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April is Autism Awareness Month: Now Let’s Go Farther

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Since sometime in the 1970s the month of April has been recognized as “Autism Awareness Month” with April 2nd being “World Autism Awareness Day”. It’s a time dedicated to increasing awareness of this disorder that is affecting an increasing amount of the population. While just how many people may be affected is up for debate, the prevalence is growing. So much so that last I heard, 1 in 50 kids are born with a varying degree of the disorder.

You’ll hear different statistics out there than the 1 in 50 I just quoted since there is disagreement between various camps in the Autism Community. Understanding, diagnosing, and much more so treating autism is difficult by the fact that “Autism” is a blanket term covering the many manifestations of “Autism Spectrum Disorder” (ASD). ASD covers a complex array of conditions, symptoms, and behaviors that someone diagnosed as being “Autistic” can display. People “on the spectrum” can be minimally affected, or “high functioning” or can be “low functioning” if they are profoundly affected.  I can’t claim to understand it myself and I’ve been as immersed in it as I’ve ever been over the last few years.

Yesterday was “World Autism Awareness Day” and I’m posting this article on April 3rd. You may be wondering why I didn’t post this up yesterday instead of the recap of the fake “news” stories I posted for April Fools’ Day. I waited for two reasons: one being that while Autism affects my life and my family it is still important to show that life goes on every day. Humor is a big part of our family life out of both fun and necessity. Another reason is that I believe there isn’t anyone reading this that isn’t “aware” that autism is a thing that exists. I can’t imagine there is an EMS professional out there who isn’t aware of autism but if you’re not, here’s a link to the Wikipedia page on it, and here’s a link to the Autism Society of America. Go read and become aware. In fact, it’s probably a good idea to go read and understand more about ASD anyway. There is a lot to know. ASD is challenging and complex and even the so-called (and especially some of the self-proclaimed) “experts” may not know as much about it as they claim to. I’m no expert by far and I want to stay out of the politics of the debate so I’ll just say this. If you’ve seen one person with “autism” you’ve seen one person with autism. Every person is an individual and there is no one right way to think about how every person will manifest their symptoms.

So since you’re all aware of autism now, let’s get to the point of this post: increasing acceptance, understanding, and respect. I’m glad that we’re all aware that autism is a thing, as would most parents of children who are somewhere on the spectrum as well as the people who are on the spectrum themselves. However, I’m sure they would be even happier if they could simply run an errand with their child without having to fear the reaction of other people in public. I’m sure they would really appreciate people not reacting to them or their child out of fear and ignorance should the child manifest typical behaviors or make noise when they go into a restaurant to eat a meal. As a paramedic, I can say that we would really appreciate not having to live in fear of calling 911 and having the responders have absolutely no clue of how to behave towards our son. That’s what I’d say people whose lives are affected by autism really want. While “awareness” is super-neat and all, let’s move on to the next step of making life a little less hard for everyone. Chances are that nobody reading this blog is going to be capable of finding an effective treatment, but everyone reading this can do their part to make the disorder less of a bad thing by working on their own behaviors towards people on the spectrum.

As you may know, my girlfriend Amy has been a huge blessing in my life. Her son, Connor, has some special needs, one of which is being on the autism spectrum, specifically diagnosed as PDD/NOS or Pervasive Developmental Disorder/Non Other Specified. Living with Connor has changed my life in many ways and has taught me more about myself than I thought I could learn. I’m different now, and hopefully it’s for the better. ASD is very complex and I’m as aware of it as I think I can be but I wasn’t always this way.Amy has shown me a lot that I didn’t know I didn’t know. When Amy and I were early in our relationship, she used to come and ride with me on the ambulance on a somewhat regular basis. EMS was as new of a world to her as her world was to me and while never really got anything all that complex while she was riding with me, we did have one call that stands out.

We were the 911 service for a smaller city where everyone knew everyone and the public safety community all hung out together. It was normal for the police, EMS, and firefighters to eat their meals together and we all listened in to each other’s radio frequencies. So one day when I heard the police get called to the local supermarket for “A child wandering the parking lot alone who appears to have autism.” We decided to head over there ourselves with the ambulance to see if we could lend a hand. Amy was with us and she was very interested, and I was the shift officer and approved of us jumping the call.

When we arrived, we found the police out with a male child who couldn’t have been more than 10. He was very afraid of the police, appeared to be non-verbal, and was walking away from them whenever they approached him. When we arrived, he was walking back into the store. I walked up to the police sergeant and offered our assistance. I told them that our ride-along had a child with autism herself. That seemed to be enough for them. They parted like the Red Sea and let Amy take charge without knowing her from anyone. We followed the kid through the store keeping a respectable distance and watched him as he searched the aisles. Finally, the boy walked up to a man who was perusing the frozen foods section and got uncomfortably close to him. Being “official” like I was in my EMS uniform, I stepped between them until Amy grabbed me. “That’s his dad Chris, chill out.”

It was his dad and he was not aware of the fact that two paramedics, three police officers, and a ride-along were very concerned about what his child was doing wandering the aisles and parking lot of a grocery store. The kid hadn’t done anything wrong and neither had his father, but we were all highly aware of the fact that we were uncomfortable dealing with a situation that was normal for the father of the child. Sure, he probably should have been watching the kid more closely, but how often would the parents of a typically developing child let their 10 year old walk alone in a grocery store. I’m not overprotective and I know that my 9yo step-daughter is capable of fending off kidnappers should I let her go pick out a box of cereal while I look for a gallon of milk… should this father be condemned for the same?

This event got me thinking that I really didn’t know as much about autism or the world of special needs children, but an event Amy and I shared later really hit home for me. We were watching Annie, the girl-child, play a little league game in a local park when I saw a man mowing his lawn which was adjacent to the ball field. He mowed row after row of grass all with a teenage boy following him in lock step about 3 feet behind. Back and forth they walked together silently, the man mowing and the boy following. I thought it was odd but Amy’s perspective snapped me into focus, “He must not be able to leave his son alone in the house while he mows his lawn. I used to have to mow my lawn at night when the kids were in bed because I couldn’t leave Connor alone for that long.”

At that moment, I realized that there was a whole world I didn’t know about. Even though I had been a paramedic for years and thought that I knew some things, I was ignorant to how the special needs community lives and gets through daily events that are easy and normal for most. I was ashamed. I realized that the reason the police and both my partner and I were so quick to let Amy handle the little boy with Autism in the grocery store was because we were scared. We didn’t know what to do with something we didn’t understand. Give us a car accident, a robbery, a cardiac arrest and we’d be fine working as a team… but give us a small boy that didn’t understand that we were there to help him and couldn’t communicate back with us and we failed.

As a paramedic, I live in fear of the day that I have to call 911 for my step-son. I know most of the EMS people that would respond to a call for help in most of the jurisdictions that we travel in and while darn near all of them are top-notch, I’m still scared. I’m scared because I would be scared of the medic that I was just two years ago. Sure, I was “aware” of autism as being a thing, but I had absolutely no understanding of what it meant. I had no idea of how to manage behaviors from a person with ASD, and I really didn’t know how to manage my own behavior towards them. I had awareness without understanding. Even though now I’m much more well-versed in my behavior towards people with ASD and other special needs, I’m still not as good as I want to be. The subject is complex and requires a lot of study and personal growth. One day I might be as good as I want to be but today’s not that day. I still have a lot to learn.

As I said before, “Awareness” is super-neat and all and as the step-dad of someone with ASD I thank you for knowing that autism exists. Now I ask you to take the next step and give us all a little acceptance and understanding. Nobody here is probably going to find the next revolutionary therapy but we all can stop being rude when we see someone with ASD having a meltdown in public. We can give a little understanding and courtesy when someone with ASD is being themselves in a way that isn’t quite within the social norm because we understand they cannot help it. As caregivers, we can react with kindness and patience when we realize that someone’s communicative needs and thoughts on the situation at hand aren’t what we may expect them to be.

So you can go blue for autism. You can proudly display your puzzle-pieces. Heck, you might even put a ribbon on your car. However all I’m asking is that you give people a little leeway to be themselves and just be nice to people. Not everyone is the same and we all need your respect and maybe even a little help sometimes. That’s what would be really nice.

So in honor of all of those with Special Needs and also the people who love them, Happy Autism Month y'all.

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If you’re looking for training for your police, fire, or EMS agency on Autism, I recommend this group: http://autismalert.org/

If you’re looking for a window on understanding the world of families with children who have special needs, I recommend the “Imperfect community” at: www.ShutUpAbout.com

Posted by on April 3, 2013 • Filed under: Command & Leadership, Emergency Medical Services, EMS, EMS ethics, EMS Health & Safety, EMS Topics, Fire Rescue Topics, new perspective, News, Paramedic, paramedic education, Patient Management, Training, Training & Development

Pushing Down the Skills – Bringing New Tricks to BLS

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A post by Peter Canning, one of my favorite EMS authors who writes the blog “Street Watch: Notes of a Paramedic” has got me thinking. The post deals with what skills we should push down a level or two from the Paramedic scope of practice and allow EMT-Basics to perform in the field. In his very well written article “Where I Stand (Today)” He brings up many of the facets to this complex issue.

