If, in moving through your life, you find yourself lost...go back to the last place where you knew who you were, and what you were doing, and start from there. Bernice Johnson Reagon.

19 November 2012

Overcoming the "Magic Words"



Over the past few days there has been a lot of attention placed, once again, upon the District of Columbia’s Fire & Emergency Medical Service. This time, the topic is Chief Ellerbe’s plan to unstaff ALS ambulances at night. You can read about that plan here.

Another blogger, Justin Schorr, who writes The Happy Medic Blog, provided his take on the subject here.

In all honestly, it is hard for me to figure out where he is being sarcastic and where he is not. But towards the end, there is this passage-

“Because it needs to be coupled to a “Respond Not Convey” program, or as we call it on the street, the Paramedic Initiated Refusal.  Refusing transport to certain patients who do not need it is the relief DC FEMS needs to better serve the population.  So long as every stubbed toe and runny nose that wants transport gets it, you will continue to have 4 person ALS engines or ALS supervisors at the scene of incidents waiting for an ambulance.  We call it “Medic to Follow” and it is the number one drain on our system. “But Happy, that’s a BLS run!” Not if they used the magic word “Chest pain” to get triaged faster.  And we all know that NEVER happens…right?”

The Paramedic Initiated Refusal. There has been a lot written about that very topic on the blogs, on the public forums, like JEMS.com, and there have been articles written about it, both media and peer-reviewed.
Seems like field people want it and managers and academic types don’t.

There is some evidence out there that maybe us folks on the front lines don’t do that very well. And over the years I can point out a couple of anecdotal events that would tend to confirm that. But each one of those events points out a single glaring shortcoming- a good assessment.

Part of that is laziness. I know of one instance where a crew went out the shift before to an elderly patient who had fallen and had not transported, and then early on the next shift, after relieving that crew, and then my partner and I were dispatched back to the same residence, less than four hours later to the same residence and transported the same patient, with an obvious shoulder dislocation.

That was nothing but callous disregard and laziness.

But I have also seen those times when well meaning paramedics have performed what they thought was a good assessment, acted in what they thought was an appropriate manner, but missed subtle little clues that their patient was getting ready to go south, and then when it happened they lost the game of "catch up".

That, I am here to tell you, is totally avoidable. But in those cases, our educational system has let them down.

I think back to my EMT class my EMT-Intermediate class, and my paramedic training. I think back to all of those merit badge classes (ACLS, BCLS, BTLS, NRP, PALS, and PHTLS) that I have had to endure over the  years, and the vast majority of all of the continuing education I have had to participate in (and sometimes painfully endure). And when I think about what was covered on the topic of assessment…there was not a whole lot there.

There was a lot of the “if you see that, do this” kind of thing, with no explanation of what the “that” you were looking at meant or really what the “this” was going to do.

It wasn’t until around 2007 or 2008, when I was taking some classes through Western Carolina University, that I received actual, official instruction and education on what all of those signs we were taught to look for meant. Of course, over the years, I was curious and had investigated it on my own, so that Dr. Trigg’s material was an excellent review, but I have to wonder how many folks out there in EMS Land have not really researched it, really finding out what all of those subtle signs and symptoms really meant?

The world of EMS has changed in the past few years.

Our call volumes are going up really quick. People are being educated to call 9-1-1 for everything. Every sniffle, twinge, and inconvenience. Every painful twitch could be a life ending heart attack, life altering stroke, of the onset of the latest influenza outbreak that will leave thousands dead in the streets.

I consider myself to be a pretty damn good paramedic. I like to think it is hard to get stuff past me, and I pride myself on really assessing my patients. And I can honestly say that a full 87.3% of the patients that I have encountered over the past three years would have been safely covered under a “respond but not convey” protocol.

But in order to address such protocols and ideals, we have to address a basic tenant of medical care- the assessment.

