Working on the Holiday – A poem

So you’ve got to work the holidays, or your boss will get real mad?

You work in a big box store in town, and your schedule makes you sad?

Well let me tell you another story, of some folks who just like you,

are working on the holiday, so that others do not have to.

We are your firefighters, your medics, your cops,

your nurses and doctors ready to assist,

just like every other day, not just December 25th.

We’d like to teach you something you’ll eventually figure out,

a holiday is just a number, there’s no need to pout.

Turkey tastes delicious on November 29th,

and sometimes we celebrate Christmas on the 26th, at night.

Your place was open last year and the year before,

on the day so suddenly special you want to blame the store.

So for those of you who complain about working this holiday,

remember the others who are always working regardless of the day.

You won’t have to work the holiday when you get a better gig,

but if you’re lucky, you will, cause you’ll be with us in the rig.

 

-HM

Community Paramedicine doesn’t belong in EMS

Community Paramedicine, or what some would rather call Integrated Healthcare, is a fantastic concept.  Why not take basic medicine and evaluation skills to the patient recently recovering from a procedure instead of making them visit the MD’s office?

Why not follow up with Mrs Jones on how her medications are doing?

Why not have a Paramedic check in on Mr Thompson and his blood sugar levels?

My first paying gig in EMS was for a system that did just this.  We visited our list of clients based on the schedule and checked their blood sugar, blood pressure, medications and checked the fridge for food.  I hated it.  I hated it because it wasn’t what 18 year old me wanted to be doing.  I didn’t see the value in the program until I was about to finish my employ there and noticed we never ran a 911 call on any of our home visit regulars.  We weren’t providing Emergency Medical Services (EMS), we were doing something completely different.  Call it by any name you like, but don’t call it EMS.

Today I’m a huge supporter of decreasing the demand on 911 by focusing on reducing the number of people who call.  One of the proven tools used to combat 911 calls is making people healthier before they need 911.

Community Paramedicine is just the thing each and every community in America can use to reach out to a niche that needs to be addressed.

When I was in England all those years ago Paramedics with only 1 year experience were out on their own making recommendations, referrals and taking people directly to what they needed, not just a 2 person cot van to an ER (Or AE for those who favourite that term.)

The concepts have been proven over and over again and some systems are even carving out revenue streams to make it profitable or, at least, not at cost.

I applaud their efforts and if the opportunity ever comes along for me to get involved…

…I’ll pass.

In my opinion Community Paramedicine is too important to be trusted to the 911 crowd.  We need folks more interested in sitting and talking than squeezing a few home visits in between calls for service.  Some systems have adapted schedules and providers to respond only on the Community cars and that’s great, but a greater separation is needed.

Yes, I’m advocating splitting EMS even further than we are now.  A split that will allow this new sub specialty to thrive.

Community Paramedicine needs to be a specialty, a half brother, not a spin off hoping to get picked up for a second season.

It will not succeed if it is tied to the chaos that is 911 for profit and must succeed if 911 for profit has any chance of surviving another 10 years.  We’re approaching a cross roads to possibly finally squeeze our little patient care machine into the main stream of medical professionals.  Do we want to squander that opportunity by having Community Paramedicine as a side project of EMS or as a full fledged community service independent of the lights and sirens?

I know 18 year old me had a different reason for having this opinion, but the opinion remains:  911 and community care shouldn’t mix.  They should each focus on their strengths and excel at the service they provide the community instead of stretching us so thin only our merit badge classes hold us above water.

Taylor Swift inspires new EMS billing model

I’ve been reading in the papers lately that Taylor Swift and Spotify have been going back and forth about royalties for her songs playing on the streaming music site.

According to sources, she was paid less than $500,000 for 12 months of her songs playing on the site.

My first two words were Boo and Hoo.

Then I looked at the feed of a friend of mine who is a musician.  They have a fair argument in that the way the industry is arranged you get a small amount for creating the music (writers, musicians, performers) then more the more the piece is performed.  It makes sense on a certain level, but the model is clearly outdated.  Before it can be changed, the industry should realize that fewer and fewer of us listen to terrestrial radio (where their songs are actually placed at cost, not at profit) and more of us are streaming music using spotify and Pandora like apps.

I start with a band I like, then it introduces me to other bands I may like as well.  Then I buy their albums, but not in a store (that used to take as much as 30% of the 19.99 for the long box), I pay 99 cents per song on itunes at no cost to the production company.

