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Another Good Cause

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One of this blogs, EMS 2.0's, and my own biggest friends and supporters, John Broyles, who is also the guy behind 1-U-801: The Netcast - is raising money for a good cause. He's walking in the Race for the Cure in support of someone close to him. He has a personal page where he is accepting online donations for his (in my opinion, too small) goal of raising (only) $250.00

C'mon, we can beat that by at least double.

Care to support the guy? It's for a good cause and a good person.

Here's the link to donate if you wish. I gave, you should too: http://memorial.info-komen.org/site/TR/RacefortheCure/PIA_MemorialAffiliate?px=14077119&pg=personal&fr_id=2926

Posted by on March 16, 2013 • Filed under: Uncategorized

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

EMS Fights the Flu – The 2013 influenza epidemic

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It’s hitting early, it’s hitting hard, and it’s no joke. This year’s flu season is filling up the nation’s emergency departments, urgent care centers, hospitals, and ambulance run sheets fast. In the US a majority of states are under “widespread” or “intense” flu conditions. No state is currently reporting low levels of flu activity and all states are affected.  According to both Google flu trends and the Centers for Disease Control and Prevention (CDC), the US is right in the throes of an intense and widespread flu season that is sickening many people all over our country. The US flu season generally occurs in winter when people tend to congregate indoors, and this year’s locally cold winter is helping the flu spread quickly.

The “flu” is an abbreviation for the disease “Influenza” which is caused by the various incarnations of the influenza virus. The disease has become such a part of our culture that people call almost any minor illness a touch of the “flu.” People say things like “I have the stomach flu” when they have a case of gastroenteritis, or say that they have the flu when they’re feeling a tad under the weather. This causes a lot of misconceptions about what influenza actually is and can cause us to let our guard down about treating the disease and protecting ourselves from it. Make no mistake that the actual flu is a serious illness that can make even an otherwise healthy person incredibly ill. While the symptoms of the disease themselves can seem relatively minor, the intensity of those symptoms and the complications they can lead to are quite serious and can even be fatal.

Influenza is a viral infection that causes symptoms similar to the common cold. However, the symptoms are markedly more severe with the flu than with a cold. The flu brings intense fever, exhaustion, and severe body aches. Influenza is a respiratory illness though it sometimes brings gastrointestinal symptoms like, nausea, vomiting, and diarrhea. The flu can lead to complications such as dehydration, secondary infections, pneumonia, electrolyte imbalances, cardiac symptoms and exacerbations of asthma and COPD. While most influenza-related fatalities are in vulnerable populations such as the very young, older adults, and in those with compromised immune systems, this is not always the case. In the Spanish Flu pandemic of 1918, the Russian Flu pandemic of 1978, and the possible 2009 H1N1 pandemic, most of the fatalities were in the young adult age range.

While modern medical practices do tend to lessen the impact of a flu pandemic in contemporary times, they are still very worrisome as even seasonal influenza epidemics can overwhelm existing medical facilities and cause an estimated 3,000 to 43,000 deaths in this country each year. The CDC cannot accurately count morbidity and mortality from confirmed influenza infections as medical facilities are only required to report deaths from Influenza or “influenza-like-illnesses” (ILIs) in children, however their estimates over the last decade show an average of 30,000 deaths in the US per year. In comparison, in 2009 the CDC estimates that 17,774 people died from HIV/AIDS.

Influenza has caused pandemics, or global infections, throughout human history. While most countries experience epidemics of influenza at regular intervals, the influenza virus occasionally mutates into a particularly virulent strain and spreads quickly throughout the globe. In the 1918 Spanish Flu pandemic it is estimated that between 1% and 3% of the total global population died with an estimated 600,000 deaths in the United States alone. In more remote areas of the country the mortality count was higher with some villages in Alaska being completely decimated. The “Hong Kong Flu” pandemic in 1968-1969 is said to have killed over one million people worldwide with over 33,000 fatalities in the US. The last official pandemic influenza was in 1978-1979, the “Russian Flu” affected mostly the younger population. In the 21st century, the World Health Organization is attempting to ascertain if the 2009 worldwide outbreak of “H1N1” influenza classifies as a pandemic, with epidemiologists still conducting research. Recently, the CDC has estimated that the 2009 virus killed between 171,000 and 574,000 people worldwide.

