory/neurological function? Pitting Edema?). You should also look the patient over from head to toe to check for any hidden injuries and for anything that doesn’t appear normal. During the secondary assessment, you should remember the acronym “DCAP-BLS-TIC” (pronounced “Dee CAP-B-L-S Tick”) that reminds you to check for the following: “Deformity, Contusions, Abrasions, Penetrations, Burns, Lacerations, Swelling, Tenderness, Inflammation, Crepitus” (The links are to the Wikipedia definition of the words, also TheEMTspot.com has a great post on this topic)

The Ongoing Assessment: The previous two assessments are useful in determining your patient’s baseline presentation and making your working field diagnosis. However, your assessment doesn’t stop there. The Ongoing Assessment is used to monitor changes in the patient’s condition and to get a trend of their progression, good or bad. You can measure the effectiveness of your treatments and see how their condition is progressing. This could be as simple as asking a patient “Do you feel any better or worse?” and rechecking their vital signs, or as in-depth as redoing your entire secondary assessment. Monitor every patient closely for changes. Recheck vitals every 5-10 minutes for compromised patients, and every 10-15 for stable ones.

Here are some tricks you can use to nail your assessment:

Just Do It! – Remember, you can’t over-assess your patient. The more information you get the better. Every patient gets a full assessment, every time. Even if you can’t act on the information you gather, the information could prove invaluable to healthcare providers further down the road. They need good information on the acute phase of the patient’s illness. Remember, the EMT is “the eyes and ears of the physician in the field.” You’d never see a physician diagnose a patient without a thorough exam, don’t skip it either.

Standardize! – Develop a standard assessment that covers at least all of the stuff I talked about above, and do it every time. Start at the head and work your way down. Think up a set of questions you want to know the answers to about your patient, and answer them every time. Not only will practicing the assessment get it down to a science, you’ll also get very quick at it. This also can help you with your narrative report writing. You can put the answers to all of your questions in your patient care report, and that’s a great way to write a narrative.

Start your assessment the second you arrive on scene – Start gathering information about the patient immediately. Note the ambient temperature. Note the condition of the patient’s living space and where you found them. If the patient is at home, look for adequate food and water. Check for disease vectors such as filth. You may want to ask the patient about their living conditions later, such as asking them if they’ve been sleeping upright in a chair when checking for CHF. Any information you gather is useful.

Check THESE THREE THINGS when you first encounter the patient – Always introduce yourself to the patient using your name and while you’re doing this, feel their radial pulse with your fingers. This tells you three immediately important things that will drive the rest of your care: The status of their Airway, Breathing, and Circulation. You’ll feel the rate and quality of their pulse; feel their skin temperature, moisture, and condition; and be able to assess their work of breathing when they answer you back from your introduction. If any of these things are compromised… the patient is probably sick and in need of intervention.

Try to determine the patient’s ultimate diagnosis – What, you’re scared of making a diagnosis because you’ve heard that medics don’t diagnose? That’s BS. We diagnose all the time, we just don’t make the final diagnosis. Call it a “Field Diagnosis” if you want, but I say you should try to piece together the symptoms your patient is having and try to diagnose the cause. If you don’t know the answer, fire up the Google and do some research. You’ll be surprised at what you can learn that way. Also, talk to the receiving physicians and nurses at the ER. You’ll learn a vast amount of information that will make you a better provider overall.

Be as thorough as time will allow – Certainly, there are times where an EMT will be focused on immediately stabilizing treatment, such as airway management or hemorrhage control and won’t be able to hit all of the possible nooks and crannies of a patient assessment. However, most patients aren’t that severe and you’ll have time to gather all of the information you can. The more you assess the better information you can collect and pass on. Check for such things as: Pulsus paradoxus; a difference in blood pressure between the arms; the Babinski Sign; hidden trauma; Cushing’s Triad; and many other interesting things. You’ll learn a lot, and might just catch a few zebras.

Don’t afraid to touch the patient – You’re a medical person. Medical people touch other people. Sometimes they see them naked. Sometimes it’s uncomfortable and sometimes you have to touch them in a way that wouldn’t otherwise be socially acceptable. Of course, don’t do anything wrong, illegal, or immoral… but when you’re checking for a broken leg you have to touch the leg. Actually Look at, Listen to, and Feel your patients. Be a professional.

Know what “normal” is, and look for things that aren’t – Eventually, once you master the art of determining what a normal presentation is, the things that are abnormal will jump out at you. Once you’ve practiced and honed your assessment skills, you’ll be able to see any abnormalities with relative ease. It takes practice, but developing the skill is well worth the effort.

Employ these tricks and you’ll be well on your way to mastering the art of the assessment. Always learn and strive to improve your craft. Keep your eyes open and absorb new information. Pretty soon you’ll be amazing your colleagues with what you know and what you can tell them about your patients.

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Want more information on the patient assessment?

Read – Assessing Greatness: Catching the stuff you’re supposed to

Or – Ten (or so) Things You Should Try to do with Every Patient

Also, Check out TheEMTspot.com’s “Mastering the Head to Toe Assessment”

Posted by Ckemtp on June 13, 2011 • Filed under: Ambulance, Emergency Medical Services, EMS, EMS practice, EMS Topics, EMS training, paramedic education, Patient Assessment, patient care, Patient Management, Training & Development, training-fire-rescue-topics

EMS 12-lead Case – Ischemia and Failure

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If you haven’t been to www.EMS12Lead.com, Tom Bouthillet’s wonderful EMS educational blog… well then I’m going to just come out and say this:

What are you doing here when you should be over there reading his stuff??

Considering how Tom dwarfs my humble traffic numbers (which is something I always kind of knew he did, but didn’t really know how much until I had a few drinks with him at EMS Today and weaseled his numbers out of him) I’ve figured that I’m going to have to do something. I’m going to straight up steal his shtick and write an “educational” EMS 12-lead EKG post of my very own for your reading enjoyment and educational purposes. Heck, I might even be able to make a point or two. Let’s find out.

I keep an archive of interesting tidbits from my EMS career locked up in a vault in my basement and among the oddities and whatnot I have a binder full of 12-leads. I blew the dust off of the old tome and pulled the EKG that I’m using for this story out of the archives. Oh my, this was a doozy. As always with my stories about patients, I may not have ran this one myself and even if I did, I don’t remember where it was that I ran it nor do I remember the age, location, or even the gender of the patient in question. I also have taken the liberty of lying about all of that stuff just to make it even more confusing and difficult for me to write. So, if you think I’m violating the female Hippo, you’re mistaken.

As I recall, the call was toned out with the dispatch information of a “64yo M Pt unable to breathe”. It wasn’t a long distance away and Our Intrepid Paramedic (OIP) responded in a response vehicle being followed up by an ambulance which arrived shortly after He did. It was a nice, well kept residence and the wife of the Pt let OIP in the door as he entered the home. She indicated that the Pt was in a back bedroom of the house and motioned down the hallway. OIP made the trek and found the Pt sitting upright on his bed, Conscious, Alert, and Oriented times 3 (CAOx3) with somewhat increased work of breathing. The patient stated that he had been experiencing pain that he indicated began at the level of his mandible and continued to his epigastrum (his Jaw to his Gut). He stated that the pain had simply become too much for him this evening and that it became very hard to breathe when he laid down for bed. A good look at him was all it really took for OIP to make a working diagnosis after feeling the patent’s weak and irregular radial pulse and pale, cool, and moist skin. OIP placed the patient on 6-LPM oxygen via Nasal Cannula and told the ambulance medic to break out a 12-lead. The initial rhythm strip showed a sinus bradycardia with an IVCD and lots of multifocal ectopy, including multifocal couplets and triplets. The 12-lead was no better. It showed bad, bad mojo. This poor guy was sick.

EEEEEEEeeeeeeeeeeeek

As the ambulance crew was packaging up on the stretcher to take the Patient to the ambulance, OIP had a few moments to speak with the patient’s wife. She told OIP that the patient had been experiencing pain in his jaw for the last week. She also told OIP that the patient had gone to see his Primary Care physician two days prior and had been told to take advil for the pain in his jaw. She told OIP about how the patient had been very lethargic lately and about how he would become winded when taking out the garbage and walking even shorter distances. She told OIP about how the pain had been getting steadily worse… and also how the doctor said he was fine.

And with a symptom profile of exertional fatigue, difficult breathing, jaw pain, substernal chest pain, and diaphoresis… what doctor wouldn’t say that… right? Oh wait… hopefully most of them.

The patient wasn’t having a heart attack… he had been having a heart attack for days and now the damage had been done. This was a clear case of the patient not being educated to the symptoms of a heart attack… or of ignoring them in the hopes that they’d just go away. The physician did not obtain a 12-lead nor do lab work and did not diagnose the problem as being cardiac ischemia (Heart attack) when the patient presented for care.

