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Too Much Information For a Paramedic?

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This is a coordinated post by our friends Greg Friese and Steve Whitehead.

 - Greg’s post on this topic can be found at: http://www.everydayemstips.com/?p=3628

 - Steve’s post on this topic can be found at: http://theemtspot.com/2010/08/25/too-much-information/

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“They Don’t Know What They Don’t Know”

It’s an established fact that 60% of fatalities within confined spaces are would-be rescuers. They see someone down in a confined space, enter the space, and are overcome by the conditions that took down the initial victim. The process sometimes repeats itself, with multiple would-be rescuers entering the space and falling victim themselves. It’s tragic really, but the cold, hard fact is that these people are victims of their own ignorance. They don’t know what they don’t know. They don’t know that there is a fatal set of conditions within the space, and they don’t know that whatever it is that killed the first victim, or subsequent victims, will kill them as well. It’s a well documented phenomenon that plays on the compassion of the would-be rescuers and ends up getting them killed.

They simply don’t know what they don’t know.

Hey Guys?? Guys?

So when I was approached by our friend Greg Friese from www.EveryDayEMStips.com the other day regarding a comment he received on one of his training articles, I was interested in doing a co-post with him. He also has contacted our friend Steve Whitehead from www.TheEMTspot.com and together we’re tri-posting on this issue. Their links will follow below and are just great as always.

The comment that followed this online training article was written presumably by a paramedic. It was a critique of the article that simply stated “too much information for a paramedic”. I read that, and immediately thought of confined space incidents, where ignorance can get a person killed. Lots of situations fit that scenario and it’s not always the rescuers who get killed. EMS providers who “don’t know what they don’t know” can and do kill patients. More often, they don’t provide the best possible care.

There’s this thing that we have made it our business to know how to repair. It’s called the “Human Body” and if you’re reading this article, the chances are good that you possess one. The human body is VASTLY complex. It’s the most complex machine we humans know about and we are still learning about it to this day. There are some amazingly smart people out there who have dedicated their lives to studying these meat machines that our brains pilot around and they still haven’t figured everything out yet. We can help set it back on course to heal itself in a lot of cases but we can’t construct a new one. We don’t know about all the minutia, the microscopic works inside of it that make it do all of the amazing things that it does. The levels of systems within systems that function seamlessly within still other systems are numerous and fascinating. I learn something new about it all the time, and still there are people who know vast amounts more about the inner workings of it and about the huge number of things that can affect it’s operating effectiveness than I do. The human body is remarkably complex yet elegant and perfect in its design.

C'mon... Don't be a wuss.

And we who call ourselves “medical professionals” are well advised to study every possible aspect of it. Consider it your “life’s work”. If your job is to fix and support the end users of the human body, you darn well better know everything you can about it.

“But”, you say, “There are people out there who are supposed to know much more about the human body than we are. They’re called Physicians, and they get paid a whole lot more than we do. We’re just paramedics. (or EMTs).” And you’d be right for saying that, of course. Physicians have the ultimate responsibility for knowing the human body. It’s their life’s work as well. Their patients live and die based upon their knowledge, skills, and talents they have for examining the human body and being able to figure out what’s going on. Their whole practice is based upon their knowledge, skill, and talent. The more they know when they’re working there, the better provider they are.

It’s that simple, and it’s exactly the same for us EMS people. The more we know, the better we are. Nobody is better served by dumbing us down. Nothing is gained by denying yourself knowledge. Not a single patient is better served by you not knowing everything you can know about what is going wrong with them and it’s your duty to learn as much as you can about what you’re supposed to know about.

What is the line for how much paramedics “need to know?” Is everything that we need to know covered by our initial training course? Is that everything we need to get out there in the world and start slinging IVs and Meds all willy nilly?

I look at the paramedic license as a “learner’s permit”. It’s the baseline knowledge level needed to function at that level under supervision. It’s a jumping off point from which the provider should immerse themselves in knowledge. I can certainly say that I’ve learned volumes past my initial certification and that the “extra” knowledge has saved lives. Did you know that Fentanyl can cause chest muscle tetany when administered too rapidly? Or how about that lasix, when pushed too rapidly can cause hearing loss?  Do you know that ST depression in the high V leads can signify a posterior MI? What about differentiating an acetabulum fracture from a “pulled groin”? Can you reliably predict the patients whose blood pressure is going to crash after Nitroglycerine administration by reading a 12-lead EKG? What about the clinical presentation of a non-ST elevation MI? Do you know the MEND stroke screen? What about the different neurological exams to find an intracranial bleed?

Etcetera, etcetera… The point is, there isn’t a cut off. The final exam we take for our licensures prepares us with the baseline knowledge to get out there and learn what it takes to make us truly great EMS providers. The true professional will learn this, and constantly seek the knowledge he or she needs. The average to sub-average provider will comment that they “don’t need to know” something.

Get out there, get fascinated, and learn as much as you can. It will never be enough knowledge… but your mind is a sponge for a reason.

Study Hard. Know Your Stuff. No Excuses.