You should read the article, but this is my favorite part:

“I guess if I could summarize my position it would be this: The distinction between ALS and BLS should not be an artificial one where BLS gives no medication and does nothing invasive where ALS does. The distinction should be a common sense one made by medical oversight after weighing risk/benefit, cost, and need. BLS shouldn’t necessarily carry a medicine or do an intervention simply because they can. In our current system, they should be allowed to do these enhancements only if there is a demonstrated need.”

“Allowed only if there is a demonstrated need.” I like that statement, even if I can come up with arguments against it in both an academic and practical sense. As I stated some years back in a previous post: “A Late Night Rant about Petty Politics in EMS” there is a hierarchy of things that guide too many EMS decisions, and they’re not positive things, they are:

  1. Revenue Preservation
  2. Area Preservation
  3. Ego Preservation
  4. Political Capital Preservation

Make no mistake. Those four things are at play in this whole debate on what skills should be in the scope of practice for every EMS level. I’d bet that if I were to take an informal poll, most BLS providers would support their being allowed to perform many new skills now considered to be in the realm of the “advanced” provider. I’d also say that most ALS providers would not support giving a lot of those skills to BLS. There would be some disagreement, as some BLS providers would see the additional education required as being burdensome, and some ALS providers would see giving ALS skills to BLS providers as lessening their workload by reducing the number of calls where they are needed. However, I look at it as a very contentious issue.

Mr. Canning is correct when he says that this should not be an arbitrary decision based upon anything other than a demonstrated need and good information, however I can argue against that statement as well. I believe that patient physiology doesn’t change when one crosses a political boundary which is why I’m generally in favor of setting a national minimum standard for our profession. However, I also believe that there are places that have a better mix of available resources than other areas and/or a specific health complaint that is represented in their area and not in others. An example would be in my area of Illinois which is not known for jellyfish stings nor altitude sickness.

I’ve sat in meetings sponsored by EMS educational institutions and listened to groups of EMS and fire chiefs decry the academic standards that dictate the pass/fail standards for EMS students. Not a one of those chiefs ever wanted the standards increased. They simply wanted their personnel to pass the classes. I’ve also had a few EMS system directors make the comments that their protocols have to be written for the “lowest common denominator” of providers… because skills that were too complicated wouldn’t be appropriate for everyone. I say that EMS has an unfortunate downward-pressure on our educational standards as it is yet I agree with the EMS coordinators when they say that there are some EMS people out there who are simply too… dumb? Unmotivated? Non-academic? Oh what’s an appropriate word for it… “unable” to provide the skills that others could reliably and safely perform.

I’ve been on a lot of sides of this issue and I know that my opinion is not any more valid than some others on this topic, as the answer is probably data-driven and I’m not that smart. However I believe that there are skills that should be pushed down to BLS providers that they are currently not allowed to perform. I believe that these skills would most probably improve patient care and have other positive impacts upon the EMS systems in the areas where these skills were moved down. On the same coin, I believe that there are skills that a provider should only attain with the requisite educational background. For instance, the motor skills required to perform a surgical cricothyrotomy aren’t really that hard. If you can carve a turkey or change an oxygen cylinder, you can probably perform one. However, the background knowledge required in order to safely know when to and when not to perform one in favor of any of the alternatives is pretty vast and requires both a lot of experience and education.

Here’s the deal. If you are a BLS provider or someone in charge of BLS providers you should be looking for skills you can add to the BLS scope of practice. You should look first for what benefit will be added for your patients by providing the skill your considering and then look for the risks. All patient care interventions, from bandages to brain surgery have both risks and benefits that must be weighed carefully by someone well-educated before being performed on or withheld from a patient. My opinion is that if a provider’s educational level cannot be reasonably expected to carry the requisite knowledge required for safely performing a skill, than that provider should not be able to provide said skill. Things like BLS IV initiation, BLS narcotic pain medication administration, and BLS endotracheal intubation fall into that category. Sure, there are numerous patients who might benefit from having those skills performed by a provider of lower educational background, but there are many more that in my opinion would be harmed rather than helped by a BLS provider choosing to employ those skills improperly over the alternatives already available to them. Another one of my EMS mantras is that a provider should have “A reason for everything they do, and a reason for everything they do not do” for every patient. These skills are too risky, in my opinion, for BLS providers to perform due to the risk of harming more patients than they help.

On the flip side of the coin, this happens with ALS providers as well. A partner of mine (who, by the way runs a very popular EMS related business and Facebook page) related his own story about bringing a new device to the very progressive medical control system that is in charge of our service. He introduced to them a point-of-care testing device that would obtain lab values such as a troponin and other valuable tests using an easily performed prehospital blood draw. He thought that it would have been useful in cardiac care and help us dial in on both STEMIs with questionable ST elevation patterns and non-STEMIs alike. He was very disillusioned when the medical directors not only denied his request to incorporate the tool, but suggested that instead of using that device “if he really wanted to help” he should place EMS patients into patient gowns before arriving at the ED to make it easier on the ED staff. Would the devices have been helpful in our area? There are a handful of services in the state that use them, but in our area it was deemed to be not useful as we have a number of PCI capable facilities within a half-hours drive of most 911 calls and we would be taking any patient with a suspected cardiac issue to one of them anyway. In other, more remote areas, this is not the case and those services are using these devices in the field to varied success. The point is, when denied with what was considered to be such a flippant denial, our paramedics felt exactly the way I assume EMT-Bs feel when they have to call a paramedic to start an IV.

I’ve said before that there are providers of all levels that in all honesty cannot intelligently debate this issue. This is because “they do not know what they do not know.” Just as it would be unwise to call your neighbor if you were having chest pain and accept their diagnosis that you “probably just pulled something” as your neighbor would have no possible way of knowing, you can’t intelligently debate these topics if you’re not willing to dig as far down into the issue as it takes to fully understand it. That requires education, not necessarily formal education, but education none the less. As an ALS provider I have heard BLS ambulances transport patients who I considered to be in need of ALS interventions without calling for an intercept too many times. I’ve also heard their justifications for doing this and a vast majority of those justifications sounded like one of the four reasons above given to me by people who wouldn’t consider that they didn’t know what they didn’t know about the care the patient really needed. To be completely fair, those providers probably left the conversation considering me to be just another arrogant “paragod” and maybe I am, but I believe in my heart of hearts that I’ve got patients’ best interests in mind.

Also, always remember… there’s a name for BLS providers that have the ability to provide more advanced skills. They were called EMT-Intermediates (now called AEMTs) and they have more skills because they’ve had more education and have been held to higher standards. Come to think of it, that’s why paramedics have more skills than AEMTs do and why Doctors have more skills than paramedics.

This debate is going to continue on for a very long time and many potential paths can be taken. Every single skill that EMS providers at any level are able to perform requires knowledge, practice, and judgment. Each skill should have a thorough risk/benefit analysis that shows clear and real benefit to a wide enough subset of patients without producing undue risk. These skills should be easy to master, carry a low risk of harm, and be either better than the existing treatments or not have effective alternatives. If you’re going to make the suggestion, make sure you do your homework because our patients deserve that we know what we’re doing.

In a later post, I’ll detail what skills I believe EMT-Bs should all be doing. I believe we should expand their scope of practice and I’ll explain how then.

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Oh! And could you please look over on the Right hand side of the screen (close to the top) at the voting widget with the picture of my bathroom? I need your help! Please also take a look at the “I need your help!” page up on the top menu bar because I NEED YOUR HELP!

Posted by on March 15, 2013 • Filed under: Administration & Leadership, ALS Intercept, change, Command & Leadership, Emergency Medical Services, EMS, EMS Management, EMS Topics, EMT-Intermediate, Paramedic, paramedic education, Patient Management, politics, Scope of Practice, Training & Development, Uncategorized

Prehospital Pain Control

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

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

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

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

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

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

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

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

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

Dirty Wet Wipes, Millions of Dollars, and the Coming Changes to EMS

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It was quickly turning out to be one of those mornings. The ER was hopping and everyone was busy. We had been taking in a lot of ambulances since the start of the day shift and everyone was trying to muddle through the increasing patient load. While I was in-between tasks, I noticed that one of the nurses had left a backboard in the hallway outside of a patient room. I figured that I had a few spare moments and took it out to the ambulance garage to clean it and throw it in the cabinet. A mundane task wrapped up into a hectic day.

I have to tell you that I wrote and rewrote that first paragraph four times because I couldn’t seem to write it in a way where it sounds interesting. Cleaning a backboard in an ER isn’t all that exciting, right? Why would I write about something like that?

Because after I wiped the board down with the disinfectant towelettes, I was absolutely horrified with what I found.

The handful of disinfectant wipes I used to wipe the thing off with came out filthy. They were mostly black but were speckled with orange-ish brown spots that come from wiping up drops of blood. The board looked a tad dirty when I started and even smelled faintly of pee but I never expected it to be as dirty as it was. It was absolutely disgusting. What makes it all the worse is that there was no way the blood, dirt, and pee came from the patient who was most recently put on the board. That patient wasn’t bleeding, hadn’t peed, and was well dressed from a clean environment. The patient had been placed on this festering petri-dish of a medical tool by the (hopefully) well-meaning ambulance crew who had responded to the call for help. They had put her on this thing and happily whisked her off to the ER for treatment.