But OIP did… about 2 minutes after meeting the patient he woke up the cardiologist and the cath lab team at a hospital a half-hour’s drive away to help take care of the man. You’ve seen the 12-lead above. It indicates a heart that is in serious trouble. The patient was treated per protocol, which included high-flow o2, bilateral IVs, NTG tablets and paste, and I’m not sure what else the ambulance paramedic did because OIP didn’t accompany the patient to the hospital. That, and it was too long ago for me to remember what happened… I just know the patient made it there alive to find out whatever his prognosis was going to be from the cardiology team at the ER.

Here’s the deal, once this patient called the ambulance, his care was stellar. OIP and the other EMTs did a fantastic job at rapid recognition, appropriate stabilizing care, and swift transport to an appropriate care facility as none of the local hospitals had the capacity to care for this guy. The EMS people did what they were trained, equipped, and supposed to do. The problem is they were called way too late to make much of a difference in the patient’s continuing quality of life.

I can understand that patients don’t necessarily know when they’re having a heart attack. To a layperson, jaw pain and fatigue could just be the flu. Chest pain could just be heartburn, and exertional dyspnea could just mean that a person has been “pushing themselves too hard lately”. All of those symptom profiles could mean any number of things… but they could also be a heart attack. I can understand how people want to think that they’re not having a heart attack. I get that no one wants to have one. They’re not fun and we as a society may hype them up too much so that people think there is a stigma to the diagnosis. I don’t know if that statement is true, but it sure seems that way sometimes to me.

What I can’t understand is how a patient can present for treatment at a physician’s office with clear symptoms of cardiac ischemia (heart attack) and not be checked for it. I’d like to think that a paramedic would rule it out first and foremost… and I don’t understand why someone wouldn’t.

Then again, I don’t know the information the physician was working with. Perhaps the patient wasn’t honest with his symptoms and tried to minimize what was going on. That’s possible too, as this patient was a proud man who has lived his life like he could handle anything. People do that. Nobody wants to be sick.

The lesson here is to have a high index of suspicion. Patients sometimes minimize their symptoms, and sometimes they over-dramatize them. Some people don’t want to be sick… and some people want to be sicker than they are. I personally will buy into false drama from someone who’s not as sick as they want to be than chance missing the minimized symptoms of someone who’s sicker. I tell my patients that as a paramedic my job is to “Treat for the Worst, and hope for the best.”

But for this guy, OIP never got the chance. This was too late for that. The damage had been done.

This patient’s quality of life was greatly impacted by the fact that he didn’t call 911 at the first signs of his illness. Had he done so, his prognosis would be much different. A quick exam, 12-lead, and appropriate care would have made this guy’s story quite a bit different. Where was the failure? Was it the patient’s fault for not recognizing and/or minimizing his symptoms? Was it the fault of “health education” in general for not reaching the patient in a manner in which he could understand? Does the fault lie with OIP for not spending enough time educating the public about the symptoms and danger of heart attacks? Does the fault lie with this patient’s doctor for missing the diagnosis and/or not providing proper education beforehand?

I don’t know the answer to the above question either. I just know that OIP and the EMS team treated him well once the call came in. I just wish that something different would have happened in the chance of events that lead up to all of this. It would have made the above 12-lead a lot different.

Be vigilant out there.

Posted by Ckemtp on March 15, 2011 • Filed under: EKG, Emergency Medical Services, EMS, EMS Topics, EMS training, Paramedic, paramedic education, patient care, Patient Management, physician, Uncategorized

Those Darn Kids!

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These darn kids and their new-fangled toys!

Hey, at least I aint @FossilMedic 's Age yet.

Call me old fashioned if you want to, but allow me to hike my EMS pants way up higher than my belly button and talk in my Old Grizzled Medic ™ voice for a second here. You see, the kids these days are doing something that just tans my hide. What, with their iPhones, and their iPods, and their iPads, and me with my iGlasses and the Etch-a-Sketch… Confound it! I just don’t understand.

You see, Youngins… back in my day we didn’t have all of these fancy techno-toys that we do now. When it came to running on the ambulance, we made do with what we had and that was the way we liked it. What, with all of the trudging 20 miles to work in the feet of snow uphill with the both ways and whatnot we earned our measly pittances and then trudged back home to our coal-heated shacks to jitterbug away the three hours we got off of work in between our 120 hour shifts. We didn’t need all the pansy stuff you enjoy now.

We did our medical care to the best of our abilities then. We actually had to LIFT our patients into the ambulances on the cot, rather than having the little button lift 700lbs with one finger. We had to look at actual paper maps to find addresses, rather than having the nice lady in the GPS tell us where to go. Heck, we even had to write paper reports on our EMS calls BY HAND USING A PEN.

Paper reports written by hand do one thing and only one thing very well. They suck. They are simply awesome at sucking. They stink on ice. They are medieval torture devices left over from the Monty Python version of the Spanish Inquisition and honestly, the day we switched over to computerized reporting I stabbed a wooden stake through a stack of the dreaded Illinois “Bubble Sheet” EMS report forms. Then I poured gasoline on them, turned around and flicked a match behind my back as I walked away in slow motion without looking back at the explosion and flames. I was wearing sunglasses. It was epic.

It was Just Like This! Only with more geekery and no little girl and I was shirtless...

Paper reports could be documented at the patient’s side but it just always seemed so darn inconvenient to do so. I did it occasionally during long transports, or when we were running back-to-back calls and I wanted to jot down the high-points of each call on the report form so I could accurately remember them when I got the chance to catch up on my paperwork. It wasn’t uncommon to be “down” four or five reports in those days because we were just so dad-gum busy and the reports took so blasted long to `complete. A stack of those paper reports could give you writers’ cramp for days. Especially the Illinois “Bubble Sheet” forms which I used for years, they were awful monstrosities constructed to worship the demon “ScAnTr0nn” who mandated that little bubbles be filled out perfectly for every name, address, and number you scrawled on the form. Those evil little dots cost me hours of my life, a good amount of my hair, and most of my sanity. After using the awful bubble sheets for years, I switched systems to a place that utilized a somewhat less-evil paper report form, and then back to a place that still used the hated bubble sheets, and then Huzzah! To a place that had computers.

Although I must admit that the hand-strength I developed from writing those awful things made my one-handed beer can crushing trick a hit at parties.

The first report I wrote on a computer was a simple little form written on a then state of the art laptop that weighed approximately 17523lbs. It took forever to load, locked up and lost reports frequently, and was an absolute gift from God. Then, the regional EMS system stepped in and put computers in the EMS report rooms at the hospitals because nobody could ever figure out how to hook up their ambulance laptops to the ancient dot-matrix printers they’d provided for us. Those programs were sweet! I hate switching my hand between a mouse and a keyboard 15 times per second to enter data and the reports we used on the desktop were forms I could simply use the keyboard with the whole time. I actually typed faster than the program could keep up and knew just how many times I had to tab through a list to mark the correct spot on the form without seeing it on the screen. I’d end up having the report typed out a few seconds before the machine caught up and put the words on the screen. It. Was. Awesome.

Still, those reports were something that could only be done away from the patient’s side. We all had note pads to jot down info we wanted to put on the report while we were treating the patient and we took those notes to the computer to enter into the report. Nowadays, them kids with their fancy technology have Toughbooks with touch-screens that they use to write their EMS reports and since their invention, I’ve noticed a trend.

It first started when I noticed my medic protégé Chad had a habit of bringing the toughbook in with him to emergency calls. He’d grab the jump kit, the o2 bag, and the computer. Then, while he was interviewing and assessing the patient, he’d be starting their report.

This dismayed me. Again, call me a crazy old coot and an old-fogey… but I believe that we should not only focus 100% on the events of the call and upon what the patient is telling us, but also that we should give the appearance that we are doing so. You just can’t make me believe that a patient is going to feel that we are listening to that which ails them and are paying attention to their needs when we have our nose in a lap-top. Sure, it may save time on the overall reporting process by allowing the EMT to get an early start on the documentation, but it also ends up taking more time on scene to wait for the computer to enter in information. I also think that it takes away the EMTs ability to fully observe everything that is going on with the patient and the scene around them. It robs one of their situational awareness and of the nuances of the patient assessment.

That, and it’s just plain rude.

It bothers me enough that I launched a whole ridicule-based diatribe against my young protégé and shamed him into no longer bringing the computer into calls with him. I have no problem if he begins the report at the patient’s side during transport as long as he has completed everything that needs to be done and he makes sure to monitor the patient thoroughly. That’s cool, I guess. I am glad that he won’t have to suffer the pain of hand-written EMS reporting. That’s a cross us Grizzled Old Medics™ bore for you with honor.

You’re welcome. Now get off my lawn, and STOP USING THE COMPUTER IN FRONT OF THE PATIENT!!