This line of thought brought me back to EMS.  Let’s apply the music industry reimbursement model to what we do:

First off, you’ll be required to create unique treatment models and protocols.  Then you’ll be paid a small amount for actually providing the care requested. (no real change there, right?)

Now here’s the BIG difference:

You get 1% of your patient’s income.  For life.

Are you motivated to provide quality care now?  Will you go to any level to ensure high quality care in any location in the world?

How quickly will our industry adapt to this new model?  Suddenly the more calls we run the more we can possibly make.  Will we focus on younger patients?  Will we ignore certain neighborhoods unlikely to yield incomes worth our efforts?  I think you know the answer to that.

 

While I still don’t feel bad for Taylor Swift only making half a million a year on 1 web site for something she did long ago I also know she wasn’t in there alone and the folks who were aren’t necessarily the ones out on tour or behind her on SNL making money.  They were brought in for a day to play saxophone, record a piano solo or sing backup with the promise of a cut of the plays in the future.

Although I think billing EMS based on future income would see a HUGE shift in our comfort with pediatric patients.  Don’t you?

The 3 Real Reasons EMS isn’t Ready to Refuse Care

Sean Eddy from Medic Madness, and fellow Uniform Stories contributor, has a new post up titled “3 Reasons EMS isn’t ready to refuse care.”

Go have a read, then come back for my comments.

Well, you’re either ready to storm Sean’s gates with your sharpened pitchfork or ready to defend him from what I’ve got to say on the subject.

Sean brings up some great issues that have been bouncing around EMS circles for decades.  With the recent introduction of Community Paramedicine and the concept that we can, gasp, leave people at home in certain situations, EMS providers are looking to build on the outdated “Transport them all and let the ED sort it out” mentality of the 1970s.

Sean’s 3 reasons are certainly worth discussion but I think he was very careful to sidestep the elephants in the room.

l’ll address Sean’s reasons 1 by 1, then give you the 3 real reasons we’re not refusing care.

Sean’s Reason #1 We’re not trained for it.

I’ll agree with Sean here on a handful of cases.  I would argue that leaving a hyperventilating patient at home simply telling them “It’s just anxiety” without addressing the symptoms we aren’t ready for, nor should we be ready for.  However, this skips over the other 99% of our calls.  When a person has an injury or illness (or nothing assessed) and asks us “Do you think I need to go?” we should not be bullied into transporting by a management who only gets paid if the wheels turn and a nurse signs the chart.  Honestly answering that patient’s question and giving them the information they need to seek the care the need should be job #1.  We are trained for that.

Sean’s Reason #2 No Legal Protection

This is one of the urban legends of respond not convey, that somehow, somewhere, we’re simply going to pull up, roll down the window, tell the person to just go to the ED and drive away.

There is not added liability in obtaining a refusal for a stubbed toe after telling the person that they don’t need to go in an ambulance than there is in obtaining a refusal after telling them they should.  Zero.  It is simply changing the amount of accurate information available for the patient to make an informed decision regarding their are.

Sean’s Reason #3 – We aren’t designed to be the end point in care

Sean brings up an interesting point that we are not meant to be the definitive treatment for patients, that that is only done by MDs.  Then I would call into question each and every refusal of service ever collected in the history of EMS.  We should be, and currently are, the end point when necessary.  Again, we’re not talking about chest pain, stroke, abdominal pain of unknown etiology, those patients are all obviously in need of evaluation and we are not their end point.  For the finger smashed in the door of the car we are also not the end point in care but that is no reason to REQUIRE ambulance transport to an Emergency Department.  I can’t fix the finger, surely we can agree, but there is nothing I can do beyond splinting and supportive care.  In addition now we’re sending an urgent care level patient to an ED, grossly over triaging “just to be safe.”

 

Sean is a friend and don’t take my comments about his concepts as disagreeing with him.  He and I have discussed this topic repeatedly, as many of us have, and it is of course far easier to comment on ideas than come up with them.  But we all need to be realistic about the REAL reasons EMS is not ready to refuse care.

Real Reason #1 – There’s no profit in it

Oh, there’s reduced cost in it, but no profit.  Spending 30 minutes on scene for a refusal is not nearly as lucrative as a 30 minute transport.  There is no increased liability, no increased training required, no fancy advanced classes or licenses, we just have to do what is right and allow the patient to make good decisions and seek out appropriate care in the community.  But so long as insurance only covers transport, it won’t happen.

