Sometimes we forget who we’re up against.

Sometimes the system is indeed rigged against us from the start.

But how can you win if the other party refuses to even play the game?

The term “blind sided” was used in a meeting today, much to my surprise.  You could even go so far as to say that I was blind sided by this blind side.

It was a jolt of reality back into my EMS 2.0 world that not all of our enemies lie within.  Some are just skirting along the outside of EMS, providing valuable services, only to pounce on ideas they find threatening.

Only problem is, I don’t see it that way, not sure I ever will.

I’ve had almost a year to figure out this whole politics thing and I still just don’t get it.  I don’t care who had the idea, or who gets credit, I need some things to just happen.

In my role, very few decisions are actually within my control.  I do research and pass the info along.  If it gets rejected, I research more.  I’ve had my preconceptions busted more than a few times, comes with the territory.  But there is this perception that others see my actions as more for me than the system.

I just don’t get it.

Some things come from out of left field, but that’s all based on the assumption that what we’re expecting was in left field to begin with.  My surprise came from the bleachers behind left field, caught my on the jaw and knocked me to the floor, blinking, wondering what just happened.  I had a ceiling do that to me once.  Once.

I’d love to say “never again!” but when you don’t know what to expect, how can you prepare?

I absolutely LOVE answering the complaint line here at HQ.  Not HMHQ, my real HQ gig.  The complaint line at HMHQ never rings. 

Many may not want to hear the public rattle on about how we stole tens of thousands of dollars from their wheelchair or lifted a priceless piece of art the last time we were called code 3 for a spoon stuck in the disposal, but I LOVE it.

My pencil jots notes as I listen to the complaint in it’s entirety never once asking for clarification.  I get the entire story out and make sure they say everything they want to say.  90% of their complaint is usually because they want to be heard, not because they have a legitimate complaint.  They want to hear that it’s not cool that they don’t have as much stuff as I do or that spoons fall into my disposal all the time.  The venting is the powerful process here, I should know, right?

However, every now and then I get a call from someone unclear on the concept.

THE EMERGENCY

Not sure that heading still fits, but we’re almost 4 years into this thing, why change now?  A woman has called me requesting the ambulance crew who transported her 2 days ago be fired.

THE ACTION

OK…

Her story goes a little something like this:

The ambulance crew was late, rude and refused to help her.  They didn’t carry her into the ER and refused to give her to a nurse.  The ambulance crew then pointed at her and make remarks that I won’t repeat here.  Her language was colorful and hurried while I made notes and pulled up the chart from that day.

When she was finally finished I assured her I would look into her claims and explained the process.  While I was doing so I returned no records of a her being transported that day.

“Could this have been yesterday?” I ask seeing her name pop up on another day, then another.  In fact the software we use turns grey days blue if a patient is contacted on that day.

There are more blue days than grey.

I also notice that today is blue so I pull up the chart.

While I’m doing so she continues on that after the rude evil paramedics left she collapsed and had to spend 2 days in ICU.  She then described the pile of bills she is already receiving.

I noted her concerns for the file and asked the only question I needed to ask:

“Were you transported to St Closest today at 10 AM?”

“What? How do you know that? That’s a violation of my privacy!  How dare you access my medical record without my permission!” a brief pause… “Well?”

“Ma’am, if you’ll permit me..” and I restated her clinical concerns and her destination concern, and the claim that she was not delivered to a nurse, all of which is directly connected to her medical record.  And although I had no way of confirming her identity, no PHI was exchanged and clearly she knows most of the fleet and they know her.  As I scan a few of the charts looking for patterns of behavior I find what I’m looking for.

Most of the crews are using her statements in quotes and they match almost to the word:

“Patient states she will file a complaint if not transported to Saint Farthest, Saint Farthest is on divert, patient ambulated away angrily with steady gait.”

When I asked if she had been transported to her facility of choice and if the Paramedics had actually been rude to her, she began the back track.  She didn’t really want them fired, maybe just talked to, or even just mention that she was not pleased with the level of service she received.  Then we talked for a good 20 minutes about her medical conditions and her use of 911.  I offered a few contact numbers for local resources and even threw in a few breathing exercises for relaxing after a long day as an urban outdoorswoman.  She thanked me and in the end apologized for taking my time.

“That’s why I’m here, Ma’am.  If my Paramedics ever do anything you don’t like you call me right back, OK?”

That was in January.

Today I noticed her name on a chart where she was transported for a chronic condition, but the colorful language was gone.  I had to go back and check the name to be sure.

Her blue squares have decreased significantly since and I’d like to think I had something to do with that.  It wasn’t a rapid response car, or an advanced skill set, it was taking the time to listen and offering support.

Try it.

…doesn’t mean you can do it.

We’ve had some confusion around the yard as to just what we’re supposed to be doing when it comes to assessing the car rather than the patient.
We all know to assess the patient, not the car, the patient, not the monitor etc etc.