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This is a coordinated post by our friends Greg Friese and Steve Whitehead. Be sure to read their posts on this

Greg’s post on this topic can be found at: http://www.everydayemstips.com/?p=3628

Steve’s post on this topic can be found at: http://theemtspot.com/2010/08/25/too-much-information/

Posted by Ckemtp on August 24, 2010 • Filed under: EMS, EMS Motivation, EMS Topics, EMS ethics, EMS practice, EMS rant, EMS training, Emergency Medical Services, Paramedic, Patient Management, Training & Development, Uncategorized, change, ems education, paramedic education, training-fire-rescue-topics

EMS: Is what you do the Best You Can Do?

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Not too long ago I was reading an article in Entrepreneur Magazine when I came across an article speaking on negotiating tactics. I wish I could find it, but unfortunately it was long enough ago that I’ve disposed of the printed issue (I subscribe) and cannot find it on the web. It was a good article and it taught me some words that I’ve since used quite a bit in my own life:

“Is that the best you can do?”

From the time our parent’s first put us out there in the world most of us have probably been told to “Do our Best” when we try to do something. No matter if we win or lose, we’ve been told that it’s ok as long as we “do the best we can” while trying. We seem to feel better at the outcome of almost anything if we feel that we’ve “Given our best shot” when we try to accomplish what we’ve set out to do. We all like to do our “best” and we hope that our “best” will be good enough.

This begs the question… is what you’re doing today in EMS “the best you can do?” Career wise, operationally, with your service’s treatments, with your own personal training and education, and with your own attitude… is this really “the best you can do?”

I would like to think that I “try my best” in my own EMS career and paramedic practice. I would also like to think that I work for an EMS organization that is trying to do the best it can for its people and its collective patients. However, there are quite a few situations where I have felt that I have not done or have been prevented from doing my best for a number of reasons. Some are reasonable and others are not. I’d think that all of us would give the answer that we always want to provide every patient with our “best” possible care. However, I’d also guess that everyone reading this can think back to any number of situations where they feel that they didn’t give it. Sometimes this reason comes down to the skill set of the individual provider. This could be a situation where the provider didn’t have the best possible information or knowledge available to them. They may have provided an ineffective or even harmful treatment modality or might have failed to act upon a missed assessment finding, such as by giving a medication for which a patient has a documented allergy because the provider didn’t know or simply forgot that the patient had the allergy. Sometimes the actions of others in the organization can prevent a provider from rendering the best possible care. This could be by failing to check, clean, or restock a needed piece of equipment or by providing inadequate care prior to a provider assuming patient care such as in the case of a first-responder crew failing to place a patient in full c-spine precautions when indicated prior to moving a patient to the transporting ambulance and the transporting EMT not having enough manpower to safely immobilize the patient. Sometimes the organization can hinder an EMS provider from doing his or her best by doing things such as providing inadequate equipment or medical protocols, or by mandating that a provider regularly work past exhaustion-level hours.

People inherently want to do well at whatever they choose to do for their careers as well as at other tasks where they feel strongly about the outcome. I may have accepted that I’ll never be as good of a basketball player as Michael Jordan, nor the same-level of cartoonist as Scott Adams, nor the best noodler in the world… but I’m certainly going to try to be the best paramedic I can be.

THIS guy, however, may be The Best Noodler In the World

Sometimes our own personal biases prevent us from doing the best we can do and for this I’m not talking about bias regarding any protected classes or topic, rather I’m talking about our own version of the status quo. A personal example of this would be my ALS Quick Response Vehicle at work. We went a solid week without having the proper forms available for the daily equipment checks and I didn’t have the computer access to print more off. During that week, I got in the habit of not using the forms and simply checked the truck based upon my knowledge of what was supposed to be in there and what was supposed to be checked. The way it played out, I ended up continuing to not use the check sheets when checking the vehicle, even though the forms had been replenished. A few weeks later, someone found that there was equipment missing in the vehicle that had gone unnoticed for some time. At that point, I realized that I had developed my own bias against using the forms for a reason that is even unbeknownst to me. I had gotten in the rhythm of not using the forms, and that caused me to miss that the infrequently-used piece of equipment was missing. I had developed a personal mental bias that prevented me from “doing my best” and thoroughly checking the truck.

Another preventer of best practices can be organizational politics, both internal and external. As a paramedic who regularly responds to other ambulance services to provide “ALS Intercepts”, I have observed that the politics between the services we work with can affect patient care for both the negative and the positive. While I am not saying that any of these arrangements result in inadequate patient care, I can say that the services with whom I interface most frequently and most pleasantly get a better provider out of me than do the services with whom my relations are less frequent or are strained due to political turmoil. When I respond to a request for an ALS intercept, I am being called to the “house” of another group of providers. While I am the highest level of care on the scene, I’m also a guest in their house. They have their own internal biases and I have mine. Sometimes the synergy in our working relationship can be strained, which results in a palpable difference in the flow of the scene and the teamwork exhibited at it. While I will ensure that I “do my best”, it’s easier to do it when I work well with the team I’m working with.

So how do we change things? We’re all human and we all have things that prevent our “best shot” from being the only thing that we “give it” in our EMS careers. This may be consciously, as in the case of internal politics; Subconsciously, as in the case of my not using the check sheet; or Involuntary, as in our service not providing us with needed equipment or our coworkers failing to replace an item in the ambulance that we did not have an opportunity to check. As in most things, the easiest thing for us to change is ourselves. Changing ourselves is a great place to start and will make serving as an example to others your main tool to use to try and get the best out of them.