Real Reason #2 – We don’t understand liability

Leaving Erma Fishbiscuit at home isn’t the problem, it’s transporting her for no reason to an ED for no reason “Just to be safe” that is the liability.  We remove needed resources from the system to satisfy decades of urban legends from the anchors about so and so who broke the rules and left someone home to die, but never about how no rigs were available for Mr Johnson yesterday.  If the rules were broken and something bad happened, it isn’t the rule that is the problem.  We shouldn’t be scared about letting patients make decisions.  We inform, they decide, we do our best to get them what they need, we complete a chart and go away.  Just like we do now.

Real Reason #3 – Adrenaline and turnover

No EMT wants to sit in Erma’s house for 30 minutes making sure she knows where her medications are and when they should be taken.  No Paramedic wants to sit with Mr and Mrs Jones and explain how their daughter’s nebulizer works.  They’d rather hit the lights and sirens, break hearts, save lives and take’em all and let the Doctor’s sort them out, after all “We don’t diagnose.”

 

EMS is having a real problem taking itself seriously recently.  I applaud Sean for making his list and putting it out in the public.  We have a decision to make in the very near future and that relates to the future of EMS and I see it will divide us even further and I think it’s a good thing.

Yes, I said dividing EMS is a good thing.  More to follow.

-HM

Tinglings of Inadequacy

In Paramedic School there were three know-it-alls in the back row.  Every Paramedic class had them.

They asked questions with 3 minutes left in class, always challenged the instructors for more challenging scenarios and seemed to always hit the airway lab right when everyone else broke for lunch.

They challenged test questions, the sequencing of interventions in answers and were eventually separated for testing, you know, “Just in case they’re cheating.”

They had their own study group, volunteered to teach the EMT and EMT-I classes when instructors needed a break.  All 3 of them stood together and graduated with their Bachelor’s of Science in EMS on the same day.

Then they drifted apart.

Weddings, kids, careers.

Then one of them got into Medical School.  He sat to my right and is now a full fledged MD.

The kid to my left we called Doogie because he was young and smart.  I just found out today he will be completing Nurse Practitioner school in December.

My 2 best friends throughout Paramedic School and our clinical rotations, the guys I laughed with, cried with, broke bread with and, come to think of it, literally bled with, have achieved so much and I couldn’t be prouder of either of them.

Dr Ian Medoro and soon to be NP Josh Kinnunen were my best friends for many years.  And even though life pulled us in different directions I am beside myself in admiration to the both of you.  We all had the same start, the same passion for quality patient care and have landed in three drastically different places.  The 2 of you seeking out more education and fitting into another form of care while I’m still in the field with my name on my shirt.

Those days listening to Larry and Kyle inspire us to do better, the anatomy lectures that seemed never ending, the waitress at the Applebees on bottomless chicken strip basket Fridays (I think we put her through grad school) will always be some of my best memories.

 

So congrats Doogie on making NP and congrats Ian on making MD!  The guy in the middle is happy where his is and proud of where he’s been.

Add Aiden Riebel to your Duty Roster

Young Aiden Reibel was brought to my attention through the Facebook.  He is a fan of the fire service in New Jersey and suffering from health issues that keep him from his dream: Riding Along at the local Fire Department.

Amidst the patch grabbers and beggars across facebook, Aiden’s supporters caught my eye when they simply asked me to add Aiden to the roster for the day.

It wasn’t a request for me to be with Aiden, but for Aiden to see he was with me.

I was moved.

I erased my name off the board at House 3 and added his name as the Rescue Captain (RC) for the Airport and sent the picture into the facebook page.  There he was with me as well as with a handful of other Departments from across the nation.

Each and every post was a photo of Aiden’s name on the roster board, gear, helmet or rig.  Aiden was riding along at FDNY Battalion 9, with me in San Francisco, and a host of other agencies even an ambulance in Spain and a wildland crew in Australia.  Each post included a phrase along the lines of “You’re with us” instead of the usual “We’re with you” you see so often.

While Aiden is indeed accepting patches, the more powerful message is that even though he is too sick to ride along like he wants, his name is being spoken across the world in firehouses, ambulance yards and volunteer musters.

And to me that is far more powerful than any patch.

Aiden was with me for 2 days last week and thinking about having him along made me think about my own health and that of my family.

