I got a strange voice mail from the Secretary of the Chief of Department asking if I could talk to a reporter about our advancements in cardiac arrest survival.

Um…yes please?

 

Laura Landro from the Wall Street Journal asked the kind of questions I wish more reporters asked.  Not just asking for our survival rate, but the more important question:

“Why is your number improving?”

We discussed continuous chest compressions, training the entire department to AHA standards and ensuring our BLS fleet can anticipate ALS interventions.  We discussed esophogeal airways, CPAP, see through CPR (from ZOLL), end tidal capnography, so many different tools that come together to make a 9% into a 23%.  And that was all before I got my job at HQ.  It’s nice to highlight the work of those who came before including Jeff Myers, Seb Wong, Brett Powell, Pete Howes.

Hopefully this is just the beginning of a conversation with the public about how EMS impacts their daily lives, not just when they, for lack of a better term, drop dead.

 

The Ultimate Lifesaver

 

Only on the front lines can you tell where the bullets are coming from.

 

Everywhere.

 

To say I might be in over my head is an understatement.  To say I thought it would be worse is also an understatement.

This is an entirely different world.  My commute is twice as long as it was 6 months ago when I first tested it, or maybe since it’s an everyday thing now it just seemed half the time before.

I wake at 5 to make the train by 6 so I can do research till 7 and make the office by 8.  Then I have to time my departure to make the train right before the tens of thousands of others exiting the City at closing time.  It’s different than wandering into the fire house after an hour and 20 minute drive.

That’s the only drawback so far.

 

I realized on my first morning of reviewing charts and advanced interventions that I am now responsible for more than my own patients.

To borrow from the meme, “I get ALL the patients!”

Seriously. I am able to act in the best interests of each and every patient this system comes into contact with.  Sometimes that will mean counseling a provider or defending them from an MD unclear on the concepts of EMS.  Other times it will be discovering where we’re not doing enough and finding the evidence to show it, then provide solutions to the command staff.

Some they will embrace, others they will reject.

I am not here to change the world for myself or even EMS, but for each and every person in my City who calls for help.  That is my new goal.  Not a 20 minute intervention, but a 20 week analysis of their experience and outcome.

 

Bring it.

On a summer day back in 1996 I walked into the trailer at the Isleta EMS and Fire Station and began my paid career helping people.  I have worked a variation of a 24 hour schedule ever since and it has become second nature to be away from my family for long stretches in exchange for a few days in between.

 

That will make Monday all that much more interesting.

 

On Monday I hang up my turnouts and late nights without sleep in exchange for a promotion and a reassignment downtown.  That also means giving up that ever so comfortable and vacation friendly schedule.

 

I was bummed at first until I realized that now the HMjrs are in school and we can’t just pick up and go somewhere whenever we feel like it anymore.  When this job at headquarters opened up it seemed too perfect a fit.

 

Monday I will take over the vacant CQI position that has been retooled ever so slightly to now officially include research.  Talk about a perfect chance to mine the data to see what is really going on out there.  I have lofty goals for my service, but it’s going to be a long while of playing catch up and learning the new job before I can start going forward with new ideas.  I also have a new political landscape to consider and will be in direct contact and communication with the regulatory agencies, budget writers and vendors that all have a stake in patient care in my jurisdiction.

 

It’s an amazing opportunity for me both professionally and personally and I am beyond excited to get started.

 

About the blog…

There will be a slow tapering off of 911 stories, I’ve got quite a few more half written and half anonymized just waiting in the wings, but there will likely be a shift in what I share.  My EMS 2.0 rants may well turn into updates about what I’m dealing with in that little office downtown.  I won’t be changing the name of the blog to Happy Captain (or Happy Cappy as MC suggested) since this is about my therapy, not necessarily an accurate mirror to my own life.

I now join the ranks of Sparrow, Morgan, Crunch and Stubing, to name a few.

 

Thanks for all your supportive messages on FB and Twitter.

 

-Captain HM 

Rogue Medic is in a great mood as of late and this article about the complete joke that is Mechanism of Injury (MOI) hits the nail on the head.  I recently had to triage a car over a patient because of strict trauma guidelines, luckily finding the always available “Paramedic Judgement” to wiggle my way out of it.

 

The simple point is this: Mechanism needs to be a symbol on a map, not the destination.  With cars designed to crumple around our patients, what if it does take 30 minutes to get them out but they are unharmed?  And the pedestrian clipped by the mirror on the arm by a passing car at 40MPH?  Why are they on a board and in a collar?

 

Because 30 years ago when this Profession was still trying to figure itself out we bought into some crazy ideas, that’s why.  Now that we’re actually starting to study some of these ideas and finding them hurting more patients than they are supposed to help, we need to start revamping a number of our “standards of care” which actually should read “That’s what everyone else does…”

Whenever I have to document damage to a vehicle (mainly for my recollection of the run later on, just in case) I try to use some basic terms that at least remain consistent in my own description of vehicles.  Those are:

Light truck, truck, large truck, coupe, sedan, wagon, van and commercial vehicle.