Clean your equipment! Don't let your truck be a vector for the spread of disease

The flu is no joke and EMS providers need to practice prevention and infection control. First off, get your flu shot. Ignore the myths about the vaccine and just get it. Immunized healthcare workers are less likely to get sick themselves, are less likely to spread the flu amongst their patients, and are less likely to bring the virus home to their families. EMS providers need to thoroughly clean and sanitize their ambulances and patient care equipment. Hand washing is extremely important, as is the use of proper PPE. All patients exhibiting symptoms of an influenza-like-illness such as a cough, fever, and/or gastrointestinal symptoms should be asked to wear a mask. EMS providers should wear a surgical mask when treating these patients as well. Influenza is spread through droplets that are aerosolized when coughed or sneezed up by an infected person. These droplets settle onto surfaces via gravity and are spread via personal contact or through contact with the droplets while they are airborne. The CDC estimates that the influenza virus can remain viable on external surfaces anywhere from between 2 to 8 hours exposed to the environment. This is more than enough time to cross contaminate your next patient or your coworkers on the next shift. The virus can be killed on surfaces with commonly available disinfectants and regular cleaning and it can be killed on your hands with soap and water or alcohol-based hand sanitizers; However, once a person is infected, the virus cannot be killed with any medical treatment. It can only be slowed down or allowed to run its course.

Protect yourself, protect your patients, and protect your community. Be serious about preventing the spread of the flu. EMS providers are the first line of defense against this insidious disease. Remember that if you are sick, stay home. A person remains infectious for around 7 days after symptoms first appear. Stay home from work until you are at least 24 hours free from fever. Flu prevention is truly an area where EMS is at the intersection of Medicine and Public Health. As with many things, an ounce of prevention can go a long way in the fight against flu.

 

 

 

A comparison of Symptoms between the Common Cold and the Flu

 

Common Cold

Flu

Symptoms

Cold symptoms appear gradually and include sneezing, cough, stuffy nose and sore throat. Fevers are very rare and fatigue is mild. Headaches sometimes occur.

Flu symptoms appear quickly (within 3-6 hrs) and include fever, chills, severe aches and chest discomfort.

Severity:

Usually does not cause severe health problems.

Serious health problems, such as pneumonia, bacterial infections, or hospitalizations can occur.

Fever:

Rare

Usually present

Fatigue:

Mild

Moderate to severe

Chills:

Rare

Common

Sneezing:

Common

Rare

Chest pain:

Mild to moderate

Often severe

Coughing:

Hacking, productive cough

Dry, unproductive cough

Headache:

Rare

Common

Stuffy nose:

Common

Rare

Aches:

Slight, but only headaches

Usual and often severe, affects the entire body.

Sore throat:

Common

Rare

Treatment:

There is no cure for the common cold. Cough syrup and other cold medications are available to ease some of the symptoms and make the patient feel a little better. Tea and nasal drops also sometimes help.

Sometimes antiviral medication helps control the flu but often patients simply wait for their body to fight the virus and overcome the disease. Medication is also available to ease patient comfort.

Duration of illness:

Symptoms typically peak two to three days after infection onset, and usually resolve in seven to ten days.

In children, the cough lasts for more than ten days in 35–40% of the cases and continues for more than 25 days in 10%. Adults usually feel better in seven days.

Seasonal?

Not seasonal (occurs throughout the year)

Seasonal (in winter). In the U.S., flu season is generally October to May and peaks in February.

Vaccine?

No

Yes

Causative Organism:

adenoviruses, coronaviruses, rhinoviruses (most common cause), respiratory syncytial virus, parainfluenza virus, influenza virus

Influenza virus

 

Posted by on January 8, 2013 • Filed under: Emergency Medical Services, EMS, EMS Health & Safety, EMS Topics, Fire Rescue Topics, infection control, News, Patient Management, sanitize, swine flu, Training, Uncategorized

Look for the Helpers

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“When I was a boy and I would see scary things in the news, my mother would say to me, "Look for the helpers. You will always find people who are helping.”

― Fred Rogers

I was planning on writing a happy piece this holiday season. It would have been about family, togetherness, hope, and all of the things the holidays are supposed to truly mean. While I celebrate Christmas at my home, I was planning on speaking of other peoples’ traditions as well. I wanted to tell everyone to have a Merry Christmas or a Happy Hanukkah, and I would have given other appropriate seasonal salutations to those who may celebrate different traditions. This piece was supposed to be about the happy, good things that this time of year is supposed to represent to us all.

And it still is, actually.

