Paramedic Blog: EMS

EMS Today 2007

Fri, 30 Mar 2007 15:37:04 GMT

EMS Today was an awesome Conference this year. I really enjoyed several of the sessions including AJ Heightman’s MCI Class, and the Safety Roundtable Discussion led by Rick Patrick.

I also got to meet with a group of EMS Bloggers and Authors that I really enjoy reading, including;

Peter Canning from http://medicscribe.blogspot.com/

Jamie Davis from http://www.mediccast.com/blog/

John Bignell from http://www.emslive.com/

Eric Augustus from http://emshaiku.blog-city.com/

Rick Russotti http://mitigationjournal.libsyn.com/

- and a few others whose names I can't remember. It was a great time, and I’m looking forward to doing it again next year! Eric put a great summary post of everything that happened at EMS Today on his site at http://emshaiku.blog-city.com/jems_ems_today_brief.htm

Tie Them Up or Run?

Mon, 31 Jul 2006 21:18:09 GMT

I was recently asked about restraining the combative or disoriented patient. The practice of patient restraint is one of the more dangerous things a Medic can be called upon to perform. It should always be very carefully considered, and even more carefully monitored. Here is what we know. About a half dozen patients every year die while restrained. Tying people up can be very dangerous to their health. Even the use of Chemical Restraints is dangerous and except for in a helicopter, usually unwarranted.

There was a day; I thought “playing with drunks” had an entertainment value. Forget the “cowboy” mentality, and view patient restraint as a dangerous practice with potentially fatal complications. EMT’s get hurt every day trying to do it. Patients get killed. Medics get sued, and lawyers get fat. Walk away. Yep, that’s right, I said walk away. Run, if you have to.

If you are confronted with a situation where you are considering the restraint of a combative patient ask yourself first why. Who is really at risk here? Is the patient really at risk of hurting himself or herself? Look for signs of self-damaging behavior, cuts, bad scrapes, and fresh bruises. If there are none, then ask yourself again, are they in immediate risk of hurting themselves? If not, they are not your responsibility.

Next ask yourself, are they about to hurt someone else? Is there a reasonable risk someone is at immediate risk of bodily harm? If yes, this means it’s time to get the guys with pretty badges and guns. Anyone who poses a danger to the public is also not your job. Police Officers have years of training in the appropriate use of force. They and only they, have the tools and training to SAFELY restrain someone who poses a danger to others.

Let’s assume for some reason patient restraint is unavoidable. How should you perform patient restraint? Always restrain the patient on their back. Never, ever restrain a patient face down. Never ever place anything on top of them. The myth about putting them face down with a scoop stretcher on top is a dangerous one. The primary reason people die while being restrained is suffocation. Always be able to continuously monitor the patient’s airway and breathing status. Always use enough people to effect restraint safely. If you do not have at least four people available (one for each extremity), call for help and wait until you do. When in doubt, see paragraph two.

I developed a well thought out restraint system for EMS use some years ago. I wanted one that worked on an ambulance cot, and kept the patient secure during the transfer to the hospital bed. It needed to lock fast, without a key – and it needed to be easy to clean. I developed the EMS Restraint System with a company called Human Restraints. They have been in this business for many years, and they did a great job on the product. But not many EMS services bought them, so I don’t know if they are even still available.

I can't advise any common device or technique, because they are all bad. Handcuffs and Nylon Ties create some nasty injuries that I hate having to explain. Kerlix and Cravats are entirely dependant on your knot-tying skill, and usually a mess. Most hospital/extended care restraints were intended for a demented granny, not a 6 foot wacko on Steroids and Meth. Typical leathers are painfully slow, and the straps are way too long for a cot.

Unfortunately, this issue is still pretty low on the national radar. I doubt any serious efforts to improve pre-hospital restraint devices will be undertaken until a few more patients die needlessly. Until then use plenty of people, or use the Police. It is not your job to secure the unruly. Instead, I suggest you run away. Once you are safe radio for help.

A Good Partner is Hard to Find

Fri, 12 May 2006 19:16:47 GMT

I owe so much to so many great partners I’ve worked with over the years. Today I was thinking about one of the best, named Bob. Bob was an EMT back when Paramedics were still new. When we first started working together it was tough. Like most EMT’s of the day, he really did not believe in Paramedics. He thought Medics just wasted time “playing doctor”, when we should be gone already. But eventually he began to believe in me enough to let me do my job. He also taught me a lot of the things I should have learned in school, but didn’t. Things like how to talk to people, and get them comfortable with us. Things like how to operate an emergency vehicle without getting my patient thrown around. He also taught me a lot about how to stay alive on the streets. Once he even saved my life.

