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.

23 July 2013

CPPs...


There is a lot of debate these days on the concept of “community paramedics”. Me personally, I like the concept. I see too often that our current way of doing things (I am not trying to start a philosophical debate on the status of our healthcare system and the desires of some to turn it into, as one writer calls it, “government run cradle-to-grave healthcare”). As an EMS provider for my entire adult life, I have seen the gaps in the care that people receive (I do, however, believe in cradle to grave healthcare, no matter who provides it.) when they are sick or injured. There are rules that have to be negotiated, minefields of insurance and healthcare bureaucracy that stand poised to ‘regulate costs” and determine eligibility.

No matter, people have needs. When those needs are not met, guess who they call? And like it or not, there are a lot of EMS folks out there who get a little bummed out when they have to transport the same person, over and over, for maintenance of that patient’s ongoing and/or chronic condition that is not being managed or met.

Is being a community paramedic for everyone? Of course not. The same reason that every paramedic is not suited to be a firefighter and every firefighter is not suited to be a paramedic (opinions of the IAFF and others not withstanding).

But it is a need that someone needs to fill. So why not us?

Over at the blog Rescuing Providence the author writes is top ten reasons he does not like community paramedics, and you can go see that list here.

Of course, there is a really good response over at Captains Chair Confessions where he addresses each of RP’s ’Top Ten Reasons’.

And then, there is this jewel over at Too Old To Work, Too Young To Retire, where Too Old throws in his $0.05 worth and he does make some good points.

So why am I a proponent of the community practice concept? Yes, a lot of these areas are supposedly covered by nurses. And I know that EMS is typically ‘fee for transport’ funded. But I do believe we have to get away from that, and that we do need to take a page form the fire service playbook- public outreach.

In my mind the idea of the community paramedic is to ‘fill gaps’.

Like Too Old, my parents have had experiences with the healthcare system and the home health care field- or lack thereof. My father never got home health care, even though he was incapacitated. Instead, it was left to my mother to care for him, with a little help from me, my wife, and my daughters. I don’t know that EMS could fill that role in the area of community paramedicine, but where I do see opportunities is public education.

I have seen patients who are discharged from the hospital for whatever condition and by the time home health care is set up for them they have already been transported twice to the ED. Is it because they are irresponsible? Sometimes. But more often than not, in my experience, it is because the doctors and nurses explained everything at a college level to someone who may not have finished high school. And nobody explained to them that the Good Old Boy Rule* did not apply to drugs like atenolol, furosemide, or amlodipine.

Recently my mother was given a medication for her COPD that she did not understand how to use. Coupled with her eyesight and arthritis, that did not turn out to well. And she is not alone. Many times people simply do not understand how to manipulate the medications or devices. And please, do not tell them to ‘check out a video on the internet’. Most of these people are like my mother and do not have internet, or even a computer.

I have seen opinion pieces about the plight of poor people and others about how they are responsible for it. Maybe. But guess who gets to take care of the aftermath?

Maybe it is a failing of our public education system, a failing of our evolving values as a society…whatever. The fact is, we have to change the way we do business. You call we haul is not sustainable.

There are other parts of the RP Top Ten that I wondered about, but then, I am not familiar with what everyone else is doing. But my own idea of what a Community Practice Paramedic program in my little slice of rural America would look something like this-

  1. Follow up on discharges from our local hospitals for patients who have respiratory diseases, heart disease, and diabetes. No we haven’t been trained in it, but there are a lot of things I have learned in the past few years. And the reason I/we cannot learn a little more is….what? I’m not so much concerned about insulin pumps, but the person who just got discharged after treatment for severe COPD or CHF and they do not understand all of the gobbledygook that the doctor or discharge nurse threw at them in rapid succession.
  2. Fall prevention. The model is based on what the fire service has been pretty successful at- fire prevention. Imagine EMS getting dispatched to the same residence twice or three times in a week or two for a fall at the same residence. No transport, so no fee. Why not send someone in to check with the residents and see if we can help them minimize their fall hazards? Maybe they did not know about how throw rugs and all of those nick-nacks are causing the problem. Maybe they just need some ideas. Maybe the other family members might get involved?
  3. Referrals. In my career I have been to many EMS calls for people who need a doctor but don’t know who to call.
  4. Mental health referrals. I am not talking about counseling. I am talking about calls that I have gone to where a medically stable person wants some help. Maybe it is with alcohol, drugs, or just…life. Maybe they did not need an ED, but there are other options out there. In my area, we have crisis counseling that can come to you.
  5. Alternate destinations. My old employer started a community paramedic program of sorts, and one thing we did was if a person just needed a place to stay, or maybe a detox, we had options other than the ED. It sort of ties in with #4.

