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What is the next “Low Hanging Fruit” of EMS 2.0 and of US Healthcare Reform?

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I’d like to ask a question to all of you medical-type folks out there, and for this one I’d like other healthcare professionals to weigh in, not just EMS. Of course, Paramedics and EMTs are encouraged to answer this question, but so are Physicians and Nurses (RN and LPNs), as well as CNAs and Techs. 

A conversation I had on Twitter regarding administration of 10% Dextrose IV (D-10) as opposed to 50% Dextrose IV (D-50) for hypoglycemic ambulance patients has me wondering something about how we paramedics can create major savings and improve patient care in a short amount of time. We need to look for more “Low Hanging Fruit”.

It is common practice for known diabetic patients presenting with low blood sugar (hypoglycemia) to receive a treatment with IV D-50, IM Glucagon, oral Glucose, or even with the “Kaiser Cocktail” and then sign off with an AMA refusal. The patients are encouraged to eat something containing protein and complex carbohydrates and are usually left in the care of one of their family members and/or friends who can watch them for a while and make sure they’re ok.

I’d say that calls like this make up a fairly large percentage of all calls for an ambulance. While I have no statistics to back me up, I would guess that it could be something like 5% or better. This complaint and resultant treatment pathway is something I do quite frequently in my own practice. Judging from my own experience, I would say it happens quite frequently in most other paramedics’ practices as well.

The question about administering D-10, as brought up by my twitter peep @un_ojo, is if all patients getting treatment with D-10 as opposed to D-50 should be transported to an Emergency Room. My answer was that I believe a 100% transport policy in this case would result in a lot of people being transported to an ER when they probably didn’t really need to be. This would result in a large population of non-emergent ambulance patients going to the ER who in the past would have been “treated and released” (at least under the guise of an AMA refusal) by EMS crews.

And that got me thinking about this question:

If paramedics did not currently have the means to treat hypoglycemia and every one of those patients were being transported to the ER, how much of a burden on the emergency healthcare system would be removed simply by giving paramedics D-50? Probably quite a bit, right?

What other common medical cases would be as appropriate for field “treat and release” (or “Treat and AMA”) care by EMS? If we save a few hundred trips to the ER by being able to sweeten-up and then release common hypoglycemics, what other conditions might we be doing the same for as safely and effectively?

Would this require some easily attainable training? What about new medications and/or equipment?

I look at this as the “Low Hanging Fruit” if you will, of EMS 2.0, and also of healthcare reform. I am a proponent of EMS crews handling more primary care duties, or failing that, of at least having more options in regards to treatment pathways.

That’s what I’m looking for here, folks. What could we do within six months that would make a big impact?

Please discuss in the comments section, and feel free to shoot me an e-mail at ProEMS1@yahoo.com. You can also weigh in on the LUTL Facebook page if you’d like.

Also, would you do me a favor and invite some of the other healthcare people to the party? I’d love to get some of their opinions on this.

Posted by on July 26, 2010 • Filed under: Administration & Leadership, Als, Emergency Medical Services, Emergency Nurse, Emergency room, EMS, ems 2.0, EMS system, EMS Topics, Paramedic, physician, potential, Protocol development, us

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

30 comments

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

Cardiocerebral Resuscitation – Change brings Fantastic results

10 comments

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

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

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

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

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

 Is that enough incentive for you?

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

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

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

 Did you read them? Good.

 So here are some things you should know about CCR.

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

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

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

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

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

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

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

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

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

Dear State of Illinois EMS…

16 comments

State of Illinois EMS… It’s time that you and I had a little talk. You see, I’m an EMT-Paramedic holding licensure in your fair state. I’m also a mostly life long resident except for a short, torrid affair with residency in the State of Iowa. I moved back, you welcomed me back with your open arms and I’ve been here ever since.

Except for now, State of Illinois EMS, while your EMT-Paramedic licensure will always be the first card I carry… I’ve been flirting with other states. Yes… it’s true. I have my licensure in Iowa as a Paramedic Specialist, and my Paramedic card from Wisconsin too. I don’t want to hurt your feelings, State of Illinois EMS but frankly their paramedicine is more exciting than yours is. Yes, State of Illinois EMS… the magic just seems to have gone out of our relationship. I can do so much more in the other states. They UNDERSTAND me and my need to take care of my patients to the best of my ability. They’ve given me exciting advanced techniques, medications, protocols, training and technology that enables me to breathe new life into my practice. They let me LIVE, State of Illinois EMS! They help my patients to live longer, fuller lives.