Posted by Ckemtp on October 29, 2010 • Filed under: ambulance humor, ckemtp rants, Emergency Medical Services, EMS, EMS Humor, EMS Topics, EMS training, Fire Rescue Topics, Paramedic, paramedic education, paramedic narrative, patient care, Patient Management, stories, technology-communications-ems-topics, Uncategorized

Primary Care Paramedics? I think it’s time

20 comments

Clinically speaking, there’s a whole lot of medicine out there that I don’t know.

I mean, paramedics like me go though a few thousand hours of training in emergency medical care. We get a few years of classes covering the things we need to know about treating the most common of truly emergent medical conditions. Heart attacks? Check. Strokes? Check. Airway Management and Respiratory Support? Check and Check. We paramedics are experts in the acute medical emergency. If you’re dying, we are well equipped and trained to support you until a doctor and a team of medical people in a hospital can take over your care. If you have a medical emergency somewhere outside of a hospital emergency room, we’re the first people you want to see.

The Medic is In

But, what if you have a particularly nasty case of Strep Throat?

Well… that’s called “Primary Care” and it covers a lot of non-emergent medical conditions. Strep throat hurts and it makes a person feel like crap. The times that I’ve chanced to become infected with a nasty strain of Strep “A” it’s made me feel like a warmed-over Code Brown Sandwich. It sucks being sick and that’s why people go to the doctor. Patients present to doctors’ offices for myriad reasons. Pink Eye, Influenza, the “creeping crud”, bronchitis, and gastrointestinal problems are common occurrences there. When I worked at an urgent care clinic we saw plenty of those. Up to two-hundred patients per day came in with just these kinds of complaints. There were lacerations, fractures, and other kinds of cases that came in too. Rarely did we need to call for an ambulance and while we did sometimes advise people to go to the ER on their own, that was rare as well. A good primary care doctor can catch most minor conditions and adequately treat them right there in the clinic, negating any need for an expensive emergency room.

However, the problem lies in actually getting access to a primary care physician to take care of you when you’re sick.

Yesterday, my mother-in-law (I call her “MIL” for short) called me up. One of the people she works with had an injury to his fingernail. He tore a good part of it clean off while working out in their warehouse. It hurt, of course, and it was bleeding. Their company is a small five person shop that they’re building from the ground up. A Workers’ comp claim would go right against their small and shared pocketbook and start-ups don’t have the cash for that kind of stuff. She wanted to know the proper first-aid for this and was trying to avoid the doctor. He was too. As owner of the company he didn’t want to have to pay for it and a fingernail injury just doesn’t seem all that severe. Still, it hurt and they were worried about infection. The guy understandably wanted proper treatment.

I told him that fingernails either grow back, or they don’t. Eventually it would be fine if he cleaned it with mild soap and water and put a non-adhering bandage over the nail bed to keep it clean and protected. I told him in a day or so to put some Vaseline-based antibiotic cream on it as well to keep it moist and stave off infection.

Don’t worry, I wasn’t practicing medicine without a license. I have my First-Aid Merit Badge from the Boy Scouts of America and that was covered somewhere in there, I’m sure. However, you’re right to think that fingernail injuries aren’t covered anywhere in the National Standard EMT or Paramedic curriculum. We are taught to bandage it up and take it to an Emergency Room.

Yep, if he would have presented to my care on the ambulance, I would have had to transport the guy to the ER for a physician to do what I told him to do. If he refused the $500 (or so) transport fee and the (astronomical) ER fee, I would have had to have him sign an “Against Medical Advice” (AMA) refusal form and could not legally give him any medical advice other than to be transported to the ER.

It’s maddening.

Fingernail guy didn’t have an option for treatment where he was other than to go to the ER. In the area where he was located, there aren’t any Urgent Care facilities. There certainly aren’t any cheap ones anywhere you go, but their cost is much lower than the local ER he was near. He didn’t have an option, so he had his coworker call her son-in-law (SIL) for advice. I gave it, and saved everyone involved a few hundred if not a thousand dollars. Sure, the guy could have called his primary care physician and gotten an appointment a month later… but I would think that as a self-employed small-business owner he probably doesn’t have access to health insurance at a less-than-oppressive cost.

A while back, I wrote the piece “Did I do Good?” regarding what I think EMS 2.0 should become. I think that Paramedics should be educated and empowered to step into the realm of primary care and be able to provide primary care in the field. Now to be sure, as Rogue Medic will point out, there’s evidence that states that Paramedics and EMTs are bad at triage and we are not currently equipped with the right education to provide these services at this time. However, I think that educating a group of excellent paramedics to the proper standards, giving them the proper tools, and empowering them with the proper legal authority could revolutionize healthcare.

Every community has a group of paramedics and/or EMTs and nearly every community (I would say every, but I have no stats in front of me) has less-than-optimal access to primary care across the spectrum of patient populations. To me, there is a clear solution that makes sense. Could Paramedics, once properly educated, equipped, and empowered, provide limited primary care services, appropriate triage, and transfer in the field? How about at fixed sites and clinics? We could follow protocols, utilize tele-medicine, and function much as we do now, but with a much lower-acuity class of patients.

Sure, there are Nurse Practitioners, Physicians’ Assistants, and other healthcare providers that can provide these services, but let them work with us as we work with them. There doesn’t have to be an adversarial relationship. We all have different training and that one set can be used to compliment the other.

EMS 2.0 is about thinking outside the box for EMS. It’s about finding new ways to face the challenges. Thinking the way we have in the past won’t fix the problems that it failed to fix before. My belief is that with Paramedics providing Primary Care, we would greatly increase access to care, more properly triage patients to the proper healthcare pathways, save gobs and gobs of money, and just might “fix” this whole healthcare mess without all that legislation and legal wrangling.

Any suggestions on where we begin?

Posted by Ckemtp on October 28, 2010 • Filed under: Administration & Leadership, Command & Leadership, Emergency Medical Services, EMS, ems 2.0, EMS Topics, new perspective, Paramedic, paramedic education, patient care, Patient Management, potential, Training & Development

Thanks Rogue Medic – What are EMS’s “Fad Diagnoses”?

13 comments

Our friend Rogue Medic has a shiny new site up there on the Interwebs. It rocks. Rogue Medic is one of the many, many bloggers, non-bloggers, and/or random people who are much, much smarter than I am. I read his site a lot and I am very pleased to throw a link to his new site. He’s part of a new blog network with the URL Http://www.EMSblogs.com. Rogue has been joined by our other friends David Konig and Too Old To Work, Too Young to Retire.

That URL again for Rogue Medic is: Http://www.RogueMedic.com

Too Old to Work’s new digs are at: Http://www.ToOldToWork.com (yes, I know the “To” should be a “Too” and it just bugs the hell out of me as well)

And you can find everyone on their network on Http://www.EMSblogs.com

Anyways, since this is my blog and you’ll come back here eventually. Rogue Medic pointed me to a site that I’m quite surprised I hadn’t found before Http://www.QuackWatch.com It’s provided me with some hours of entertainment tonight and since I’m a nerd and I admit it, that’s ok for me.

On QuackWatch, I read an interesting article on “Fad Diagnoses” with a handy checklist at the end that tells one how to create a bona-fide fad disease. (The article is here, with a lot of handy links: http://www.quackwatch.com/01QuackeryRelatedTopics/fadindex.html)

The checklist, which is just entertaining as hell, is below:

Recipe for a New Fad Disease

Pick any symptoms—the more common the better.
Pick any disease—real or invented. (Real diseases have more potential for confusion because their existence can’t be denied.)
Assign lots of symptoms to the disease.
Say that millions of undiagnosed people suffer from it.
Pick a few treatments. Including supplements will enable health food stores and chiropractors to get in on the action.
Promote your theories through books and talk shows.
Don’t compete with other fad diseases. Say that yours predisposes people to the rest or vice versa.
Claim that the medical establishment, the drug companies, and the chemical industry are against you.
State that the medical profession is afraid of your competition or trying to protect its turf.
If challenged to prove your claims, say that you lack the money for research, that you are too busy getting sick people well, and that your clinical results speak for themselves.

This checklist got me to thinking about what “fad diseases” we may be treating as Paramedics and EMTs in the prehospital setting. While logically, I can think that we must be treating diagnoses that are more en-vogue than others, I can’t really seem to think of one off hand. I blame it on a mixture of my long day and my ADD. I would guess that our contemporary collective attention to STEMI care could be one. While ST-Segment Elevation Myocardial Infarction’s are quite serious and require immediate intervention, haven’t you noticed that we never call anything a “heart attack” anymore and now everything’s a STEMI? Do we emphasize the diagnosis of the STEMI at the expense of other conditions, such as Thoracic Aneurism or a Pulmonary Embolism? What about non-STEMIs?

Since I’m drawing a blank on something where I believe that logically, I should be able to think of something, I’m asking for your opinions:

What are the “Fad Diagnoses” of contemporary EMS? Feel free to add your own in the comments section below. I’m sure this could get wildly entertaining.

