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Appendicitis – An EMS Case Review

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It’s a dreary, grey late fall day outside and your partner is driving your rig back from the hospital after clearing from a call. You’re feeling very comfortable in the passenger seat of your ambulance as the radio’s playing some annoying pop-drivel by whatever flavor of boy band is popular this month. You’re tired from working the day before and having to pick up overtime today and seem to be getting sleepier by the minute. It may be cold outside but the heater in your ambulance is working quite well and the warm, comfortable seat is lulling you to sleep. It’s a perfect time to doze off for a little snooze and your eyes just seem to close on their own…

And with that, the secret alarm goes off in dispatch to alert them to the fact that an EMS provider has dozed off and they subsequently set off your tones to alert you to a call. The dispatcher’s voice harshly cuts into your mid-afternoon nap by sending you to the local community college for a 23yo female patient experiencing an onset of abdominal pain. Your partner flips on the lights and sirens as you sleepily acknowledge the call and mark your unit en route. So much for nap time.

You arrive shortly thereafter and pull up to the entrance by the college health center behind the security vehicle. The security officer is holding the door open for you as you grab your equipment and wheel in the cot. He leads you to the health center office while attempting to engage you in small-talk. Through the fog of your still-tired brain you try to politely converse along with him but it doesn’t work so well and you think that you may have agreed to take him on a ride-along. Oh well.

Your patient is a 23yo female who is sitting on the exam table in the health center. She is slightly bending forward and is holding the right lower quadrant of her abdomen. There was no nurse on-duty today and the administrative assistant called 911 after the student came in complaining of the abdominal pain.

“Howdy!” you say to the patient, professionally. “My name’s Joe and I’m from the ambulance. What seems to be the problem today?” you ask.

“My stomach hurts like, really bad.” She answers, wincing as she talks. She seems to be in a significant amount of pain and grimaces as you get near her. She doesn’t seem to want you to touch her abdomen and seems scared that you’re going to. You continue to ask her questions while your partner gets out a blood pressure cuff and starts to take her vital signs. You check her radial pulse and find out that her pulse is elevated, about 118bpm, her respiratory rate is about 20 and shallow, and her skin is warmer than normal and slightly moist. Your partner reports a blood pressure of 108/88.

“What’s been going on today? Can you point to where your stomach hurts?” you ask her in succession. She tells you that she’s been experiencing abdominal pain that has been steadily worsening over the last three days and that it’s suddenly gotten much, much worse over the last hour. She rates it at an “8” out of 10. She says that it doesn’t quite hurt as much as did the birth of her child, but that it’s “getting to be right up there.” She indicates with her hand that the pain started in the middle of her abdomen around her umbilicus, but points to the area between her right iliac crest (hip bone) and her navel and tells you that this is where it hurts the most since the pain has gotten worse. She denies diarrhea, vaginal bleeding, and trauma but tells you that she vomited this morning and is feeling nauseated. She doesn’t remember when her last oral intake was because she “just hasn’t been hungry” since this began.  She also complains of chills and her skin temperature suggests she has a fever. You confirm it with the oral thermometer that’s handily on the wall of the health center and find out that her temperature is 101.3. She tells you that it hurts to cough and that it hurts more when she moves.

You lie her down on the table and examine her. Her lung sounds are clear and her abdominal sounds are hypoactive. Her abdomen is rigid and tender in all 4 quadrants, especially over the RLQ which she guards with her hands. She winces noticeably when you take your hands off of her abdomen and says that the pain seemed to be much worse when you let the pressure off.

You and your partner move her to your cot and sit her in semi-fowlers position. You bundle her up tight with blankets while your partner and the security officer grab up your gear to carry it to the rig. The motion of moving her to the cot seems to have made the patient’s pain worse and she is obviously struggling against it. As you load her in the ambulance, you try to think about what this could be. You quickly remember that “All abdominal pain in a female of child-bearing age is an ectopic pregnancy until proven otherwise” and ask the patient when her last menstrual period was. She tells you that it ended last week, that it was normal, and denies any activities possibly leading to pregnancy in the last four months with normal menses throughout. You have a low index of suspicion for an ectopic pregnancy in this case, but are still concerned that the patient is at serious risk. Your partner turns to you and asks “So what do you think this is?”

Acute abdominal pain is a common cause for EMS calls as well as for Emergency Department and Urgent Care visits. Abdominal pain can be frustrating for EMS providers as there are a great number of conditions where the generic chief complaint of “abdominal pain” may be stated. While a complete understanding of all potential causes of abdominal pain requires extensive study and is well beyond the scope of this article, this patient is presenting with the signs and symptoms of a common and serious acute complaint. This patient complains of an onset of diffuse abdominal pain with anorexia (reduced appetite), nausea, and fever over a three day period. She stated that the pain became worse with a relatively rapid onset of right lower quadrant pain between the right iliac crest and the navel (McBurney’s Point), rebound tenderness (increase of pain when pressure is released from the abdomen after palpation), and increased pain to coughing.

The Appendix, or the “Vermiform Appendix” as it is properly known is a small organ located between the junction of the large and small intestines at the level of the cecum. It can be described as a “worm like” dead-ended tube averaging 11cm in length but ranging anywhere from 2-20cm and usually being around 7-8mm in diameter. For a very long time, the appendix has been through to be a “vestigial” organ, in that there seemed to be no obvious function for it in the body. Therefore it was assumed to have been a remnant of an organ lost to evolution. Recently there has been information suggestive of it having a role in maintaining proper levels of intestinal flora following severe diarrhea however there seems to be no obvious affect in individuals who have had it removed. “Appendicitis” or as it’s also known “epityphlitis” is an inflammation of the appendix.  In otherwise healthy individuals, the opening to the appendix can become blocked and the appendix can become inflamed and filled with excess mucous causing a build-up of pressure. The pressure caused by the trapped mucous compresses the blood vessels in the appendix which eventually causes the appendix to become ischemic, then necrotic and infected. Eventually this infection spreads to the outside of the appendix which can then cause the infection to spread to the peritoneum. In late or severe cases, the necrotic walls of the appendix can rupture or “perforate” and spread infection throughout the cavity causing an abscess or possibly sepsis.