We were called on an “Unresponsive Party”. When we arrived nothing to set off alarm bells, no sign of drugs, clean well kept apartment, nicer furniture than I owned, a smart and sincere young women told me her boyfriend had just “Fell Out”, for no apparent reason. He was about 6’4”, with a stocky well-muscled build at about 260 pounds. He arms were huge. He had a rapid pulse, normal respirations, and normal pupils, with warm & dry skin. I got a pretty normal pressure. “OK, what’s up?” I’m thinking. So I let the guy know I am going to rub on his chest and it might be uncomfortable. His arm is still in my lap as I give him a sternal rub & then POW!

His fist came straight up & caught me solid under the chin. It actually lifted me up several inches, and then I heard myself hit the floor. My world was spinning sideways, as I struggled to get my eyes focused and to see him poised above me. He is standing upright holding an old brass floor lamp with one of those weighty marble bases. He had the lamp in two hands, with the marble base at the end. I could see him raise the lamp above his head to finish me off for good and then – Bob hit him from behind like a linebacker.

I got my rubbery legs to work well enough to get up, as Bob was rolling around the floor with the guy in a Full Nelson headlock. I grabbed a roll of 2” athletic tape and began binding his wrists and legs together, all while Bob held his vise-like grip. Once I had used up the whole roll of tape Bob says, “Do you want me to let go yet?” “No Bob”, I said, “why don’t you just stay right like that until the cops get here.” So he did, and never let go until the Police arrived.

The rest of the job went fine, and away he went in that very special Police ambulance with steel walls and floors. Then we find his many psych medications, most of which he had apparently stopped taking. Sometimes EMS is like playing the TV game Jeopardy – they give you the answer first and then you have to figure out the question. The bonus round that day was learning that I had a partner that would risk his life to save mine.

Bob has been dead over 10 years now, but I still think of him now and again. I remember a loving guy that would treat even rude, angry drunks like human beings. He was never late for a shift. He never “stabbed me in the back” with management, and Lord knows I probably deserved it. A good partner is like a good marriage, almost the exception rather than the rule. For it to really work, you both have to be willing to work at it. At it’s worst; a bad-working relationship with your partner can make your job simply miserable. At it’s best; a good partner can save your life. I never told Bob thank you as much as he deserved. I wish I could tell him now.

Maybe if you are blessed with a great partner, you could say, “Thanks for riding with me today. I always enjoy working with you and really appreciate all that you do for me”. They will not be with you forever, and you will only get so many opportunities to tell them how you feel. They deserve it, and truthfully – you deserve the chance to share your appreciation.

Be Polite and They Will Act Right

Tue, 28 Feb 2006 19:32:00 GMT

One trick I learned years ago, was how to better control a bad situation when everyone around you is showing signs of panic. I learned it from a great Osteopath who worked in a Kansas City ER many years ago. I noticed that whenever he was working a code, or any similarly intense situation - he was always much more polite than usual. I asked why and he explained that if you are very polite, it tends to calm people down. It also calms you down.

I tried this and quickly learned how remarkably effective a tool it can be. Slow down and take the time to phrase every communication as a request. Barking orders may look good on TV, but it rarely works well in the field. Ask for everything, even from your partner, as though you were asking a favor of the Queen of England. Always say Please, and always say Thank You. Use Sir and Ma’am as much as you can. The results will amaze you.

The first thing you notice is how everyone works better together as a team, and how it helps calm excited people down. The most surprising thing you will notice is how it helps calm you down. It gets your brain working a little better, when you slow things down. Turn chaos into purpose, and you can do a better job of patient care.

Cops know how to control a conversation. They ask the questions. They know the person controlling the conversation is the one asking the questions. You become the person asking the questions. An example is; could you please hand me the blue bag sir? Using polite language in question form can put you firmly in charge of an otherwise difficult to manage situation.

Lights, Sirens, & Speed

Fri, 21 Oct 2005 20:14:21 GMT

I have probably caused more initial friction with my new EMT’s over my driving preferences than anything else. I really hate lights & sirens, perhaps weird for a longtime Medic. Early in our getting acquainted, I request that we never leave the scene lights & sirens unless I specifically request them. This makes some folks nuts. In my last EMS System, the County had the most insane policy of ordering all scene responses lights & sirens. The dismal rationale is that if the patient called 911, it must be an emergency. That meant everybody got a little too used to running around hot.

I always deeply resented that the County was willing to risk my life, my partner’s life, and even the public - because they had been neck deep in sand so long they never heard of Prioritized Dispatch. This is real dangerous, and even those that attempt to support the practice, do so with dubious evidence. One recently published study concluded that the difference in time was worth the risk because they recorded a 4 to 6 minute shorter run to the hospital. Some other evaluations have concluded running hot saves an average of only two minutes. Either way, I feel confident enough in my Medic skills to say – “I can handle the extra few minutes of care without a problem”. After all, how many times have you run hot to the hospital only to be told "Stick him in room 3, the Doctor will be around after awhile.." - and by the time you pack up and go the patient has still has not been examined yet.