And now, State of Illinois EMS, this conversation comes on to the prospect of what we should do about our relationship.

Yes it’s been a torrid love affair, State of Illinois EMS. Really it has. Unfortunately, I’ve changed. It’s not you… it’s me.

Literally. It’s like you haven’t changed in ten years. What’s up with that? Medicine’s changed. Techniques and research have changed. Evidence based EMS practice has changed… but, State of Illinois EMS… you haven’t hardly changed a bit. You’re not a national state, your CE requirements are strange, your license hasn’t gotten easy reciprocity anywhere I’ve tried, and your policies are dictated by the ‘Little Kingdoms’ that you call EMS systems and EMS regions, and well… it’s just not working for me anymore.

I’m not leaving you, State of Illinois EMS. I wouldn’t, you mean too much to me and a good chunk of my income is dependent on that little green card I carry with your picture on it. Remember when you gave me that card, State of Illinois EMS? It seems like just yesterday… but it was a while ago I guess. We’ve been together a long time, haven’t we? I think that our relationship is worth salvaging, don’t you?

Here’s what I think we should do, State of Illinois EMS: Let’s work together on a plan that I’ve come up with. It’s a plan that I think will help fix everything that is wrong with our relationship. I think that the way you’re all set up, the way you’ve parceled yourself into EMS regions and the Little Kingdoms that you call “EMS Systems” has given too much control to local politics and individual egos without enough accountability. I think that the EMTs and Paramedics that work within these EMS systems, you know the ones working for actual EMS agencies, are actually “customers” of these EMS systems. Only these EMS systems seem to treat the EMTs and Paramedics like “Bothersome Bastard Stepchildren”  instead of the customers they are and don’t give them any support or service.

Yes, I know that not all of these Little Kingdoms that you call EMS systems function like this, State of Illinois EMS… some actually treat their EMTs and Paramedics like (gasp) People. However, in my decade or so of toiling in these Little Kingdoms, State of Illinois EMS, I’ve seen that to be the exception and not the rule.

So here’s what I propose to you, State of Illinois EMS. I propose that we inject these three things into the whole system: Information, Competition, and Accountability.

Yep, I think that we will both benefit by adding healthy dashes of those three items into our relationship. I’ll explain:

  • Information: I want to put every little policy, procedure, and standing medical order from every EMS system in Illinois on the interwebs. I want every form, personnel roster, and individual quirk of every Little Kingdom in the land to be posted up for scrutiny by every individual EMS provider and provider agency in the state and elsewhere. If they do something, I want everyone to know how and why they do it.
  • Competition: When EMS systems compete, we win. Really, if your hardware store sells your widgets for cheaper than the store across the street, you’ll get more business. If they lower their prices to match yours but your service is better, you still get the business. If their service is just as good but your widgets are of better quality, you still get the business. They have to improve their service, quality, and price just as consistently as you do. It’s called competition and it’s healthy in any food chain or market. Right now as things stand, there’s barely any competition in the EMS systems in the state. EMS provider agencies stay within their systems usually no matter what the conditions are and only rarely change. It’s difficult for new and better ideas to flourish in the current system. It’s also hard for the EMTs and paramedics working under the systems to get any kind of service. Remember, I think that the EMTs, paramedics, and EMS provider agencies are customers of the EMS systems. Now they kneel… with competition and information, they can vote with their feet. EMS systems will be forced to improve or wither and die. The cream will rise to the top, the others… well they may be floaters or sinkers if you know what I mean.
  • Accountability: Are EMS systems accountable to anyone? I mean, if there are complaints against them, to whom are the complaints addressed? If the paramedics and EMTs working under the system are treated like diseased cattle and they are unhappy mooing and coughing like that, whom do they complain to… their EMS provider agencies that don’t want to switch systems due to the immense amount of effort for no real perceived benefit? We need to make them accountable not only to competition, but accountable to a public airing of grievances and peer evaluation.

So there you have it, State of Illinois EMS. Three little words that I’ve come up with that I think will fix our long-term relationship. Sure, I’ll probably keep dabbling in the other states… but I feel entitled to because I know that I’m not your only one either. We can tell people that we have an “arrangement”.

————————————

Look, Illinois EMS could use some repairs. Not every EMS system behaves badly or treats their members poorly, and that’s just it. Those systems should be encouraged to flourish and expand. I don’t think that one blog, one blogger, or one paramedic can disband the Illinois practice of creating EMS systems… but I do think that there should be competition and accountability injected into the system.