Then I go and describe the damage using 3 terms, light, moderate and considerable.

Those are mine and can be widely interpreted.  Maybe I’ll get Motorcop to jump in on this but…A coupe hitting a brick wall at 40MPH will look differently than a van that hits another van at 25MPH.  One is a trauma, the other not by protocol, even though one may indeed have carried far more force.

And even if I do mention light damage to the front of the vehicle, what does that mean? What kind of car? What kind of impact? Against what? Did the vehicle’s protection systems discharge properly?  If the driver was able to self extricate and has no chief complaint, why am I chasing him down with a C-Collar? Because the folks who wrote the policy are in a committee long ago and far away.

MOI is important as far as it gives us an idea of POSSIBLE injuries to consider.  I consider it as a part of the Past Medical History and weigh it just as heavily.  If it does not apply to the patient’s presentation it will be considered, but not relied upon.

One rollover will have a 17 year old girl sitting on the curb completely unharmed while a minor damage collision could yield significant injuries to the passengers.  We won’t know until we assess them.

I remember long ago in far off new Mexico, some medics would launch the helicopter just based on dispatch information of the reported damage.  And we’re back to the telephone game of one person’s “Oh my God! They’re trapped!” and another’s “She’s just not getting out, but looks fine.”

Assess.  Use MOI as a tool, not a guide.  We always look inside the passenger compartment for deformity, blood, marks, bent steering column etc, but we should not be basing a transport on the vehicle.

 

Then again, try documenting that you let a driver refuse transport who had moderate damage after a head on collision into a guardrail, deploying front airbags with a non-complete recollection of events.

Now if I tell you they hit the guardrail head on after sideswiping another vehicle at 40MPH and spinning around, coming to rest in the slow lane and is avoiding telling the police they cut across 6 lanes of traffic to make an exit…now can I let them go home?  Or should I be chasing him down with a collar?  We all know the answer to that one.

 

Looking forward to more, Rogue!

It’s easy to see an accident and keep on walking, but something in some people kicks in to make them want to learn more. At a recent accident we’ve all seen on video by now a motorcyclist collided with a car and, surprisingly, they caught fire.
As random folks come to the car and look inside a woman in flip flops does what EVERY rescuer needs to do at EVERY roadway incident:

She looks under the car.

Seeing the unconscious body of the motorcycle rider she tries to lift the car off of him. Others seem interested and when she confirms again “there’s someone under there” the troops are flocking to the scene to lift the car.

You can give credit to the worker who pulled the rider out of harms way, the cops and their interesting fire attack or even the firefighters and paramedics who magically appear, but the real credit goes to flip flop lady and her desire to answer the burning question she had inside: “Where is the rider?”

From NPR: According to the Salt Lake Tribune, Wright suffered a “broken leg, a shattered pelvis, bruised lungs and burned skin,” when he and his motorcycle collided with a car. But, thankfully, he is “well on his way to recovery, his doctors said.”

 

Each year I choose 1 story to share in an effort to keep alive the memory of those who died. Buying a sticker or a T-shirt that says “Never Forget” isn’t enough, heck it’s nothing. Learning about the lives of those who went into that morning not knowing if they would be coming out and sharing their stories with others is the only way to remember and keep them alive in our hearts.
I used to think the ancient Egyptians were foolish for claiming they were going to live forever, yet we still speak their names and honor their traditions in our museums and textbooks. They truly did accomplish living forever and if we want these men to be remembered in the same way we must continue to share their stories and speak their names aloud.
In my search for a story to share about those who died on September 11th, I kept coming back to a number: 10.  10 years, 10 Engine, Ladder 10…10 House…

A firehouse is much like a family and when a member of a family dies it can have an impact on the survivors. But what if more than 1 dies? Or 2. What about 6?

This year I share the memories of 10 House and the day she lost 6 of her children.

 

10 House is the quarters of Engine 10 and Ladder 10 who, in 1984, adopted the logo of a firefighter straddling the tops of the twin towers on fire reading “First due at the big one.” And they were.  Reports from survivors say that even as they rolled out the door there were already bodies in the street.
The firehouse is on Liberty Street directly across the street from the World Trade Center. The house survived the collapse and was re-opened after getting fixed up, but her family is still healing.
Both companies were established in 1865, later moving to the same house.  It is one of the few houses where the engine and ladder companies happen to have the same numbers. For almost 150 years she saw only 3 deaths in the line of duty, on that September morning the number would triple.

Lt. Gregg Arthur Atlas – Aged 44 years, Lieutenant Engine 10

Firefighter Paul Pansini – Father of 3 children, Firefighter Engine 10

Lt. Stephen Gary Harrell – Age 44, Member of 10 House assigned to Battalion 7

Sean Patrick Tallon – 26, Marine Reservist and only weeks away from completing Probationary status on Ladder 10.

Jeffrey James Olsen – Age 31, Firefighter Ladder 10

James J. Corrigan – Retired Captain from 10 House, oversaw Fire and Safety Operation for the WTC complex

 

The house was a gathering point for those wishing to visit the FDNY to offer their condolences.  Like many houses it was covered with patches and shirts from visiting firefighters, letting the members know they were in others’ thoughts.  A beautiful memorial was erected inside dedicated to the 6 members who died and included was a newer plaque honoring the 3 that had fallen between 1867 and 2000.