Most situations can be made better and almost all of us can try harder. The secret is to attempt to do our “best” at all times and to try and ingrain our own best practices into our daily routines. This can be as simple as always trying to check the truck in the most thorough way possible or by making sure that you always check and recheck things to ensure that they’re done right. It helps to continuously seek out and recognize one’s own personal biases, (remember my check sheet?) to make sure that our own preferences and routines aren’t leading to suboptimal performance. Consistently ask yourself if what you’re doing is the “best you can do” and then ask yourself what you can do to make it your best. Mentally prepare yourself for your shifts with adequate rest when possible, manage your stress level so you can keep your thoughts focused on your care, and train hard. Ingrain your best efforts into the systematic way you do things and make your best way your normal way of doing things. We can’t change everyone around us in an instant, but our quiet positive efforts can pay large dividends in how people around us think, feel, and act. Our best may in turn get the best out of our partner, which may in turn get the best out of the next crew, and so forth. Soon enough… deciding to give our best may change your organization, our industry, or our profession.

And I assure you, doing your best will indeed make the difference in someone’s life. It’s just what we do, Folks.

“Is that the best you can do??

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For more on doing your best in EMS and in getting the best out of your EMS people read:  “The Shine Factor”

Posted by Ckemtp on August 19, 2010 • Filed under: ALS Intercept, Administration & Leadership, Ambulance cleaning, Command & Leadership, EMS, EMS Topics, EMS ethics, EMS training, Emergency Medical Services, Fire Rescue Topics, Firefighter, Management, Paramedic, Patient Management, Training & Development, Uncategorized, edemse, politics, pride, profession, professionalism, training-fire-rescue-topics

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

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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: EMS, EMS Topics, EMS ethics, Emergency Medical Services, Paramedic, Patient Management, STEMI, Training & Development, ems education, patient care, politics

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

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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, Command & Leadership, EMS, EMS Health & Safety, EMS Humor, EMS Management, EMS Topics, EMS safety, EMT, Emergency Medical Services, Ethics, Fire Rescue Topics, Firefighter Safety & Health, Management, Paramedic, Patient Management, Uncategorized, ambulance humor, patient care, salary, shift length

Should EMS Improvise? And the Recipe for the “Kaiser Cocktail”

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Here’s the recipe for what I call the “Kaiser Cocktail”:

  1. Look in the patient’s kitchen cupboards until you find a box (or a bag) of some type of granulated sugar, powdered sugar, or brown sugar. (in a pinch, you can use honey or syrup)
  2. Find one of the patient’s own cups or glasses, wash it if you have to.
  3. Dump a bunch of the sugar in the glass.
  4. Look in the patient’s refrigerator until you find some soda pop or some type of sweet juice like orange, apple, or grape juice.
  5. Pour that in the glass with the sugar.
  6. Mix it up really well with some type of stirring device. Don’t use your pen or your finger. (Your partner’s pen or finger is ok though.) (Not really.)
  7. Serve warm, chilled, or tepid. Garnish with a peanut butter and jelly sandwich.

Have you guessed what the “Kaiser Cocktail is used for? If you’re in EMS I’m pretty sure you may have figured it out. It’s for sweetening up your local mild hypoglycemic… and no, it’s definitely not for serving to my son right before I drop him off with the in-laws for revenge purposes. The Kaiser Cocktail is for those patients who have blood glucose levels in the mid double digits but that still have the mental faculties necessary for drinking fluids and for protecting their airway while they do it. It’s a home remedy of sorts and it isn’t exactly the kind of thing that they teach you in EMT school. It works like a charm every time and I’ve never seen it not be well tolerated by the patients I’ve used it on or by the families that watch me do it. In fact, the families always seem more than willing to help whip one right up when I ask them to do so.

Picture this scenario: Your ambulance is dispatched to the “Known Diabetic with Altered Mental Status” at an address a short 8 minutes away. You respond to a well kept address in a nice neighborhood and are directed into the residence by a twenty-something female who tells you that her grandfather “Just isn’t acting right and won’t get out of bed”. Seeing no obvious hazards, you enter the residence with the granddaughter and follow her to the back bedroom of the residence to find a 60-something male patient sitting on the bed. He acknowledges you when you introduce yourself and you can see that he’s trying to talk but that he cannot seem to form the words. You say to him “Howdy! How are you feeling??” He answers: “Um… hello…” with a normal voice quality. His airway is patent, his skin is pink, warm, and sweaty, and he doesn’t appear to have any hemispheric neurological deficit. His pulse is bounding and regular at the radial and his respirations are normal. The granddaughter tells you that the patient is diabetic and that he takes insulin.

