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.