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. 


Ambulance Driver said...

Well said.

No matter what name you hang on it, paramedic-initiated refusals are going to be unworkable until the level of EMS education is increased.

We all know medics who we think can be entrusted to make such decisions wisely. I like to think I am one of them.

Problem is, those medics are the minority.

When the number of medics I work with who I wouldn't trust to treat my dog is vastly outnumbered by those I'd trust my the lives of my loved ones, then medic-initiated refusals will be a viable option.

9-ECHO-1 said...

Thanks, AD. Like you, I have read the studies and they have merit. But it seems that they do not address why there is a problem- education.

And it seems that every time someone mentions an increase in what are essentially minimal standards to start with, everyone carries on as if we're getting ready to start killing puppies or something.