The signs and symptoms of appendicitis start with pain first, nausea and vomiting next, and fever last. Anorexia, nausea and vomiting, and diffuse abdominal pain that is hard for the patient to localize are good potential indicators. Since the appendix is innervated at around the level of T-10 into the spinal cord, the pain starts generally in the umbilical region. As the condition progresses and the peritoneum becomes more inflamed the pain will localize to the Right lower quadrant, especially notable over “McBurney’s Point.” The pain may increase with coughing.  Peritonitis, or the inflammation of the peritoneum caused by the spreading infection will cause rebound tenderness upon palpation, notable by the abdomen hurting more when pressure is released than it did when pressure was applied. In some cases, appendicitis can cause a bowel obstruction as the intestine becomes inflamed to the point where fluids cannot pass or the patient may become septic.

Causes of appendicitis include a blockage of the lumen (opening) leading to the appendix from the cecum. This can be caused by trauma, intestinal worms, and/or lymphadenitis. However, most commonly the condition is caused by “Fecaliths,” or small, calcified pellets of bowel that form in the intestine. In some rare cases, appendicitis may clear on its own but most commonly the only option is surgery to remove the infected appendix which can be done using a few different procedures. Appendicitis is diagnosed using a proper physical examination, ultrasound, CT scanning, and sometimes abdominal x-ray films. Blood and urine testing can also be valuable. Field treatment includes keeping the patient still, keeping them hemodynamically stable using IV fluids or vasopressors in the case of septic shock, and treatment of pain using narcotics. In older times, general surgeons recommended against giving pain medications to patients with appendicitis in the fear that the medication would decrease their diagnostic sensitivity upon a physical exam. This has since been proven to be not true and patients receiving timely and proper pain control have been shown to have better outcomes overall following removal of the appendix.

Keep a high index of suspicion for your abdominal pain patients and assess them well, there’s a lot that can go wrong down there and EMS oftentimes may be the first people to catch it.

Posted by on November 27, 2012 • Filed under: Emergency Medical Services, EMS, ems education, EMS Topics, EMS training, Paramedic, paramedic education, Patient Management, scenario, scenario based training

Tracking Traction – When Traction Splints Should Pull Their Weight

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“What’s that mailbox say?” You ask your partner, “14338 Hansen Road? Good, we’re here. Your partner calls “on scene” to dispatch as you pull into the gravel driveway of the farmhouse you’re responding to. It’s set some distance from the road, but as you pull up you’re met by two teenagers who are waving you towards the gate to a field. You stop and ask them where they’re directing you.

“He’s out in the field!” They both exclaim at once. You ask the older of the two what’s going on. “Our dad was trying out our new dirt bike and he fell! He’s about a quarter of a mile out in the pasture! He’s hurt real bad! We think his leg’s broke! He’s yelling a lot. You’ve got to go help him!”

Judging by the amount of rain your area has had in the last few weeks, the dirt lane out into the pasture doesn’t look all that friendly for your ambulance to travel down. Luckily, the guys from the station are following you in Utility 984 which is a 4-wheel-drive pickup truck. They arrive shortly after you get out of the ambulance and pull out the gear you need. You take a backboard, the c-collar bag, your trauma kit, the drug box, and on a whim you dust off the traction splint and take it with you. As the utility unit pulls up, you throw all of your gear in the back and ask them to give you a lift down to the patient.

After about a 3 minute ride you find the patient, an adult male in his late 40s. He’s lying in a kind of fetal position on his left side holding onto his right thigh very tightly with both hands. He’s pale, cool, and diaphoretic and even though he’s trying to be brave for his sons, you can tell that he is in extreme amounts of pain. You introduce yourself to the patient and ask him what happened while your partner attempts to protect his c-spine. He seems to be conscious and alert but has trouble getting the words out. Through the story told by him and his sons, you find that he was turning sharply on the new dirt bike and had stuck out his leg to help him keep his balance. Apparently he must have caught something with his foot because he felt a terrible pain in his thigh and flew off of the bike at a fairly high rate of speed. On assessment, you find a few superficial abrasions to the patient’s arms and one on his forehead, but no other injury other than to his obviously deformed leg. You ease the patient to a supine position and can see that the leg is shortened and rotated. Then you expose the patient and see that his right thigh is swollen to about twice the size of the left one. He has no pain to palpation to his head, neck, back, chest, abdomen, pelvis, arms, left leg, or right ankle… but that deformed, shortened, rotated, and swollen left thigh suggests a mid-shaft femur fracture, and a painful looking one at that.

Since you’re working a paramedic truck, you have your partner pop in a large bore IV line while you get out the drug box. The patient’s going to need a line anyway as people can lose a huge amount of their total blood volume into their thigh without spilling a drop externally and he could probably use some pain control before you move him. You choose to give him 50mcg of Fentanyl and have the rest drawn up to give him after you see his tolerance to the medication. While you’re doing this, you‘re thinking about how lucky you are that you remembered to grab the traction splint. You’re also desperately hoping that you remember how to put it on. It’s been… a while since you put one on a patient last and you think you were sick that last skills review day where you were supposed to practice it. Your partner wasn’t however and you put the patient on the traction splint together. Once you pull the traction, you see the relief spread over your patient’s face as the bone is pulled back into alignment and his muscles stop spasming. His pain drops markedly and his blood pressure is actually up a bit since you last took it. You give him a repeat dose of Fentanyl to prepare him for the bumpy ride back in the pickup truck and package him the rest of the way on the long-board for spinal precautions.