Got the case diagnosed yet? I’d bet you do. The next thing I would do with this patient is to take a quick finger stick glucose check. For the above fictional scenario, the reading would be 40mg/dl (which is um… “something’ MMOL for you British folk). It’s mild hypoglycemia. I ruled out a possible stroke (CVA/TIA) with the Cincinnati Pre-Hospital Stroke Scale and he patient’s cardiac function seems very normal with his bounding, regular pulse rate. The diaphoresis (sweating) and skin color are differential signs of hypoglycemia, and the patient’s past medical history helps clinch the field diagnosis. This patient’s blood glucose level dropped too low for his brain to function normally and he needs more sugar coursing through his veins in order to feed his brain.

You may be wondering why I brought forth such a common, run-of-the-mill patient presentation on the blog today. As pre-hospital providers, we have a few options available for us that could be considered proper care for this patient. Most EMTs have oral glucose paste at their disposal and a growing number of EMT-Basics carry Glucagon for IM injection. EMT-Intermediates and Paramedics usually have both of the previous medications available and almost all of them carry D-50, or 50% Dextrose solution in water, for IV administration. All of these treatments could be considered for this patient; however I would pull out my namesake concoction in this case. Call it experience, but starting an IV and giving D-50 seems like it would be risky overkill for this patient and an IM injection of glucagon saps the patient’s natural reserves of glycogen for quite a while after administration. Patients seem to hate the taste of oral glucose paste (Lemon?? Really??) and one tube never sees to do the trick. We only care two of them anyway.

That’s why I use a Kaiser Cocktail with these patients. As long as the patient can maintain their own airway and there’s not an aspiration risk, I can’t think of any contraindications once you rule out a possible stroke. It’s cheap, easy, and it has worked like a charm for me every time I’ve tried it. I like using it too, as it feels like a “Mr. Wizard” type home remedy that always fascinates the patient’s family members who watch me make it up.

Here’s the rub though, nowhere in my protocols does it give me authority to give a patient any nourishment or fluids by mouth. In fact, I can’t give a patient anything to eat or drink that isn’t specifically allowed by my standing orders. In EMS, even something as innocuous as sugared-up orange juice can be a legal difficulty. Common sense isn’t allowed by lawyers, unless of course they’re saying you should have used some. The reality is that every time I whip up a Kaiser Cocktail, I’m putting my license at risk.

I used a Kaiser Cocktail as recently as of the day I’m writing this post and I’m asking for a debate here. I’d like it if you would please answer some questions for me below the post in the comments section:

  1. Do you think that the Kaiser Cocktail is an appropriate treatment for mild-to-moderate hypoglycemia in a known-diabetic patient with a patent airway?
  2. Do you see any contraindications or risks that I have missed?
  3. Would a tube of oral glucose paste (or tablets, if you use them) be more appropriate than the Kaiser Cocktail?
  4. Should EMS providers be allowed to improvise treatments such as the Kaiser Cocktail for these and other like situations? Why or Why not?

I can’t wait to see your answers.

Posted by Ckemtp on June 21, 2010 • Filed under: Administration & Leadership, Ambulance, EMS, EMS Topics, EMS ethics, EMS protocols, EMS training, Emergency Medical Services, Paramedic, Patient Management, Protocol development, SMG, SMO, ems 2.0, ems scenario, ems scenario based education, medical ethics, paramedic education, scenario, scenario based training

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

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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, EMS, EMS Topics, Emergency Medical Services, Fires, In the Line of Duty, Paramedic, Patient Management, Training & Development, ems education, ems scenario, ems scenario based education, funny, paramedic education, patient care, professionalism, scenario based training, stories

To Kneel or not to Kneel

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

 

 

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

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

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

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

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

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

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

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

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

Posted by Ckemtp on May 5, 2010 • Filed under: Ambulance, EMS, EMS Health & Safety, EMS Humor, EMS Topics, EMS rant, EMT, Emergency Medical Services, Fire Rescue Topics, Fire department, Firefighter Safety & Health, In the Line of Duty, Paramedic, Patient Management, ambulance humor, ems pants, ems uniforms, infection control, inside the mind of a paramedic, kneeling, paramedic education, paramedic pants, puke

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

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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, EMS, EMS Humor, EMS Topics, Emergency Medical Services, Fire Rescue Topics, Paramedic, Patient Management, ambulance humor, funny, humor, patient care, stories

Trust… It’s everything

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(more…)

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

The Perfect Emergency? Well, almost

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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, EMS, EMS Management, EMS Topics, EMS ethics, EMS system, Emergency Medical Services, Ethics, Fire Prevention & Education, Fire Rescue Topics, Paramedic, Patient Management, everyday ems ethics, patient care, scenario, scenario based training

Why I am Passionate about the Chronicles of EMS

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

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

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

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

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

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

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

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

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

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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):

  1. 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?”

     

  2. 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. 
  3. 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.

     

  4. 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.

     

  5. 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.

     

  6. 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.

     

  7. 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.

     

  8. 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?”

     

  9. Explain to the the patient WHAT you are going to do and WHY you are going to do it.

     

  10. 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, EMS, EMS Health & Safety, EMS Humor, EMS Topics, EMS training, EMT, Paramedic, Patient Management, comfort, courtesy, patient care

Firefighter Vs. Nursing Home – I can relate, can you?

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Yesterday morning when I came into work, the guys were laughing about something playing on one of their cell phones. Being that I work with some um, “colorful personalities”, it literally could have been anything playing on that little screen and heck yea I was interested in seeing what it was they were busting a gut over.