The above quote from Mr. Fred Rogers is absolutely appropriate right now. With the recent horrific events that have unfolded in our local area and the nation in the last two weeks it is important to be reminded of the good things that we’re supposed to remember during this season. Mr. Rogers's quote helps us bring that back into perspective. We will always see reminders of the fact that bad things will happen to good people and I fear that we will always struggle with trying to find the reason why. Truthfully, the fact that bad things happen is the reason EMS people have something to do. If bad things never happened then we wouldn’t need paramedics, EMTs, Firefighters, Police Officers, or the military. If bad things never happened, we could go about our lives in relative peace.

And as unfortunate as it is, the fact that bad things happen is a truth of the human condition.

If bad things never happened to good people we wouldn’t be able to see the other side of tragedy. We wouldn’t see the helpers. If bad things never happened we wouldn’t be exposed to the most powerful aspects of humanity. We wouldn’t see compassion. We wouldn’t see heroism. If bad things never happened we couldn’t experience how people come together for good and cause real good to happen in this world. If bad things never happened we wouldn’t see the true power of the human spirit. We wouldn’t see the good if we didn’t experience the evil.

If you listen to an emergency radio you will hear a constant drum beat of bad things happening. You will hear about crimes, about fires, about accidents and injuries, and of people becoming ill. It is incessant and unrelenting in most communities and those of us in the public service know that bad things happen at a rate much higher than what most members of the public allow themselves to believe. It can be quite easy to think that the bad is winning if you listen to the radio long enough. I counter, however, that for every bad thing you hear on the radio you also hear a miraculous fact shortly thereafter. You hear a response. The good answers the bad. You hear someone helping. You hear the fact that someone has decided to charge into the situation to do as much good as they can within a system that our society has built upon intention of helping and doing good. The bad is immediately met by the good.

My favorite quote by Kurt Vonnegut goes “I can think of no more stirring symbol of man’s humanity to man than a fire engine.” I like it because he trumpets the fact that our society has decided to spend money, effort, and time to help those in need. A fire engine doesn’t judge who it helps, it just helps as it is asked. Firefighters, EMS people, and law enforcement people don’t judge either. We were all called to be helpers and we stand in the company of heroes from all walks of life.

Look around you at your fire station, police station, ambulance base, hospital, or wherever it is you work. Look at your coworkers or your fellow volunteers. When you look at them, realize that you are in the company of a group of people who would risk their lives to help a stranger. Remember that these kinds of people exist in this world. Remember that there are more good people than there are bad people and that there are more helpers in the world than there are those who would seek to cause harm. Remember that good is actually winning, will continue to win, and has already won.

This week as we mourn those lost in the recent shooting incidents, the tragic crash of the REACT helicopter, and all of the other bad things that have happened we need to celebrate those who are the helpers. Celebrate the heroes and the good that comes out of the bad. Celebrate the lives of the helpers who were lost. Celebrate and carry on with their spirit of helping.

This piece really is about what the holidays represent. Hug your children, hug your families, help those in need, celebrate the good in your life and remember what life is truly about. God bless the helpers. God bless the good in life and the fact that there is so much of it to see when we open our eyes. The bad may be shocking, but the good is much more powerful.

Merry Christmas.

Posted by on December 16, 2012 • Filed under: Emergency Medical Services, emotions, EMS, EMS Motivation, EMS Topics, EMT, Fire Rescue Topics, Major Incidents, Mass Casualty Incident, Paramedic, Uncategorized

Rockford REACT Crew Memorial Fund

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As you may know, the REACT medical helicopter out of Rockford (IL) Memorial Hospital recently crashed, tragically ending the lives of the three heroes aboard. It’s a tragedy that has profoundly affected the local healthcare and EMS communities. The grief has been palpable and has been expressed far and wide from many communities in Northern Illinois, Southern Wisconsin and beyond. When some of our own are injured or killed while they’re out there just doing what they do it affects us all. We all feel it because EMS is a family. When a tragedy like this one strikes our natural reaction is to want to do something for those directly affected by it. We want to help in any way we can, even by doing something small if it’s worthwhile.

Here’s how you can do just that. The Rockford Memorial Development Foundation has started a fund for the families of the crewmembers killed in the crash. They’re calling it the REACT fund. I have spoken with their foundation and they state that the plans for the fund are to give the total amount collected directly to the families of the three crewmembers, split equally into thirds.

And it’s Christmas and all of the crewmembers have families and kids who will be missing them greatly. I can’t describe how this fund or your support will help them because I don’t know them, but I do know that right now they need to know their loved ones are being cared about by our wider EMS family. They should know that we care about them too, and that their loved ones will be remembered. They need our support and I want you to help see to it that it gets to them.