The femur is one of the strongest bones in the body and is said to be able to withstand forces of up to 15-30 times a person’s body weight before breaking. It does this because it is surrounded and supported by the powerful muscles within the thigh that contract around it to provide reinforcement. Femurs are connected proximally to the pelvis through the femoral neck or acetabulum, and are connected distally at the knee joint. When the femur is fractured, the muscles of the thigh spasm and contract, pulling the jagged ends of the newly fractured femur past each other, shortening the leg and causing great pain and damage to the internal tissue as the bones lacerate and damage the structures around it. The damage from an improperly splinted femur fracture can be worse than the injury from the trauma taken to break the bone in the initial injury. In fact, due to its proximity to the femoral artery and vein, a patient can completely exsanguinate from an isolated femur fracture. It is of vital importance to stabilize and realign a femur fracture as soon as possible after an injury in order to prevent further damage and potential other complications.

Traction splints are required by law to be carried in most ambulances in the United States. They come in three popular varieties, the Kendrick Traction Device, The Hare Traction Splint, and the Sager Splint. All of them are designed to perform the same function for a wide cross section of patients however their design and application vary greatly. They serve to pull distal force along the leg to lengthen it back to its normal length. The traction applied by the splint pulls the femur back into normal alignment and the splint then serves to immobilize the leg. The traction and immobilization stop the muscle spasms and realign the bone, preventing further injury and greatly reducing pain. It is amazing the first time a provider sees a traction splint being properly applied to a femur fracture and realizes the amount of immediate pain relief the splint provides. While EMS providers don’t tend to use traction splints very often, once they do they consider them to be extremely valuable pieces of equipment.

A traction splint is indicated for a mid-shaft femur fracture with no pelvic involvement and no injury distal to the femur on the involved leg. Mid-shaft femur fractures present with a history of an injury from a specific force, such as the story above or from a front-end vehicle accident, but can also occur from incidents of lower energy transfer. Femur fractures will be present with shortened, rotated extremities with swollen, painful thighs in the affected leg. Be sure to check distal pulses before and after application of the splint.

Get to know your traction splint and pull it out to play with it every so often. When you need it, you’ll *really* need it and it’s good to know how to use it. Your patients will thank you.

Posted by on September 25, 2012 • Filed under: Emergency Medical Services, EMS, ems education, EMS Topics, EMS training, Paramedic, paramedic education, Patient Management, scenario, scenario based training, Training, Training & Development

Pericarditis for EMS – A Short and Sweet Case Review

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“Man it’s hot!” you think to yourself while cleaning the back of your rig in the hospital ambulance bay. Those glass garage doors they put on here might make the garage look pretty, but they sure heat the place up in the summer time. You convince yourself that it was nice of them to install a sauna for the EMS crews and let the thought sustain you as you mop the floor of the truck. You and your partner have been running steady since you came on shift this morning, and the noontime sun is really blazing down out there. As the tones come across your radio and the dispatcher calls your unit, you realize that you’re not getting a break anytime soon.

Your partner comes out from the report room as you check the address on the map book. You’ve been called for the 47yo male patient complaining of chest pain. It’s not too far away and you arrive within a few minutes of the call. The patient’s wife lets you in to the house.

“He’s been sick in bed all day, really sick” she tells you as she leads you inside to the back bedroom of the house. “He’s been running a fever and having trouble breathing. I told him I was going to call you when he started telling me that his chest hurt.”

You find the patient sitting on the side of his bed leaning slightly forward and crossing his arms across his chest. His skin is flushed and warm to the touch. He’s breathing slowly and carefully, wincing slightly as he finishes every inhalation. You introduce yourself to the patient and ask him how he’s doing. He answers that his chest is killing him and that it’s been becoming progressively more painful to breathe. He denies feeling short of breath but states that it’s just too painful to get enough air in. He indicates with his hand that the pain is sub-sternal, and that it radiates to the bottom part of his left shoulder blade. He describes the pain as intense, “sharp and raw” and constant. He says that it’s worse when he lies down and when he moves.

Your partner checks the patient’s vital signs while you continue your assessment. You notice what you think may be a little bit of jugular venous distension when you look down at him but it’s hard to see in the light. His lung sounds are clear, His abdomen is soft and non-tender, and His recent history includes a slight fever and chills with progressive upper respiratory illness over the last two days. He adds that he’s been sick since he came home from his dentist’s office after having a cavity filled the other day and he’s wondering if the numbing medicine the dentist gave him had anything to do with it. Your partner tells you that his vital signs are: Pulse 112 and slightly irregular, BP 106/74, respiratory rate 18 with a pulse-ox of 98% on room air. Your partner said that something seemed strange when he listened for the patient’s blood pressure and he had to check it a few times. He says it was almost like the systolic pressure disappeared when the patient took a breath in.