The video, surprisingly related to EMS for that setting, was one of those videos made with the lego characters entitled “Firefighter Vs. Nursing Home” and I immediately related to it. The setting is supposed to be a nursing home, the “firefighter” in the video is supposed to be a paramedic or EMT, and it’s as funny as it is sad. It’s funny because you hear the “nurse” talking in the video and she’s saying things that you’ve heard from every nursing home you’ve ever been in. I mean, this could have been the “nursing” home up the street from me, or one of the myriad up the street from me in my other job, or any one of the ones in any place I’ve ever worked.

Let me know if you’ve heard these phrases:

“I just came on shift”, “She’s not my patient”, “She’s altered”, “I don’t know her history”.

If you’ve been in EMS for like, 5 minutes and have been to ONE “Nursing Home”, you’ve heard these phrases. It’s like there’s a nursing home handbook that every person that works in one has to read to get the phrases that they’re supposed to use with EMS providers… Really it’s uncanny how similar this is to hundreds of interactions I’ve had with nursing home staff.

I’ve embedded the video below here… and I have to put some warnings on here. First of all: There is some blue language, including a few utterances of the grand poobah of swear words. There’s also a reference or two to an “adult situation”, and obviously the person who made this (and I don’t know who it was, it was not me) was expressing huge amounts of frustration with his or her own interactions with “nursing” home staff. So if you don’t want to hear swear words, sassy-talk, and a reference to an adult situation, don’t watch it.

Oh, if you’re a nursing home nurse, or a CNA, or anyone who has worked in a nursing home, or has a friend who’s worked in a nursing home, or has someone who might work in a nursing home that you might be friends with and you’re mad at me for putting this up there… here’s my stock reply:

“Not everyone who works in every nursing home is a bad person, it just seems that way sometimes”

“Some of y’all are actually almost human beings”

and…

“I sure would NOT want to do your job, I couldn’t… ever… so Thank God for you if you care and you’re good at what you do.”

Posted by Ckemtp on February 3, 2010 • Filed under: Ambulance, EMS, EMS Humor, EMS Topics, Emergency Medical Services, Fire Rescue Topics, Paramedic, Patient Management, RN, Videos, humor, nursing home

Mental Quickness – Do Smart Alecks Make Better EMTs?

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

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

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

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

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

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

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

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

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

EMS practice

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

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

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

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

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

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

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

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

I think that my football coach would have been proud.

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

Questions About EMS on a sleepy morning – Care to answer?

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It is a very sleepy morning for me today. Yesterday was a hard-fought day on the ambulance by our standards. For the first part of the day I couldn’t run a call without somebody getting angry at me. It really didn’t bother me all that much, but you know how it goes. I actually got about 6 hours of sleep during the night though, so I got that going for me. Perhaps it’s the morning fog mixed with the lack of coffee available in the station this morning that’s causing my AM neural firings to generate random questions… perhaps I’m just nuts. However, if y’all would like to think about some things (and perhaps answer in the comments section, please) I invite you to join in on my personal morning groggies.

Here goes:

  • If Medicare would assign a payment that you could access for treating and releasing patients, thereby diverting them from the Emergent healthcare system and redirecting them to the more cost effective healthcare system, how would that change the industry?

 

  • If your service could choose to accept a lower payment from Medicare and Medicaid for every transport without regard to the nuances of medical necessity and never have to be denied reimbursement in exchange for a lower payment for every call, would your service take it? How would that change the industry?

 

  • How would you improve your service if all of a sudden a big, national competitor moved into your service area and started taking your share of the market… you’re losing calls to them and it’s affecting your bottom line… What do you do to improve your service to keep yourself in business?

 

  • How would you change your care if your medical director was watching over your shoulder on every call? What would change if it were your mother watching you?

I think that these questions aren’t the biggest questions facing the industry today, but I’ll bet ya’ that if they were considered by peons like us and also by the powers that our landscape would change quite a bit, wouldn’t it?

See you in the comment’s section.

Posted by Ckemtp on January 26, 2010 • Filed under: Administration & Leadership, Command & Leadership, EMS, EMS Management, EMS Topics, Economics, Emergency Medical Services, Funding & Staffing, Patient Management, change, ems 2.0

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

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Did I do good?

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

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

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

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

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

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

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

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

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

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

What do you think? Did I do good?

QGE5GE5AAH4W

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

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

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

————————————————————————–

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, EMS, EMS Blog, EMS Health & Safety, EMS Topics, EMS ethics, EMT, Emergency Medical Services, Ethics, Fire Rescue Topics, Paramedic, Patient Management, The EMT Spot, Training & Development, bad calls, cpr, emotions, everyday ems ethics, inside the mind of a paramedic, medical ethics, patient care, psychology, sadness

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 Intercept, Als, EMS, EMS Management, EMS Topics, EMS paramedics, EMS protocols, Emergency Medical Services, Paramedic, Patient Management, patient care

My Biggest Blogging Fears and Heart Attacks

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Want to know what my biggest fear as a blogger is? It’s that one day you may find out that I’m an idiot. You’ll find out that there are things that I don’t know, and those things that I don’t know will be something that “any idiot should know” and if I don’t know them you’ll think that I’m not as smart as “any idiot”.