Your drill for today is to put Aiden’s name on your roster, rig or gear and let him ride along in spirit for the day.  Then shoot a pic and share it with Aiden’s page on FB.

 

It is literally the least you can do and will mean the world for a sick kid and will do wonders for your soul.

Trust me.

-HM

The EMS Ebola Checklist

Since it seems the nationwide panic known as Ebola has overflowed into the EMS sphere I thought it a good time to step in and calm everyone down for a moment.

We’re experts at dealing with interventions based on a thorough assessment.  Hemorrhagic Fever can’t be ruled out via ECG, stroke exam or any of our other tools.

To successfully deal with a patient exhibiting signs and symptoms of hemorrhagic fever in the pre-hospital environment, preparation is going to need to be solid.

  • Contact your local Department of Public Health for an updated copy of their response policy and local resource deployment.  Test the phone numbers in the plan and make sure they work now and that you know what information they want when you call in the possibility of an infected patient.
  • Train and retrain on your PPE.  This is not  race for speed, but a checklist for proper donning and, more importantly, doffing.  Improper removal of the best PPE negates all precautions.
  • Ask direct questions when still at a fair distance.  Monitor CDC bulletins for updated travel alerts at the beginning of each shift and ask questions that can rule out travel and contact with infected persons.
  • Treat the scene like a Hazardous Materials scene.  Isolate, identify, deny entry.  Limit exposure using pre-existing structures like walls, doors, airplane lavatories, car interiors, etc.
  • Ebola is still only in fluids, so limit contact with fluids using approved PPE barriers.  This includes gloves, gown, goggles, booties and cap.  It seems like an extreme measure, but think of all the things we touch with our gloves on.  Push hair out of our face, adjust pants, replace goggles…all these movements could introduce a small bit of vomit on a glove to another portion of the body and eventually we rub our eye or nose and…poof…infected.
  • Avoid unnecessary movement prior to Health Department assessment of the scene.
  • We are the eyes and ears of the local Health Department and CDC.  There is no treatment, no rapid transport, no EMS tool or technique that can help your patient more than making sure the system is in place and responding to what you see and hear.

The trick on a call you suspect to be Ebola (It’s likely not) is to treat it as such until you can reasonably determine the likelihood that I’m right.  That means being a PPE expert, doffing properly and knowing who to call and how to keep people calm in the face of a perceived zombie apocalypse.

As the world panics, we will remain calm, gown up and get the job done.

 

If a photo is never shared, but a photo of it being taken is, did it ever exist?

A few of you have emailed me asking what I think about Sacramento Kings basketball player Nik Stauskas photographing his per diem money.  Well, not exactly THAT, but the fact that teammate DeMarcus Cousins photographed the per diem photo shoot and shared it.

For those of you who haven’t seen the picture, have a gander:

We’ll save why a pro player needs that much money a day when clearly being taken very well care of when traveling and focus on why this photo even exists.

Who is responsible for this image?

Who is responsible for it being shared?

Is there a difference?

These are questions many public safety agencies skip past when writing short sighted social media policies.  Even though it feels like Facebook and Twitter are here to stay, there are already rumors of the “Next Myspace” with invites to the exclusive Ello drawing hundreds of dollars on ebay.

Departments are encouraged to apply existing rules to new technology by focusing on WHY their members share and how to break the impulse.

CBS reports that the image of the per diem has not been posted to Nik’s public accounts on social media, but he still took the photo.  We can’t say why.  Perhaps bragging to a friend?

Tough part here is that it isn’t the initial photo that caught the attention (although I’m sure it would have) it was another player that thought the situation needed to be shared.

And likely without Nik’s permission, which is where this situation will start getting complicated should the Sacramento Kings organization decide to take action against DeMarcus Cousins.

I’m not saying they should, but what if they did?

What would he be in violation of?  Does your agency have rules about sharing photos, quotes or speaking to the media?  If so, that will apply to in person interviews, emails, texts, posts…all possible methods of sharing media.

Now let’s go back a few decades and pretend someone photographed this and had it developed, then hit the xerox machine and posted it all over the office?  Would the same rules apply?

They should.

“But Justin, it’s the internet!  It’ll be there forever!”

A: Not true

and

B: Who cares, it’s there, let’s try to prevent the next one.

I found this image funny but I’ve been there.  I remember being the new guy who showed off that first paycheck that had a comma in it.

