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.

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.

11 October 2012

Seat belt use and poorly designed ambulances...

Over on Facebook, a ‘question’ was posted by ‘Paramedics on Facebook’-

Here is a good question to throw around...... How many actually use their seatbelts in the back of the Ambulance???

From the responses, it seems that most people don’t. A scarier thing is that it seems that most of those either think it is not necessary or just not possible.

For years I didn’t wear one. Many of the ambulances that I have worked on over the years just did not have seat belts for the crew member(s) in the back to us, or the ones that were present were not a very good design.

However, seeing all of the crashes that involve EMS units, and realizing that many of the fatalities are the unrestrained medics in the back, I have adopted certain rules for myself. They may go against some generally accepted practices, but these are my way of helping to ensure I go home at the end of my shift-

1. Seat belt is on.  The only time it is off is if I have to change positions to use the radio (note, only in a poorly designed ambulance is the radio controls and switch panel on the opposite side of the ambulance from the primary care position, which happens to be the patient’s left side).

2. If I cannot do it while sitting down and belted, it is done before we leave. My taking 1-2 extra minutes to secure an IV if needed is not going to be clinically significant. I gather everything that I will need beforehand for patient care that I will be providing during the transport. If those guidelines that 10 minute scene times are so clinically significant, then we need to be doing everything we can to ensure we are set up to cut out inefficient practices that hamper us, like bags with too much stuff, pre-attached backboard straps (especially those that are tangled up), etc.

3. Strap down everything. Actually, this is easier said than done. I at least strap down my monitor. That only leaves the ‘jump’ bag and the airway bag, and maybe the drug box and suction unit, left lying around.

I have found that I can do a lot of things, things that most people say you cannot do, from a seated and belted position.

As to those that say “but what out CPR?” , it has been proven and documented in peer reviewed studies and research that effective chest compressions are not consistently possible in the back of a moving ambulance. Like one respondent stated in his reply in the referenced thread- "Doing CPR while moving the patient is a guarantee of a final outcome - death. Work 'em where you find them and call them if it's not successful. There is nothing to be gained by moving to the hospital.

In my own experience over many, many years, in several counties here in NC, I have never once seen a full arrest, adult or pediatric, medical or trauma, that was resuscitated and discharged home, that did not experience ROSC on scene and maintain it. I’ve never even heard of one. So why are we still transporting arrests? We are doing nothing more than endangering our crews and the general and motoring public.

But the basic question, "do you wear seat belts?" is also influenced by the poor design of the 'modern' US ambulance. We are still stuck with the bench on one side, the 'captain's chair', and a pretty useless CPR seat.

Take a look at your ambulance. Most ambulances establish the primary care position at the patient's left side by virtue of the bench. Whether that is the ideal location and whether or not we really need to have 'walk-around' access is something to tackle later. But going on the idea that the left side is the ideal position, ask these questions-

1. Do you have to get up from the primary care position to get to the radio(s),light switches, oxygen connections, suction unit, and climate controls?

2. Do you have to get up to access 'routine' items to provide care for the patient, like gauze pads, syringes and needles, tissues, wash cloths, or some medications?

3. Is there a way to secure all of the equipment in a compartment or cabinet, or do you have to rely on materials carried in 'the bag' to provide care during transport? Or do you just 'set' all that stuff (potential flying objects) down on the floor because you keep in on the stretcher between patients?

Maybe if our ambulances were a little bit better designed (OK, a lot better designed), we would not have to asking questions on Facebook like "Do you wear seatbelts in the back?". And maybe we would not be reading about medics getting killed from being thrown around or out of the patient compartment.

Just a thought (or two).

Ambulance crash picture from internet source. Seat belt picture from personal files.

03 October 2012

Random Thoughts

Local law enforcement around my home  should concentrate more on looking like Andy Taylor, Andy Renko, Bobby Hill, Jim Reid, and Pete Malloy, rather than a Navy SEAL.

It amazes at how many of my EMS brethren fail to grasp the importance of a pillow and a blanket on the cot as an important aspect of patient care. I also have also been quite disappointed in the number of them that look at me funny or act as though I am crazy for providing them.

If your child is seizing, or heaven forbid, not breathing, and I am asking you questions, don't get upset with me when I, after you look up at me all surprised and stuff because you have been texting the whole time I have been trying to ask you questions about your child, tell you to put your freakin' phone down and listen to me.

0.9% Sodium Chloride is an awesome substance. It cures what ails you (or doesn't).

Does anyone really believe all of the dribble that is spouted out in political TV ads? And worse, what does it say about the average voter who may be swayed by such dribble?

It does not look like the 2012 Hockey Lockout is going to end anytime soon. Maybe we could get Gary Bettman a job as commissioner of the Afghanistan Hockey League. Or maybe Pakistan. Or Ghana.

It is insane that I bought gas the other day and thought $3.51 per gallon was a bargain. And no, Romney can't do anything about it. And Obama is not going to, either.

No, going to the hospital by ambulance does not necessarily get you seen quicker. And no, you cannot smoke a cigarette before we go.

Sometimes we make less-than-ideal decisions or choices. We can dwell on them or we can just learn and move on. I've decide to do the latter.