Take this issue for an example. Say you have a 48yo M Pt with substernal chest pain. He indicates with his hand that it’s radiating towards the lower left part of his chest from the manubrium. He stresses that he doesn’t perceive it as “pain” per se, but that he feels it more as a “pressure” and he rates it at a 4 out of 10. He denies that it exacerbates to movement or palpation, and it doesn’t change with respiration. His skin is slightly flushed and moist and he complains of some shortness of breath. He states that he’s been experiencing it for an hour or so, and that it’s getting worse despite antacid tablets and an aspirin he took. The patient has no medical history and takes no meds. He does have a family history of heart disease but has never experienced any problems.

What would we do here? Easy: a 12-lead, IV, o2, and EKG Monitoring is in order. You do that and get…

A normal 12-lead EKG. Nothing is wrong with it. Not a darn thing.

Doesn’t that suck? I mean, no, not for the patient of course… but for you. Now what are you going to do? Are you sure that this patient’s chest pain isn’t caused by cardiac ischemia? You’ve seen the 12-lead… but you also see the patient’s presentation. They seem to contradict each other, don’t they? If this patient had three boxes of ST segment elevation in three leads, you’d know right what to do and the treatment would be pretty straight-forward, right? Now it’s not so clear.

I’ve vacillated in my career between giving nitroglycerine to these types of patients to make sure that there isn’t something I’m missing with them. My usual decision is to prophylacticly give one NTG tablet (0.4mg SL) after the IV is in place under the doctrine of treating the patient and not the monitor; but I don’t call the cavalry, activate cath lab, or give them the bigger drugs we have to give them (Our STEMI protocol includes: o2, Asprin, Nitroglycerine tablets and paste, Morphine, Metoprolol, and Heparin while bypassing the closest ER by a minimum of 45min to go direct to a hospital with interventional cardiology capabilities)

You tell me that I should contact medical control for these cases and I do if I have something vital to ask that I’m unsure of. I do know that I can’t possibly know everything about everything there is to know about. I also, like probably a good number of providers out there am sometimes afraid to be found out as an idiot by asking a question that “any idiot should know”.

So there you have it. Like most people, I’m afraid to be found out as an idiot and it’s keeping me from asking questions that may give me the appearance of being stupid and ignorant.

Unfortunately for my urge to go hide underneath a rock, I have a blog about EMS that I feel compelled to write something on every day. This means that eventually, I’m going to write something that is so stupid and ignorant about something that you are going to find me out for being an idiot. I may even ask a question about something that I should know by now and you may laugh at me for not knowing the answer to the question I ask.

So I’ve made up my mind. From now on, with you as my witness, I am going to be unafraid to ask dumb questions about things I should already know about. If I don’t know something, I’m going to assume that there’s someone out there that doesn’t know it either… and I’m going to write those answers down here on this blog just for that person… and for you.

I hope that maybe you might start being unafraid to ask those types of questions too. You never know what you might learn. The only cure for this affliction is to buck up and ask the questions, knowing full well that every single person out there feels the same way that you do… and is scared of being found out themselves.

Or you can come here and find out the answers that I’ve found out for you. I’m already a known idiot… no sense in you risking your own neck.

See you tomorrow, Folks.

Posted by Ckemtp on December 10, 2009 • Filed under: EMS, EMS Blog, EMS Humor, EMS Topics, EMS blogosphere, EMS pep talk, Emergency Medical Services, Paramedic, Patient Management, STEMI, blog, blogger, blogosphere, ckemtp

Paramedics Providing Physicals? Decreasing Healthcare Costs and Improving Care – EMS 2.0

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Sitting down at your station one night finishing paperwork, you’re startled from your daydreaming by a knock at the door. You get up, and answer it to find one of the off-duty firemen from the town standing there at the door. He looks like heck warmed-over. He’s pale, sweaty, and his respiratory rate is elevated. He says He’s “Glad it’s you on tonight” and that he feels worse than he looks. He asks if you can “Check him out” since you’re “all medical and stuff”.

Treating this like a walk-in medical call, you help the guy walk into the back of the ambulance and have him sit on the bench seat. Your fire and EMS departments aren’t connected so you’re not really on a first name basis with the guy, but you know him from sight and know him from seeing him around the town on calls and social things and such. He just looks sick, he says that he’s having a bit of trouble breathing and that he feels like he’s freezing one minute and hot the next. He also says that he’s been coughing up “all kinds of stuff” for the last few days.

Putting on your best caring EMS provider face, you begin your assessment. He’s a 26yo Male patient in generally good health and with good appearance other than for right now. His skin is very warm and moist to the touch and he seems to have a fever. His pulse is rapid and bounding at around 120bpm, but that decreases after a few minutes of rest as does his respirations. He states that for the last few days he’s been sick. It started with a sore throat and some sinus gook and now has “gotten into his chest”. You listen to his lungs and hear some diminished sounds in the bases bilaterally with diffuse rhonchi throughout.  His abdomen is soft and non-tender but says that he’s had some mild bouts of diarrhea. He complains of exertional dyspnea and his BP is way high at 184/98. His temperature is 101.4 degrees F taken at the tympanic membrane.