Your partner places him on 4-litres of oxygen via nasal cannula as you strap the patient on the cot. He seems very uncomfortable when you try to lay him down and asks to be sat almost completely upright. You wheel him out of the house and put him in the rig. You decide to place the patient on the monitor, both the 5 lead and to acquire a 12-lead although you’re pretty sure that the patient’s complaint isn’t cardiac in nature. Your partner starts an IV with Normal Saline and you decide to transport the patient to his hospital of choice. You choose to follow the chest pain protocol just to be safe, and administer 4 baby aspirin and one nitro-tab sublingually. Then you look at the 12-lead and are horrified to see all of the changes. The patient has flipped T-waves and ST-segment changes in nearly every lead. This just got serious, and you ask your partner to flip on the lights and sirens as you transmit the 12-lead to the ER.

So what do you think this is?

We all know that not all chest pain is a heart attack and that many conditions that can lead to a patient feeling pain in their chest. This patient describes his pain as increasing with motion and respiration and as feeling “sharp” and “Raw” with radiation to his back under his scapula and states that the pain is relieved by sitting up and leaning forward. As any chest pain can be a symptom of a myocardial infarction or pulmonary embolism, it’s important to look at the total picture and try to rule out immediately life threatening conditions as best as possible. The medic in this fictional case followed protocols and “treated for the worst while hoping for the best” but even he was surprised to see the changes on the 12-lead.

The heart is contained in a tough, fibrous sac called the “Pericardium” which encases and protects the heart inside the chest. This sac positions the heart properly within the chest and keeps it from rubbing directly against any other structures within the thoracic cavity as it moves. Usually, the sac contains a small amount of fluid for lubrication. When the sac becomes inflamed, it is called “pericarditis”. This condition causes pain and other symptoms as described above, which include:

  • Diffuse pleuritic chest pain that tends to lessen with sitting upright and leaning forward but increases with breathing and lying flat. The pain is worsened by movement, but not necessarily by exertion. It does not decrease with administration of nitroglycerine.
  • The patient may present with a fever, or a cough. Usually the patient has the pain for hours or days before presenting for care.
  • The presence of diffuse EKG changes is usually associated with pericarditis, showing non-specific T-wave inversions and ST segment changes in multiple leads as shown on a 12-lead EKG. This is caused by the inflammation of the pericardium and the vasculature of the heart rather than a blockage in the arteries. However, occasionally a coronary artery can spasm and cause classic MI symptoms.

Pericarditis has many causes, including a bacterial or viral infection, an autoimmune response, or inflammation following a heart attack. While there may be a possible link between the condition and dental procedures, research has not yet discovered a direct link. However, some dentists prefer to place their patients on prophylactic antibiotics prior to an invasive procedure to help prevent infective pericarditis and/or endocarditis, which is a rare but serious infection within the inner chambers of the heart.

Field treatment for pericarditis includes judicious use of the system’s chest pain protocols. Place the patient on oxygen and administer aspirin and nitroglycerine as per protocol. Pain may be relieved with opiates but is not generally reduced with nitroglycerine. Acquire and transmit a 12-lead EKG early in the treatment so that the patient can go to an appropriate destination for care.

Posted by on June 25, 2012 • Filed under: Emergency Medical Services, EMS, ems education, ems scenario, ems scenario based education, EMS Topics, EMS training, paramedic education, Patient Management, scenario, scenario based training, Training, Training & Development

EMS case law? AMA Refusals, Death, and Documentation

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Our friend Valerie DeFrance, who runs the EMS House of Defrance from way up in the Vast Frozen Wasteland facebooked this article this morning and you need to read it.

http://www.leagle.com/unsecure/page.htm?shortname=inmoco20100921246

Yep, check that URL. It’s from a site that specializes in putting out snippets of case law and this one’s simply all-too-common.

You should read the article, or at least skim through the salient points, because this affects you personally. You as an EMS provider should know about this. Pay attention to this case and what it means to you.

In this case, a Paramedic/EMT-B ambulance responded to a person experiencing Chest Pain and Difficulty Breathing. This is a quote from the article: (The emphasis is mine)

The unit arrived at decedent’s home and Respondents performed a primary survey of the decedent ten minutes after the initial call was placed. Respondents followed up on their primary survey with a secondary survey a minute later. They then obtained a set of vital signs. Based on their examination, Respondents diagnosed decedent with acid reflux and recommended a treatment of over-the-counter Maalox/Gaviscon. Believing decedent was in no immediate medical danger, Respondents left the home fifteen minutes after arriving.

The next morning at approximately 10:30 a.m. decedent again called 9-1-1, still complaining of difficulty breathing and chest pains. An ambulance unit from Community Fire Protection District was again dispatched to decedent’s home arriving five minutes later. This unit was manned by a different two-person team than had responded the night before. After finding the decedent was experiencing pain across the chest and into the back, shortness of breath, diaphoresis and nausea, the team began administering emergency treatment with oxygen, aspirin and EKG. At 10:55 a.m. the team initiated emergency transport of decedent to DePaul Health Center where he was admitted ten minutes later. At the Health Center decedent was diagnosed with cardiac arrest and pulmonary embolism and began receiving treatment. The treatment was unsuccessful and decedent died at 4:00 p.m. on 11 July 2008.

So do you see a problem there?

First off, I’m assuming they obtained an AMA refusal form (and if they didn’t, they’re idiots). This case highlights exactly what I’ve always said about refusals being worthless. There’s no mention of the patient having refused transport here. In fact, this isn’t a case on whether or not the EMTs actions were correct or incorrect. This is simply a case to see whether or not they have protection under the doctrine of Sovereign Immunity. It looks to me like they were basing their defense on whether or not they have that legal protection, not basing it on their thought that they provided proper care. It looks like they were assumed not to have provided it. In this case, a signed refusal meant nothing. If they were successfully sued with no mention of the AMA form, what good is it?