(Oh, and I’m not making any clams as to the existence or non-existence of any of the “Fad Diagnoses” posted here or on the other site. If you think they’re real, then heck… why not?)

Posted by Ckemtp on August 12, 2010 • Filed under: Emergency Medical Services, EMS, ems education, EMS ethics, EMS Topics, Paramedic, patient care, Patient Management, politics, STEMI, Training & Development

You Can Nap if You Want To! Or You can Leave Your Calls Behind!

17 comments

What a week! You’ve been pulling at least a double shift a week at your full-time ambulance job and have been hitting it pretty hard at your part-time job as well. Both services can’t seem to keep their schedules filled and everyone’s been working lots of hours in order to keep the doors going up and the trucks going out. To top it all off, the citizens just can’t seem to be good lately and both services’ call volumes have been high.

You were tired when you got up this morning and were seriously considering a nap after your morning shower, but after a gallon or two of coffee you were bright and shiny in your uniform at your station, ready for another day of EMS greatness.

That was five hours ago though, and the early barrage of calls fired at you this morning has turned into an afternoon lull. Now you’re sitting at your main station, close to the brass, with the words in the educational article you’re reading fading in and out of your bleary, cross-eyed vision. Since the activity level has decreased, you’ve gotten yourself a case of the sleepies that you just can’t shake. Since you’ve been consuming the steaming bean juice religiously lately, your stomach just won’t let you think of having another cup of the acrid station coffee and there’s no shift chores left to do, since you did them an hour ago fighting the same lethargy.

Unfortunately, in three hours you can see a long distance transfer scheduled that you’re probably going to have to do. Four hours of monotonous highway driving and the radio in the truck doesn’t have that great of reception. You don’t have any idea how you’re going to stay awake enough to drive the truck and that’s not even considering the fact that if the tones went off right now for an emergency you probably wouldn’t remember how to put on a band-aid, let alone remember a drug calculation.

You’re tired, you’re fatigued, and your body’s telling you that you’ve been pushing it too hard. It wants to shut down for a while. Your brain won’t think. You’re mouth won’t talk. You can’t keep your eyes open and wake up with a startle when you’ve realized you’ve dozed off for a bit. This is torture.

Sleep deprivation is no stranger to EMS people. We’ve all fought the lethargy caused by long 24, 48, and more-hour shifts. A great number of us work more than one job to make ends meet and pack as much family time and recreation into our off time as we can. A lot of us are going for more education and all of us get woken up from our sleep a lot more often than is healthy to run on calls. I regularly miss full nights of sleep and rarely have a night when I can say I got a full night’s sleep. We get use to it some of the way, but our bodies just aren’t meant for chronic sleep deprivation. We need to reset and reorder our brains and let our bodies recharge once in a while.

Unfortunately, our communities need us and we have to be there for them. EMS is important and it’s easy to get sucked in.

That’s why in this situation, I have very little dispute with taking a “Safety Nap”.

"SSSS-AAAA-FFFF-EEEE...."

The “Safety Nap” is a quick power nap. A shut-down and reset period where a person who never knows when they may be called to be up all night without sleep can rest and relax for a while and ensure that they’ll be wide awake and alert for whatever they may be called to do. I took an hour last shift around 3pm as a matter of fact. I didn’t get to sleep until 1am afterwards and I was up at 5am for a call. EMS is like that, shift work is like that. We have to ensure that we’re well-rested enough to make quality decisions of the type we have to when they need to be made… and we can’t do them well when we’re drooling on ourselves from exhaustion. One of Murphy’s laws for EMS states that “You know you’re in EMS when your favorite hallucinogen is sheer exhaustion” and I have to tell you, I’ve done that while on duty before. It’s just not safe.

There are problems with this, I know. Some will say that we shouldn’t allow ourselves to be scheduled this many hours and that it’s irresponsible to do so. Well, then they can come talk to my bosses and pay my mortgage. Some people will sleep all day if they let them, and won’t put any effort into their shifts unless they have to. That has to be monitored. With that said, a balance has to be sought. I see nothing wrong with the occasional safety nap and I believe that EMS managers should allow it. They also should be unafraid to throw a cup of cold water on the Rip Van Winkles among us to ensure that they pull their weight with the non-call-response aspects of an EMS job.

What do you think? Does your employer allow “Safety Naps”? Do you take them?

I’d write more but Zzzzzzzzzzzzzzzzzz

Posted by Ckemtp on August 4, 2010 • Filed under: Administration & Leadership, Ambulance, ambulance humor, Command & Leadership, Emergency Medical Services, EMS, EMS Health & Safety, EMS Humor, EMS Management, EMS safety, EMS Topics, EMT, Ethics, Fire Rescue Topics, Firefighter Safety & Health, Management, Paramedic, patient care, Patient Management, salary, shift length, Uncategorized

Police Car Drivers, Ambulance Drivers, and their responsibilities

12 comments

Look at the pictures below and see if you can identify the three occupations represented by the people in the pictures.

What are their jobs?

What are their areas of expertise?

What would you expect them to be responsible for?

Yep, pretty much everyone reading this and almost every lay person you can think of should probably be able to answer the above questions. The Police Car Driver chases bad guys; The Fire Truck Driver squirts water at things; and the Paramedic takes care of people who are sick and hurt, right? Sure, their jobs sometimes overlap and so does some of their training, but the jobs and the requisite education and responsibilities are different and separate for a reason. The different roles up there are different, specialized, and require expertise in order to be effectively performed… right?

And before you think that I’m opening the Fire Based EMS can of worms, I want to direct you to this news story I just read on EMS1.com – Kentucky EMTs not called for 5 hours until coroner ruled woman was alive. Go read this and then come back please. It got me all riled up and I’m sure it will you as well.

The moral of the story, is that police officers were called for a dead body found in some bushes some where. They started doing their cop stuff and didn’t call EMS to evaluate the body because their cop training told them that the woman was obviously dead. Unfortunately for all involved, when the coroner arrived he told them that their police-issued medical training wasn’t adequate and that the woman was indeed alive.

And yes, I am 100% sure that nobody intended for that to be the tragic result.. people make mistakes, I know… but:

How many times have you been called out in your ambulance to a potential medical emergency and then cancelled while en route? Have you ever wondered who is cancelling you and for what reason? When we arrive on scene, we evaluate the patient and determine their need for transport. We have extensive training to help us do this and we function within a complex set of laws and regulations to help ensure that bad outcomes like this happen as infrequently as possible. Unfortunately, however, things like this do happen, even to experienced paramedics. How many times have you heard news stories about paramedics calling someone dead only to have them be found alive later on? How many times have you heard about occult neck fractures and other severe injuries being found later even after a patient was evaluated by a physician? It happens, folks… and it happens to us medical people too. Even with the training, knowledge, skills, and experience we have that is specifically geared to emergency medical care that is again enhanced by the fancy tools that we carry with us, we sometimes still make mistakes…

So why in the heck would a police officer, who as stated above chases bad guys and does other kinds of “cop stuff”, want to make the decision that someone was dead or not? It simply doesn’t make any sense to me. I have always been leery of having police officers call us off of medical scenes. Even when I know the officer and trust his or her judgment, I know that my medical training and tools are superior to theirs. That’s the way the system is designed, we do medical stuff and they do cop stuff.

I think that there’s a pervasive trend out there that causes dispatchers to send police units first to things like auto accidents and possible crimes in progress and then potentially forget to send EMS. Most of the time, it’s perfectly ok and turns out just fine. Other times, incidents like the above happen. How many times, also, has a police officer determined an auto accident to not require medical response and an occult injury been found later? I don’t know and haven’t seen any statistics… but I’ll bet it happens a lot more than is ever reported.

My advice? I promise to let the cops to their cop stuff. They just need to always remember to call me out to do my stuff. I don’t mind doing the report if I’m not needed or I get a refusal, I just don’t want anyone to suffer needlessly.

Be careful out there.

—————————————————

Want more of my thoughts on Fire Based EMS? See: “Fiddling While Rome Burns… The ambulance “industry”

Posted by Ckemtp on June 15, 2010 • Filed under: 911 fail, Administration & Leadership, Ambulance, Command & Leadership, Emergency Medical Services, EMS, EMS Topics, EMS training, Firefighter Safety & Health, Paramedic, paramedic education, patient care, Uncategorized

When all you have is a hammer… Every problem looks like, lasix?

9 comments

A few years ago I responded to a structure fire on the main engine out of my station. The fire was at a house that had been converted to a dog kennel and grooming shop just a few blocks away from the firehouse and was a short response time. It was a light-staffing day and we responded as a three person engine company. As the senior firefighter I was the acting company officer and my new girlfriend at the time, who just happens to be my wife now, was the backseat firefighter. Get ready for the “Awwww” moment… it was our first fire “as a couple”. There was a number of cool things that came out of the fire, but one of them was the fact that Gina grabbed *my* maul.