This is a worthwhile way where the small support from individuals in our EMS family can add up to a big outpouring of care and comfort from all of us. I’ve seen what we can do when we all get together to help our own and now is the time to do that again.

All donations will go through the Rockford Memorial Development Foundation. They have set up a website here: http://www.rockfordhealthsystem.org/REACT.aspx – There is a link on the page where you can donate online in whatever amount you choose, whether it’s $5 dollars or $500 dollars. It’s a worthwhile way to let some deserving family members know that the wider EMS community supports our fallen heroes. Let’s all show them that we care.

I’m also asking all of you who read this to share the web link and the information above through your agencies, networks, and social media friends. I’ve seen the readers of EMS blogs pull together before and I’m asking us to do it again. You can share this page directly, or share the direct link to the Rockford Memorial Development Foundation REACT fund page.

Here’s that link again: http://www.rockfordhealthsystem.org/REACT.aspx

Be safe out there.

Posted by on December 13, 2012 • Filed under: Emergency Medical Services, Emergency Nurse, Emergency room, Emergency Room Nurse, EMS Health & Safety, EMS Topics, Major Incidents, Uncategorized

Tragedy Strikes Rockford

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UPDATE: Memorial Fund Established – http://lifeunderthelights.com/2012/12/rockford-react-crew-memorial-fund/

I have some exceptionally sad news to report this morning.

On December 10th, 2012 around 8:30pm the REACT medical helicopter out of Rockford (IL) Memorial Hospital crashed into a field near Compton, IL. The crew was en route to a hospital in Mendota, IL to pick up a patient.

Tragically, the pilot and both flight nurses on board were killed in the crash.

I don’t know any more about the story than the local news sites do, so please go read about the details on their pages. Here are some links:

I don’t usually report on line of duty deaths on the blog. There are too many of them and I can’t say anything helpful. Losing any brother or sister anywhere is tragic. To some extent, everyone in our EMS family feels it when it happens. Losing our society’s heroes to tragic accidents like this one is senseless. It feels wrong because it is wrong. People who dedicate their lives to doing the right thing and helping others shouldn’t die just because they grew up to be heroes. It’s not fair and it never will be.

It’s time to mourn the heroes who died just doing what they do. It’s time to support the children who lost their parents and to step up to ease the suffering of those whose lives were irreparably changed. Please forgive my lack of eloquence, but I don’t have the words to express the sadness and grief that has stricken our local EMS community and our community as a whole over this horrific accident.

This happened yesterday and I’m writing today to tell you this: Think safety. Cut back on the risks you take while you are out there just doing what you do. Be safe every minute of every day. Think about coming back home after every call. Wear your seatbelts. Wear your PPE the right way. Actually wear your PPE. Don’t take risks that aren’t worth taking. We all know things happen that are beyond anyone’s control and we all know that we accept an amount of risk in this profession. We all get that. However, let’s all work to make that amount of risk the absolute least it can be. I don’t want to read about any more tragic deaths. We’ve had too many. We all need to take responsibility and make it stop.

I’ll be posting information on memorial services and/or things that the public can do to show our respects on the LUTL Facebook page as I become aware of them.

Be safe.

UPDATE: Memorial Fund Established – http://lifeunderthelights.com/2012/12/rockford-react-crew-memorial-fund/

 

Posted by on December 11, 2012 • Filed under: EMS Topics, Uncategorized

On the Topic of Ectopics – Ectopic Pregnancy for EMS

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

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

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

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

Early signs of an ectopic pregnancy include:

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

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

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

More severe internal bleeding may cause:

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

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

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

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

Appendicitis – An EMS Case Review

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Routinely Not Routine – Good EMS Makes the Difference

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One of my EMS truths is that while there may be boring calls and calls that are less than exciting, there are no “routine” calls. There is no EMS patient that doesn’t deserve the absolute best that we have to give them. Every single patient we take into our care, be it a scheduled dialysis transport or a simple discharge from a hospital to a nursing home deserves to have professional, competent, and caring EMS providers taking care of them. They all deserve our best care, our best assessments, our best comfort, our best compassion, and most of all, our simple act of caring about them as a person and a patient. Never forget that, you may just save a life during one of your “routine” calls.

This gues post in the form of a case study comes to us from a paramedic who works in Tennesee. He was kind enough to write it up for our benefit and I think that it hammers the EMS truth above home quite nicely, what do you think?