The trouble is, Mr Cousins, maybe it didn’t need to be shared.

Mr Nik Stauskas didn’t feel the need to share his photo publicly.  Mr Stauskas gets it.

From Trade to Profession – Thoughts from a Reader

Here on the blog I’ve had a favorite photo of Johnny and Roy in the Squad and Johnny looks like someone took a steamer in his cereal. (Chet most likely)

Under it I imagine Roy saying “Don’t worry Johnny, one day we’ll be a profession rather than a trade, just you wait.”

Well, he’s still waiting.

The folks over at Webster’s say a profession is:

A field in which one is in a paid occupation, especially requiring prolonged training and qualification.

We can argue the merits of 2000 hours, but that is certainly prolonged and we do require a state license and there is even a list of folks who passed a special test and get “registered.”  It would appear that, technically, we’re there.  You can relax, Johnny.

 

However, ask any EMT struggling to get by if they feel part of a larger Profession and they’ll likely tell you no.

Reader Garrett Kajmowicz shot an email to me asking the following question in regards to being considered a profession:

“How many professions exist where you aren’t allowed to buy your own tools?

As it stands, as a paramedic, can you go online and buy your own supply of medications? How about diagnostic equipment like a heart monitor? I think that some form of legal independence is going to have to exist as a part of the trade to profession shift, though I don’t know when, where, or how.

Thoughts?”

Interesting question there, but I’ll have to go with no. Being able to purchase our own tools won’t steer us one way or the other.  Case in point, no one would argue that being a pilot is not a profession because the pilots do not own the planes.

By the way, now that I work at the airport most of my bad analogies will be aircraft related.  Sorry for the inconvenience.

Being recognized as a profession takes time.  A long time.  Some will argue that we need an over arching Federal office to oversee licenses, skills and practices.  I agree and disagree at the same time.  While many similarities can be drawn looking to our close cousins the fire service (started as slaves chained to street corners) and nursing (started as prostitutes) who both have National level organizations, cabinet positions and offices in DC, we still have no idea what we are so where would our federal agency live?

Are we in the public safety business or the public health business?

Both need to be filled but with drastically different professionals in drastically different fields of specialization.

Our trouble is that we still sit on the fence and cry that the other kids won’t let us play when both teams are a player short.  Do you want 911 or Community Paramedicine?  Can’t do both.  Those who say you can are the same who say you can’t be both a firefighter and a competent Paramedic.

In the past I’ve caught flack for suggesting I was competent in both, but have since specialized.  As my position required more focus on EMS I had to pick a side.  And did.

I say pick one and run with it.  A community can certainly offer (and would be doing a dis-service not offering) both services, but not using the same person.

You want to run 911?  I need you also swim certified, low angle rescue certified and in haz mat and active shooter training.  I need to put you in harm’s way.

You want to do Community Paramedicine?  I need you back in school. Advanced A&P, pharmacology, psych, social work, community planning, administration and education and none of this community college stuff, I need you in the cadaver lab with the pre meds.

Two distinct professions can emerge from our little trade house if we want it enough but back to the original comment from Garrett, no, I don’t think buying my own LifePack 30 (Are we up to the 30 yet?) will make me part of a Profession.

Only I can do that by lifting up my co-workers, my agency and my passion for patient care.  I would hope we are all doing the same.

What do you think of Garret’s thought?  Will being able to order a monitor, ambulance and medications, the tools of our trade, allow us to become a profession?  If so, how? If not, why not?

Tell me in the comments.

A House Divided…

Not a political post, just thinking about firing up the EMS 2.0 machine again here in my home system.  This speech keeps coming to mind.

An excerpt from Senator Lincoln’s Speech to the Illinois Legislature in 1853:

If we could first know where we are, and whither we are tending, we could then better judge what to do, and how to do it.

We are now far into the fifth year, since a policy was initiated, with the avowed object, and confident promise, of putting an end to slavery agitation.

Under the operation of that policy, that agitation has not only, not ceased, but has constantly augmented.

In my opinion, it will not cease, until a crisis shall have been reached, and passed.

“A house divided against itself cannot stand.”

I believe this government cannot endure, permanently half slave and half free.

I do not expect the Union to be dissolved — I do not expect the house to fall — but I do expect it will cease to be divided.

It will become all one thing or all the other.”

 

A therapy blog with an EMS problem