My wife and I fighting our first fire "as a couple" - We're the ones in turnout gear

On our main engine, there’s an 8-pound maul (big hammer) that I grab as my tool of choice every time I jump off the truck for a fire. It just tucks so neatly in my SCBA’s belt and is so compact yet handy that I make a beeline for it every time. This time, Gina had taken it, so I grabbed a pick-head axe.

It’s amazing that when I have my maul that every access problem looks like something that I can solve by whacking it with a hammer of some sort. On this fire, I learned that when one has an axe, every problem looks like it can be solved by some sort of chopping.

Moral of the story, Gina and I entered the structure, saved the pooches, and stopped the fire in its trucks with minimal damage. There’s actually a hilarious video that I believe is still on our department’s web site that I’d let you see if I didn’t hide the name of the department(s) I work for due to “I want to remain employed reasons”.

And, like a lot of things on here, I told you that so I could tell you this about an EMS call I responded to an indeterminate amount of time ago. I have the honor and privilege to be the senior medic on most shifts I work and I precept a lot of students on the ambulance. This shift was no different and this 0-dark-30 call illustrates a point that I’d like to explain to you.

The doggies were SHOCKED that Gina took MY maul

For this call, the primary ambulance out of our station responded because they were on the way back from another call and my partner and I responded in our ambulance because we were up on the alternating call rotation. They arrived at the poorly-accessible apartment complex a few minutes before we did and made first patient contact. As it turns out, the middle age patient had ran out of his/her prescription Lasix (a potent diuretic, or water pill) a week or so prior to the call and had been retaining a great deal of excess bodily fluid. The patient’s legs were markedly and grossly swollen and weeping fluid out of fluid filled blisters. The Patient called us because he/she could no longer stand the pain of the cellulitis (infection) that had developed. The patient had no respiratory compromise, his/her lungs were clear, and he/she really had no other complaints. The patient had an extensive medical history of organ failure and disease. He/she was fully alert and oriented, and was able to assist us as we simply picked him/her up and carried him/her to the cot.

As we were loading the patient up in the ambulance and I was about to get into the back to continue my assessment and treatment of the patient, the EMT from the other ambulance who happens to be an almost-done Paramedic student told me, “So those legs are the worst I’ve ever seen fluid wise, you’re going to push some lasix on this one”. I mumbled something and got into the truck. I was tired and wasn’t really able to form complete sentences at the time due to sleep deprivation. I got in the truck and continued my assessment where I found that the frail patient had a blood pressure in the 70 systolic range (Low!) and that in addition to retaining fluid in his/her legs, he/she was also retaining fluid in his/her abdomen and was probably in need of a paracentesis. I managed the patient with a (beautifully executed) IV stick into an impossibly small crooked vein, and gave just enough fluid to bring his/her BP up a bit without adding to his/her fluid overload all that much. I put the Pt on oxygen and a cardiac monitor, which revealed a normal sinus rhythm without ectopy. I obtained a 12-lead EKG as well, which was not indicative of any acute problems. The patient stated that his/her pain was managed by padding and positioning of his/her swollen legs and even though he/she complained of no breathing problems, I put him/her on a bit of oxygen via nasal cannula.

The transport was uneventful, although his/her blood pressure never did come up. The ER later diagnosed the Pt with complete liver failure and toxicity.

But the interesting part of the story is this, when I got back the medic student asked me about giving IV lasix to the patient, as we carry that in our medication stock and have it available as an emergency diuretic for patients in congestive heart failure and/or fluid overload with pulmonary edema and respiratory compromise. He was almost taken aback when I said that I didn’t give any.

I asked him if he did a full assessment. He said that he had tried… but that he didn’t have enough time before I arrived and we took the patient out to the ambulance. I gave him my assessment findings and the news of the very low blood pressure. He said that he agreed with me on not giving the lasix with the markedly low blood pressure but was curious when I explained that it wasn’t the reason I didn’t give the medication.

We in EMS, and especially new providers carry our own hammers… our treatments and medications that we’re able to give in the field. Medics that use these treatments more often are called “aggressive” and it is a badge of honor. In fact, in some cases, aggressive field treatment is indeed warranted and improves patient outcomes. However, in a lot of cases it is not indicated and patients benefit from what we don’t do more so than from what we could have done.

This patient didn’t have any respiratory compromise and while he/she obviously could have benefited from the dieresis or removal of the excess fluid, she didn’t meet the criteria for emergent field administration of lasix, which is respiratory compromise from pulmonary edema. I made the decision to let the physician evaluate the patient and determine the best treatment path that would fit in with the patient’s ultimate plan of care. I didn’t believe that the patient would ultimately benefit from my administration of lasix twenty minutes earlier than the ER could have done it if the physician so chose.

Every treatment we administer must be given with a full assessment of the risks and benefits to the patient for doing so. Every EMS person should familiarize themselves with the long-term care paths of the conditions we treat and try to maximize the long-term benefit to the patient with the acute and short-term care we give. Not every problem is “a nail” and sometimes the hammers we carry aren’t the best ultimate solution for excellent patient care. Remembering how we as EMS people fit into the grand scheme of the overall healthcare system and in the ultimate care paths of our patients will help us all to do what we’re supposed to do, which is to provide excellent and appropriate patient care.

It is also of note, I guess, that Gina rarely steals my maul anymore. Now that we’re married… I “give it freely” to her.. What’s mine is her’s, as they say.

Posted by Ckemtp on June 14, 2010 • Filed under: Ambulance, Emergency Medical Services, EMS, ems education, ems scenario, ems scenario based education, EMS Topics, Fires, funny, In the Line of Duty, Paramedic, paramedic education, patient care, Patient Management, professionalism, scenario based training, stories, Training & Development

Foot-in-Mouth-Itis. Stupid Things We Say in EMS

21 comments

A letter I received from a reader who states that she is a paramedic student has gotten me thinking. I’m going to include her letter in this post with her permission, but before I do I would like to speak a little bit about things that we say to patients. EMS and all of emergency medicine tends to be full of emotionally charged situations being handled by emotionally drained people. Sometimes our experience in dealing with situations that lay people find to be traumatic can lend itself to our making comments that we find perfectly acceptable to make at the time we make them, and yet upon reflection seem like the wrong thing to have said. I can’t tell you just how many times I’ve been in trouble for my mouth. I will say something that I intend to relieve the tension of a situation and to provide comic relief that I think is cute and funny, completely thinking that it is above-board and not-offensive to anyone, and then find out that some wet-blanket took offense.

Honestly, I make it my policy never to make a dirty joke. All of my “patient friendly jokes” are clean enough to tell to my five-year-old with nary an off-color word or adult reference in sight and sometimes still people look at me like I’ve dropped a live weasel in the ball-pit at the McDonald’s Play Land. Like some random time ago where a patient who had overdosed, scratched her wrists with a dull knife, and was found trying to hang herself apologized to me during my assessment of her because she hadn’t shaved her legs. I said “Oh that’s quite alright, Ma’am.. You weren’t planning on needing them anymore and besides, you shaved your wrists real nice”. I believe the question I got from my partner after the call was “Does your Brain-Mouth filter even work anymore?!” He was laughing as he said it, so obviously it was funny. The patient laughed too.

I have stock comments to the common questions and situations that come up on calls that I trot out when needed to liven up the situation. Some are movie quotes, some are lines that I’ve stolen from other providers, and some are straight up from my strange brain. Like when I find someone lying in bed that needs to be lifted over from the bed to the cot with a sheet and a couple of people. Some beds are way too wide for me to work from my feet and it’s often useful to crawl right in bed alongside the patient to lift them over. I ask them “So when was the last time you had a strange man in your bed?” The unconscious ones almost always laugh. I have yet to have an older lady blush and be embarrassed and the comments I get back are always entertaining. Also, when I’m palpating an area of a patient’s body to see where they’re hurting such as for an injured extremity or the like, if the patient yelps out in pain when I touch something I excitedly declare “Found it!!” It’s much to their relief to know that I know where it is that they hurt. I also have what I call the “Poor Man’s X-Ray”. If someone thinks that something’s broken on their body, I grab it, give it a good squeeze and a shake, and ask them if it hurts. If they say “Yea that hurts” it’s probably not fractured. If they say “YEeeeeEEaaargh!!!” it probably is.

So, exactly how serious do you think I’m being with all of that above there? Here’s the test. If you took me serious enough that you want to call my medical director to tell him to pull my license… I was joking!! Ha Ha!