Frankly, the only time this nominal transport time difference will ever matter is on a multi-systems trauma patient, which all get flown anyway. The benefit of saving just a few seconds on non-critical trauma and emergency medical patients to me is not worth the cost. What is the potential cost?

The cost could easily be your life, or even worse, the life of an innocent. The cost is an unstable, and noisy work environment that makes it harder to render high quality patient care. The cost is simply too high for the little proven benefit in outcomes. A good, competent Paramedic would rather be able to see & hear what is going on early enough to do something about it. A good Paramedic will be just fine alone in the back for a few more minutes. A good Paramedic relies on experience, skill, and confidence – not just Speed & Prayer.

Speak Out, EMT!

Sat, 08 Oct 2005 16:06:08 GMT

I’m fond of saying; “it takes at least one good EMT to keep a Paramedic out of court”. Like most great anecdotes, there is always truth in the words. Sometimes I see Paramedics talking down to their EMT's. I also see many EMT’s that are reluctant to speak up during a call to ask a question, or voice a concern. Reluctance to speak out is usually caused by having done so before, and as a result having been made to feel stupid by their Paramedic. These are signs of inexperienced Paramedics who have let their ego off its leash. A good EMT simply MUST speak out and be heard. A good Paramedic will NEVER speak ill of an EMT who does so, and here’s why.

Most of what Paramedics really do is EMT level. Over 90% of the job is BLS, and most great clinical saves are achieved because of good BLS. Since your EMT is fully trained in over 90% of what you do, their comments or concerns are no less valid then yours. Nobody is so smart they see everything. Paramedics can also become task focused and might loose track of time or objectivity. A good EMT will remind you of what you need to be aware of. Their comments may call your attention to something you did not notice. I remember one great EMT I worked with for over two years. He would often let me know when I was missing something. One example is that I would sometimes get kind of tunnel vision when intubating. Bob would always let me know “Hey, you maybe want me to bag him a minute while you prepare to try again?” This was his polite way of letting me know I had lost track of time. He also often picked up on subtle environmental clues to patient behavior like pointing out the spoon and works under the bed, or seeing a psych drug on the kitchen table while I was busy doing an assessment.

My EMT’s extra set of eyes and ears combined with a lot of good common sense actually kept me alive on one occasion. They must be respected and valued for their skills and abilities. An EMT has an important obligation to speak up when they see something that concerns them. Just like a good ER Nurse will let the ER Doctor know when something they notice may have been missed. It is not an option it is your professional obligation. If you remain silent, you are not doing your job. Just because you have the misfortune to work with a Moron Medic, does not remove this obligation. He or She will have to get over it, and if they can’t its on them and not you.

Don’t let demeaning comments go unanswered. Pull the Medic aside AFTER the call, and explain that you feel obligated to speak up when you see something that you think might be important. “No matter how dumb you think I am Mr. Medic, I still have to say something. I only hope you can react a little more professionally next time. When you show me a lack of respect in front of a patient, it can easily cause them to be less confident in our care. I don’t want that, and I’m sure you don’t either.”

How the Medic answers this exchange is really not important. What is important is to speak up, and if the Medic has a problem, fine. You still have to do your job, and speaking up is an important part of it. Paramedics please have a little more patience and grow up. You are not the sole source of righteous truth in the world. Yes, maybe today’s comment or observation by your EMT was off the mark. That does not mean you should demean your partner. The next time, they may see the handgun out before you do. You sure do not want to have “trained” your EMT to remain silent when it matters most, do you?

Courage & Compassion or Dead is Dead

Fri, 19 Aug 2005 22:21:39 GMT

I have often heard Medics say things like “He was way gone, but we worked the Code for the family”, or “It was just easier to Code him and go, plus it’s always good to practice.” These are things I’ve said and done myself, and so I understand the logic behind it. That does not make it right.

These are uncomfortable situations for many Medics, particularly the less experienced. You really feel like they called you here, so you should do something. We want to do something, but what to do is more important. Maybe first I’ll share what not to do and why.

Don’t work obviously dead people, because dead is dead. Don’t give the family false hope. Don’t waste and risk the expensive and inherently dangerous emergency trip to the hospital only to get someone immediately pronounced on your cot. The family already knew in their hearts what happened, they just did not know what to do about it so they called 911. Imagine them watching you poke & pump, then following you to the hospital. Getting their hopes up only to have them dashed again, borders on being cruel. Plus, they get the bill for this abuse. The last thing the family needs is a huge ambulance and emergency room bill, on top of all the other responsibilities they will now be faced with.