At a recent training evidence was presented that contradicts our current protocols as set forth by our regulators.
It seems a number of folks took that training to heart and are trying to apply it to the patients they encounter in the field.

Problem is, the treatment, or omission of treatment in this case, is causing trouble for me in the CQI office since I now have to talk to folks about doing the right thing and breaking the rules.

First a note on one of our favorite terms: mechanism.

Motor vehicles today are designed to crumple, absorb energy and disperse it around the passenger compartment. This design allows for a great deal of damage to be incurred prior to the passenger, if properly restrained, is injured. This is the reason that recent CDC wording of field trauma triage criteria specifically mentions intrusion into the passenger compartment. Your protocols and policies likely have a similar clause.
The problem is when the protocols and policies start making assumptions about the possible damage to the car and how it relates to possible damage on the patient, then prescribes treatment based on the car, not the patient.

Rollovers used to be a big deal. If everyone is belted chances are they’re self extricating before you get there and strap their curved spine to a flat board. You know…just in case.

Even more frustrating is when you finally convince the patient that the hospital will take careful care of them in case they have a back and neck injury only to arrive to a triage nurse removing the collar, performing the same assessment you did, then removing the board if your treatment was based only on mechanism.

Even worse is when you convince them to be seen at the trauma center based on damage to their car, only to see them moved to the hallway prior to your chart being completed…no board, no collar.

I asked a few of my crews to think of the worst Paramedic they had ever seen and if they would want that person “clearing” C-spine injury in the field on them. The point set in that most of us can barely get our noses out of the cookbook long enough to do a complete assessment now. Those folks have no future in EMS if I have anything to say about it.

So what to do?

Attend the meetings of the groups that make the rules. Get on the agenda and speak. Bring research, evidence, examples from other systems already doing what you want to do.
You get a lot more attention when you bring in a multiple page presentation on Community Paramedics rather than complaining in the yard that we need more training to be able to do more.

Follow the policies. If they aren’t what your patient needs, lobby to change them. Don’t ignore them in the field or your next patient may suffer when you’re on suspension and that medic you despise has to treat them.

Which is worse?

brrrrrrr…

“Coldest winter I ever spent was a summer in San Francisco” – Mark Twain

“Don’t believe everything you read on the internet” – Abraham Lincoln

“Quotes are stupid” – Some idiot

Summertime is here and I for one am glad.  Glad that I get into my car in the high 70s and get out in the City somewhere in the high 50s.

At home it’s shorts and flip flops, at work it’s jackets and glad we wear wool pants.  When I return home, however, to temps in the 90s we rethink the wool.

In a recent conversation with a respected hospital administrator the term “therapeutic hypothermia” was tossed around rather freely, as if saying it for the 500th time would win them a set of steak knives.  It seems the powers that be are interested in bringing some active cooling measures to the only recently mostly dead.  This was the result of a series of meetings I somehow never made it to.  Laziness one possibility, apathy another, or I could have been reading charts and yelling at people.

In our discussion of the merits of the term “therapeutic” we wondered if having to mention a treatment is good in the title is a red flag we’ll look back on in the future.

“Try this therapeutic oxygen, it’s amazing, but avoid that passive oxygen, it’s no good.”

Making people cold can apparently help them recover from a cardiac arrest.  I guess some papers have been written and some friends looked at it and agreed so it became the thing to do.  Trouble I have is the recommended window of initiation of treatment.  It seems that if we can get their heart beating on it’s own again, then make them slightly cold within 4 hours and keep them there for 12-24, we can improve their chances of survival.

4 hours.

Our average transport time hovers in the teens and tack on a few minutes to get pulses back…let’s call it 1 hour.

One full hour, 60 minutes from when the heart stops to when we hit the doors of the ED with pulses and a BP.  That leaves 3 hours to initiate CONTROLLED cooling in a CONTROLLED environment.

My conversation with the hospital rep then turned to the process that will be used to monitor the cooling efforts.  Thermometers perhaps?  Maybe, we’ll see.

On a side note, we also have a problem with a little something called passive hypothermia wherein Erma Fishbuscuit drops a few tenths of a degree just by sitting in her drafty bay window, then we carry her out to the rig on a cold chair with a single wool (wool again!) blanket.  Then we have to get her all tucked in and cozy warm.  Makes sense.

But for her the hypothermia is not therapeutic, had she suffered cardiac arrest, then yes, but late for her dialysis, then no.

So what to do?  Hypothermia seems to be the next big thing, but I’m not sure the effects it will have in my system.  Could we get more people leaving the hospital without deficits from cardiac arrest if we focus on the weakest links of the chain of survival?  Bystander CPR, Public Access Defib and ED CPR quality? (See how I threw that in there?)