Second off, it’s in the official record that their PRIMARY survey took less than a minute… and I can believe that if they were solely attempting to rule out an immediate life threat. That’s what the primary survey is for. As evidenced by the fact that the deceased lasted another ten hours, I can assume that there was no immediate threat to his life. However, they then did a “secondary survey” one minute later and cleared the scene with what I assume to be an AMA refusal in just fifteen minutes. So if we time this out, they made it to the patient’s side in one minute, did two assessments, obtained a refusal, and cleared the scene in 15 minutes? That’s one minute to grab gear and walk to the patient, a minute to rule out immediate life threats, a few minutes to do a secondary assessment and vitals, with no mention of an EKG, and a few minutes to carry whatever gear they took in back to the truck, get back in the truck, and clear? Um… Either these are the fastest medics in the West, or they did a very poor assessment.

And the guy died. And they got sued. And they lost. And they freaking deserved to lose.

The second crew seems to have provided proper care for the patient, and that is evidenced in the case outcome. In fact, the lawyers and the judge seem to have made it a point to show the poor care provided by the first crew in contrast to the proper care provided by the second crew. It’s clearly evident here and I’ll bet that if we were to go to that agency and inspect it, we could probably see the difference in dedication and motivation between the first and second crew. The first paramedic comes off as lazy, callous, and stupid whereas the second paramedic comes off as competent and caring. I’d be willing to bet that this is honestly the case. That the first medic was a “good enough” medic who often encouraged AMA refusals and performed just to the bare minimum and the second medic was somewhat better than the first.

So how, as EMS providers, how do we protect against the precedent set by this case law?

The answer is still now as it always has been, do a thorough assessment every time, kick the decisions up to the physician, and document, document, document. This case was in 2008 and if you were doing EMS back then, you know that a 12-lead EKG was the standard of care. This patient should have had a working diagnosis (Chest pain), attempts at making a differential diagnosis (lung sounds, History and Physical Exam, EKG, SpO2, and trended vital signs and 12-leads) and should have been transported. If the patient wanted to refuse, the physician medical control should have been contacted and this should have been documented. The time limit of 14 minutes of assessment and/or care in this case is evidence that this didn’t happen. The medics blew his call for help off and the patient died.

Here’s what I would have done: I would have performed a thorough patient assessment including lung sounds, ABD assessment, and a history. I would have gotten the OPQRST of the patient’s complaint, and performed serial 12-lead EKGs. Then I would have transported. If the patient refused, I would have transmitted the 12-lead EKG, spoken with a physician about the case, and attempted to have the physician speak with the patient. This all would have been thoroughly documented.

Patients have the right to refuse care if they are conscious, alert, and oriented. They have this right even if they’re being stupid. We have the responsibility to help them make a proper, rational decision and to show that we made every effort to provide them with the best possible information. Proper patient care and excellent documentation are the way we protect against these types of lawsuits… and that really hasn’t changed.

This kind of situation can and does happen. Protect yourself and your agency by never becoming lazy. Document! Document! Document! Do your best every time. Be thorough and don’t succumb to mediocrity just because it’s easy. It will catch up to you just like it did to these two.

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For more tips on EMS documentation:

Posted by on September 27, 2010 • Filed under: Administration & Leadership, Case law, Command & Leadership, Emergency Medical Services, EMS, EMS ethics, EMS Management, ems narrative, EMS narrative report, ems patient care report, ems report, EMS Topics, EMS training, Management, narrative, narrative report, Paramedic, paramedic education, Patient Management, scenario, scenario based training, Training & Development

What Difference Does EMS Make? Choose Your Own Ending

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John didn’t need his alarm clock this morning. In fact, he was wide awake just a few minutes before it went off. He turned it off so as to not wake up his wife and got up quietly to start the day. Today was going to be great. It was huge. Months of work at the office were finally going to be recognized today in the biggest project meeting he’d had in a year. Today’s meeting would launch his career faster than almost anything he’d done before. He was excited. He was ready.

John showered, shaved, and got dressed up in his new suit that he’d bought the day before. He wanted to look his best for this meeting. Everything was counting on it. His wife Joanne had coffee and a quick breakfast ready for him when he came down the stairs. He sipped on his coffee for a bit as he ate his breakfast. It was really sweet of her to do that, He thought and he told her so with an extra hug and kiss as he left for his commute. He wanted to be to work early today to make sure that he was there to answer any pre-meeting questions. This was the day.

Traffic was light on the interstate that morning and John was moving at a good clip. It was strange, he thought, for traffic to be this kind to him on a Monday morning but he figured it was a good omen. His phone buzzed with an e-mail and he glanced at it. It wasn’t anything that couldn’t wait until he was in the office, he thought. Then a great song came on the radio. John reached down to turn up the volume so he could get pumped up for the drive…

He never saw the cars stopped just in front of him.

Mary took care of herself pretty well for a type one diabetic. Her doctor had told her that. She stuck to her diet, maintained her sugar levels meticulously, and took her insulin on a sliding scale that seemed to be working perfectly. Her blood sugar readings were always right where her doctor said they should be. Mary was proud of that. She worked out and tried to get out walking or jogging the trail at the park at least 3 or 4 times a week. She felt good, looked good, and thought that she was doing all she could to take charge of her health.