Case Presentation: The Importance of Diligence

Setting: You are assigned to an ALS unit which is staffed for 8 hours during the daytime hours and is tasked with interfacility, clinic/MD office, and back-up 911 response. It is the last hour of your shift and you are dispatched to a local dialysis center for a patient return post Dialysis treatment because all of the BLS units are busy. The weather outside is cool and rainy. The only dispatch information you recieve is the previous run number from the pick-up and the patient’s name and age. You are responding to a 69 year old male patient who is “unable to maintain balance in a wheelchair” based upon the PCS form on file and who suffers from End Stage Renal Disease requiring Mon-Wed-Fri dialysis.

Initial Presentation/Nursing Report: Upon arrival on scene you enter the clinic to find the nursing staff beginning their tear down and decontamination for the day. This patient was the last one to be sent home and they are anxious to get him out of the facility. The LPN who took care of the patient tells you that the patient has successfully completed a full dialysis treatment with 1800ml of fluid pulled off. The patient did not receive any antibiotic therapy while at the facility and the patient has a right chest dual-port indwelling catheter. The catheter has been flushed with heparin prior to capping. Per facility, patient did not bring a lunch to eat, and it is “normal” for him not to eat. He is a diabetic and he did receive his scheduled insulin. His baseline mental status is normally awake, alert, and oriented, but the patient has generalized muscular weakness as a result of a previous stroke that affected his right side. His last blood glucose was reported as “normal”, although an actual reading was not readily available. Vital signs post treatment were reported as 138/72, Pulse of 90, Respirations 16/min, and Pulse Oximetry of 98% on room air. After report, the nurse directs you and your partner to the patient who is seated in a chair waiting for you. It is cool in the clinic.

Initial Assessment: You find a 69 year old African American male patient who is initially slow to respond to questions (requiring obvious mentation to answer simple questions), but is otherwise oriented to person, place, and time. The patient is in no obvious distress but on approach you notice the patient appears jittery and is having fine tremors in both upper extremities. You feel his wrist for a pulse and note the patient feels cool and dry with somewhat poor skin turgor. His radial pulse feels highly irregular and weak. You ask the patient for permission to assess his blood sugar due to his history and then move the patient to the cot via a stand-and-pivot to assess his gait. The patient denies any chest pain, shortness of breath, dizziness, nausea, vomiting, diarrhea, visual disturbances, or trouble swallowing.  You secure the patient to the stretcher per policy in a semi-fowlers position for comfort and then move the patient to the unit for further assessment.

In the ambulance you assess the patient’s vital signs. His blood pressure is actually 178/92 and his heart rate is highly variable. You place him on a four lead EKG which reveals a sinus arrhythmia interspersed with episodes of severe sinus bradycardia. His heart rate varies from the 90s down into the 40s. This correlates with the palpation of his radial pulse as well as the reading from the pulse oximeter. His respirations are 18, his lungs are clear/equal x 4 anteriorly, and his heart tones do not reveal a murmur or gallop. His room air oxygen saturation is 95%. There is some trouble with the glucometer but the initial BGL reading verified by two checks with separate monitors reveals a blood sugar of 38mg/dl by finger stick. Curiously enough, the patient is still protecting his airway and able to swallow. His distal pulses are intact at the dorsalis pedis and equal bilaterally, as well as at his wrists. His pupils are equal, round, and reactive to light. The neuromotor check reveals no deficits beyond what you assume to be his normal right sided motor weakness. His cranial nerves appear grossly intact. The patient does not feel warm and he adamantly denies any chills or feeling feverish. He has not had a fever per his discharge paperwork. Of further note, patient has a history of cardiac disease including CHF and past MI with CABG, renal failure, stroke, hypertension, insulin dependant diabetes mellitus, and high cholesterol. The patient’s last oral intake of food was at breakfast approximately 7 hours ago but he states he has been drinking small amounts of water all day. He states he does not bring food to the clinic and that he “feels this way all the time,” and the crews “just take me home” where he eats.