I remember probably the worst thing that I’ve ever said to a patient ever, and in all seriousness I still feel bad about this comment to this day. Early on in my career I worked as a Security Guard *slash* EMT at a big regional 400 bed hospital/trauma center/psyche center/everything center. Usually I worked alone on weekend nights and it was an absolute zoo. While this was one of the most enjoyable jobs I’ve ever held, I was in way over my head for an eighteen year-old country boy working in the big city. One day we had a patient come in who had been witnessed swallowing baggies full of what was presumed to be crack cocaine during a traffic stop. He was belligerent as all heck, swearing at us and trying to swing at the police officers who brought him in, the nurses, and myself. He looked at me and said “So what the (colorful word) is going to happen to me now you (something my mother would be unhappy with me if I typed on my blog, or even thought about for that matter)” I asked him “So, are you a religious man?” To which he replied “Blankety-Blank No!! You Blankety Blankin Blank blank!” I said back to him “Well you probably should be, because you’ll need to be saying some prayers”. Then he seized and went into V-Fib. I have no idea if he survived. I honestly feel really, really bad about that. I wish I hadn’t have said it.

So when you read this letter, go easy on the paramedic student who sent it in. She seems to feel pretty bad about saying what she said and since I’m going easy on her, you probably should too.

Here it is:

I did something colossally stupid today. Something so… irresponsible and cocky that I truly can’t believe I allowed it to happen.

I allowed myself… to assume.

To assume that as a paramedic student I knew enough about a patient’s condition that I could safely make a statement to a family member, when in reality, I should have just kept my mouth shut.

It was careless. It was reckless, and it resulted in a family being given false hope.

He was brought into the ER by two of his daughters for a syncopal episode. He hadn’t been feeling well for a few days, and his daughters had been forcing him to eat. When they found him on the floor next to his bed writhing in pain, they loaded him up and drove him over to the local ER.

His VS upon arrival were… less than ideal. Hypoglycemic, hypothermic, hypotensive. He had the hypo’s covered. His coloring was even less impressive than his vitals. A few amps of D50 and some warm blankets later and we had 2/3′s of the hypo’s resolved. He was no longer altered, he was flirting with the nurses, and the color had improved.

Still, his BP was crap. His tank was dry. He needed fluids, and after his third liter bag, his BP in the 60′s started to creep it’s way towards 70 and 75. I did a happy dance in my head.

Then it happened.

I was removing some of his blankets and replacing them with some that were straight from the warmer when daughter number 3 asked me a question. “His blood pressure is still so low, should we be worried?” Me. The only one in the room with them that had any medical experience.

Five sets of eyes were on me in an instant.

I finished tucking a piping hot blanket in and casually said something to the effect of, “His BP is coming up, he’s just a bit dehydrated. One more bag and I’d be willing to bet that his pressure is better than mine.”

Ugh. How could I let myself say something like that?

I didn’t know that he had a fractured hip.
I didn’t know he was in kidney failure.
I didn’t know he had a leaking AAA.

I didn’t know the complete picture, and I should have just kept my mouth shut.

I guess it goes without saying, but his blood pressure never came up. It dropped, and it dropped again, and it dropped again.

The family was informed of the complete picture. A DNR was signed. Hospice was called. He died before he could even make it to the inpatient hospice facility.

A family was given hope, because I gave it to them. And I had no right to do that. Watching them emerge from a family consultation room, one by one with blood shot eyes, holding each other when just two hours earlier they had been laughing and joking with their father…

That was probably the hardest lesson that I’ve learned in school. It’s one I’ll never forget, or forgive myself for.

——————————-

So the student who wrote this letter expects to be flamed for it… I’m willing to bet that the response will be just the opposite. We’ve all been there. We’ll all be there again.

What about you?

Posted by Ckemtp on April 20, 2010 • Filed under: 911 fail, ambulance humor, Emergency Medical Services, EMS, EMS Humor, EMS Topics, Fire Rescue Topics, funny, humor, Paramedic, patient care, Patient Management, stories

Trust… It’s everything

4 comments

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 Ckemtp 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

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 Ckemtp 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

The Perfect Emergency? Well, almost

16 comments

So a while ago, I went to an emergency medical call that was about as perfect as an EMS call could be.

Picture this if you will. Our ambulance was in service. The system was at normal operating levels which are well funded and are adequate for our response loads 90% of the time. I had thoroughly checked and cleaned my ambulance and the equipment inside of it at the beginning of my shift and I had even gotten a chance to have a cup of coffee or two before the call came in. When the call did come out over the radio, it was merely a short walk to the ambulance for my paramedic partner and I. We climbed into our dual paramedic staffed, well maintained, state-of-the-art ambulance, and rolled out to the scene of the emergency which was about 8 blocks away through light traffic. We arrived within 4 minutes of the 911 call and were informed by our dispatcher that the residence was equipped with a “Knox Box” entry system so we could quickly gain entry. We retrieved the key from our ambulance, were able to open the Knox Box, and easily entered the residence using the key inside of it. While entering, we noticed that the resident had a “Vial of Life” sticker on the front door, which signified that the patient was most probably participating in our “Vial of Life” program, meaning that the patient had all of their medical information written down properly on one of our stock forms. In fact, we found the “Vial of Life” right in the refrigerator door, where it was supposed to be. The patient, an elderly person, had used a (Non brand-name specific) home emergency call button to summon assistance, which we also had recommended to him/her during the public outreach that convinced her to have everything else in place for our arrival.

In short, this patient had done almost everything right. He/She had paid taxes throughout his/her long time living in the district and had supported us in order to allow us to have quality, state-of-the-art equipment. He/She had supported us so that we could get good training as well. He/She had listened to us when we suggested that He/She wear an emergency call button as he/she got up there in years, had written down his/her medical information in the “Vial of Life”, had put the Vial of Life in the correct place, and had even installed a Knox Box on the home so we could gain access quickly.

So what wasn’t right with this call? The patient had been experiencing symptoms consistent with a stroke. In fact, it was an easy diagnosis from across the room type of stroke. The patient had noticed that he/she was possibly having stroke-like symptoms and had decided that it would be best to get cleaned up, get dressed, clean up the house a little, and call a neighbor over to see if he would take him/her to the doctor’s office before the neighbor convinced the patient to press the button and call us out to help. By that time… well let’s hope the doctors can work some magic.

With all of the bloggers, paramedics, EMTs, and everyone else out there harping about “BS” 911 ambulance calls, one would find it easy to overlook cases like the one above. I for one will come right out and say that I will gladly run 100 nonsense EMS calls rather than miss just one of the above… I don’t want someone to die or suffer further morbidity simply because they were too scared, or polite, or timid to call an ambulance.

I don’t know how to fix the problem, I’d just like to remind you all out there that our job is indeed to take care of people when they’re scared, when they’re sick, and when they’re just plain-ol’ stupid. We’re healthcare providers and it’s our duty. No exceptions.

Remember that.

Posted by Ckemtp on February 22, 2010 • Filed under: 911 fail, Emergency Medical Services, EMS, EMS ethics, EMS Management, EMS system, EMS Topics, Ethics, everyday ems ethics, Fire Prevention & Education, Fire Rescue Topics, Paramedic, patient care, Patient Management, scenario, scenario based training

Ten (or so) things that you should try to do with every patient

9 comments

I am not a perfect medical provider. In fact I’m really only practicing prehospital medicine (Ha ha!) but there are a few things that I try to do with every patient to improve my care for them and improve their comfort level as I care for them. I can’t claim that I always remember to do these things, but I really try to. I think that you should too.

Here they are (in no particular order other than ZIP code):

Always introduce yourself and your partner to the patients and their loved ones using your first name. I wouldn’t want some upstart guy in some uniform type thing just randomly poking at me. I think that it reduces patient anxiety when you properly introduce yourself to your patient. I say “Hi, I’m Chris and I’m a paramedic with F&B Ambulance Service and Taxi Squad. This is my partner Fuzzy McGee. What is your name Sir/Madame?”
When you’re in the back transporting the patient after you’ve given them most of the care you were planning to give them, go over your assessment again. Ask the patient questions that get them to expand on their original answers. Challenge yourself to find anything that you may have missed.
Play a game with yourself. Try to have the patient diagnosed by the time that you get them to the ER. If you can’t figure it out, fire up the internet when you get back to quarters and look it up. You’ll learn a lot of good medical information by doing this. I have.
Once you get the patient in the back of the ambulance if they’re not facing an immediate “Life-or-Death” crisis ask them “Is there anything I can do to make you more comfortable?” Maybe another pillow or moving the head of the cot up or down would help them. Do it if they ask.
Try not to have the pillow stuffed under the patient’s shoulder blades. It makes it uncomfortable when they’re lying on the cot. Moving the pillow up from under their back and placing it under their heads makes them a lot happier. They won’t know to ask for it. Just do it.
If you find a patient down with an isolated fracture or dislocation get pain meds in their system before you start splinting or packaging them. It does take a bit more time, but you’re not being very humane if you don’t.
You are the patient’s advocate when you walk in to the imposing world of ER care. Your job is to present them to a medical system that is overworked and overtired. Stick up for them and make sure that the medical care providers that are following you learn about what is wrong with the patient before you throw him or her to the wolves… er, um, nurses. I mean nurses.
Before you hand off your patient to the ER, ask them: “Is there anything that I haven’t addressed? Is there anything that you would like me to be sure and tell the ER about?”
Explain to the the patient WHAT you are going to do and WHY you are going to do it.
Approach EMS with a servant’s heart. No matter what some EMTs may think, we are here for the patients. It’s not the other way around.