The conversation ended with a desire to see all policies and protocols require footnotes showing the research that supports the contents.  Then we realized half the manual would need to be discarded and laughed.  It wasn’t a triumphant laugh, but more the kind of laugh when you realize your car was stolen.

As Clinical Supervisor I am tasked with ensuring my crews follow established policy and protocol while acting in the best interests of their patients.

But Justin isn’t sure what kind of an impact making the recently deceased shiver will have.  On a cold summer’s day in the City we could probably just leave the blanket off and get good results.

I’ve been going about it all wrong.

Here I was scouring the laws, policies, regulations and statutes looking for a way to get alternate transport vehicles, like vans, SUVs and cars classified as ambulances.

Turns out all levels of regulation are quite clear on what an ambulance (the 9 letters, in case you’re wondering) is.

It starts at the State level defining an ambulance (I’m paraphrasing these) as a vehicle modified to accommodate a stretcher and staffed by 2 people, at least one of them an EMT-1 and that meets all local standards for an ambulance.  So that kicks the details to the local EMS agencies.  I’m OK with that, let the communities decide what specifics they need.  Oh, but there is the 2 person standard and the stretcher part I need to change.

The California Highway Patrol has standards for a vehicle to be LABELED ambulance and allowed to violate certain aspects of the vehicle code by using red lights, siren and blocking the right of way etc.  It requires a forward facing red light, distinctive paint, a cot and 2 people.

Dang it.

Then the County Health Code breaks down an ambulance and a routine medical transport vehicle, both requiring cots and 2 people.  This is looking bad.  So far I have to change a state law, a vehicle code and a County Health Code.

The local EMS Agency is specific on the staffing requirements of a BLS and ALS ambulance, equipment for first response vehicles (do all ALS first response vehicles really need a long spine board?) and are also charged with certifying that all ambulances in the system comply to the standards.

I have a huge uphill battle if I want to start transporting people in something other than a 2 person ambulance.

Or do I?

What is surprisingly lacking in all the statutes I’m reading are 2 things:  The definition of a patient, and a definition of what a patient uses to get to the hospital.

It appears the automatic default is that a patient will go via an ambulance and vehicles carrying those 9 letters are well regulated, and for good reason.  But what about when we let folks refuse transport, then they climb in a car and go to a hospital anyways?  Is that drier violating the state law, vehicle code, County Health Code and local ambulance ordinance? Of course not, silly, it’s not an ambulance.

It’s not an ambulance.

I’ve been going about this all wrong.  A complete 180 is in order.  Instead of trying to wiggle my solution into a decades old understanding of 9 letters, we could simply exist without them.

This theory applies only to my pilot project of course, the 9 lettered certified ambulances are still meeting all local, state and applicable laws, but now imagine being able to call the company taxi and send the person who meets criteria in something not labeled ambulance and they get the care they need.

Won’t someone think about the billers?!

Oh, I forgot to mention 1 little law that does go against my idea: Medicare part B.

Medicare part B is the legislation that looks retroactively and decides if the ambulance was really necessary and reimburses accordingly.  This is the main reason so many systems tell their practitioners not to walk patients to the ambulance like I do.  They’re likely not going to pay you for that trip.

So why are we still making the trip in the most expensive, regulated manner possible?

Because of 9 little letters.

Medicare has strict definitions as to what makes a BLS and ALS ambulance and gives subscribers guidelines as to what is and is not covered for reimbursement, even being as specific as to where you are when we declare you dead.  Another reason some agencies transport all cardiac arrest patients.

Turns out the folks who would meet criteria for a retriage to alternate transport wouldn’t be eligible to have Medicare cover the bill anyways.  So why not arrange for alternate transportation at far less cost?  It’s a cost more likely to be recovered and freeing up the ALS ambulance to find another paying customer patient in need.

I was always told there was a big law somewhere telling us we had to do things a certain way.  And there is, if you want to keep doing things the same way.

There’s still a lot of research required and permissions to get, but the biggest blockade to my desire to introduce alternate transport options is gone.

Just leave out those 9 magic letters.

I was asked this question by a rather influential law maker recently and my answer surprised me.

Being someone who used to hate the term “First Responder” thinking it dumbed us down, I realized we had to be dumbed down for the general public to grasp what we did day in and day out.  The term is not accurate, but then again, when has the TV and radio ever been given the opportunity to learn why we are so secretive about what we do?  Be it HIPAA or a desire not to owe steaks or ice cream, we avoid the press like the plague, then reprimand them for not knowing what we’re doing.

So there I was, being asked what a “First Responder” was.

“A neighbor coming to another’s aide,” I started, “A father seeing signs of distress in a friend’s child, a teacher noting the early signs of an allergic reaction in a student, a college professor noting a suspicious package, today, we’re all first responders.”