So why, you ask, is this important enough for me to write about. Why would I write about one single backboard carrying one single patient brought in by a small ambulance service to a small hospital? Why is that worthy of wider attention?

I’ll tell you why:  This one incident epitomizes a coming tsunami of liability, headaches, and hardship for EMS providers around the US that is going to completely blind-side EMS. A few years back the Centers for Medicare and Medicaid (CMS) quietly stopped paying for things considered to be “preventable medical errors” including hospital acquired infections. They believed that they could save substantial amounts of money by not paying for injuries and illness caused by the hospitals that were treating the patients they were financially responsible for. You might have guessed that Healthcare Acquired Infections (HAIs) happen to be the largest group of these preventable medical errors and hospitals have gone in to full battle mode to combat them.

It is estimated that one in twenty patients will contract a HAI during their hospital stay. It is also estimated that around 98,000 patients die each year from them. HAIs are the most common complication in hospital care of patients costing the US healthcare system around $45 Billion annually.

Hospitals have to take care of patients who contract HAIs in their facility; they’re just not paid to do it. There are estimates out there that say it costs an individual hospital between $10,000 and $25,000 (or more) for every instance of an individual patient contracting a HAI while in their facility. That’s not small change and hospitals are spending money like crazy to fight germs. Infection control departments are being fully staffed and well-funded, housekeeping and environmental services workers are sitting through hours upon hours of training, policies and procedures for cleaning and disposing of potentially contaminated items are being written and enforced by the truckload and they’re just getting started.

And we in EMS are largely oblivious to this fact.

Think of this. If this patient would have been admitted and found to have a HAI, who would have been at fault? Think hard, because tens of thousands of dollars are on the line per each individual patient. Is it the hospital, which has an army of environmental services staff, a battalion of infection control nurses roaming the hallways, and a forest of policies and procedures in place regarding meticulous cleaning practices? Or the EMS agency that brought in a patient on the backboard that was as clean as those wet wipes showed us it was?

To my knowledge, no hospital in the United States has ever sued an ambulance service or otherwise attempted to collect from one due to non-payment related to a HAI. But it’s coming. It’s coming sooner than you think it will come and if you’re not ready it will blind-side you and potentially bankrupt your service. If you think that I’m mistaken, fine… however when Millions of dollars are on the table locally and Billions are on the table nationally… I don’t think that I am.

Clean your stuff. Wash your hands. Write policies regarding cleaning and infection control, enforce them, and document their continuous use. It’s not a small issue. This is one of those things where EMS must act now or someone will act for us.

Oh, and on that note, have you heard about Medicare’s new concept of paying for patient outcomes? This is where hospitals that have better results for their patient care will get more money than hospitals that have poorer results for their patient care? That’s coming too. What do you think it will do to ambulance services when the hospitals start to identify services that consistently bring in patients who do poorly as opposed to services who consistently bring in patients who do better? Right now, nobody knows… but that issue is coming too. Believe me, the hospitals are tracking it. It’s time to get to work.

Here’s some light reading for you as well as my references.

http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf – CDC analysis paper on cost of HAIs and benefits of prevention.

http://www.huffingtonpost.com/glenn-d-braunstein-md/hospital-acquired-infections_b_1422371.html – Good article with statistics from about hand-hygiene

http://www.medicalnewstoday.com/articles/80074.php – Medicare to stop paying for HAIs

http://www.hfma.org/Templates/InteriorMaster.aspx?id=22142 – Article about pay-for-performance and pay for patient outcomes

Posted by on September 27, 2012 • Filed under: Administration & Leadership, ckemtp rants, Command & Leadership, disinfection, Emergency Medical Services, EMS Health & Safety, EMS Topics, Fire Rescue Topics, Funding & Staffing, infection control, Patient Management, Training, Training & Development

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

FIrefighter Pre-Hydration – Fight Fire like a Marathon Runner

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Has anybody else noticed that it’s sweltering outside? There’s no other way to describe the oppressive heat we’ve been facing without trotting out the word “sweltering.” The word itself is almost fun to say. I recommend that you work it into as many conversations as you are able these days while you toil outside in the intense heat. It won’t keep you any cooler, but at least you’ll be adding to the vocabularies of the other sweaty people working around you. It sure beats asking them if it’s “Hot Enough” for ‘em. That gets annoying.

In the last few weeks here in Southern Wisconsin we’ve been having some terrible fires requiring response from multiple area departments. Some of them have been heat related and some of them have just come at a bad time, but all of them have had one common denominator. They’ve all been dangerously hot. Not just the fires themselves, but the oppressive, dangerous, and potentially deadly heat on the fire ground due to the weather conditions has contributed to multiple firefighter injuries. Thankfully, most of the injuries have been minor and heat-related but some of them have been worse. I don’t know if the heat contributed to all of the injuries suffered by those brave firefighters, but it certainly couldn’t have helped.

In times like these, all firefighters need to remember the fact that active firefighting activities are nearly the same as competitive sporting events. Firefighters working on active fire grounds have the same or higher demands put upon their bodies as do athletes on the playing field. It is of extreme importance to remember that fact and take appropriate action to keep yourself and your brothers and sisters safe. Extreme weather is a great equalizer. It affects all of us no matter our station in life. Everyone on the scene has the responsibility to recognize the risk they’re taking by exerting themselves outside in these conditions and take appropriate steps to protect themselves. Nobody wants to see their fellow firefighters fall ill and even less than nobody wants to be the firefighter who goes down themselves.

By design, firefighting personal protective equipment provides an effective barrier to thermal energy. This becomes a problem in hot weather because it doesn’t allow for the shedding of excess body heat and raises the core temperature of the wearer quite sharply. While after years of promoting rehab, even the staunchest believer in their own invincibility can usually be coerced or threatened enough to go to rehab after heavy work on the fire ground, rehab is of even more importance during hot weather because it allows the firefighter to shed his or her PPE and allow that body heat to escape. However, it is important to remember in times of extreme hot weather like we’re facing now that rehab after working is not enough to keep you safe from heat-related injuries and illness. It’s simply too hot for normal people to work effectively without prior planning and preparation. Athletes spend days preparing themselves before competing in physical events by resting adequately, storing up calories and carbohydrates, and pre-hydrating. We should as well.

While it is important to keep yourself nourished with healthy food, I don’t recommend that firefighters load up on calories and carbohydrates before every shift like runners before a race. I do recommend pre-hydration. To pre-hydrate is to drink water before you need it and it is important to realize that one should drink water before they are thirsty to maintain normal hydration. While the adequate daily intake of water for healthy adults varies due to temperature conditions, levels of activity, and other factors, the Institute of Medicine (IOM) recommends that adult males take in 3 liters of water per day and adult females take in 2.2 liters. The water doesn’t need to come only from drinking water, and can come from water stored in food we eat. The IOM says that if a human is producing around 1.5 liters of pale yellow to clear urine per day and is urinating at least once every 3-4 hours they are at close to normal hydration levels. However, many factors affect our hydration and it is easy for a person to become dehydrated without realizing it. Dehydration leads to fatigue, headaches, tachycardia, low blood pressure, and other nastier symptoms that greatly affect firefighting performance and safety. It has been stated that it is not uncommon for firefighters to lose two liters of water through sweat while working on the fire ground in full PPE. If you start to sweat that much when you are already dehydrated, you will not be effective for very long.

Pre-hydration is all about keeping your water tank full before you respond and is as simple as drinking water throughout the day and maintaining your hydration levels. Since fighting a fire in full gear can be compared to running a marathon, we may want to emulate their guidelines. Marathon runners are taught to drink 20 to 32 ounces of water 2 to 3 hours before running and then to drink 8 to 10 ounces of water every 20-30 minutes before they run. While actually running, they are advised to drink 8-10 ounces of water every 20-30 minutes as well. It is not advisable to intake a large amount of water before engaging in strenuous activity because it takes time for the water to move from the stomach to the large intestine and be absorbed into the blood stream. Too much water in the stomach at once can lead to nausea and vomiting during periods of strenuous activity. Sports drinks with electrolytes like Gatorade, Power-ade, and others like them should be consumed occasionally to replace any electrolytes lost through sweating however there is no need to pre-load yourself with them as the body does not store more electrolytes than it needs and excretes any excess quite rapidly. Replacing lost electrolytes through food is of great value, and most can be replenished by eating fruit like a banana. In addition, avoid soda pop, carbonated beverages, or beverages that contain high amounts of caffeine and/or sugar as these drinks can actually contribute to dehydration by acting as diuretics.

It is easy to encourage pre-hydration among your crews. People need to drink water before they feel thirsty, and should continuously drink small amounts of water through the day. Place water in conspicuous areas throughout the station and the living quarters. Water that is out of sight is out of mind and can be forgotten. By placing water right in the line of sight of everyone, they are reminded of the need to have a glass or two. You can make the drink more attractive by adding commercial flavorings like lemonade, crystal light, or Mio mixes that add taste without adding too much sugar. Another trick is to place the bottles of water in the engine next to every staffed seat and encourage every firefighter to drink a bottle during any response to a working incident.