We have to start placing more emphasis on patient assessment in our initial education programs. Classes on assessment have to have included in them more substance, more than mnemonics and catchy phrases. And it has to be included in our continuing education programs, as well.

I have to agree with Justin in that EMS needs to pursue the “respond but not convey’ protocol in the not-too-distant future. Community Practice Paramedic programs are a start, but there will have to be a way for educated and capable paramedics to “not convey” every little runny nose, cut finger, and chronic body ache by ambulance (ALS or BLS) to the emergency department.

Even if they do throw in some of those “magic words”.

The capabilities and the technology are here to enable us to do just that. 

18 November 2012

Isn't it about time we look at alternatives to long spine board torture? (UPDATED 11/20/2012)



UPDATE 11/20/2012: Justin Schorr from The Happy Medic has recommended an article on EMS World on this same topic. Please go here and read it.

Over at Rogue Medic, he has posted another entry about spinal immobilization. You can go here to read about it, but he reports that there are several agencies that are doing away with or limiting the use of long spine boards.

Thank. You.

I think it is high time that this idea of putting a curved body on a straight and flat board is done away with. There are other options that need to be investigated and tried.

I think about a recent incident that a patient who was up and walking around earlier, after an incident, and in fact drove himself home and then called 9-1-1, and upon our arrival was placed on a board (I was an observer), even though he met all criteria in any clearance protocol. During the ride to the hospital on the smooth riding ambulance (note sarcasm) I had the opportunity to watch the patient wince up every time the ambulance it a bump, and I watched him rock from side to side as we traveled down the road. I focused on a specific point on his right flank and observed what looked like at least four inches of travel up and down as he rocked from side to side.

So what was accomplished? His movement was not restricted. His comfort was severely compromised. And I would venture that his spine, if it was not injured before the ride, probably did not feel too good afterwards.
And the board was placed upon a stretcher with the bolstered mattress...

I think it would have been more appropriate, if spinal injuries were really potentially present, to have placed the patient directly on the stretcher, maybe a c-collar in place, with a set of towel/blanket rolls to help stabilize the head.

But back to the LSB, I think that the design of many of them compounds the discomfort. Looking at several at a local trauma center recently, many of them are truly flat, and some even arch in the middle. A few are contoured, somewhat, but even they are uncomfortable more than, say, 90 seconds.

Is there any scientific proof that placing people with curves on flat boards, ineffectively strapped to that board, with poorly performing commercial CIDs?

If we are going to continue this barbaric practice, we need to include certain caveats-

1. Padding has to be placed at different places, particular in the voids that exist between the shoulders, the small of the back, and behind the knees. Additionally, we need to place some sort of padding under the head.

2. If we are going to use a cervical immobilization device (CID), it has to perform better than the average disposable commercial device, cannot easily move, and must take into consideration the dynamic and non-stable environment of the back of the average American ambulance.

3. We have to realize that the strapping methods we currently use (clip straps, tied straps, and spider straps) do not restrict movement from side to side unless we utilize some sort of padding (rolled blankets or towels) to fill in the voids between the patient’s body and the straps.

I tried it once and the only way I could place a patient on a spine board, reasonably comfortable, and restrict all motion from side-to-side and end-to-end required four or five straps (with eight or ten contact points on the board), a folded towel under the head, a folded blanket in the small of the back and another under the shoulders, a rolled towel under the knees, and four blankets rolled up and placed on the sides, pus the rolled up blankets for head rolls. Seven blankets (plus the two needed to keep the patient warm) and two towels.

Admittedly I don’t do that for every patient I put on a long spine board, mainly because I usually don’t have that many blankets on an ambulance on any given day (and if I put them on the ambulance co-workers in times past usually take them off or use them without replacing them and a lot of hospital EDs like to hide their blankets).

But then, the question remains- Is there any benefit to placing a patient on a long spine board?

And another question that I have to ask- If we are unwilling to do away with the practice of torturing immobilizing patients on long spine boards, are there better alternatives than a long flat board and poorly performing CIDs?