I gulped, thinking I had just sold a generation of actual “responders” down the river, discounting them to be equals with a school teacher who deploys an Ei-pen.

But we’re not, are we?

In a community that looks out for one another, we are not needed.  We are a footnote in the history books of when people used to need emergency care via tiny mobile hospitals.  EMS becomes a truly unneeded service, except for the rare true emergency.  Not unlike the Fire Service has found themselves, all full of budget and not sure what to do with it.  How did they become so successful at putting themselves out of business?

Prevention.

It is my goal to put EMS out of business.  It should be every Paramedic and EMTs goal to do the same.  We may have the occasional emergency, sure, but the day to day BS we deal with needs to go away.

And perhaps if neighbor started helping neighbor, friend started helping friend and we all realized the sweeping epidemics of obesity, diabetes, heart disease and cancer and did something about it maybe, just maybe, we could actually see our call volume start to drop.  See our stress levels start to decline, and see the eventual funeral not for another neighbor, friend or family member, but for EMS as we know it.

Get involved in your own community.  Be a first responder to those you meet by chance, not by dispatch, and become a positive force for change in your own community.

If Uncle John is able to lose weight and exercise, maybe he won’t need Medicare so soon.  If your neighbor recognizes his need for asthma care and to quit smoking, he lives another 20 years to contribute to the community.

We can make a difference in our communities, EMTs or Paramedics or just regular folken.

Get involved, be the force for positive change you’re waiting for.

It doesn’t take a badge, look below it.  It takes heart.

-HM

I got to sit in on a meeting with our billing company the other day and had a nice little discussion about what constitutes an ALS call.

In their non-clinical world only a call where a person performs an ALS skill is an ALS call.

I couldn’t disagree more.

I see what they’re going for, thinking about justifying our ALS rate for the guy who claimed to be suffering a stroke, but got no treatment.

But WHY did he get no treatment?  Because of a good ALS assessment.  That, to me, makes it an ALS call.  If we get on the scene with a BLS engine and they’re able to determine the transport is BLS, great.  Trouble is I have no BLS cars in my fleet, so even if I stick an EMT in the back I still have a Medic driving.  Plus there’s the stickler that the regulatory agency requires an ALS assessment on all patients.

So there we were, arguing whether or not running an EKG is an automatic ALS transport, him taking the side that it can’t be because it didn’t show anything and me arguing that that’s the entire point.  ALS isn’t the tools we carry or the skills we practice, it is our assessment skills.

I can train a cat how to intubate, but I can’t train him when not to.

Our assessment skills are what make the difference between a BLS and an ALS patient.  Plenty of ALS patients can be treated with BLS in the short term, sure, let’s not get into a BLS vs ALS pissing match, but instead shift our focus from what’s in the toolbox to when and WHY to use what’s in there.

Discussion finished, and me having lost, I wondered about the inefficiency of an all ALS transport system.  Perhaps I can convince the state and County to open their minds to alternate options.  We already transport to a specific alternate facility, perhaps more research is in order?

Just hope I can bill it at the ALS rate.

Please enjoy!

When I attended ZOLL Summit there were a number of presentations about unifying the crews around a common goal, a mission statement.

I’m sure most of you have a mission statement in the 5-8 sentence category going on and on about what high level, competent sensitive care you give pre-hospital and how you strive and compassion and blah blah blah.

Can we get a REAL mission statement here?

If you were asked to write your company’s mission statement… what would it be?  Bloggers, what should it entail? What should it mean? Who should it inspire? our people? Their People? Anyone? Anything?

Once again another great ZOLL Summit has come to a close and I have so many exciting things to take back to my system my brain hurts.

I know many of you think that means I didn’t get too much, but the trick is prioritizing.

Many of the data systems currently deployed by my agency are not being leveraged for their full potential.  Many of the reasons for this can be traced back to one problem in particular:

Moving data.

Many of the users I have spoken to are moving data reliably and are able to analyze it and act on it.  We have trouble moving data and as a result spend time we could be using analyzing on chasing data.

There have been a number of solutions presented, but a glaring system wide issue keeps us from moving forward and maximizing our efficiencies.

I attended a session today where the speaker talked about how to leverage technology to get your crews from a .4 UHU to a .44 UHU.

.44?!?

We’re averaging a .9.  If my crews had a .44 they’d probably throw a parade for whoever did it.

After the presentation I was approached by my counterpart at a large East Coast agency who wanted to know how we got so efficient with our field supervisors.  We’re all doing something great and need to share it.

Getting ready to head for the airport I wonder if my excitement about the small enhancements I can implement will get drowned out by the problems awaiting me back at the office.  I can only hope that because I have networked with systems who are succeeding where mine is struggling, we can work on solutions that are mutually beneficial.

We’ll see I guess, but first it’s the 14 day drive from Denver to the Denver Airport.  I’ll send up a beacon if we get lost.

HM