It was a beautiful Saturday morning and Mary thought that she should take her dog Patches out for a walk around the pond. Patches was a 1 year old Golden Retriever and loved jumping in the lake to fetch sticks. Mary had taken her morning dose of insulin, popped a multivitamin tablet from her new bottle that she’d bought the day before, and ate a quick bit of breakfast before she put Patches on his leash and started walking to the park. It was about five blocks away and patches knew the route well. Everything was great, until the nausea hit… Mary tried to fight it but knew that she was going to throw up when she started salivating and breathing heavily. She ended up throwing up in some bushes next to the sidewalk. She thought that she was lucky. Nobody saw her hurl up her breakfast and she immediately felt better. It must have just been the new vitamins that made her stomach upset, she thought as she continued walking to the park. She figured that she just wouldn’t take them again.

Mary never felt sick. She just thought that she should take a nap. The rock over there looked like a good place. Why was she so sleepy? Never mind… Just lay down and nap. Nap good.

Luckily, another jogger happened by to find Mary unresponsive.

Work had been scarce lately and Steve was happy to get his truck back on the road. He drove a live-bottom trailer hauling asphalt for a big local paving company and they hadn’t had many big projects come their way lately. Driveway work was steady, but rarely did the company need Steve to drive a big truck out to a site for a driveway job. Steve made his best money and hours when the company had highway work and today was the first day of a big job they’d just gotten. He’d been in line with the other trucks waiting his turn to dump his load into the paver for hours and even though he was happy to be working, he had to pee. Minutes turned into hours and finally it was his turn to drop his blacktop and head back for a new load. He couldn’t wait to be done. He really had to pee by this time and he knew exactly where his next opportunity would be. He backed his trailer up to the paver and raised the bed. Then through his rear-view mirror he saw the people scramble and jump off of the paver. He felt his truck lurch forward as the paver machine was pushed into it from the impact of a car travelling too fast in the construction zone. When he jumped out of his truck after looking to make sure there was nobody coming at him, he saw his friend Luke laying on the ground. Luke was bleeding, bad. The car and the paver were a tangled mess of metal and there was someone screaming at an unmoving figure in the passenger seat of the car.

Steve no longer had to pee…

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Note to blog readers:     I can’t quite decide on what I should do from this point on. I can take two paths, one is a rallying call to community members asking them to put themselves in the place of the people in the above cases and get out there and support their local EMS. The other, is a rallying call to us EMS people… I’ve written it both ways. You can see what you like best.

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Option #1

Every day, Paramedics and EMTs put on their uniforms, fire up their ambulances, and get ready to face the onslaught of whatever mayhem the streets produce for them during their shift. They do a job that is unpredictable, complicated, and vital to the community. These three stories could happen to you or someone you love tomorrow and each of them will require the response of a highly trained, expert Emergency Medical Services (EMS) provider. There are times when your local ambulance service makes the difference between life and death but there are far more times when they make a big difference in a person’s continuing quality of life. By interceding in the first few moments of a medical emergency with highly trained experts, EMS makes a difference for us all. Communities that support their local Emergency Medical Services have better services and community members that are more educated about what makes quality EMS are better suited to support their local services.

You may not think about the people who respond to your call when you dial 911, but all we do is think about you. Get informed, get involved, and support your local Emergency Medical Services.

We’re there for you. We need you to return the favor.

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Option #2

As you come in to work today, lace up your boots, or turn on your pager, think about the patients in the above cases. They’re people just like anyone you see in your day to day life. They and others like them didn’t intend to be placed in the situations they’re facing and to them; theirs is one of the most intense situations of their life. Their very life and the continuing quality of their lives could rest in your hands today. They are depending on you. Their families are depending on you. Your knowledge, skill, and preparation to perform your best are paramount to these people. Their care rests on you. You owe them your best and there is no excuse they’ll accept for poor performance.

EMS providers transcend their self when they lace up their boots and sign on for duty. Society needs us. Our patients need us. We need us. We will never know the impact we’ll have on the lives of our patients, their families, and their communities… but it’s huge. We as EMS providers play a pivotal role in our communities. They’ll never acknowledge it en masse… but that doesn’t diminish its importance. Recognition for our skills isn’t necessary for our skills to be vital. EMS people do their jobs because they’re important. We do our jobs because our guts tell us that what we’re doing is right… and even when we stumble and find ways to improve ourselves and our care, it doesn’t diminish the importance of what we’ve done. We have acted, and we continue to act in the best interest of humanity.

Today you can make a choice. You can make the choice to seek out and become the best EMS provider you can be or you can choose not to. I suggest that you make the right choice but no one will ever be able to force you. Your care is an art and a science. Your performance is based upon hard science and soft intuition. There can never be a book that will tell you exactly what is right for every situation… you simply have to learn it and learn how to make the right decisions to fit the situations you find yourself in.

My advice to all EMS providers is to take the high road. Err on the side of what you truly feel is best for your patient. Do your best. Study hard and learn from those you consider the best among us. As an EMS provider, you bear the burden of an overloaded system that pays poorly and garners little respect. I feel it too. I say that it doesn’t diminish the importance of what we do and it isn’t the individual patient’s fault. They deserve our best no matter what the system is doing to us. It’s our responsibility and our calling. It has been said that the definition of a “Professional” is one who can perform their duty adequately in conditions that would cause the amateur to turn back. I’d say that we’re living in those conditions today, but we still have to perform. Do your best and know your stuff. Lives depend on your commitment.

It is our job to promote ourselves. It is our job to elevate EMS. It is our job to speak out and optimize the system. The fault for its failings lies within our profession and it is our job to change it. All of us, individually and collectively have the responsibility.

Will you answer?

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So I got a little philosophical in this one. Which ending do you like better?