13 November 2012

The Law of Unintended Consequences



No doubt you have heard about DCFEMS’ latest idea to not staff ALS transport units at night. Haven’t heard? Go here and here to read about it.

Without getting into a long drawn out diatribe- it’s a Band-Aid on a bigger problem.

There have been some reports of late about DCFEMS’ inability to recruit or retain paramedics. They speak of a shortage.

There is no shortage of paramedics. What there is a shortage of is paramedics that are willing to work non-stop in less-than-desirable circumstances.

It seems like a lot of people go to DCFEMS to get some experience and then head for the suburbs. Better staffing, lower call volumes, and in some cases, better schedules. Maybe more money, but money isn’t everything.

I hear a lot of EMS manager types speaking of EMS working conditions. Things like they’re creating career ladders, providing all of the neatest toys, have great protocols…

Things like that really don’t matter when you are running what seems to be non-stop, whether it is actual calls, or posting/move-ups. And regardless of what the stats say, what matters is in the minds of those personnel that feel like they are running non-stop, posting non-stop, etc.

So what about this latest idea?

Well, if ALS is available, even though there is a lot of debate on the value of ALS, then maybe it can work.

But…

What if ALS is not available? You know, if the fire suppression crews that are supposed to be providing ALS are committed elsewhere, you know, suppressing fires?

And how many of those folks that ride on the fire trucks that are holding paramedic certs really want to be on the ambulance? You know, I am willing to bet that a significant number, well, don’t. If they did, they would be working the ambulance. Or, as some folks in that regions refer to them, the ‘shit box’.

And of course, there is the aspect of, no matter how well-meaning the folks involved, how long is it going to take before someone that should have had ALS transport (respiratory distress, seizures, or cardiac issues) gets sent BLS with a less-than-desirable outcome.

And you know it will happen, and when it does, the media will be all over it.

Given the publicity that DCFEMS has generated over the past few years from their prehospital exploits, I am sure that even with the best of intentions, this is going to be a lesson in the law of unintended consequences.

06 November 2012

The ability to not become a victim



Over at JEMS Chief Skip Kirkwood has written an article concerning self-defense for EMS folks. You can go here and read it.

It is a pretty good article and it addresses what seems to be a growing problem.

The standard response is always “Don’t get yourself into that bad situation”, “Stage for law enforcement”, and “Retreat when things start to go bad”.

Good advice. When it works.

You see, EMS folks get themselves into all sorts of situations that have the potential to go south without warning. And there you are, in the back bedroom of a house. On the second floor.

What do you do?

Retreat? You have several family members to get through. And the stairs. And you’re on the second floor.

You could push that orange button? If your service has one. And if your digital radio system has 100% coverage (yeah, right).

You could call for help. But wait, that radio is stuck cutely to your belt in the small of your back.

Well?

Think about it while you and your partner are getting your asses kicked. Or worse.

Now, there are those that are going to say arm EMS. Give EMS concealed carry. OK, as a former Army medic I am OK with packing heat. I packed an M16A1 and an M9, along with a pair of M67s. But it was a different situation and is another entire topic.

So what's taking you so long?
In this scenario, you were caught off guard. It was a “Grandma fell down and went boom” call. 17A3G. Good neighborhood. The family is pissed off because you are not helping Grandma fast enough Now the feces has hit the fan.

It’s simple. We need training and education that goes beyond “Scene safe and PPE”.

The days of narrow focus EMT and paramedic classes are coming to an end. Actually, they should have 
already ended.

We spend a lot of time talking about how to do things. How to put on a splint, dress a wound, start an IV, and place an ET tube. We do not spend enough time on why, but that, too, is another topic. 

We also spend a lot of time sending our people into potentially bad situations with no preparation and no real plan on how to deal with that situation when it arises.

We also need to include, as a part of our initial training and our ongoing training, instruction on self-defense tactics, verbal and physical. If it adds 50-75 hours to an EMT class, the so be it.