By trying to do these things you’ll provide better patient care. I think that I’ve grown as an EMS professional by doing these things. I’ve also grown as a person by doing these things. Let me know how this works out for ya.

Posted by Ckemtp on February 7, 2010 • Filed under: Ambulance, comfort, courtesy, EMS, EMS Health & Safety, EMS Humor, EMS Topics, EMS training, EMT, Paramedic, patient care, Patient Management

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 Ckemtp 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

Are We the Gatekeepers to the Emergency Healthcare System? – EMS 2.0

13 comments

Did I do good?

The Chronicles of EMS, if you’re living under a rock and you haven’t heard, is a cooperative effort between the Great Filmmaker Thaddeus Setla (EMSmedia.tv), the Remarkably Strong Paramedic Mark Glencourse (Medic999), and the “Ruggedly Handsome” firefighter/paramedic Justin Schorr (The Happy Medic). Their cooperative venture has taught me things that I’ve put to use in my own EMS practice that I believe have improved my care. Mark showed me the UK’s “Front Loaded” model and Justin has been talking about EMS providers being a gatekeeper to the emergency healthcare system. It’s a powerful collaboration. (Be sure to follow #CoEMS on twitter and become a fan of Chronicles of EMS on Facebook as well)

So here’s an example of what I mean. I can talk about this now because it’s been long enough that I can sufficiently muddle any possible trace back to the patient and fulfill any patient confidentiality concerns. I work in two very diverse service areas and cover approximately 35 different skilled nursing facilities at any one time. So in the time since the Chronicles of EMS has come out I’ve transported umpteen-hundred patients from those facilities and the patient I’m writing about could be any of those umpteen hundred. So there’s no way to violate confidentiality, Mmmm ‘Kay?

Anyway, some time ago I was dispatched as the ALS response to backup a BLS ambulance for the “unresponsive” patient at a skilled nursing facility. I arrived a few seconds after the ambulance did and carried my drug bag and EKG/Defib into the facility with the ambulance crew following close behind with their jump kit, the cot, and a backboard. After a few seconds in the facility, a staff member directed me to the Physical Therapy area of the facility which was a bit of a walk. When I got there, I saw three other staff members huddled around an elderly female patient who was seated in a reclining chair.

The staff members were fairly excited about the situation, as was the patient, who was very much conscious and alert. The story everyone told me at once was that the patient had finished her physical therapy session on her upper body to strengthen her shoulders and had been sat in the chair by the PT Assistant to rest. After a few minutes, the PT asst. came to check on the patient and found her unresponsive to verbal stimuli, by which I mean that the patient would not awake when spoken to. The PT asst. called the facility’s emergency response team and another staff member activated 911. When one of the nurses arrived, the patient awoke to a sternal rub and was quite surprised to be the subject of so much attention. She had been fully alert and cognitive since that time and when I asked her she denied any chief complaint other than being understandably emotional about the situation.

As I do with every patient after I rule out any immediate life threats I moved into a more detailed assessment. My lady here had skin that was Pink, Warm, and dry. Her pupils were PERRL and her Cincinatti Pre-hospital stroke scale was negative. Her Lungs were clear, her abdomen was soft and non-tender with normoactive bowel sounds, and her extremities were warm and had good pulses, motor, and sensation. Her blood glucose was well within limits, and so were all of her vital signs. All of my other assessment findings were not indicative of any acute abnormalities other than a complaint of slight shoulder pain and weakness which could have been indicative of either an acute MI or of a rigorous PT session. So, to be even more thorough, I hooked her up to my 5-lead EKG which showed normal sinus rhythm with some peaked T-waves. I then ran a 12-lead EKG which was admittedly probably better than mine is.

I asked the nurse “Has she had a potassium level drawn recently?” She looked through the patient’s chart and found out that the patient in fact had been tested for that two days prior and had been found to have a slightly elevated serum potassium level. Since they had been active witnesses to my assessment we agreed that other than for perhaps a bit too much potassium there was little chance of anything being wrong with the patient.

Since we were here in the US and not in the UK like Mark, where he can treat and release (or “Respond, not Convey”) I asked the patient if she wanted us to take her to the hospital. She didn’t want to go and said that she just wanted to go back to bed. When the staff members weren’t completely convinced that we shouldn’t transport her, I suggested that they call the patient’s primary care physician to ask him what his wishes were. The nurse did so, and called from her cell phone in front of us. She did a good job of explaining in detail the events of the call and our collective assessment findings, I provided my interpretation of the 12-lead EKG and chimed in with my assessment findings that I use in my acute care practice.

For his part, the doctor was amenable to treating the patient at the facility and stated that he was comfortable with us not transporting the patient. He ordered a few stat labs and requested that we leave a copy of the 12-lead for the patient’s chart, which I was happy to do. Bottom line: The patient signed a refusal and was happy not to have to go to the hospital; The skilled-nursing-facility staff members were happy that the patient was in no immediate danger; and I was happy that we had made the best possible decision for the patient and that I wasn’t exposing her to unnecessary risk.

What happened here is exactly one of the things that I and others have been talking about with the EMS 2.0 movement: EMS people having the ability to make an educated and sound decision about the best possible healthcare options for our patients and not simply having to activate the full emergency healthcare system for every complaint. This case had every element of that and I believe that the patient being redirected through her normal primary healthcare pathway was a much better choice than taking her to the emergency room.

Heck, since there turned out to be no adverse results to this, and since the patient was probably on Medicare, I would surmise that I’ve ended up saving the taxpayers thousands of dollars in unneccesary costs… Huh? Can educating and empowering paramedics “save” the healthcare system in the US by creating a huge savings in the most expensive form of providing healthcare?

What do you think? Did I do good?

QGE5GE5AAH4W

Posted by Ckemtp on January 21, 2010 • Filed under: change, edemse, EKG, Emergency Medical Services, EMS, ems 2.0, ems education, EMS ethics, EMS Topics, Ethics, everyday ems ethics, medical ethics, new perspective, patient care, Patient Management, physician, politics, potential, Skilled Nursing Facility, US economy

“CPR Theatre” – Pediatric Deaths, resuscitations, and futility

16 comments

This post is a cooperative joint topic with two widely respected EMS bloggers, Steve Whitehead from Http://www.TheEMTspot.com and Greg Friese, from Http://www.EveryDayEMStips.com – Our topic is supposed to be on why it is that EMTs, Paramedics, and other healthcare providers will sometimes “go through the motions” and continue on with futile resuscitations with pediatric cardiac arrest victims. I’m sure that they will have very insightful posts on the topic, as they always do. Here’s my take.

————————————————————————–

Can someone say “emotionally charged”?

One of the truths about where I’m sitting right now is that I’m chained to a lot of potential responsibility. Today, like a lot of days I’m one of two paramedics on-duty in my service area and the next call is mine. No matter what the next call is, it is my responsibility to get up and answer that call… without regard the horror that fate may be sending me to bear witness to and intervene in. All medics have to accept this inherent part of the job. One of the worst of those possibilities is that it may be a call that involves the significant injury or illness to, or even the death of a child.

Mention the possibility of a child’s death to even the most cynical and seasoned of healthcare providers and you will send a very cold chill down their spine. It’s just horrible. For me, the blessedly rare times that I’ve lost a child have been sentinel events in my life, things that are often thought of but rarely spoken of… almost always spoken of only to comfort the pain of a colleague experiencing the same thing. The loss or suffering of a child just burns into our souls and leaves an indelible scar that only someone who has experienced it can have true empathy for.

And I for one, wish that I didn’t have the empathy that I have for it.

Heaven forbid that I ever have to be one of the parents with pleading eyes at one of those tragic and traumatic scenes. I just can’t imagine what they go through when I’ve said “I’m Sorry”. I can’t imagine their pain, and frankly I don’t want to. As a parent myself the thought is blocked from my conscious mind and relegated only to the deepest recesses of my subconscious fears. Losing an adult patient is one thing, as we humans come to know that our lives are fragile and that our price of admission is to be removed from this existence. It’s a knowledge that we get as we progress through life and gain the experiences, both good and bad, that make us who we are and will become. However, the terrible thought that one could be ripped from us in their age of innocence is an affront to everything that almost everyone holds dear… and it’s more than a lot of us can bear to make the last decision of a child’s life. Instead, we try. We try hard and we keep trying. We hold out hope against thought and fight on, sometimes against futility.

But in my mind, I think I know why it is… because no healthcare person wants to be the person who looks into those pleading eyes and says “I’m sorry”. That decision takes an enormous emotional toll upon the parents and family, of course… but also upon the EMT or Paramedic. It’s ultimately easier on us as EMS people, we reason, to fight on. To race headlong into futility and hold out hope that someone else won’t have to say “I’m sorry”. At least we won’t have to.