So based upon the assessment, you’re thinking that he’s got a respiratory infection, probably bronchitis. Just because you can, you run a 12-lead EKG which is otherwise normal other than for the sinus tachycardia. His pulse ox is 94% on room air. He says that he doesn’t have insurance and that he can’t afford the emergency room, but that he’s willing to pay for a visit to the urgent care doctor if you think he should go in.

Now, faced with the above, as I have been a few times in my career, you have a few options here. You could do what we’re supposed to do by the book and recommend transport to the ER even though you know the guy’s condition probably isn’t life threatening right now. You could also tell him that you think that he may have a respiratory infection and that while he should see the doctor as soon as he can, that he probably doesn’t need the emergency room.

(Remember, we’re talking about today’s protocols, not the ones I want that I posted in “The Current US Economy and EMS – An In-depth look at how this mess will affect 911 in your community”)

Usually, I choose to tell my buddies that they should consult their regular doctors or go to an urgent care clinic instead of going to the ER. Sure, in cases where I thought they had a life threat or needed immediate care above the level of the local Urgent Care, I’ve transported my friends a few times. However, most of the time I give them my assessment findings written down on a piece of paper, hand them a copy of their EKG if I took one, and send them on their way to the non-ER doctor.

The last time I did this, it hit me: I’m conducting a physical when I do this. Sure, in the above case and in the cases where I’ve done this before it is a complaint-based assessment, but a patient examination is a physical exam. When I write my assessment findings on a sheet to give to the doctor, I’m writing them on a physical examination form. While my assessment isn’t as in depth as that of a physician, it certainly is better than not being examined, and a paramedic has specific training in detecting disease processes that may go undetected by a patient and their families.

(Note: In all of the cases where I did not transport the patient to the hospital, I did obtain a proper refusal form after educating the patient about their condition as best I could. They made the decision, not me.)

If you type “Annual Physical Exam” into Google, you’ll see quite a few articles about the topic, including a study published in the Archives of Internal Medicine and this article published in US News and World Report basically, they say that Preventative Health Exams account for approximately 8.0% of all ambulatory care visits costing approximately $7.8 billion in health care costs. They also say that the cost of providing these services may outweigh the benefits of receiving them. In 2005, a survey of 800 Primary Care Physicians reported that 65% of them recommended an annual physical, that 74% felt that it improved early detection of illness, and that 94% felt that it improved patient-physician relationships, there is currently “No major North-American clinical medical association” that “currently recommends that health adults get a physical each year.”

So there’s a debate being held in healthcare circles. On one hand, patients probably perceive a benefit to the annual physical exam, and certainly the people who have disease processes detected and stopped with early intervention see a very tangible benefit. There are also a majority of physicians that when questioned individually state that they see a benefit to the exam. However, there is also the fact that the costs probably outweigh the benefit of the exam, even though “preventative care” is batted about in the current healthcare debate quite a bit and most organizations and physicians recommend health screenings for specific disease processes that benefit most from early detection.

My opinion is that when the cost outweighs a benefit, there is the choice to either forgo the benefit or find a way to decrease the cost. I am suggesting that we can decrease the cost to the overall healthcare system as well as increase the availability of preventive care by introducing paramedics into the debate. I believe that paramedics could provide a more than adequate annual physical examination in most cases for a large subset of the population. In fact, most of us probably already do without thinking about it. The articles state that 80% of preventive health care is provided within the context of complaint-based ambulatory care visits. I would say that paramedics in ambulances provide this care to the rest of the population. I’d also say that we provide a lot more patient education on chronic health issues to a larger segment of the underserved population than any other healthcare provider. Think about it, how many times have you personally attended to a patient who called you for a complaint such as a “fall” and upon assessment found evidence of an undiagnosed chronic condition? I have, and I like to think that with a thorough assessment on every patient, I can improve their overall health more so than just helping them with their current complaint.

To implement this plan, I would think that functionally, paramedic training already gives us a strong background to provide a detailed physical exam. We would, however, have to undergo more intensive training in examination skills and pathophysiology to be able to detect subtle underlying signs and symptoms of disease processes, mental health and substance abuse issues, and sexual health problems. I would envision that there would be a detailed and formalized set of procedures, tests, and paperwork that would be completed in full that should be pre-agreed upon with the Primary Care Physicians in an ambulance service’s wider sphere of influence. Tests such as a random fingerstick glucose, a monitor strip, and a baseline 12-lead EKG could be obtained as well as a review of the patient’s social and other risk-factors. These findings would then be forwarded to the patient’s personal physician, or could be given to the patient to bring to a physician of their choosing.

This is an easily implemented service that we could be providing our communities with tomorrow with the right planning. The chance to improve the overall health of our patients exists coupled with a chance to decrease overall healthcare costs. It’s also another potential revenue source for ambulance services, which is sorely needed in order to implement EMS 2.0 and improve the EMS profession for tomorrow. Imagine the revenue boost to your service’s and your bottom line if every crew started performing ten physicals a day for $50 a pop. It’s a bargain for the patient, but would be a boon for us.