The courageous and compassionate Medic does what is hardest, they tell the truth. They explain clearly and factually what has happened and how they reached that conclusion. Then they do the only thing harder, they give this deceased persons loved ones a hug. They need your compassion now more than they need your lights and sirens. This stuff is tough, and it took years for me to learn it. Help the grieving family, and show some humanity and caring for those left behind. They need it badly at this time of crises, and you are the only one there to give it. They are your “patient”, not the body on the floor.

Some years back, my wife’s only child passed away. He was terminal, but I was not there at the time so she did the only thing she could think of, she called 911. They did what I least expected, they told the truth and gave her a long hug. They asked if they could call someone for her, and so she had them call me. It took me 20 minutes or more to get there, but when I arrived the Medics were still there waiting for me. They explained they did not feel comfortable leaving her alone with her deceased child. Those two Medics have my deepest appreciation and respect. To the rest of you, try to match their courage and compassion. They sure had it to give, and it was exactly what was needed most on a Mothers worst day.

What Happened to Ventilation?

Fri, 05 Aug 2005 20:38:57 GMT

Today’s EMS Providers still use the Bag-Valve Mask device, despite the many years of research which have conclusively demonstrated that it is a poor performing and difficult to use resuscitator. We keep using it even though it delivers low volumes at high flow rates and high pressures. Every day somebody dies of hypoxia while being bagged. I often wonder if we use it because we want to ventilate, or because we have a primal need to squeeze something. Tidal Volumes with the BVM are typically very low. I guess nobody was actually meeting the standard of care (10-15cc/kg), so they lowered it. Completely forgotten is that the volume you deliver should vary with the patient size. Remember that oxygen is a drug. It should be administered in doses tailored to the size, age, weight of the patient coupled with their clinical condition. Does the same dose make sense for all adults? No. How can a BVM address this? It can't. Most of our ventilation patients are either in Cardic Arrest or Respiratory Arrest. They are not hemodynamically stable patients in an ICU bed. Because they are critically compromised, they need more and not less oxygen.

A recent article in a leading EMS Journal stated that “the lowest possible pressures and tidal volumes should be used” and that “using one hand instead of two will help avoid over-ventilation.” By the way, this was otherwise one of the better pieces written about ventilation lately. You really cannot "over-ventilate" (meaning deliver excessive tidal volumes) with any commercially available device. The maximum volume setting on any EMS Ventilator is 1.2-1.5 liters. The maximum one can deliver with any BVM is less than 1 liter, even two-handed on an ET Tube. A Demand Valve at 40LPM can only deliver 1.3 liters over a two second inspiratory time. The average adult lung Vital Capacity is 3 to 5 liters, so how can you over-ventilate with volumes that are always less? Obviously you can’t. What you can do is use too much pressure. This is directly caused by too high a flow rate, which is quite common with a BVM. Without any control over flow rate, pressures can get as high as 60-80cm, well above esophageal opening pressures of about 20-25cm (or less). This means if you put the air in too fast, the limited opening of the trachea will turn these high flow rates into high airway pressures. It’s the high pressures that cause complications like aspiration, not tidal volume.

That is why it is so important to control flow rates, because it is the key to delivering good tidal volumes safely. We live in a world where hyperventilation only means “Bag Fast”, when it really means to “Increase Alveolar Minute Volumes”. Hyperventilation can be done with either Rate or Volume, or a combination of increasing both. It is not just rate alone. Going real fast gets you to squeeze faster, resulting in shorter inspiratory times and higher pressures, which forces air into the stomach. Then they vomit, aspirate, and die. You can easily and safely deliver a liter or more of tidal volume IF, you extend the inspiratory times and control the flow rate to keep the pressures low. A basic Pocket Mask or Pulmonary Resuscitator can do it, and better than a BVM. This too has been well documented.

If you really must squeeze something rhythmically, please do it in the privacy of your own home and not on a viable patient. Maybe buy a nice roll of Charmin to squeeze, and then go buy a decent time cycled, volume constant ventilator for your patients. Or even just use a Pocket Mask; hold the seal firmly with two hands, and blow real slow until you see a nice chest rise. I recently ventilated a patient for over 30 minutes on just room air with a pocket mask type device, to see them stand up and walk away. NOBODY bagged on an unprotected airway 30 minutes with a BVM ever stands up and walks away.

I still like the words of a UK Medic who once said to me (when I commented on the nice ventilator they carried) “Back in the States, aren’t you guys still zipping them up?” It took a few minutes before I realized he meant, “bagging them” but on reflection I decided he did not to be need corrected, I did. Yes, we are still “zipping them up”, -into body bags. We have stuck our heads in the sands of blissful ignorance, and steadfastly refused to either learn basic ventilation mechanics, or any of the many technological advances in ventilation over the last 25 years.