Is a community practice paramedic program for everyone? Maybe not. But it is another option that we need to really look at. And no, not everyone is cut out to be a community paramedic. Just like all of those paramedics that are not cut out to do high angle rescue, firefighting, confined space rescue, etc. And just like all of those people who do high angle rescue, confined space rescue, water rescue, trench rescue, and firefighting who are not cut out to be a paramedic.
 
*- Good Old Boy Rule- If a little bit is good, then a whole lot is better.

16 July 2013

Scene safe, PPE...NOT!


We’ve all heard it for years. The first thing we do and say when we are testing or going through a scenario for any EMS class is raise our hands and recite “Scene safe, PPE”. We’ve fooled ourselves into thinking we work in a ‘safe environment’. We’ve fooled ourselves into believing that maybe the presence of a law enforcement officer will provide a ‘safe environment’. We’ve fooled ourselves into thinking that since we are the ‘good guys’ no one is going to try and hurt us.

Guess what? We were wrong.

It is getting to be a common occurrence to read about another incident that has happened somewhere in our country where a member of an EMS crew has been attacked or assaulted, either with a knife, a firearm, or just a physical attack. Here are two links that I have seen in the past few days-



 


And over at EMS1.com, author Steve Whitehead has a pretty good take on the whole thing of "scene safe, PPE". I like his idea of teaching risk assessment and management. Like he says, it is not enough to 'acknowledge' that many of our scenes are not safe- we have to prepare for it. We have to realize that just because the scene was safe in the first 10 seconds, that does not mean it is safe in thsecond, third, or fourth 10 seconds.

It reminds me of something Sergeant First Class Bruce Grimes once said to me and the other members of my basic training platoon- "Stay alert and stay alive".

But anyway, in getting into the debate about unsafe scenes and assaults on EMS, the first thing someone is going to say is “let’s arm EMS”. The biggest flaw with that idea is that who is going to pay for the training necessary to be familiar with a firearm, let alone proficient with that same firearm? And then who is going to pay for the firearms? I can go on, but let’s just say that there are a bunch of hurdles to that one. Plus, I have worked with a lot of people that I really don’t trust with a firearm.

There are various courses out there that seek to educate and prepare EMS folks in how to evade or escape these encounters as well as how to defend themselves when escape or evasion is not an option. DT4EMS comes to mind.

But then, who pays for these classes?

I don’t know about some of the other states, but in my home state we are required to get 24 hours of continuing education each year of a four year cycle, with mandatory requirements in certain categories. There’s not a whole lot of leeway within the requirements, unless hours are added for something like DT4EMS.

So what are we to do?

First, we have to get out of the mindset that we work in a safe environment. We don’t and we never have. Think otherwise? Ask those five firefighters in Gwinett County, GA. Ask the EMS crew in Omaha or the EMT in Jersey City, NJ. Hell, you can ask one of my coworkers here with my current employer.

Every single scene we are on has the potential, the very real potential, to go very badly very quickly. And quite frankly, many of the folks I have worked with over the years are woefully unprepared to deal with it.

Second, we have to provide training and education to our people in how to deal with these situations. Simply saying “well, maybe it can happen to us” is not enough. We’ve got to prepare. I’ve done some research on the course and I like the concept of DT4EMS. I think it (or something like it) should be mandatory for every EMS responder in the country. It should be a part of the national curriculum, every state curriculum, and the National Registry requirements. Period. If it takes extra time, then so be it.

It has to be geared to our environment. I am not talking about martial arts training or some modified version of law enforcement or corrections training. What we have to have is some sort of training that is geared to us and to our environment. But is that all there is to it? Is taking a course that prepares us to evade a hostile encounter or defend ourselves really enough?

Well, no, it is not.

Thirdly, we have to develop plans, procedures, and protocols that cover how we deal with these situations. We have to have the equivalent of the fire service’s “MAYDAY” or law enforcement’s “SIGNAL 25” (maybe we can use one of their terms, but it has to be one or the other- I prefer MAYDAY since, well, I just do.).

And we have to train with it. More than “once in a while”.

We also have to change the way we train and re-train.

Sure, wear your gloves. Use your PPE. But don’t assume you are working in a safe environment. You’re not.