By pre-hydrating, you will ensure that you and your fellow firefighters hit the fire ground with full water tanks and can perform at peak levels in this oppressive heat. Keep yourself hydrated and stay safe out there. We’ve sickened and injured too many firefighters lately and I don’t want it to keep up. Turn the tide and drink up. You’re worth it.

Posted by on July 9, 2012 • Filed under: Administration & Leadership, Command & Leadership, EMS Health & Safety, fire, Fire Rescue Topics, Firefighter Safety & Health, Firefighting Operations, Training, Training & Development, training-fire-rescue-topics

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

Heat Emergencies for EMS – The Summer Time Blues

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It’s just about here! Summer time is awesome in where I live. It almost makes those long winter months seem worth it. Almost. With the warm weather close upon us it’s time to review some of the common complaints that EMS providers seem to see more of in the summer time. Gone are the days of frostbite and hypothermia and here are the days of heat stroke and bee stings. It pays to brush up on these complaints because we’ll be seeing them before we know it.

Heat Emergencies

We humans are a fickle bunch. Get us too cold or too hot and we tend to get sick as the dog days of summer. Since there’s little chance of hypothermia coming in the summer, a review of the hotter side of environmental emergencies couldn’t hurt. In emergency care, heat emergencies are generally classified into three levels in terms of severity. These are:

  • Heat Cramps
  • Heat Exhaustion
  • Heat Stoke

It’s important to remember that these classifications aren’t absolute and are harder to pin down when combined with concurrent medical conditions and other factors such as age, gender, and physical health. It’s also important to realize that some physical conditions, caffeine and alcohol consumption, and prescription medications can diminish a patient’s capacity for thermoregulation and precipitate heat injury.

Heat Cramps – Generally occurring in athletes or those undergoing physical exertion in a hot environment, heat cramps are muscle spasms that mostly occur in the abdomen or extremities. (Core temp 99.1-101.3)

Treatment for Heat Cramps includes general medical care, removing the person from the hot environment, providing oral fluid replacement, and cooling them gently.

Heat Exhaustion – Characterized by Fatigue, weakness, anxiety, intense headaches, profuse sweating, nausea/vomiting, and decreased urine output, heat exhaustion is caused by inadequate fluid intake and excessive fluid loss through sweating. It is essentially hypovolemia caused by hyperthermia and may be the result of several days of inadequate fluid replacement and dehydration. (Core temp 99-104)

Treatment includes much the same as the treatment for heat cramps. Do not give oral fluids to patients with a decreased level of consciousness. If your level allows, start an IV and consider a fluid bolus. Begin active cooling with ice packs to the axilla and groin. Monitor the patient’s vitals closely and watch for cardiac arrhythmias. BLS providers should consider an ALS intercept for fluid replacement.

Heat Stroke – This is a true medical emergency and aggressive treatment is warranted. It is characterized by a decreased level of consciousness, increased pulse and respiratory rates, and hypotension. Skin color, temperature, and moisture findings are not reliable but are generally hot and dry. It is becoming shown that patients that suffer near-fatal cases of heat stroke have a strikingly high 1 year mortality rate. (Core temp >105)

 

Treatment for Heat Stroke includes aggressive cooling with ice packs, evaporative cooling, and IV fluids. BLS providers should request an ALS intercept. Rapid transport is warranted. Manage the airway and other complaints such as arrhythmias as per protocol.

Watch your coworkers too. Make sure that your fellow EMS people are staying cool on incident scenes, especially when they may be wearing turnouts or other protective gear. When you're not actively performing tasks that require protective gear, strip it off to allow yourself to adequately cool. Push them to drink plenty of fluids and go to rehab when they need to. Be safe out there and watch each other’s backs. We need you out there.

Posted by on April 16, 2012 • Filed under: ALS Intercept, Emergency Medical Services, EMS, ems education, EMS Health & Safety, EMS Topics, EMS training, Firefighter Safety & Health, Paramedic, paramedic education, Patient Management, Training, Training & Development

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

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

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

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

Lead Placement

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

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

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

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

Skin preparation

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

Baseline

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

Multiple EKGs

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

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

Conditions Requiring an EKG

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

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

GPS in the Ambulance – An overreliance on Ms. Kitty

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Actual conversation between me and my partner a few years ago right after receiving an emergency call:

Me:        “Lemme get this on the map… I think it’s South of us. Head South… Southeast! Yeah, it’s Southeast of us”

Her:       “Whattaya mean Southeast!? I don’t know directions. You’ll have to tell me Left or Right!”

Me:        < Scanning the map> “Um… Ok, we’re heading North, so make a Right up here on River Drive and head to Mulford. The street is right off of State and Mulford, one West and two South”

Her:       “It’s what?”

Me:        “Just head to State and Mulford and I’ll get ya in”

Remember that? Remember those days when we used to use paper maps? I do. Man, those days were crazy… back when we had to use those archaic things, right?

Actual conversation between me and a different partner in the much more recent past while driving to an emergency call:

Me:        “Dang it! The GPS won’t get satellite signal! I can’t lock in the address”

Him:       “Where do I turn? What street is it off of?”

Me:        “Hang on, I’ll try to look up the address from my phone… Gah! Why is the connection so slow!?”

Him:       “I’m going to turn down this street… what was the address again??”

Me:        “Um… I think it was… 432 Mulberry… I think… Don’t we have a paper map in this truck???”

Him:       “I didn’t see one. Maybe I can get the address on my phone.”

Me:        “Wait, is that a cop up ahead? I think he’s at the call, drive up there.”

Cop:       “Hey! What took you guys so long!?”

Ain’t modern technology great?

It was only a few years ago that we got GPS machines in the ambulances I ran in. Previous to that we had survived off of our “Stacy Maps” which were these awesome map books designed by a local company. They weren’t sexy or technologically sufficient for the times… but they always got the job done if you knew how to use them. Sure, they were hard to read by yourself if you were the only one navigating the truck, but they worked… every time. No outside force could stop them from working. If you had one, you weren’t lost, period.

Now, with our increasing reliance on the magic voice in the GPS box (I call my GPS voice Ms. Kitty) we seem to be able to get to our calls seamlessly and smoothly… 90% of the time. There are times when the GPS doesn’t work, times when it’s just too darn slow, and times when it doesn’t have an address to lock in to. The GPS just isn’t always optimized for emergency response. I’ve found that my GPS is great when I am dispatched to 9933 Harrison St as a physical address… but not so much when I’m dispatched to “The bike path in the field behind Costco off of the side road next to the blue house”.

I remember a call I got once when I was working a relief shift at a contracted rural station. We had just cleared a call from a downtown hospital when the service got a call for a nasty auto wreck out in the country. Their dispatch asked us to respond as the third ambulance. I usually worked in the city the hospital was in so I knew how bad the regular routes were clogged with construction, being as it was summer in the Midwest. I drove and was able to use my knowledge of the city to get us around every bit of it. I took State St to Prospect, Prospect to Guilford, Guilford to Highcrest, Highcrest to Springcreek, Springcreek to Springbrook, Springbrook to Perryville, to… well, you get the idea. I was able to bob and weave through that city so much that we arrived at the scene in record time… which was just in time to be cancelled and sent back to quarters.

What I’m saying is that I knew the city so well because I had been forced to learn how to navigate it by reading paper maps. A skill that sadly, I’m afraid we’re losing as we increase our reliance on the magic directional box and the voices inside of it. GPS is a great tool, but since a huge part of our effectiveness as EMS people is actually being able to arrive at an address in a timely manner, it can’t be our only tool to find one. If you're relying on your GPS as the only tool you have to find the address of an emergency call, you're turning your GPS machine into a life-safety device. I'm sure the manufacturer will agree that It was never intended to be one of those.

My advice is to learn to love your paper maps. Read them. Study them as much as you study your medical protocols. Drive around your wider response area without turning on your GPS. Get lost in it every now and then and try to find your way around. Be sure to pay attention to the hundred blocks, the street names, and the short cuts. Don’t become clueless when Ms. Kitty takes a coffee break.

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For more of my “You Kids Get Off My Lawn!!” ramblings, you may want to check out “Those Darn Kids!”

Posted by on October 26, 2011 • Filed under: 911 fail, Command & Leadership, Emergency Medical Services, EMS, ems education, EMS Health & Safety, EMS Humor, EMS Management, EMS Topics, EMS training, Fire Rescue Topics, Paramedic, paramedic education, stories, Technology & Communications, technology-communications-ems-topics, Training & Development, training-fire-rescue-topics

Blood Pressure – Vital Knowledge for EMS

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

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

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

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

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

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

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

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It can diagnose Orthostatic Hypotension

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

What does this mean?

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

(Read More? http://www.medicinenet.com/orthostatic_hypotension/page2.htm)

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It can help diagnose a Thoracic Aneurism

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

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

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 It can help detect increased intrathoacic pressure and other conditions

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

What does this mean?

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

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

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

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

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Want to learn more stuff about stuff? Check out:

 

 

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

EMS Narrative Report – Ckemtp on the MedicCast EMS Podcast

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EMS Narrative Report writing is one of the most important skills an EMT or Paramedic should hone in order to make themselves a better provider. They can improve their long-term patient care, and improve the image of the profession in other healthcare providers' eyes through a well-written, informative narrative report. Not only is a properly documented EMS narrative report critical for communicating vital information about the events of an ambulance call, it also helps shape a patient's overall progression through the healthcare system. Last but definitely not least, a well-written EMS narrative report can keep your butt out of legal hot water and may just save your career. 