Now the AHA also seems ready to abandon emphasis on proper ventilation. Sure, shock fast is great when the down time is under two minutes, but when it is longer you better oxygenate the myocardium or you are not going to get anywhere. To simply abandon efforts to improve emergency ventilation is only going to get us one thing, more dead people. It’s time to learn the most important job an EMT or Medic will ever do. It’s time to say, “We will no longer accept ineffective ventilation technologies and improper techniques that don't work”. I'm convinced that a continued lack of emphasis on ventilation science in EMS is leading us down a wrong road. I'm not following because I like my clinical saves way too much.

A wise man once said to me, "Keep doing what you have been doing and you will keep getting what you have been getting." I don't use BVM's and I keep getting saves.

What have you been getting?

Understanding Group Purchasing

Mon, 25 Jul 2005 15:39:13 GMT

Group Purchasing Organizations (GPO’s) were originally designed as a means of controlling healthcare costs and providing members greater economies of scale. The basic idea is to combine the buying power of members together to get better pricing. The US Senate has held numerous hearings about the questionable benefits and business practices of some GPO’s. Below is an excerpt from a New York Times article on GPO’s, which summarizes some of the United States Senate and the General Accounting Office (GAO’s) concerns.

“The Senate Judiciary Subcommittee on Antitrust, Competition Policy, and Consumer Rights held three hearings regarding the practices of Group Purchasing Organizations (GPOs) and Dominant Medical suppliers. As a result of these hearings, most of the major GPOs, including Premier and Novation, created Codes of Conduct to attempt to reduce anticompetitive conduct relating to clinical preference products. As part of these investigations, the General Accounting Office published two reports. The first report found that GPOs do not always offer hospitals lower prices. The second GAO report addressed certain anticompetitive contracting practices used by GPOs including sole source contracts and bundling arrangements and discussed the various Codes of Conduct implemented by the GPOs to correct these practices -.”

The bottom line is that GPO’s do not always deliver the latest products at the best price. GPO’s charge money for their services. They receive rebate payments called an Administrative Fee, of up to 3% of the purchase price. GPO’s have been permitted a Safe Harbor from anti-kickback statutes that prohibit these type payments in other industries. These additional costs are either included in the product price and rebated from the manufacturer back to the GPO, or are added to the invoiced amount and paid back to the GPO by the Distributor.

The Catalog/Web Only Distributors who typically win low bid GPO contracts are those that offer the least to their customers. Yes, you save a few cents by changing your Vendor from one that has a local presence, to an out of state mail order house. But no longer will you have access to qualified on site In-Service Training. No longer will you be able to make a simple call to get returned items picked up. No longer will you be offered the full range of products available, or the latest technology. No longer will you have a knowledgeable, objective source of product information. If something breaks, you are the one who deals with the manufacturer. They will not offer product repairs or service. They will not come to your golf tournament, or be at your Regional Conference. These companies are often called “box movers”, because that is all they do. You will pay a little less and get a lot less. No magic here folks.

The benefit of Group Purchasing is that you can save some money by giving up product choice, flexibilty, and access to support. The savings will not be dramatic, since most of the savings goes to pay the GPO Administrators salary and overhead. You just trade who gets your money, more than control how much you spend. It seems few business school educated Hospital Administrators ever ask the obvious question. When presented with the annual rebate check none ask, how much extra did I spend to get it?

I Still Have a Dream

Wed, 13 Jul 2005 20:59:17 GMT

My dream is about a new type of out of pre-hospital healthcare provider who cares for the sick and injured at home, work, or public location. The Paramedic Physicians Assistant, or PPA for short, could redistribute valuable healthcare resources. They could help reduce ER diversions, long delays in treatment, while cutting costs. They would be educated to render comprehensive care to the pre-hospital patient.

Such a person would first be an experienced Paramedic that then completes PA School, with an emphasis on Emergency Medicine. Then they would complete a 1-year ER internship at a major medical center. I remember two such programs that once and may still exist for PA’s, one in Southern California and one in Minneapolis. They work the PA’s hard for a year doing casting, suturing, learning advanced diagnostic techniques and all treatment therapies specific to the Emergency Department. I heard about one such program where the PA’s did virtually everything in the ER, with a Coordinating Physician directing several PA’s at once. I envision this ultimately as a single, integrated baccalaureate degree program. In the UK this type of program is now being considered, but perhaps with a less well rounded educational foundation.

You take these PPA’s, and put them on a whole new type of response vehicle. It would have about 30 unit dose medications in a mini-dispenser, a built in mobile X-Ray, Casting and Suturing stations and materials. Tabletop ABG and basic mobile Laboratory would complete the package. Of course they would have state-of-the-art emergency equipment, complete with 12 lead ECG, CPAP, and Automatic Ventilator. This is not future think. This level of technology has been available for many years. How would this new type of professional work in the field?

Let’s take an example; Sally called Friday night with shortness of breath. She has decent blood gases and Pulse Ox, with a low-grade fever and pneumonia confirmed by X-Ray. She has a good family support system and can follow directions well. So you bang her with a gram of Rocephin, give her a 3-day supply of oral antibiotics, and put her back in her house. Give her a referral card, if she does not already have a family doctor. Done.