Treatment/Transport: The patient initially refuses to be transported to the hospital. Upon obtaining the blood glucose level (BGL) of 38mg/dl, the EMT is instructed to administer 15 grams of oral glucose gel over five minutes, which the patient takes without difficulty. Oxygen is NOT administered due to there being no evidence of hypoxia or respiratory distress/increased respiratory drive. After five minutes, a blood glucose check is performed on the opposite extremity. The BGL after the first tube is 43mg/dl. The patient is still refusing transport to the ER, so a second tube is administered by the unit EMT. At this time, the decision is made to involve medical control at the patient’s hospital of choice where the ER physician is NOT comfortable with the patient going home. The physician agrees with the unit Paramedic that transport should be “highly encouraged”. After conversation and the second tube of oral glucose, the patient agrees to be transported and asks his daughter be notified. Scene time at this point is 20 minutes. The third glucose check is 51mg/dl. A phone call is made to the daughter, who becomes angry and demands he be brought home. She continually protests his decision to be taken to the ER. When she is informed that he will be taken to the hospital, she says “fine” and that she will “meet us there.” Due to the patient’s presentation and history, an attempt is made to establish IV access on scene without success. Transport is initiated with the plan of performing an emergency access of the indwelling line should IV administration of medication be necessary.

During transport, the patient’s blood pressure reaches around 200 systolic and 90 – 100 diastolic over consecutive readings. His head is repositioned and he is placed in the high fowler’s position due to the hypertension. His sinus arrhythmia continues. A 12-lead is obtained which is non-diagnostic for any ST changes, T-wave peaking or inversion, or underlying arrhythmia. The patient remains awake and responsive, and while some improvement in mentation is noted after administration of glucose his blood sugar remains in the 40s during transport despite a third tube of glucose being administered. Transport time is 20 minutes to a definitive neurological and cardiac facility with PCI and IR capabilities.

Post Transport/Hospital Course: Upon arrival at the hospital the patient continues to be severely hypertensive and continues to have profound episodes of bradycardia from the sinus arrhythmia. During triage, his blood pressure spikes to 238/114 and his blood glucose is found on consecutive readings to be “LO” from multiple extremities. The patient is placed in the resuscitation room. The ER Fellow immediately places a central line due to an inability to establish an EJ or PIV by ED Techs and RNs. The patient is placed on a Dextrose solution once this is done and the Cardiology service is called in for further assessment.

The family continues to be belligerent and derisive and actually calls to complain about the crew, threatening to change services because of what they feel was an unnecessary trip.

During follow-up the next day, the patient was reported as continuing to have persistent hypertension requiring inpatient medication therapy as well as requiring antibiotic therapy for a possible blood stream infection. The cardiology consult discovered that the patient’s right carotid artery was nearly fully occluded which necessitated the patient to undergo a carotid endartectomy to remove the plaque and clot. The nursing staff told both the crew and the family that the care the patient received more than likely prevented him from having a massive and fatal stroke.

It was later reported that the patient continued to utilize the ambulance service despite the complaint they called in on the crew members involved in this call.

Discussion: This case illustrates the importance of diligence on the part of EMS crews. In this case, the patient’s presentation could easily have been dismissed by the crew for a number of reasons: the unfamiliarity with the patient combined with the history could lead the crew to ascertain this was “normal” for this patient, the findings could have been explained by the environment the patient was in, the end of shift factor could have made the crew anxious to finish a “simple dialysis” transport, and so-on. Despite these factors, suspicion lead to the identification of a major initial issue – hypoglycemia – which led to an even greater issue being identified and fixed before a major adverse event occurred. Had this patient gone home, these issues would not have been rectified, and the patient would have most probably suffered because of them.

This call underscores the importance of performing an initial assessment on every patient, no matter how “routine” the call is. The discharge information and post-treatment vital signs provided by the dialysis clinic were completely incorrect. The patient had not received a competent acute care assessment. Had transport been based upon the information provided by the dialysis facility alone, significant harm could have come to him.

As EMS we need to always remember that we are Patient Advocates. Our patients deserve us to always stand up for what is best for them. Apathy should never stand in the way of proper patient care.  

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Nicely said, Chance and nicely done. Nobody said that doing the right thing was always easy, but you did it here. EMS providers have to be focused on patient advocacy for every patient and every call. Thanks for sharing, and thanks for caring.

Chance Gearheart, AAS, EMT-P is a Paramedic who works part-time as a 911 and Critical Care Transport Team Paramedic, he also volunteers with a County Sherriff’s Rescue Team, and is full time for a Children’s Hospital as a Pedi/Neo Critical Care Transport Team Paramedic. He has been in EMS for 9 years, with three and a half of them spent as a Paramedic. He can be reached for any questions or discussion at chancegearheart (at) gmail.com.

Posted by on October 8, 2012 • Filed under: Ambulance, Emergency Medical Services, EMS, ems education, EMS Topics, EMS training, Paramedic, paramedic education, Patient Management, scenario based training, 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.

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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
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