If it adds 26-48 hours of training every other year or so to our continuing education program, the so be it.

If it means that we have to have better physical fitness standards, well, so be it. And if it means we have to maintain those standards, well, so be that, too.

We should not be setting our people up to be victims.

28 October 2012

It's the little things that turn out to be big things in the end...

Over on the Legeros Fire Blog there is this entry.The main question was about who provides pet masks for their field crews.

Every so often you see it on the news about how firefighters or EMTs treated a family pet on the scene of a residential fire. Usually, it seems, when it makes the news there is a positive outcome. And this works out more positive than most people imagine.

It signifies compassion. It signifies going the extra mile, and then some. People place a high value on their pets. Don't believe it? Obviously, you've never had a dog or cat (or any other creature) for a pet. Heck, I think more of my dog than I do most people. And that's a fact.

So when we have these stories about pets being 'rescued from the jaws of death', the PR value is immeasurable for the agencies involved.

Anywhoo, in reading the post on Mike's blog, there was the comment about how someone removed the pet masks from a truck, even referring to it as "stupid crap".

Folks, anything we do that makes the public feel better about their shitty day, as well as feeling better about us and the job we do, should never, ever, be considered "stupid crap".

Unfortunately, I have worked with several people over the years that have never quite grasped that fact.

There are a lot of things we can do to make things better for people that are having their worst day possible. pet masks are just one.

How about kids? Something I used to do was buy kids' masks for nebulizers. A kid can feel really crappy, but somehow, a cutesy nebulizer mask will not only make them feel better, but it makes Mom and Dad feel better about who is taking care of their kid. I've gotten more than one hug over the years for such little stuff.

The sad part is I left them on my ambulance one day, and when I came back from four day break, they were gone. As I was told "They ain't on the checklist, and this ain't the Hilton".

It goes further. Just making sure your patient, particularly elderly patients, have a pillow (or two or three), along with a couple of blankets ('cause Grandma always gets cold) provides a tangible measure about who you are as a caregiver (and that's what we are in EMS- caregivers). People notice it. I sued to try and make sure I had pillows (at least three) on my ambulance at one of my old employers. I also used to try and make sure I had multiple blankets for warmth and padding.

It was a sad thing when these were always removed because "This ain't no Motel 6". It was also a sad state that supervisors thought my propensity to take care of my patients (like I want my mother taken care of) was 'funny', something to be mildly tolerated.

I've said it before- the public has no idea how knowledgeable you are, whether you can read a 12-lead at 50 yards or calculate three drips in your head at once.

But they know when you are nice.

They notice when you take care of them. Or their Mama. Or their pets.

And they are the ones that vote. That run for public office. And they have long memories.

23 October 2012

Bumpy rides



There is a report over on EMS1.com about concerns over the safety and comfort of Montreal’s new ambulances. There is even a short video that seems to show the rough ride provided. You can read that report and see the video here. There is also a report in the Montreal media here.

Well, to anyone out there who has ridden a type I, type III, or medium duty chassis ambulance over the last, oh, 20 years, this is nothing new. If you make an ambulance on a truck chassis, guess what? It rides like a truck.

Part of the answer to durability and braking issues a few years ago led to the proliferation of the Ford E450 and GM G4500 series chassis, in many cases replacing the Ford E350. Of course, when you beef up the suspensions to handle the extra weight, well, they ride rougher.And to add to that, the idea that medium duty trucks would offer better power train and brake life, plus added carrying capacity, led to their popularity.

Seems like patient comfort, much less medic comfort, has ever entered into the idea of ambulance design. I have even seen some discussion board threads about ambulance design, and it all comes down to something other than patient and medic comfort.