So, could we do that?

If there’s any fellow Illinois EMS people out there reading this, feel free to interject. I’d love to get a conversation going on this. Grassroots activism to change EMS from the professional level up? Wow, that’s way EMS 2.0

Posted by on October 28, 2009 • Filed under: 911 fail, Administration & Leadership, change, ckemtp rants, Command & Leadership, crisis, edemse, Emergency Medical Services, EMS, ems 2.0, EMS ethics, EMS Management, EMS protocols, EMS system, EMS Topics, idph, illinois, Iowa, Iowa EMS, new perspective, northern illinois, Protocol development, southern wisconsin, wisconsin

Something I found in the Iowa State EMS Protocols

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I hold licensure in three states as well as my NREMT-P certification. This is partially because I work in both Illinois and Wisconsin but also because I used to work in Iowa and maintain my license as an Iowa EMT-Paramedic Specialist. I keep that license too. Since Iowa’s a National Registry state, it’s a simple matter of forwarding them my National recert paperwork to keep it up. Also, because I’m um… “Rather Opinionated” and one never knows when I’ll get ran out of a state with pitchforks and torches from the townsfolk, I need a backup plan.

Oh, and I like being called a “Specialist” in something. Cool, huh? I’m Special, it says so right here on this card I carry. “EMT-PS”

Today, my friend Google landed me on the web link for the new revision of the Iowa State EMS protocols (Revision Aug 2009) and I had the chance to study up on them. There’s some interesting things in there. You can find the link below.

While they aren’t as advanced as the EMS protocols that I function within in Wisconsin, there is something I found in there that I really like and want to bring to the attention of the EMS 2.0 crowd.

- From the Iowa State EMS Protocols – August 2009 Revision

APPENDIX D GUIDELINES FOR NEW PROTOCOL DEVELOPMENT A RATIONAL DECISION MAKING PROCESS*

(Also can be used to evaluate existing protocols) Making a decision to develop a new protocol or evaluate an existing one should be based on a rational process. Questions that should be asked and answered when considering a new drug therapy or procedure are as follows:
Key Questions for any New Protocol
1) Is the drug therapy or procedure medically indicated and safe?
2) Is it within the scope of practice for the provider?
3) How specifically will this protocol benefit patient care?
4) What specifically is needed to implement this protocol (education/training, medical director protocol development/authorization, equipment needs, etc.)?
5) How will this protocol impact operations?
6) What is the opinion of providers concerning this protocol?
7) Does the medical community support this protocol change?
8) What are all the costs versus benefits associated with implementation and maintenance?
9) What are the medical-legal implications?
10) What ongoing provider involvement such as skills maintenance and continuous quality improvement is necessary?
11) How will success be measured?

Rational Protocol Development Process to Make the Right Protocol Decision
1) Study the issue thoroughly
2) Identify key questions
3) Compare with goals
4) Assess fit with system
5) Cost benefit analysis
6) Identify measuring tools

Stakeholders in this process are recognized to include, but not be limited to:
2) Medical direction (on-line and off-line)
3) Educators/training programs
4) Regulators of policy and rules
5) Service directors
6) Service providers
7) Consumers
8) Third party payers

*Developed based upon discussion at the October 1998 meeting of the Quality Assurance, Standards, and Protocols subcommittee of the Iowa EMS Advisory Council; and on concepts from the article „When to Implement Clinical Protocol Change?’ From EMS Best Practices September 1998.

My understanding of the Iowa State EMS system is that they have mandatory state EMS protocols that all providers must adhere to. Each service may have a medical director, who may choose to use the state protocols at their base level, or may choose to add additional protocols for more advanced treatment. 

Huh… A state that says “This is the minimum standard we’ll hold you to. Now go make them better and report back to us” Then actually gives each individual paramedic and EMT the logical framework to evaluate ideas and make revisions and improvement? 

Also, and this is just HUGE. A state that posts the name and phone number of the State Director of EMS on the protocols… Know what? He actually answers his phone. I know, I’ve called him.

Bravo State of Iowa EMS. Bravo a lot.

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Posted by on October 26, 2009 • Filed under: Administration & Leadership, Ambulance, Command & Leadership, Emergency Medical Services, EMS, ems 2.0, EMS protocols, EMS Topics, EMT-Paramedic Specialist, idph, Iowa, Iowa EMS, Paramedic, Protocol development, SMG, SMO
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