There are probably psychological studies out there that I haven’t read that deal with the issue of whether “CPR Theatre” is harmful or helpful to the long-term well being of the surviving family. These studies are probably well-researched. I took a class once that told me that it was better for family members to be in the resuscitation room inside of a hospital to witness the events as healthcare people try to save their loved ones… and I can understand that I guess. Perhaps it is better to witness that “everything possible was done” for your departed loved one. I don’t know.

As healthcare providers, it is our sworn duty to alleviate suffering as best we can using the tools at our disposal. I, like most of my colleagues, realize that the secondary and tertiary patients that we treat are the family members and their grief reactions to the tragic circumstances that resulted in their calling us. I am reasonably comfortable handling their grief reactions and sadness when an adult passes on scene but I am humbly inadequate to be of much comfort to a parent that has just lost their child no matter how I might try.

My guess that futile CPR theatre can be explained as being more for the parents and families of departed children than it is for the slight chance that we might have missed something. We make the effort in the name of showing to the family members that “everything possible” was indeed done, up to and including running their child lights and sirens to a hospital. I’ll even admit that in the back of the ambulance while I’ve done this, I’ve prayed right along with the family that just perhaps this once we would have a miracle. Never once has it happened.

Here’s a mea culpa for you, even though every time I’ve gone through the motions I’ve said it was for the family… It may really have been for my own benefit as I’ve stated it could be above. I am a paramedic and I’ve seen my share of pain, but I don’t think that I can look a parent in the eyes and say “I’m sorry” ever again. I just don’t want to and as I write this, I can’t imagine that I could do that and then come back and look the guy in the mirror in the eyes without wondering if maybe this time would’ve been the miracle. I am probably selfish for this practice… but is that wrong?

From a completely actuarial perspective, no futile resuscitation should be performed due to safety concerns and the unnecessary costs involved. I agree that with adults, transporting cardiac arrest victims is probably deadly. I also understand that no ambulance should risk a lights-and-sirens trip to transport a body to the emergency room. However, I am not an actuary. In those cases I’m a witness to horrible emotional pain and I want someone else to be the one who says “I’m sorry”. It’s human nature, perhaps.

In my career, I have told parents “I’m sorry, there’s nothing I can do” in cases where it was blatantly obvious that the child was long beyond hope of any intervention. I’ve done it more than once and I can see the places where I’ve done it in my mind to this day. Sometimes it’s completely obvious that there is indeed nothing that anyone can do. However, occasionally I have indeed known this and just done it anyway. Perhaps it’s completely subjective. Perhaps it was my level of experience and intuition that guided me at the times I’ve made the decision. I’ll tell you this, it certainly wasn’t a decision made from the pages of a textbook.

I don’t have the answers to this. But I do want to go home and hug my kid. My only advice to the EMS people out there is to realize that we’re all human, and that all you have to do is your best. Be compassionate, and use your best judgment. For that’s all we can ever do.

For more on this powerful topic for EMS, head over to Greg Friese’s page and also to Steve Whitehead’s page. You also may want to read “Splashed Sadness – A look at Negative Emotions in EMS” where I further explore the sad side of EMS and our reactions to it.

Posted by Ckemtp on January 5, 2010 • Filed under: Ambulance, bad calls, cpr, Emergency Medical Services, emotions, EMS, EMS Blog, EMS ethics, EMS Health & Safety, EMS Topics, EMT, Ethics, everyday ems ethics, Fire Rescue Topics, inside the mind of a paramedic, medical ethics, Paramedic, patient care, Patient Management, psychology, sadness, The EMT Spot, Training & Development

The Paramedic Intercept – Rural EMS

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It may shock some of my more urban readers out there, but not everywhere is a city.

Why did I say that? It’s because there’s not much talk out there regarding rural EMS. I live rural EMS and I believe that someone who calls 911 in a rural area deserves just as good of service as someone who lives in the city. To further my goal of increasing the dialogue, I’m writing about some of the issues facing rural EMS and the techniques that we use. Hopefully it’s educational.

Here’s the first part in my series on Rural EMS: The ALS Intercept:

Not every 911 call for an ambulance brings forth a paramedic-staffed Advanced Life Support ambulance. There’s a lot of ground in this nation covered by dedicated volunteer EMT-Basics that answer the call for their communities day-in and day-out. In fact, I got my start at one of these all-volunteer 911 EMT-Basic squads. We covered 275sq miles of sparsely populated terrain in the rural Midwest and ran about 200 or so calls for service per year. I have to say that it made me a very good basic, because there wasn’t any back-up for our BLS skills. However the patient presented, they got treated with the best that our Basic Life Support ambulance had to offer.

Of course, back then we had an ace in the hole. The big-city hospitals that were 45 minutes away at a minimum laid in the service area of ambulances with paramedics in them that could be called to head out our way and meet up with us for an “ALS intercept”. It still happens that way in a lot of communities, in fact, I ride around in an “interceptor” while at one of my jobs, which is an SUV with lights, sirens, and a full complement of ALS gear in it. Working out of that vehicle I respond first-due in our own jurisdiction and upon call for some of the surrounding communities. We meet up either on scene or enroute, and I hop in to dazzle the crew with a stunning display of ALS-sy goodness.

I have to tell you, I remember that from the perspective of an EMT-basic racing to the meet-up point with an “Oh-My-God” critical patient, having the paramedic jump on board was such a feeling of relief. Now, from the perspective of the paramedic who jumps in, it’s sometimes a bit of a pucker factor… because now you’re working with an unfamiliar audience watching your every move.

ALS intercepts are a great tool in the arsenal of rural EMS systems. There are a lot of small communities out there that do not have the capabilities to staff and support full paramedic ambulances. Even if they have the money to pay for all of the equipment and training needed for paramedics, they may not have the call volume needed to keep the paramedics busy and their skills sharp. That’s why consolidating the paramedics and sharing them between multiple services makes sense to me. The community volunteers respond as an initial stabilization, and a faster, more mobile unit runs out to meet them with higher skills. It’s a truly tiered response system.

Rural paramedicine and rural EMS take a different mentality than does urban EMS. For instance, the distance that we must cover mandates long response times. At my previous all-BLS service, we covered the 275sq mile 911 area out of one station. We had under 5000 people in that jurisdiction and that made staffing more than one ambulance infeasible. To cover the gap, we had outfitted volunteer EMT-Bs as “Satellite” First Responders to augment the response. It worked… if they were home or in the area. Nonetheless, the response times went up to and over 30 minutes in the most remote areas. “Call Early” and “Call First” were necessary philosophies for the community. In addition, the longer transport times made necessary some long protocols that had lots of tools in them to keep the patients stable for the long time we were with them.

Today, I respond to my calls with some of the most advanced EMS protocols that I know of in the region. For example our service and our resource hospital is committed to meeting the AHA’s goal of a 90minute symptom onset-to-balloon time for STEMIs (ST segment Elevation Myocardial Infarction or, the classic heart attack) this requires either ground-bypassing the closest community hospital ER by almost an hour to make it to a hospital equipped with a cath-lab. Most urban services that I’ve worked for carried Nitroglycerine, Aspirin, and Morphine for these cases. For our rural protocols, we add Nitro Paste, a bolus of Heparin, and IV Metoprolol. We also carry transport ventilators on the trucks to free-up a pair of hands from bagging during the long transports with minimal personnel. It takes a strong and independent paramedic to be able to handle anything that’s thrown at them as a single medic. It takes a very strong an independent medic to handle it with an unfamiliar team of EMT-Basics in unfamiliar circumstances.

The relationship between the ALS provider and the EMT-Basic services that they support must be strong in order to be effective. There has to be a high-level of trust between both organizations and the providers working within them to keep the service level high. Holding joint trainings and understanding that everyone has a role within the continuum of patient-care is necessary. Dispatch protocols that pre-deploy ALS resources make a difference as well and take the responsibility off of the BLS provider to make the decision on whether the ALS response is necessary. I personally subscribe to the idea that it is good to be proactive with ALS dispatch protocols and in addition to sending ALS to the obvious complaints, such as Unresponsive patients, Chest pains, and difficulty breathing calls; it is also a good idea to send them ALS to non-specific dispatches such as the unknown medical. BLS providers that arrive first can always cancel the responding ALS if they determine that they’re truly not needed.

And always, always, always… the ALS and BLS providers must check their egos at the door and realize that what’s best for the patient is the most important consideration.

The ALS intercept is a great tool that extends the reach of paramedics into areas where we can’t be effectively based from. It takes work, but it’s good for our patients and our communities. Rural EMS takes different strategies, and this is a good one.

What are your thoughts on this?

Posted by Ckemtp on December 18, 2009 • Filed under: Als, ALS Intercept, Emergency Medical Services, EMS, EMS Management, EMS paramedics, EMS protocols, EMS Topics, Paramedic, patient care, Patient Management

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