Recently, Jamie Davis invited me to speak on the MedicCast EMS podcast, his ever popular educational EMS show that comes out every Monday. In this two-part series, we discuss my piece: "Six Tricks You Can Use Today to Improve Your EMS Narrative Report." and various other ways an EMT can improve their narrative report-writing skills. As always, Jamie offers excellent guidance on the topic which helps drown out my babbling.

If you'd like to download it, head to the post page by clicking HERE or clicking on the logo on the Right.

Otherwise, you can view it here.

Part two will be posted here when it comes up. Look for it next week!

Also, look for all of my stuff on EMS Narrative Reporting, click here.

 

Posted by on June 14, 2011 • Filed under: Emergency Medical Services, EMS, ems education, ems narrative, EMS narrative report, EMS Topics, EMS training, emt narrative, Paramedic, paramedic education, paramedic narrative, Patient Management, soap, soap charting, Technology & Communications, Training & Development, training-fire-rescue-topics, Uncategorized

Eight Ways you can Ace your Patient Assessment – EMS

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

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

Take a look at the three general types of assessments:

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

 

 

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

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

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

 

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

                                                    

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

 

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

 

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

 

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

 

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

 

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

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

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Want more information on the patient assessment?

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

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

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

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

Keeping an Eye on the Sky

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If some of you out there don’t know it yet, I’m away from my home area working one of my jobs in another state. I’ve been gone for just over a month at the time I write this and I haven’t gotten my end date quite yet. I may be here a while longer.

Last night I came back into my hotel room and turned on the TV to find none other than Jim Cantore on the screen talking about my home area. Apparently, the wrath of Mother Nature isn’t limited just to other areas of the country. My area took it pretty hard last night and thank goodness there weren’t any injuries.

My girlfriend (Oh yea, I have one of those now by the way, which you would know if you followed me on Facebook or Twitter) was driving my car during the storm and just happened to drive right into the heart of the gust line, the leading edge of this monster storm. She ended up taking the brunt of it and had to leave the car and take cover in a ditch (Which by the way, is the smart thing to do) she got scraped up a little bit by flying debris and all; but thank goodness… the car is fine. (Love ya honey!)

This storm blew up quickly and just exploded out there. To my knowledge, there wasn’t a tornado formed, but the wind gusts were reported at upwards of 80mph and were forecast to hit over 100mph. The rain was torrential and the storm lasted a long time, lashing the area with high winds for quite a while. It was a bad one, but thankfully not as bad as other areas of the country have been getting. There was some damage, and my local Facebook buddies have been posting pictures of it on their accounts all morning. It could have been much worse, but it was pretty bad by itself. It certainly was a wake-up call.

Talking to my girlfriend on the phone last night after her scary ordeal she told me how she figures she was able to be caught off-guard by the storm. While she drives, she listens to MP3s rather than listening to the radio and therefore did not hear any severe weather warnings. She said that as soon as she saw how bad the storm was getting that she turned on the local radio, but by then it was too late… she had driven right into the path of the oncoming fury. A few days prior to this, I had discussed with her the possibility of employing underground storm shelters in our area and she said how she thought it was overkill. She didn’t think that we had bad enough weather in our area. I assured her we do get bad enough storms often enough, but the conversation didn’t go much further. Storm preparedness, like fire safety, is not a flashy topic. It doesn’t seem to be taken seriously until after something happens. However, as Mother Nature has proven to us this season, we need to be prepared.

The girlfriend is a smart lady, very smart actually. She’s not one to be taken off-guard by anything and can handle most anything that comes. This, however, was a surprise to her and I’m sure it surprised a lot of other people as well. It’s not that we don’t get storms like that in my area, in fact they come quite frequently, but people are still complacent about them. They just don’t think that it could ever get that bad, no matter what they see on the news happening in other areas. There are a lot of things in our society that are affected by our natural tendency to become complacent in our contemporary lifestyles. There are lots of things we just seem to forget can happen to us when we’re caught unaware by the realities of our world. Everything from storm preparedness, to fire safety, to cardiovascular health, to crime prevention, to drinking and driving, to most of the behaviors that keep EMS in business can be attributed to this fact. It’s just how we’re wired, I think.

If I can offer you all out there any advice, it would be to consistently remind yourself of the need to be aware of your surroundings. Maybe it’s the fact that as a paramedic my life is spent cleaning up the messes of the more unwary of those among us, but I tend to believe that most “accidents” can be attributed in most part to a lack of planning and situational awareness. I don’t want anyone to be afraid of living their lives, but keeping an eye on the horizon seems prudent these days. Don’t be caught off guard. I need all of my readers out there and want you to be safe.

Also, if you’re driving and you see or suspect severe weather, turn on the radio and turn off the CD or the MP3 so you can hear emergency broadcasts. It might just save your life.

Have you been to these websites yet?

As always folks, stay safe out there.

Posted by on June 9, 2011 • Filed under: Ambulance, ckemtp, Emergency Medical Services, EMS, EMS Health & Safety, EMS safety, EMS Topics, FEMA, Fire Rescue Topics, first responder, Paramedic, severe storm pictures, Training & Development, Uncategorized

Assessing Greatness – Catching the stuff you’re supposed to

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What the heck is wrong with this guy!? You just can’t figure this one out and your patient seems to be crashing before your eyes. You were originally called for the “Unconscious unknown” at a party house frequented by college students and found the 28 or so year-old male unresponsive. Everything you check seems to be a dead end. His heart rate is fine, but slowing… His respirations are adequate but you’re certainly considering getting out the bag-valve-mask… You’re popped your line and given 2 full milligrams of Narcan but that hasn’t had any response. His pupils are PERRL but sluggish. His skin is pale, cool, and moist but not diaphoretic… and there doesn’t seem to be any trauma. Everything with this guy is a dead end treatment wise and you decide that this guy simply needs to be treated with diesel. You have your partner hop up front, turn on the twinkles and the woo-woos and beat feet to the hospital. All the way you check and recheck, trying to figure out if you can fix this guy. Unfortunately, you don’t make any headway before you reach the ER.

After you finish cleaning and restocking the truck to return to service from the ER you walk past the patient’s room on your way to get a cup of coffee. You’re shocked to see that the patient is sitting up, is alert and talking, and seems to be doing just fine. Incredulously, you ask the nurse what happened. She asks you what the reading you got for the patient’s blood sugar in the field was, and before your mouth can speak, all of the voices in your head seem to scream at you in unison “Holy Flying Pig Tarts!!” you forgot to check the patient’s blood sugar, thinking that it was most probably a narcotic overdose. The ER didn’t however, and found that the patient’s blood glucose was 20.

Have we all been there? Can we just admit that we all have found ourselves in this or a similar situation at least once or twice in our storied careers? As much as I am ashamed to admit it, I have found myself in similar situations where it seems I just messed up and left out an important part of my assessment. Somehow, something important like taking a quick blood glucose reading on an unresponsive is going to slip your mind somewhere in your career and in your adventures in the field and it’s going to bite both you and your patient in the hindquarters. Mistakes, or rather oversights like this are all too common in all branches of medicine because we as the healthcare professionals are simply human beings trying to absorb and process way too many pieces of information at once.

Much has been decried about the practice of “Defensive Medicine” where healthcare providers, mostly physicians, order unnecessary tests simply to avoid missing an obscure case and being sued because of it. People are constantly irradiated for unnecessary X-Rays, CT scans, and other such tests or so say the detractors of these practices. They say that it exposes patients to unnecessary testing, causes a false sense of security, and drives up the costs of healthcare exponentially. Popular culture has even jumped on the bandwagon, with the heroes of popular medical dramas coming out against the practice and being regarded as cowboys or mavericks. The public then eats it up… until they have a headache and don’t get a CT scan to ease their worried nerves.

However, not all practice of defensive medicine is a bad thing and in fact, in EMS I believe that this practice can be a good thing. I have long believed in my career and in my professional paramedic practice that every patient deserves a thorough and standardized assessment. Sure, I am pretty darn good at coming up with my working diagnosis based upon my solid initial assessment with a few secondary and tertiary assessment tricks to narrow in on the diagnosis and get my differentials, but the foundation remains the same. Everybody gets the same head to toe assessment. I’ve standardized it so that I don’t miss anything… or at least that I don’t miss as much as is possible not to miss. Standardizing your assessment and performing the same assessment on every patient every time becomes a security blanket and helps keep your assessment skills sharp with every call. Sure, it may seem silly to listen to lung sounds on a patient with a twisted ankle, or to check pupil reaction on the finger amputation, but you don’t have to let the patient know you’re doing it. Just look at them. Make sure you hit every high point in your standardized assessment with every patient, and you’ll catch a lot more zebras than you’ll miss.