It's amazing how disappointing some people can become. It always pays to be careful with your respect and who you give it to and they should have to earn it every day.You can only accomplish so much by fancy slogans, catch phrases, and quotes. Eventually, we will see though it all and find out that what was looked upon with so much enthusiasm and amazement really wasn't so impressive after all.

WSFL 106.5FM, a classic rock station in Eastern NC is pretty freakin' awesome. Not what WQDR 94.7FM was back in the day when they first went on the air as an album rock station, but better than anything else in the Raleigh area. WRVA or WBBB, you guys need to take notes.


Over on Facebook there are a couple of threads amongst my friends and acquaintances going on about professionalism, enthusiasm, support for causes, etc. It has been a pretty interesting and lively discussion all the way around. It is obvious that people on either side are passionate about their point of view.

Basically, what got it all started was the decision on the part of two EMS agencies in a particular county to allow their medics (EMTs and paramedics) to wear pink t-shirts with an agency logo while on duty. Some folks in another agency got a little upset because their agency chose not to participate. And so the discussion (well, maybe discussion is not the right word, but it is what I will use) went on. There was even a little name calling and inappropriate terminology used.

There was a point that was attempted to be made about “being professional” and how the pink t-shirts are not professional looking.

So, what exactly is “being professional”? Is it truly about how you look and what kind of uniform you wear? Is it wearing the same thing that your partner is wearing so that you match (and therefore “look professional”)?

Does it matter if you are wearing a class ‘A’ shirt with badge and nameplate, a polo-style shirt, a job shirt (with or without denim elbow patches), or a t-shirt? What about ‘scrubs’? What about tactical style uniforms (what I refer to as BDUs)? What about pocket pants or regular pants?

Does what you wear really go that far in gaining the public’s (and your patient’s) trust?

Actually, no.

I know, there are all sorts of people reading this that are getting red in the face, or shaking their heads, or area all ready to send me an email about how wrong I am.

It doesn’t matter. Really, it doesn’t.

It’s how you present yourself and carry yourself. It’s about how you treat people. Are you nice and polite? Do you convey the idea that at that moment, that patient there in front of you is the center of your universe at that moment? If so, then you have the idea. It does not matter what you look like, as long as you don’t smell bad and are clean.

Patient care is not even about professionalism. It is about compassion. Seems like I read a mission statement once that had that word (compassion) in it (actually, it was compassionate, but you get the idea). Seems like I also that I heard a well-known EMS medical director make a statement, over and over, that it does not matter about the patch on your sleeve or the color of your uniform or ambulance.

I have worked with, around, and for some people over the years that could wear a uniform, look real good in it, but be absolute jerks the whole time. Their patients knew it, the patients’ families knew it, and their co-workers knew it. They knew absolutely nothing (nor did they care) about how to take care of people.

So what has this got to do with the pink t-shirt craze? Well, a lot, actually.

One of my friends and co-workers on Facebook also posted a rant, of sorts, about her employer’s decision to allow their employees to wear pink t-shirts while on duty during the month of October. One of the terms that she used was ‘m o r a l e   b o o s t e r’. (Good one, Candace)

And here is a new concept for some folks- morale boosters  (the kind the employees ask for that are not going to hurt anyone) make for   h a p p y    e m p l o y e e s . And guess what kind of care happy employees provide?

It doesn’t have to be t-shirts. My own employer has authorized our personnel this month to wear pink ribbons on our uniforms. These are morale boosters. Many people today have been touched by breast cancer. In my own household, me and Mrs. 9-ECHO-1 had our own breast cancer scare a few years ago.  

So yeah, I think it is a good idea. T-shirt, ribbon, or bracelet; it shouldn’t matter.

And then you have the people who say “If you support one cause, you have to support them all”. Well, no you don’t. But is there a real problem with that?

Is there a problem if people support their causes on duty? No. I wear a black and red ID lanyard at one of my jobs to support firefighters. I wore a yellow bracelet on duty in support of one of my co-workers who had a son deployed to Afghanistan. I have a key lanyard in support of the Wounded Warrior Project that I wear on duty.

But my partners didn’t. Does that make us less professional because we did not match or this was some article that my employer did not ‘authorize’? Not ‘no’, but ‘hell no’. If anything, it highlights our compassion for our fellow human beings.

I for one like the idea of the pink t-shirts. If my organization would authorize them I would wear them in a heartbeat. I think that the pink t-shirts (or other gestures) show a tremendous amount of passion and compassion on the part of those agencies. My hat is off to them.

And maybe there are other causes. Worthy causes.

I like the idea of yellow ribbons and bracelets for our troops who are deployed overseas. Maybe for National Military Appreciation Month we could wear military themed t-shirts (maybe for 2013 we could get ACU camo t-shirts), bracelets, or ribbons. How about red, white, and blue during July?  And is there a problem with wearing the various colored ribbons for the various cancers during their month?

Not a bit. Like someone said, it gets people talking, interacting, and involved. And there is nothing wrong with that.

So to those agencies that opted for the pink shirts or pink ribbons, high fives and fist bumps all around.