But if her oxygen saturations are low and she will need oxygen, or if she does not have family to watch her, or if you are uncertain about how well she will follow your directions, she would need to be admitted. You call up her doctor and report the situation. He agrees she needs a hospital bed. So you ring up the receiving hospitals Nursing Supervisor and get a bed assigned. You finish working the case up, complete with the Floor Nursing Orders done, and roll her in the hospital door and straight up to her room for the night. Only if she is real sick and/or does not have a doctor will she need to see the Emergency Room Physician. Isn’t that what they are for anyway?

The end results are the patient gets the care they need, and they don’t wait for hours. They save a small fortune off their bill. Everybody should be happy right? Emergency Room diversions are dramatically reduced because they see fewer non-critical cases. Insurance Companies, PPO’s and HMO’s cut about a third off their total emergent care costs. We all get better insurance at lower prices. We get these savings while creating a new valuable type of healthcare professional that starts around 75-90K per year, and is well worth it. Livable pay results in longer careers, with more experienced people now the norm rather than the exception. The EMS System starts working again. Clearly it is not working well now, yet we keep doing what we have been doing, because that is the way we have always done it. It is time for a change.

But that is what I said over 15 years ago, when I first proposed this concept. Instead of designing an education around the real needs of the pre-hospital healthcare patient, we designed it around the needs of the sponsoring government entity, volunteer community, or ambulance business operator. Somewhere along the way we forgot about the patient. I thought this rather simple and obvious solution would by now have been adopted in some form. But we have resisted positive change. In fact if any real change has occurred, it has not been to the improvement of patient care, healthcare costs, or our communities needs.

The public waits longer and longer, for higher and higher cost care, which is not getting any better. Think about it, the Paramedic Physicians Assistant could be an answer to our worsening emergency care crisis. It would also be a great job, and provide a hopeful future for today’s EMT’s.

Training vs Education

Wed, 06 Jul 2005 21:34:06 GMT

Training is what you do with a Pet.

Education is what you do with a Person.

Right now Paramedics are just that, pets to the healthcare system. You are trained like a Dog, so you get to work like a Dog and get paid like a Dog. Yes, once in awhile they will add new skills, and perhaps award you another paper certificate of completion (like Dog Training School). For those insecure enough to need more, they might even throw in a new letter or two for your title. But please, do not get these Training Programs confused with Education. Training teaches you what to DO. Education teaches you how to THINK. Professionals are Educated, not Trained.

A college-level specialty education is one of the hallmarks of being a true professional. Professionals have degrees, not certificates. Professionals don’t use time clocks. If being professional was only a description of behavior, than most of the Paramedics I know are true professionals. But the healthcare world sees us as little more than ambulance drivers, trained monkeys who follow rigid protocols and work for bananas. If we would do the hard thing and demand a real education, this would fix itself in only a few short years. Increase the educational requirements and the available workforce would suddenly drop. Then the economics of supply and demand would exert its influence to increase wages dramatically. More good people would stay in the field, and with their improved education and experience they would provide better patient care. The real impact on healthcare costs would be pocket change. Actually, we could CUT healthcare costs by increasing pre-hospital pay, and I’ll share why in a later blog.

We should keep our best and brightest, and use their valuable experience to save lives. We all know how much turnover EMS has, and for very good reason. You can make more money sitting in a tollbooth giving change. Everyone has to grow up sometime; I know I did when my kids came along. Only by demanding an education equal to our responsibilities will we advance our standing in the healthcare world. Some will say it is too much and they will protest they don’t have the time or money. But only with the education of a true professional will we ever be able to stop begging for treats.

Hero or Fool?

Mon, 27 Jun 2005 15:18:17 GMT

Here I am, stuck way up high on the side of a near vertical hillside, in the dark, wearing soaking wet slip-on boots. Not good. It started simple enough; I was on my way back to my tent after the last act at 2AM. Nick says, “Hey we just got a call about some guy with a broken arm, you want to help?” Well OK I said, and mounted the four-wheeler. We were wandering around in the dark for a half hour when somebody finally flagged us. “He’s across the creek up on the ridge,” says the helpful person. So I follow him through the brush, and forded the ice-cold creek. I remember thinking “my brand new Redback boots” (insert mournful tone).

I play follow the leader through the sticker bushes. We soon reach a steep river bottom hillside covered with trees, rocks, and more sticker bushes. I’m picking my way carefully up the slope that just keeps getting steeper and steeper. Now it’s nearly vertical, and my footing gets real uncertain. I finally get to where I can see a couple dimly backlit folks at the summit. “Hey you OK up there?” I ask. Yah, we are OK but he has a broken arm, came the reply from one of the dark silhouettes. Sounded encouraging. But how do I get up there? I took a few more tenuous steps upward, but my wet boots felt like greasy flip-flops. I had zero confidence in my traction. So I stopped and just waited. I reflected on the question of whether or not I am being smart up here. I know nothing about high-angle rescue. I would rather parachute then hang from the end of a rope.