In addition, there are some ground rules that I follow with certain types of patients and those fancy diagnostic tools that they give us to play with. First and foremost, if they say that skin condition, color, temperature, and moisture is the fourth vital sign, then blood-glucose level is the fifth. Sure, not every patient needs a lancet poked into their finger to have the machine read the number, but certainly every patient with an altered level of consciousness does. Even if you think the cause of the patient’s condition is something else, like the patient I had the other shift who was hypotensive and septic with a high fever, check it anyway… because the patient in the above example had a blood glucose of 40mg/dl and responded quite well to some fluid and the D-50 I gave him. Other patients who may not need to be poked can still have hyper of hypoglycemia ruled out by asking them their bladder habits (hyperurination), their last oral intake (Have they eaten enough not to be hypoglycemic) and other sugary questions.

Then, there’s the 12-lead. Can I just say that I see darn near close to zero reason that every patient who gets into an ambulance cannot get a 12-lead EKG done on them? To be sure, I don’t give every patient a 12-lead… but for anything that could be even remotely cardiac related I will perform one. Lethargy? Check. Flu like symptoms? Check. Syncope or near-to-it? Check and Check. It takes only a few minutes to perform and you can really make a difference in a patient’s overall healthcare pathway and well being by taking a symptomatic 12-lead tracing and starting the trend of monitoring. Before we all had the tool (Sorry Chicago… you should be catching up with the rest of the world soon) just how many ischemic cardiac events went undetected?

The crime here lies firmly in the realm of the underassessment, not in overassessing. The patient assessment is the cornerstone of everything we do and takes priority to all but the airway, breathing, and circulatory status of all patients. Making sure to be thorough and methodical in your assessment practices saves not only lives, but your own butt in the process. You cannot over assess just as you cannot overeducate yourself as to what potential findings mean. Just as an EMT basic can ask the same questions as the most seasoned paramedic, they can also ask the same questions as an ER doctor with the proper self education.

EMS needs to see itself as playing a role in the overall healthcare system and in the final care pathways for the patients we treat. Becoming an expert at the patient assessment is a big role in this. Remember, you’re the person who sees the patient in the first stages of their acute illness and in their entry into the healthcare system. Your thorough assessment goes a long way into the wellbeing of every patient you touch. Be great at it.

Posted by on January 13, 2011 • Filed under: Emergency Medical Services, EMS, EMS Topics, EMS training, Paramedic, paramedic education, Patient Management, Training & Development

Primary Care Paramedics? I think it’s time

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

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

The Medic is In

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

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

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

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

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

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

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

It’s maddening.

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

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

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

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

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

Any suggestions on where we begin?

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

Colorado CRNAs Vs. Virginia Physicians? An interesting feud for EMS

25 comments

This article came across my Twitter stream this morning. It regards a letter sent to the Centers for Medicare/Medicaid Services by the Governor of Colorado informing them that in some Colorado hospitals it is now acceptable for Certified Registered Nurse Anesthetists to work independently of physician supervision.

The article, which is in the form of a letter written to the editor of The Aspen Times, is written by a Dr. Paul Rein who is the President of the Virginia Anesthesia and Peroperative Care Specialists. He takes issue with the lack of physician oversight and is “quite concerned” about it.

I think that the letter is important for EMS people to read. Especially us EMS people that are looking at how to expand our profession, grow our scope of practice, and expand our skill sets. It shows that there are struggles over these kinds of boundary and oversight issues all over the healthcare arena and that the politics and power struggles aren’t just limited to those of us that ride ‘round in ambulances.

The full text of the letter can be found here at The Aspen Times: http://www.aspentimes.com/article/20101004/LETTER/101009942/1020&ParentProfile=1061

The parallels I can draw from this issue to EMS are striking and enlightening. Here are some of the parts of the letter that I found the most interesting:

“A nurse anesthetist is an advanced practice registered nurse who has received special training to administer anesthesia, usually being supervised by an anesthesiologist. Anesthesiologists are physicians who, after medical school, receive an additional four to five years of specialized training during residency. Not only do anesthesiologists function in the operating room but they are trained to medically evaluate patients prior to surgery and to take care of problems that may arise immediately after surgery. In a few small hospitals a nurse anesthetist may be supervised by the surgeon if there is no anesthesiologist.”

I was curious as to the educational standards of a Certified Registered Nurse Anesthetist and so I went to their National Association’s web site: Http://www.AANA.com – It says this:

“The requirements for becoming a Certified Registered Nurse Anesthetist (CRNA) mainly include having a bachelor’s degree in nursing, or other appropriate baccalaureate degree, Registered Nurse licensure, a minimum of 1 year acute care experience (ICU, ER for example), and the successful completion of both an accredited nurse anesthesia educational program and the certification examination.”

(Source: http://www.aana.com/BecomingCRNA.aspx?id=98&linkidentifier=id&itemid=98)

Huh.

Actually, I wasn’t familiar with the requirements for a CRNA before I read that, but it says that they have to have:

  • A four year degree in Something
  • Licensure as a Registered Nurse
  • A minimum of One Year Acute care experience
  • Completed an Accredited training program
  • A passing grade on the certification exam

I was curious, so I popped on over to Salary.com and typed in “Registered Nurse Anesthetist” in my own zip code for a base salary search. I found that they start out at $131,000 and top out at over $170,000 in my local area.

Then, after giving serious consideration to changing this blog from “Life Under the Lights” of Fire Trucks and Ambulances to “Life Under the Lights” of an Operating Room, I decided to point something else out about the differences and similarities of a Paramedic and a CRNA.

 “The didactic curricula of nurse anesthesia programs are governed by COA standards and provide students the scientific, clinical, and professional foundation upon which to build sound and safe clinical practice. The basic nurse anesthesia academic curriculum and prerequisite courses focus on coursework in anesthesia practice: pharmacology of anesthetic agents and adjuvant drugs including concepts in chemistry and biochemistry (105 contact hours); anatomy, physiology, and pathophysiology (135 contact hours); professional aspects of nurse anesthesia practice (45 contact hours); basic and advanced principles (sic) of anesthesia practice including physics, equipment, technology (sic)  and pain management (105 contact hours); research (30 contact hours); and clinical correlation conferences (45 contact hours).

Most programs exceed these minimum requirements. In addition, many require study in methods of scientific inquiry and statistics, as well as active participation in student-generated and faculty-sponsored research.

Clinical residencies afford supervised experiences for students during which time they are able to learn anesthesia techniques, test theory, and apply knowledge to clinical problems. Students gain experience with patients of all ages who require medical, surgical, obstetrical, dental, and pediatric interventions. The results of a 1998 survey of program directors show that nurse anesthesia programs provide an average of 1,595 hours of clinical experience for each student.”

(Again, from http://www.AANA.com – the emphasis is mine)

Remember that the CRNA’s have a Bachelor’s Degree and a RN license prior to beginning their training. This is different from the Paramedic curriculum. We have hour requirements as well:

“The emphasis of paramedic education should be competence of the graduate, not the amount of education that they receive. The time involved in educating a paramedic to an acceptable level of competence depends on many variables. Based on the experience in the pilot and field testing of this curriculum, it is expected that the average program, with average students, will achieve average results in approximately 1000-1200 hours of instruction. The length of this course will vary according to a number of factors, including, but not limited to:

-student’s basic academic skills competence

-faculty to student ratio

-student motivation

-the student’s prior emergency/health care experience

-prior academic achievements

-clinical and academic resources available

-quality of the overall educational program”

 (Source: Http://www.EMS.gov – Thanks to Chris Webster, Sam Bradley, Greg Friese and Kevin Reiter)

Not that the above is related to the article I read, I mean it’s saying that people with a BS degree in something, a medical license, and what amounts to a little more than an EMT-B class plus an EMT-P class from an accredited school make an average of $150k… but I digress.

Back to the article, Dr Rein has this to say about CRNAs:

“It is interesting to note that the United States is the only westernized country in the world that allows nurses to administer anesthesia unsupervised. Countries such as Canada, Australia, New Zealand, Japan and Israel, just to name a few, have no nurses administering anesthesia. In some European countries there are a few nurse anesthetists who work under the strict supervision of a physician.”

He continues and says this:

“So what’s up with us? Well, it seems that the American Association of Nurse Anesthetists have convinced our government in Washington that unsupervised nurses are just as safe as a physician. They point to the fact that there are no comparative studies to show they are not. The reason there are no studies is that it would be unethical to perform such a study in which some people get a physician and some do not. Can you imagine a patient agreeing to participate in such a study?”

Can you imagine indeed?

Dr Rein is right when he says in the letter that Anesthesia is a Medical profession and is a specialty of physicians for a reason. When he says “Just because we have made it safe is no reason to take it for granted”, he’s right as well. Anesthesia is dangerous for the untrained and inexperienced provider and it is a specialty not to be taken lightly. However, where’s the line? Is this an attempt by the”Virginia Anesthesia and Peroperative Care Specialists” to fire a shot at the “American Association of Nurse Anesthetists?” Are Doctor Anesthesiologists afraid of losing jobs to the nurses? Where is the line where patient safety is best maintained while being most cost-effective and efficient?

If this doesn’t provide incentive to you to think about requiring a degree for Paramedics, I don’t quite know what will. I’m not doing this job for the money and neither are you, but does that make us any more or less moral than a CRNA who “Isn’t doing his/her job for the money” either, but still makes a ton more of it than any paramedic I know?