Posted by on September 7, 2010 • Filed under: 911, edemse, Emergency Medical Services, EMS, ems 2.0, ems education, EMS Motivation, EMS pep talk, ems scenario, ems scenario based education, EMS Topics, EMS training, Ethics, everyday ems ethics, Fire Rescue Topics, In the Line of Duty, inside the mind of a paramedic, letter to the editor, Line of Duty, Paramedic, paramedic education, Patient Management, pride, profession, professionalism, Public relations, scenario, scenario based training, stories, Training & Development, training-fire-rescue-topics

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

Trust… It’s everything

4 comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Perfect Emergency? Well, almost

16 comments

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

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

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

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

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

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

Remember that.

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

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

13 comments

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

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

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

Question #1:

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

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

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

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

Question #2:

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

Do you:

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

Question #3:

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

Do you:

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

Extra Credit Question:

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

Answers:

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

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

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

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

Scenarios. A lot of EMS, a little Einstein

2 comments

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

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

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

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

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

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

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

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

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

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

Still more Everyday EMS Ethics – Gkemtp(it) is born

1 comment


I’ve been on this kick lately for medical ethics in EMS. So, I’ve decided that “Everyday EMS Ethics” is going to be a featured area on my blog. I think that It’s annoying my wife Gkemtb who, by the way, is starting Paramedic school today and is now becoming Gkemtp(it). The (it) means, “in training”.

The unfortunate thing is that she’s now reading her paramedic textbook and she’s asking me ethical questions as she’s studying medical legal aspects of paramedicine. Tonight, she asked me this question:

Imagine you’re in the back of an ambulance with a patient on a long-distance transfer. During the transfer, the patient states to you: “I think that I’m ready for my life to end. I’ve had a good run and I’m just comfortable with the idea of the end of my life. If I die, don’t do anything to bring me back. I’m ready to go”.

 I said, “Well… it depends. Is the patient in his right mind?”, “How old is the patient?”, “is this a suicidal ideation? Or is this someone who might be getting ready to sign a DNR but hasn’t yet?”. She indicated that in her mind, it was an elderly person with a long medical history. If it was someone that was possibly mentally ill… the likelihood of which increases with decreasing age and better long-term prognosis, then I wouldn’t honor it just the same as you wouldn’t kill someone who asked you to kill them because they wanted to commit suicide. However, if it was, say, a long term brain cancer patient that had metastasized and was causing great pain… then it’s a different question. Ultimately, if I was the only person that the patient said it to, I would try to get them to say it in front of other witnesses. If that couldn’t happen, and the patient did in fact go into cardiac arrest… well then I would probably resuscitate them because I would never be able to prove that I acted in accordance with the patient’s wishes. But I wouldn’t like it. Please tell me what you would do, because heck, I don’t know…

The other thing she brought up was if I knew about the “Oath of Geneva” and um… I didn’t know about it.
A quick Google search brought it right up for me, so here it is:

Physician’s Oath

At the time of being admitted as a member of the medical profession:
  • I solemnly pledge myself to consecrate my life to the service of humanity;

  • I will give to my teachers the respect and gratitude which is their due;

  • I will practice my profession with conscience and dignity; the health of my patient will be my first consideration;

  • I will maintain by all the means in my power, the honor and the noble traditions of the medical profession; my colleagues will be my brothers;

  • I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;

  • I will maintain the utmost respect for human life from the time of conception, even under threat, I will not use my medical knowledge contrary to the laws of humanity;

  • I make these promises solemnly, freely and upon my honor.
According to the article I read on it, which surprisingly wasn’t from Wikipedia this time, and is located at (http://www.cirp.org/library/ethics/geneva/) this oath was adopted by the World Medical Association (A group made up of National Medical Associations… well, read it yourself:

The World Medical Association is an association of national medical associations. This oath seems to be a response to the atrocities committed by doctors in Nazi Germany. Notably, this oath requires the physician to “not use [his] medical knowledge contrary to the laws of humanity.” This document was adopted by the World Medical Association only three months before the United Nations General Assembly adopted the Universal Declaration of Human Rights (1948) which provides for the security of the person.

Paramedics come from physicians. Therefore, I believe that we are to honor much of the same ethical standards as they are. Healthcare is an honorable profession. We have the obligation to carry it on that way.

Sorry about the serious posts lately guys J I’ll go back to posting about driving fast and kneeling in poo soon.


 
Posted by on August 27, 2009 • Filed under: Ambulance, edemse, EMS ethics, EMS paramedics, medical ethics, scenario, whattaya do

Everyday Ethics for EMS Providers

1 comment


Mike left a comment on the last post I wrote “EMS Politics, Medical Ethics, and… What would you do?” with a good quote that I’d like to bring the forefront of discussion: “Your next call could be your last call”.

That sentence sums up something that I’ve always said about EMS quite nicely. Bravo to you and your old partner, Mike.

I firmly believe that EMS professionals face “No Win” scenarios several times in their careers. There are things that come up and situations we face that would test the most knowledgeable medical ethicist. Often times we have to make terrifyingly difficult split second decisions using woefully inadequate information that will not only affect the very life of a patient but also our careers and our livelihoods. It’s not fair, and it’s not fun. Paramedics are entrusted with huge responsibility for clinical judgment but can be quickly chastised and sanctioned for even stepping a little bit outside of the box. No, we’re not physicians and No, we’re not licensed to perform everything that a patient may need. I understand that there are some things that are just too dangerous to do in the field, and that yes, patients sometimes die in front of us and we are powerless to stop it.

However, in the scenario presented in the abovementioned post, that was not the case. In the case presented, the patient needed a surgical cricothyrotomy and needed it NOW. The paramedic described in the scenario had been trained in the procedure, had the tools available to him to perform the procedure, and the patient was going to die quickly without the procedure. The catch was that the protocol system he was working in did not allow him to perform the procedure.