Up climbs Denny, a great EMT from Miller County. He goes right past me like a billy goat, never missing a step. In a couple minutes he is up on top, confirming the broken arm but that otherwise the guy is OK. Except for the fact that when he fell, he landed against a couple of saplings right at the very edge of the precipice. So I suggested caution in trying to do anything, and volunteered to go for rope to tie the guy off with until we had a way to get him safely down.

Back down the hill and through the bushes. At the streams edge, I let our team know we really needed somebody up here with technical rescue equipment and experience. I then got my best idea of the evening and asked “Can’t we just tie him off, give him something to keep warm and wait for daylight?” My idea fell on deaf ears. No Dan, we really need to do something. Well, at least I could try to make sure nobody gets killed trying to interfere with this evolutionary process of natural selection. I mean, these folks really did try to sneak in a concert by heading over a densely wooded high ridge, and then try to slither down a near vertical 100 foot wall in the dark, one of them with only bare feet.

So back up the hill with the rope, until I got close enough to toss it up to Denny. Then we waited, and in about an hour I got word the Park Rangers Rescue Team was here and needed to be lead in. One last time I went down the steep hill, and then lead the well-equipped Ranger rope rescue team up. In less than an hour, they had belayed him safely down. Duty done, I crossed the stream one last time and headed for camp. It opened my eyes. It’s important in life to know ones limitations. If I were still a pup, I would have gone ahead up instead of stopping when I found myself in danger. With age comes wisdom. If not wisdom maybe an appropriate dose of self-preservation. It’s nice to be a Hero, but even better not to be a Fool.

Questions about EMS Workers

Tue, 21 Jun 2005 18:38:52 GMT

I'm open to readers answers about a few long-held questions;

Why do Paramedics and EMT's fill every bag they get 20% beyond it's maximum internal capacity?

If you only have one oxygen tank in the bag, why do you need to carry 13 non-rebreather masks?

If you only intubate one patient at a time, why do you need so many different ET Tubes? I mean, half sizes too?

Why do you soak laryngoscope blades in solution? Is it really bcause you would rather the guy on the next shift clean them?

If it only saves an average of two minutes, why risk an accident going lights and siren to the hospital all the time?

Why on earth would you call in a helicoter for a broken ankle? Is mechanism of injury alone a legitimate reason for a flight?

Clinical Save at Camp Zoe

Tue, 21 Jun 2005 15:57:11 GMT

So far it has been a great summer. I started helping out at Camp Zoe, where they call the First Aid Station Safestock. It is an old youth camp in Southern Missouri, owned in part by members of the band called The Schwag. They have music festivals all summer at Zoe. The first this year was Zoe Jam, featuring great bands like Hot Tuna, Garaj Mahal, and one I simply flipped over, Karl Denson’s Tiny Universe. This is my idea of fun. Zoe has fabulous camping on a beautiful, 330-acre site with a crystal clear spring-fed creek full of happy smallmouth bass. I can go on canoe float trips, listen to nonstop live music, ogle the hot hippy chicks, and do some freestyle EMS. This is basically everything I’ve ever enjoyed, rolled up in a ball.

My first visit there resulted in my first clinical save in years. During the Zoe Jam festival, we jumped on the four-wheeler to respond to a campsite where “we had a problem”. Looked like a pretty big problem when I got there, like he isn’t breathing. Please, no, you can stop shoving ice up his rectum. Please just give me a second to find something to use to ventilate this kid. I just knew this would happen. I intentionally left my Intubation Kit at home. Yes it has everything in it you could dream of, even toys most anesthesiologists don’t have. But I just relocated back to Missouri from Philly, and I need to stay within the scope of practice of a basic CPR card. So I left it at home where I could NOT actually use it, if it were needed. Well, now I needed it. I sure as heck would have used it. I suddenly realized I had my very first product invention with me, The White Pulmonary Resuscitator (or WPR). I was overjoyed because I knew if I had to Bag him a long time with just an oral airway on room air, he would have no chance at all.

The WPR (patented in 1981) was the first disposable ventilatory adjunct with a non-rebreathing valve. It really predates the pocket mask, as we know it today. The big advantage is it can deliver very high concentrations of oxygen, and is comfortable to use because of the long oxygen reservoir. Like most exhaled breath powered devices, it is much easier to control the mask seal with two hands, and deliver better tidal volumes, constant flow rates and lower inspiratory pressures than with any BVM.