You could change the names of the players in this argument, fiddle just a bit with some of the details, and change this into one of a thousand other feuds going on under the healthcare umbrella. This is the same story that paramedics face when we’re trying to get new skills, new techniques, more money, and more responsibility. While I’m not taking a stand on the CRNA/MD issue because it’s not my specialty, I’m offering up this debate as a study in professional growth and conflict between two of the myriad of medical camps out there. As we push EMS forward, grow as a profession, and promote the EMS 2.0 agenda, learning from things like this will be of value to us all.

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Thanks to the following for their contributions:

Posted by on October 4, 2010 • Filed under: ckemtp rants, Emergency Medical Services, EMS, ems 2.0, ems education, EMS pay sucks, EMS pep talk, EMS Topics, EMS training, medical ethics, News, Paramedic, paramedic education, Patient Management, physician, politics, potential, profession, Training & Development, Uncategorized

EMS case law? AMA Refusals, Death, and Documentation

18 comments

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

17 comments

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

Shining through Suffering – Learning How to Cope with Sadness in EMS

7 comments

Medic Trommashear, who writes great stuff has offered to co-post with me on this. You can check it out at her blog: http://lookingthroughapairofpinkhandledtraumashears.com/

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This morning the wife came home from her night shift on the ambulance and told me a sad story. During the wee hours of the morning she handled a rather nasty fatality accident. The victim, a 20-something male was walking home from a party on a dark country road and tragically, a passing motorist didn’t see him in time and the accident ensured that he’d never make it. Pedestrian vs. car accidents at high speeds have a way of doing that.

Sad stories like this are getting more common for her as she’s immersed herself fully into paramedic school and professional EMS in general. She’s been seeing sad stuff multiple times per week it seems. I can see that it’s wearing on her and I feel her pain. I have experienced it quite a bit myself in my own career and I continue to do so on a regular basis. Jumping into full-time EMS exposes a person to sadness on a level that can’t easily be prepared for. A person just has to jump in with both feet and not be afraid to feel the range of emotions that they’re going to be exposed to. It’s hard, it’s tough, and it’s one of those things a person just has to learn how to overcome if they want to make EMS a part of their life.

That’s the part that most people don’t get, I think. The part where you have to “Learn How” to overcome the sadness and negative emotions we’re faced with as EMS people. A common statement that lay people make when they hear that I am a paramedic is “Oh, I could never do that job and see what you see. I just couldn’t handle it”. Perhaps they’re right, but I would guess that anyone can train themselves to handle almost anything. My pseudoscientific opinion is that we develop our tolerance and our healthy ways of dealing with being exposed to such negative emotions on a regular basis through experiencing it and learning ways to function and feel happy afterwards. It’s harder for some than others and I can’t imagine that there is a single roadmap for learning it. It’s individual. Friends help and so does an understanding family. Good coworkers are great to observe and learn from as long as they realize their own humanity and aren’t simply trying to fool themselves out of bravado. We’re all human and I can testify that we’re all affected, no matter how thick our skin may appear.

Back when I was a new medic I was working a ton of hours. I mean, I worked a lot. I worked TOO much. I worked for days on end without sleep for multiple jobs. At the time, I felt I had good reason. I was attempting college for the first time, taking care of my recently deceased father’s businesses, and trying to sock away money to help my mother. I worked a full-time EMS job, a full-time hospital job, ran the businesses, and volunteered for a separate fire department and EMS agency. It was nuts. I would literally go for days without sleep. During that time it seemed like I was getting slammed by horribly sad calls. I felt I was surrounded by suffering and death. I was working at least two codes a week on average. Mayhem and madness seemed to rule the day. I was getting deeper and deeper and…

I was going nuts.

I was horribly, deeply depressed.

I almost went insane.

I was at my darkest hour when I found myself angry at anything that was cute or fun. Literally things like jokes, teddy bears, and Hallmark cards made me angry. I just couldn’t see how people could stand to look at that kind of stuff when there was so much suffering in the world. How frivolous! What a waste of time! It made me angry to think of anything that didn’t acknowledge the pain I was bearing witness to on such a regular basis. I was depressed and angry. I just couldn’t understand anything other than feeling the pain that the people I was taking care of were feeling. It affected my life, my work, and my human interaction. It was horrible.

Then I had an epiphany that changed my personality and who I am to this day.

Those who meet me know that I like to joke around. A lot. There are things that I take seriously however I do not personally happen to be one of them. My epiphany was that the stuff that was cute, fun, loving, friendly, and/or happy was all that actually did matter in life. We combat the bad with the good, the yang with the yin. I chose to pay attention to the comedy of life and downplay the tragedy. After that revelation, my whole outlook on life and my personality changed for the better. I had found that comedy, friendship, and love were the ways to live my life. Come what may, I can make a joke about it and that makes it ok. I laugh at inappropriate times and seek out the good in life. My life and career ensure that I’ll still have an onslaught of human tragedy thrown at me whether I’m ready for it or not but If I can actively seek out the positive, I may just end up ahead of the game.

To my wife, I love you. Hopefully you don’t end up where I have been… but I’ll be here for you, come what may. I understand what you’re going through and I love you for this any many, many other reasons. Always.

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You may want to read one of my most popular posts. It’s an older post of mine where I explore what I call “Splashed Sadness”. It’s along these lines. We EMS people have to deal with a lot. Never be afraid to share it. Don’t hold it in. Get it out and learn how you can cope with it because there’s not a one of us ain’t human.

“Splashed Sadness – A look at Negative Emotions in EMS”

Or “Reflections on an Easter Morning” – another post about a bad call.

Also, don’t forget to check out Medic Trommashear’s co-post on this. You can check it out at her blog: http://lookingthroughapairofpinkhandledtraumashears.com/

(Note: I’ll link to the post directly when it’s up)

Posted by on August 30, 2010 • Filed under: bad calls, Emergency Medical Services, emotions, EMS, EMS Health & Safety, EMS Topics, Fire Rescue Topics, Firefighter Safety & Health, inside the mind of a paramedic, Line of Duty, Paramedic, psychology, sadness, Training & Development, Uncategorized

Too Much Information For a Paramedic?

20 comments

 

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

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

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

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

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

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

Hey Guys?? Guys?

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

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

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

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

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

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

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

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

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

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

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

Study Hard. Know Your Stuff. No Excuses.

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

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

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

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

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

11 comments

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

“Is that the best you can do?”

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

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

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

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

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

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

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

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

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

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

“Is that the best you can do??

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

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

Automatic Window Roller Uppers and Other “Great” Ideas

12 comments

A few years back I had the chance to drive a 1997 Saturn 5-speed coupe for a while. It was a pretty nice car and I drove it back and forth on my tri-weekly 2 hour commute from the Quad Cities of IL to the Chicago Suburbs for my 24hr ambulance shift. It actually worked out well because the pay for paramedics was so much higher in the Chicago area than it was where I lived. I’d go up, do a 24 or a 48 hour shift, and have plenty of time to work my other jobs back home.  I didn’t really mind the drive but I’d save so much money by driving the Saturn instead of my full-size truck that I’d drive it whenever the ex-gf would let me.

One thing about driving the highways around Chicago is the incessant amount of toll-booths that one must cross while driving there. There are literally more toll-booths than I can count and every one of them requires a person to get out of traffic, stop, and pay the toll. It’s annoying in a car with an automatic transmission and even more annoying with a manual transmission. It aggravates me to say the least.

One of the features of the 97 Saturn SL 2 Coupe is an automatic window roller downer (is there a better name for that?) where the window will roll all the way down with just one click of the button. It was actually pretty handy for going through a toll-booth in a car with a manual transmission. I could click the button, then focus on downshifting for the quickest stop possible. This feature is common on cars nowadays, but back in the primitive turn-of-the-century it was my first Automatic Window Roller Downer Feature and I thought it was pretty cool… Except for one problem:

The window only went down automatically, It wouldn’t roll back up with only one click and had to be *manually* automatically rolled back up again. Yes, by this I mean I actually had to use one whole finger to hold the button. It was kind of a minor annoyance when I had to reaccelerate while shifting the manual transmission. Back then I didn’t think it was a huge annoyance, mind you… but I thought that the simple addition of an automatic roller back upper feature would have been much better. I could just imagine that the simple change would make it more useful and I was a tad angry about the shortsightedness of the engineers. I mean, why couldn’t they have thought of this when it seemed so obvious to my 20yo self? If I had thought of it had to be a good idea, right?

Well then some years later, I rented a car that actually had both an automatic roller downer feature *and* an automatic roller upper feature. I was so happy to find that! It was SO COOL! Finally the engineers had listened to my private thoughts that I never shared with anyone and put in my feature! I was happy.

Then I tried it for a while… and it sucked.