The scenario gives two choices:

  1. Don’t perform the cric. Use your full airway bag o’ tricks such as first trying BLS techniques (Heimlich Maneuver, abdominal thrusts) attempting to remove the object with Magill forceps under direct laryngoscopy, attempting to intubate the patient with an ET tube and push the blockage into the right main stem bronchus with the tube allowing the left lung to be ventilated (It’s better than nothing), and scooping the patient up and running really fast to the hospital. If all that takes more than 5 minutes from the time the airway got blocked, including the time from incident to the 911 call, the dispatch time, and your travel time, expect brain damage at the very least. If it’s much longer than that, expect the patient to die.

     

  2. Perform the cric. You’ve got the knowledge, you’ve been trained on the procedure, and you have the equipment available to perform the procedure. The procedure is in the standard scope of practice for paramedics all across the country. Unfortunately, even if the patient makes a full recovery, you’re in deep trouble. The Medical Director in the scenario has not authorized the procedure for paramedics under his/her direction and therefore you’re practicing medicine without a license which is a violation of the letter of the law. It may very well be the only thing that will save the patient’s life, but you’re likely to face severe penalties for violating your protocols.

So what do you do?

I firmly believe that medical direction should not hold paramedics back and that there has to be some leeway in the standard operating procedures that paramedics function under to allow for these situations. Every protocol system and EMS service that disallows such procedures that are allowed under national accepted scope of practice can have situations where patients have poor outcomes up to and including death. In these systems, the EMS provider bears the brunt of the negative result. If he allows the patient to die, it could be argued that he withheld lifesaving care and violated a duty to act. If he was protected legally by the letter of his protocols and the fact that he followed them, he at least could be committing a moral and ethical violation that will haunt him for the rest of his life. I would suspect that the medical director and/or the authorizing body would not be sanctioned in this case… if they were even aware of it. By performing the procedure and saving the patient, the paramedic will be punished quite severely. Even if the patient survives but has residual morbidity resulting from the prolonged anoxia, the medic could be sued for and be held liable for the damages.

In any case, the paramedic carries the burden. It’s a no-win situation.

For the record, I didn’t actually have this happen to me, but I have worked in two systems simultaneously where one is more progressive than the other. In fact, I do right now. Fortunately, both of these systems allow surgical cricothyrotomies, but they carry different medications and have different dosages. One of my services uses CCR (Cardiocerebral Resuscitation – http://www.callandpump.org/) and the other follows an older version of the AHA guidelines. While both are acceptable and I follow the protocols for the system that I am working at when I am working there, I can see the potential for ethical conflict. I’ve been a full-time paramedic for a long time and I’ve flexed the rules occasionally when it was in the best interest of the patient. Luckily (and yes, I know I’ve been lucky) the patient has always had a good outcome when I’ve had to do this.

Here are my rules for “bending” the rules:

  • Above all, always act in the best interest of the patient – If you can show that you acted in the best interest of the patient, disregarding any other potential motives, you’re well on your way to vindication. However, remember that ‘rule bending’ must be for the patient’s best interest, not your own. Something like not placing the shoulder straps on the patient during transport because it makes it more comfortable to care for them is in your own best interest, not necessarily in the best interest of the patient. Taking a patient to a hospital closest to your next errand and not to the most medically appropriate is also in your best interest and not in the patient’s. The cric scenario regards whether the patient will live or die at great peril to the paramedic.
  • Know what your protocols are and why they are the way they are – Knowing your protocols inside and out is essential to being a good professional provider. Knowing WHY they are the way they are, i.e. the reasoning behind them is essential as well. Be able to show that you know them inside out when you’re questioned, to show that you’re not negligently ignorant of the rules you have to function under.
  • Be able to prove what information you had available for you to consider – In these situations, you’re working with incomplete information. However it is your professional obligation to gather as much information as possible as quickly as you can gather it. Do a thorough assessment, and talk to the patient and any bystanders, if possible. When questioned about the incident later, you need to be able to present the information that you were presented with to the people who are going to play armchair quarterback. Be able to put them inside of your shoes.
  • Be able to prove what options you had available to you, how you considered them, and why they did not or would not have
    worked – In the previous airway control scenario, I laid out possible options that the paramedic in the scenario considered. I also laid out why they would not work as the situation unfolded. Be able to show your thought process and how you ruled out options that were within the letter of the rule book.
  • Be able to prove why you thought that the option you chose was absolutely necessary – If it was a “do or die” call, be able to prove it as best you can. You should be
    able to show why it was necessary that you chose the option you did. In the cric scenario, transporting the patient to the hospital so that a physician could perform the procedure would most likely have resulted in the death of the patient. In that case, the best interest of the patient, obviously, would be to continue living… which he would not have done without the paramedic violating the rules. BE THAT SURE of yourself.

I would love for people to jump in and offer their takes on this topic. Please comment away. If you haven’t read the great comments on the previous post, left by such people as Medic999, HappyMedic, and TOTWTYTR you can find it here.

I use scenarios like the one that I wrote out in the previous post as a teaching tool for new EMS people and students that I precept. I think that scenario-based teaching is a great way to promote critical thinking skills and to evaluate what a person would do when faced with the situation presented. In the future, I’m going to be featuring scenarios that challenge ethical standards as a way to educate ‘Everyday EMS Ethics’. Look for the “Featured Areas” to showcase these and other interesting articles.
And thank you for reading.

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Posted by on August 26, 2009 • Filed under: edemse, EMS ethics, EMS paramedics, Ethics, everyday ems ethics, medical ethics, scenario, whattaya do
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