So I settled in for what I was afraid would be a very long wait for an ambulance. I did not have much doubt what was going on, he had needle holes in his skinny arms, pinpoint pupils, fast pulse, no breathing, and that special look that screams, “Get the Narcan Now!” Guess what friends, no ET Tubes, No Narcan. Nearest unit 45 minutes away. I thought, “This is going to be fun” (not), and I slowly, steadily, began breathing for him. One long, slow, low-pressure, high tidal volume ventilation after another.

About 15 minutes later, his color was a lot better. His pulse slowed back down to normal. Jeez, then he started to try to breath. So I kept at it, keeping a tight seal with both hands on the mask. Nice long slow breaths, now timed to go in right when he tried to take his own. A few minutes later he was moving air well enough so I sat back a second, and collected my thoughts. “Well, this is it I guess, -you better give him a sternal rub and see if anything is left”, I thought to myself. I had little hope for much reaction. Maybe some bad posturing was what I expected. After all, I have no idea how long he was really down before we arrived. It took us at least five minutes just to find him. I rubbed my knuckles on his chest and he freaking sat up, then opened both eyes and looked right at me.

I reached over and pulled the Berman airway out of his mouth and “-Wha, wha, what’s up man?” comes out of his mouth. You could have knocked me over with a feather. Five minutes later he was up weaving around, still pretty high by the looks of him. When the helicopter landed he refused care. I transferred care to the ambulance and left the scene. As soon as my back was turned, he talked his way out and refused the trip by ambulance too. I heard later that Security put him and his little group of junkie friends out. Well, I have seen a lot in my long career. I have seen people die at festivals. I have seen security throw people out of festivals. But I have never seen people die and then get thrown out.

Short Spine Immobilization

Mon, 20 Jun 2005 18:05:10 GMT

A Lost Art?

Do you perform a “Rapid Roll Out” on almost every MVA? How can you clinically justify this practice? It is intended to be reserved for the multi-system trauma patient with low blood pressure. But today very few MVA victims get any short spine precautions other than a c-collar. They just get yanked out on a long board. While this appears to ignore basic standards of care, little has been done to prevent it.

One illuminating review of this issue was performed several years ago in Eastern Pennsylvania. MVA Run report data was reviewed and compiled. It is hard to believe, but only 170 patients out over 20,000 long spine boarded had any type of short spine device applied. Don’t your patients deserve better? I have been upset about all these patients getting at best a "No-Neck"(wrong) sized cervical collar & then rolled out the door. It makes no sense. So I decided to do something about it.

It had been many years since any original thought had been devoted to short spine care. I thought the key design objectives would be; Easy to Apply, Easy to Use, Easy to Clean. A simple, fast, shortboard for rapid extrication was what I had in mind. I think I did it. The Speedboard has been used by many with great success.

For more information check out the Speedboard at Prolite or just click this link .

Walt Disney

Fri, 17 Jun 2005 21:12:35 GMT

Walt Disney, EMS Pioneer In the summer of 1918, Walt was 16 -- too young for the military. When he heard that the Red Cross Ambulance Corps would accept 17-year-olds, he lied about his age, joined, and began training. All the same, he almost missed his chance when he came down with influenza in an epidemic that killed about 20 million people worldwide. The war ended. But the Ambulance Corps still needed 50 more men, and Walt was the fiftieth selected. He was on his way to France. For the next year, Walt drove an ambulance, chauffeured officers, played poker, started smoking, and wrote letters.

Universal Precautions

Fri, 17 Jun 2005 21:10:13 GMT

Universal Precautions What Are They Really?

Today many EMS personnel wear gloves on every call. Many even leave their gloves on for the entire call. Some even leave them on after patient contact and drive with their gloves still on. EMS Instructors now require students to verbalize, “I’m putting on gloves” at the beginning of every scenario. Are these appropriate applications of Universal Precautions? No they are not. In fact, inappropriate use of gloves is probably the single biggest contributing factor to developing skin problems associated with gloves.

Universal precautions means wearing appropriate protection when you may be at risk of direct contact with blood or body fluids. Do you need gloves on just to take a blood pressure on a regular medical patient? No, and if blood or body fluids are not present you are exposing yourself to long-term risks of acquired allergic response by wearing gloves too much, for too long. Do you need gloves on to drive the ambulance? No, and you are probably creating more risk by contaminating the crew cab. When should you take them off? Gloves should be removed after performing the procedure or contact, which required their use. In other words, take them off right away after you have completed the procedure that placed you at risk.

If you leave your gloves on and then handle your equipment, including the Defibrillator, Cot, Medical Bags and Cot Mount locking bar, you are contaminating surfaces you are likely to touch later barehanded. You are SPREADING disease, not preventing it. In the process, you create an unwanted risk of long-term problems. These are problems that can even shorten your healthcare career. Use common sense, and wear gloves when you need them, and then take them off as soon as you don’t. In this way you better protect yourself, your partner, and your family.