Paramedics are underutilized for our skill sets and education, this is a way that we can further contribute to the health of our communities while improving our profession overall.

References:

US News and World Report “Do You Actually Need a Physical Exam” – http://health.usnews.com/articles/health/2007/09/24/do-you-actually-need-a-physical-exam.html

Archives of Internal Medicine “Preventive Health Examinations and Preventive Gynecological Examinations in the United States” – http://archinte.ama-assn.org/cgi/content/abstract/167/17/1876

Posted by Ckemtp on December 8, 2009 • Filed under: Administration & Leadership, EMS, EMS Blog, EMS Topics, EMS paramedics, Economics, Emergency Medical Services, Paramedic, Patient Management, Training & Development, US economy, change, ems 2.0, patient care, physician

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

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

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An open letter to the Physicians of Wisconsin:

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

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

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

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

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

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

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

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

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

Respectfully,

Todd A. Bluhm, Paramedic

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

Cardiocerebral Resuscitation – Change brings Fantastic results

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

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

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

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

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

 Is that enough incentive for you?

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

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

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

 Did you read them? Good.

 So here are some things you should know about CCR.

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

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

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

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

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

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

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

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

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

A Motivational EMS Article Geared towards Newer EMTs

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The following article is what I submitted to my Fire/Rescue/EMS department’s monthly newsletter for this month’s EMS column. It has a readership of every one of the the 110 or so members of the department, their families, and a good percentage of the 30k or so people in our district. They know me personally as someone who (Imagine this) likes EMS.

If you like this article, feel free to steal it and use it for your purposes. All I ask is that you keep the links intact and give byline credit. Shoot a comment to me too so I can see if it indeed does go anywhere.

Oh, and here’s a thought. If you would like a short EMS related piece to put into your department’s newsletter, shoot me an e-mail at proems1@yahoo.com I’ll be happy to come up with something.

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It’s well known around the department that I like the ambulances and EMS in general. I do, and I’ve always been proud to be a part of (My Department’s) EMS program. I think that the level of dedication and professionalism in our department is second to none and that our program is certainly one of the best in the region and in the state.

With that said, in EMS there is never a time to slow down and rest on our laurels. The science that drives our brand of medicine is constantly evolving and the only constant is change. In my EMS career, I’ve seen “The Right Thing to Do” for my patients change more times than I thought possible. Continuing education, reinforcing the basics, and studying the latest research is key in keeping oneself in step with how best to care for our patients. As with any community based Emergency Medical Services provider, our citizens are our families, neighbors, and friends. We have the responsibility of being the first line of defense against the very worst times in peoples’ lives and it is our duty to be at our best when we are called to make a difference. The people we care about most are depending on us.

Just as in firefighting, in EMS, the little things make the biggest difference. It really is the Basic Life Support care that makes everything else work and our calls run the smoothest. Patients do not necessarily perceive the skillful application of Advanced Techniques or medications given to them, but they certainly appreciate the attention given to treatment of their ABCs, their comfort on the cot, pain relief and stabilization through proper splinting techniques, the compassion of the care providers, and the cleanliness of our ambulances and equipment. It has been said that “Perception is Reality”, meaning that the way someone perceives you or your organization affects their own reality. In EMS, good perception actually has been shown to provide for better patient outcomes. Really, if you have more confidence in the skill or effectiveness of your medical provider or a technique, you’re statistically more likely to have a better outcome.

It is so important for us as healthcare providers to focus on providing the best care possible for our current patients, but also to keep an eye out for future patients. Start now by making sure that the ambulance is thoroughly cleaned at the start of every day and after every call. Make sure that your equipment is ready to go and that you’re an expert in its use. Read something educational every day to keep yourself in the right mindset and to keep your skills sharp. Pull things out and practice with them. Come up with questions to ask the more experienced providers and don’t be afraid to ask them. It is every EMTs duty to become an expert in prehospital care and you are the only one who can expand your knowledge enough to become one. Study every day.

Here are some resources I use every day, they teach me something every time I use them:

-          Http://www.happymedic.com – A San Francisco Firefighter/Paramedic and his adventures in EMS.

-          Http://www.999medic.com – A British paramedic working EMS with our neighbors across the pond.

-          Http://www.theEMTspot.com – Educational tidbits, tips, and tricks from a Colorado Paramedic.

-          Http://www.EveryDayEmsTips.com – A Social Media, training, and EMS guru with daily tips to improve your care.

-          Http://paramedicine101.blogspot.com – In-Depth Educational Articles for EMS providers.

-          Http://www.LifeUnderTheLights.com – Your’s Truly’s random musings on the EMS.

Of course, getting your hands on a copy of JEMS or EMS Magazine is great too. Learn something every day, take pride in yourself, your service, and the care you provide. Your next patient could be your loved one, make sure they’d get care that you’d be proud to give them.

Posted by Ckemtp on November 3, 2009 • Filed under: Ambulance cleaning, EMS, EMS Motivation, EMS Topics, EMS pep talk, EMS training, EMT, Emergency Medical Services, Patient Management, Public relations, Training & Development, Your Happy Medic, courtesy, ems education, medicblog999, profession, professionalism, technology-communications-ems-topics, volunteer fire department, volunteer firefighter