The whole power and weight and suspension thing was really highlighted in a couple of Freightshaker, er, Freightliner ambulances I got to enjoy back in the late 90s. One, a remount, utilized a lower horsepower engine with a lower GVWR rating. While you had to be a little patient in driving it, since it was going nowhere fast, it really did not ride too bad, relatively speaking, in the way that cup of boiling water will not burn you as bad as a pot of boiling water. Contrastingly, there was a Freightliner unit that was built new with a beefier engine, which of course had the higher GVWR and heavier springs. With the extra HP it would scoot, but the ride was horrendous. Really horrendous.

Same sort of thing with a couple of Ford E350 chassis units that I used during the 90s. They rode really well, even in the back, and they handled good. They were a little underpowered (but how fast do you really need to go?) and they had really short brake life (it seems like something around every10,000 miles they needed brake pads, and every other brake job got rotors and drums). Fast forward to now with the E450s and Powerstroke diesels (that are no longer available in the E450 for ambulances) and the GM G4500s- they have power but they have terrible rides.

And we won't even talk about type-I ambulances.

At any rate, there are some stretches of road that I would like to take ambulance designers across, while they are laying on a stretcher, or better yet, strapped to a back board. And since it is getting to the point that many hospital EDs do not switch out pillows and blankets, well, they cannot have those either for their 'test' ride.

You can tout the virtues of your ambulance all you want, but until you can design a smoother ride into them, along with a safer environment for  the medics that have to ride in them, well, people are going to complain. And with good reason. Maybe if the designers understood what was happening.....

I have seen all manner of crap (yes, crap) that has been inflicted on patients and medics in the name of efficiency and "better patient care" for a large part of my EMS career. I have seen one former employer spend thousands of dollars trying to get a medium duty ambulance to not qualify as "cruel and unusual punishment" because of the ride they dish out. I remember air suspensions, hydraulic suspensions, Velvet Ride, Comfort Crew, and techniques of tinkering with the air in the air bags, tinkering with the air bag and spring capacity, and even messing with tire size and pressure.

Guess what? They still rode like.....crap. And in some cases, the handling characteristics got......interesting.

I have a couple of observations.

First, we carry too much stuff. I know, we like to think we need all of it to save a life, but there is a lot of stuff that we could probably do without. I mean, how much sterile water and oxygen tanks do you need? Wouldn't 500ml bags of fluid suffice? I mean, seems like I read somewhere that all that fluid we use to give trauma patients was detrimental. And I know 250ml bags are kind of expensive, so how about 500ml bags? With a couple of 250mls for drips, of course.

I know, IV bags are but just a part of what we carry, but I really think we could cut out a lot of what we carry on our ambulances and in our bags. Which would cut down on the weight of the gear, which would cut down on the GVWR, which would, maybe translate into something smaller, lighter, better riding, and, maybe, fuel efficient. Because after all, if they have to spend $4.00 per gallon for diesel fuel, and these ambulances are NOT known for their fuel efficiency, what do you think that does for money that might be available for...salaries?

Second, I think our ambulances are too big. A while back, well-known EMS author Thom Dick wrote an article for JEMS about a smaller, safer ambulance. You can go here to read it. I think he is on to something. Of course, judging by the comments he got recently on Facebook, there may be a lot of people that don't want to let go of their big, rough riding trucks.

Do we really need all of that room? There is tons of evidence out there (real, scientific evidence) that we should not be transporting full arrests- ever- since all of the evidence shows that this is a futile gesture. A futile gesture that needlessly endangers our crews and the public. Do you really need to be up and walking all around the patient on the way to the hospital? Do we really need to be carrying more than one patient in an ambulance? Can you really manage two patients? Really?

Does your dentist, doctor, barber, hair stylist or banker try to take care of two patients/customers at once, in the same office? Of course not. So why do you think you can?

It all boils down to these trucks are too big. To me, the current crop of large type I, type III, and medium duty ambulances are reminiscent of the Big American cars of the 50's, 60s, and early 70's- big muscle, big steel, and big tail fins..... If only they rode that good.

We deserve better and our patients deserve much better.