Yea, having a “one click” roller upper feature means never just cracking the window open a bit. One click may bring the window down a touch, but the auto feature keeps it rolling down all the way. In the previous design, without the automatic roller upper, this could be stopped by one quick click in the other direction. However, with the automatic roller upper feature, the window just rolls back all the way up! Getting the window open just a little bit is nearly impossible. Then I thought that if a kid or a less-than-intelligent adult chanced to stick their head through the open window and the button got depressed, the window could roll all the way up and choke them. The automatic window roller upper feature is annoying as heck and wasn’t the great idea that I thought it would be. It was an idea that I didn’t think all the way though. I thought I was smart and well, I wasn’t. It’s probably a good idea that I didn’t get all fired up and start a national letter writing campaign to lobby the car companies to put in automatic window roller upper features (Which I would have urged them to rename to “Chris’s Awesome Mega RoLL uPPahhz”) because then I would have looked like an idiot to more people than just myself. It’s the reason why I rarely orchestrate nationwide letter writing campaigns: experience. 

This got me thinking about all of the ideas that I’ve had about things in EMS and in other aspects of my career that I didn’t think wholly through. Steve Whitehead, the genius behind http://www.TheEMTspot.com wrote an article recently that spoke of the fatal flaws in the heroes of Greek Tragedy that I really liked. You can find the article here “8 Tragic EMS Behavior Flaws to Avoid” (I’ll link it at the end too, because you really should read it) but here’s what struck me so blatantly in the article:

The Critic – “This is all so stupid”

This is perhaps the easiest of all the hero flaws to slip into and the toughest to shake. The critic is convinced that the world desperately needs his or her opinions on the way things ought to be.  They figure out that offering opinions is so much more fun and rewarding than working to solve a problem and then it becomes like a drug. Soon they’re framing everything they see with the question, “How should this be done better?” and then offering their sage analysis. Usually with a poor understanding of why the thing is the way it is in the first place.

The problem with the critic is that they genuinely believe that the world wants to hear their endless assessments and when an army of engineers doesn’t show up to start doing the hard work of implementing all their great ideas, they get frustrated. The second problem is that they jump to analysis without seeking to ever understand the nature of the problem. Research and implementation are hard, but critical evaluation is fun and easy. As long as they don’t build anything real, they never have to worry about the next critic showing up, spending a few minutes looking at what they built and offering up their sage criticism.

This is the part of Steve’s article that really got me thinking. Have I been “The Critic” too often in my career? I mean, I don’t try to do this… but I find faults in a lot of aspects of contemporary EMS. I look at things and try to find ways to make them better. If you’re a regular reader, in-fact, that’s probably why you come to read what I have to say as often as you do. New ideas are great.

However, as my Automatic Window Roller Upper debacle (that yes, wholly occurred only within the boundaries of my own cranial cavity) has shown, some ideas that come to me and seem so obvious can also be bad ideas. My experience has proven to me time and time again that I need to think things through. I try, but EMS doesn’t always allow us the time to consider all options, let alone every aspect of every option. The Law of Unintended Consequences abounds and rears its ugly head quite often.

As the years have drug on, I’ve been trying to analyze my “Great” ideas more fully, but one person rarely has the ability to completely devise the correct answer to every problem. Two heads are better than one a lot of the time and systems have a way of developing themselves.

So as we go forth to change this thing we call EMS and usher in the new world of EMS 2.0, let’s remember to consider as many reasoned opinions as we can. We need your input and we need your participation. The more we grow together, the better our ideas become.

Oh, and here’s that link to Steve’s Article again: “8 Tragic EMS Behavior Flaws to Avoid”

Posted by on August 16, 2010 • Filed under: Administration & Leadership, ckemtp, Command & Leadership, Emergency Medical Services, EMS, ems 2.0, EMS Management, EMS Motivation, EMS Topics, Fire Rescue Topics, Firefighter, grumblemedics, inside the mind of a paramedic, Paramedic, paramedic education, Training & Development, training-fire-rescue-topics

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

13 comments

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

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

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

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

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

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

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

 Recipe for a New Fad Disease

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

 

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

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

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

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

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

Four Words: EMS, Apathy, Disgrace, Massachusetts.

12 comments

By now you’ve all heard of the flap that is happening in Mass. regarding the 200 or so EMTs and Paramedics that had their licenses suspended or revoked for running a non-existent training program or for falsely representing that they attended non-existent training classes. If you haven’t heard about it by now, you’re probably not following EMS news as much as you should.

Here is one of the articles on the subject from JEMS.com

The issue has been discussed quite a bit around the EMS blogosphere. Some big name bloggers have written on it, and I even discussed it a little bit on the EMS Educast the other day.

Here’s TOTWTYTR’s take on this: I’m Not Very Sympathetic

And here’s Rogue Medic’s take on it: (this is a part-2 that reiterates the first)

Here’s the episode of the EMS Educast where we discussed the issue briefly

Other than for speaking about the issue briefly, I’ve been avoiding writing on it. My job is usually to report positive things that are happening in the EMS world and this is definitely not a positive thing. In fact, it’s a disgrace to us all. Rogue Medic has it right when he asks the question “Why do we Encourage such apathy in EMS?”

And that’s what this is. It’s not just that it’s apathy for the boring destruction of brain cells that we call “Continuing Education” in most areas of EMS, it’s the apathy for the whole process. The apathy where we as a profession have let the standards get to this point.

I mean, really. How many of you feel that the continuing education you receive is anything more than something you have to do in order to keep your license up? How many of you feel that your regularly scheduled, mandatory, continuing education classes are of any quality? How many of you feel like they’re actually doing anything good for you?

And that’s the system in which we function. TOTWTYTR made the statement that he sits through boring traning classes all the time because those are the hoops he has to jump through in order to maintain his licensure. I do too, of course. I sit through probably as many or even more classes than anyone reading this article because I am a practicing paramedic with National Registry and licensure in three states. Sometimes the training from one state carries over into the next, and sometimes it doesn’t. At any rate, I get to listen to unmotivated speakers read flat material whilst sitting in an uncomfortable chair on a very regular basis. We all do.

However, I feel that I keep up my continuing education quite well on my own through other means such as extensive self study and non-credit medical education. Keeping my professional skills sharp is very important for me because not only am I proud of my professional skills, but I am well aware of the fact that the quality of my skills translates into the quality of life for my patients. If I keep myself sharp, I’m a better paramedic. If I let them get dull, well then I’m an apathetic paramedic who isn’t doing my duty. Duty is important to me. So are things like Pride, Professionalism, and Honor. In fact, those three words are more than just the slogan for my blog, they are how I think that I and other EMS professionals should live their lives and careers.

Others have been quick to demonize the 200 suspended EMTs. Others have been quick to defend them. The ones defending them have said that these people are apt to lose their incomes, their livelihoods, and that the punishment is unfair. Well, for that part I disagree. The punishment is indeed fair. You could have killed someone by being untrained oafs with lackluster skills. You never proved you were otherwise. However, if you were to ask me if I thought that a state EMS agency – ANY state EMS agency – was competent to manage such a program, I would laugh at you.  Every state has made an attempt to regulate continuing education and I agree that there is a good reason for them to do so. I would also agree that the prospect of regulating a group of EMS people in their continuing education efforts is a daunting task. I would say that the perfect system has yet to be developed and that a good number of the 200 were simply “playing the game” and thought that since their states EMS continuing educational system was a joke that they could make a joke out of it as well.

Here’s the most biting apathy of all to me. If you believe that a system that you work under is a joke. If you believe that there is a better way to do something. If you believe that what you’re made to do is pointless and obsolete… then why the heck haven’t you done anything about it?

I’d like you to look at this issue from this perspective, folks. Sure, not everyone in that group of 200 were caring, competent professionals. I’m sure some of them were jackasses. (And yes, I said “Jackasses). However, I’m also sure that there is a percentage of them in that group that sincerely care about being the best they can be in EMS and they simply got caught up in the mob mentality. I’m sure that some of them had just given up. I’m sure some of them were good people who just became apathetic.

I hate apathy.

If what, say 50% of that group were of the caring kind, that leaves 100 people who thought that the system was broken. Did it not occur to any of those 100 people to try and change it? Did they not try and band together to improve the system? Could one person do it? Could 100 people do it?

If we are to be regulated and controlled by obsolete and ineffective bureaucratic systems, then it is our duty to rise up and change things. Sure, that sounds melodramatic… but how many times have you thought that your state regulations were stupid. One of the defining aspects of a Profession is Self-Regulation. Look at your states “Bar Association” for Lawyers, or the states “Medical Association” for physicians.

Is there any state out there that has a “Paramedic’s Association” that has any teeth to it?

No continuing education system or relicensure processes is even close to perfect. That’s because of a few reasons, not the least of which is because the government is the one running it. The other reason could be because it isn’t being policed by the paramedics who care about it the most.

I’ve said it before, I’ll say it again. It’s time for us to take ownership of our profession. Stand up and make this the profession it deserves to be. Stamp out apathy and band together to let your voices be heard. If you don’t start the process of meaningful change, who do you expect to do so?

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For more positive discussion on EMS, check out the comments section in “Negativity? You Won’t Find That Here” or for a description of two real-world moral and ethical dilemmas in EMS, check out “Two Cases, one letter. From one paramedic’s struggles, change can come”

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Posted by on July 9, 2010 • Filed under: Administration & Leadership, ckemtp rants, Command & Leadership, edemse, Emergency Medical Services, EMS, ems education, EMS ethics, EMS rant, EMS Topics, Ethics, everyday ems ethics, Paramedic, paramedic education, politics, Training & Development, Uncategorized
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