10 House became the site of a 56 foot bronze relief sculpture donated by Holland & Knight , a Law Office, who lost  employee Glenn J. Winuk, also a volunteer firefighter, when 10 House lost her children.  The relief was dedicated in 2006 and is the only 9/11 related site on my list of things to see when I visit New York later in the month.

I don’t want to see where 10 House lost, I want to see where she lives on.

You can learn more about 10 House on their excellent website.

2009′s memory

2010′s memory

When people call 911 for an intoxicated person, which amazes me to begin with, I have to wonder why the badges start to bump into each other.

“Code 3 for the PD request” is a call classification I hate hearing because it means the call taker has not completed a triage of the call.  There is a glitch (yes, I’ll call it a glitch because if this is done purposely I need to fix it) that allows PD to bypass call triage and get an amulance immediately.

There is no reverse for this system.  When I request PD code 3 I get barraged with questions.  And when I’m fighting someone no less.  When I get on scene to the PD request, they are most often standing, looking at someone.  Not providing care (which they usually don’t need to and are not trained to do), so why not take the time to classify their call too?

Who knows.

The reason this is fresh in my mind is because on a recent run with our boys in blue I was told “We’re not arresting him, it’s too much paper work and too expensive for the department to hold him until he sobers up.”

I stood up and cocked my head aside.

I responded that our paperwork is just as burdensome and the cost was exponentially more to the same city for what he was requesting.

Drunk is not an emergency, nor is it necessarily an arrestable offense, so what do we do?  If a person is unable to refuse transport (meaning unable to sign, not that they don’t need an ambulance, which they don’t) we’re trapped in a way.  We HAVE to take them and the ER HAS to accept them, meaning the actaul patient we bring in later has no room and has to be diverted.  This is not an argument to have on scene. When on a run THAT patient is your concern, not the next one.  Let me worry about the next one.

This is an opportunity for a third service to step in and handle intoxicated individuals.  We do have “sobering centers” although I’d reclassify them as ambulance drop-in and pick-up zones with a 2 hour waiting period.  We take people there in an ALS ambulance, then when they awake and vomit, the center calls us back code 3 for the “unconscious.”

Public intoxication is more common in my area than sudden cardiac arrest, yet there is no tool in my kit or on my radio to help.  The van service for shelter and detox requires a person to be ambulatory and climb in the van unassisted.  Most folks that meet that metric wander away when they hear us coming.

So why not let them sleep it off in the holding cell at the local PD?  I’m sure there’s a person there to monitor them and it is remarkably less expensive than an ALS transport and hospitalization.

But that’s not where they belong.  That is not the right place for them.

But the hospital is the more inappropriate place for them.  Why not check them out in the field, clear them of life threats (which the triage nurse will do from 100 yards) and let them sleep it off somewhere less expensive than an ER?

Motorcop?  Trauma Pig?

Turfing them to me is easy for you, but not for us, nor for the citizen.

Fodder for a Crossover indeed!

This call was fabricated to see what different kinds of treatment options and requirements exist amongst my 4.75 readers.

 

The kid seems fine, but the language barrier puts us in a gray area and learning that he fell to the hood of the car with mom on top, then to the ground adds to the dreaded M word.

 

But in this situation, unfortunately, many systems’ hands are tied.  In some areas a new category has emerged called the “High Risk” population, commonly those under the age of 5 and over the age of 65.  Some protocols are requiring MANDATORY precautions for patients who meet criteria regardless of physical assessment or paramedic judgment.

I am against blanket policies that take my clinical judgment out of a decision matrix.  If this is the future of EMS, let me off the train, we need to rebuild the track.

 

My system has this group but luckily we are still clinging to a “paramedic judgment” line in our policy to let me use my skills to evaluate the patient, not the protocol.

There is always a debate as whether to “immobilize” this child or not, mainly because we all know attempting just such an intervention will cause more range of motion and trauma than letting him stand still.  I don’t need research to tell me that.

Spinal Immobilization is useless at restricting cervical movement,  a nice splint for other things, but until an agency is willing to admit the truth, we’re afraid some lawyer will bring up a 30 year paramedic who will testify that they used the board for 30 years and never had a problem.  Groan.  Defensive medicine.

Instead, they would rather us pull out the pediatric LSB, wrestle the kid into submission, twisting and contorting his little body far worse than anything he’s experienced already, then, because he doesn’t understand our requests to stop ripping the tape off his head, we have to restrain him.  Restrain a 2 year old based on someone’s warped definition of a “high risk” group.

In the end I have 2 options for this kid, neither of them appropriate for the situation.

First, full C-spine immobilization and trauma activation based on the “High Risk” matrix or convincing mom that further evaluation is warranted and she and the kiddo should come calmly in the ambulance, no lights, no sirens.

A refusal on this kid is going to be tricky and a tough sell to the Medical Control MD on the other end of the line.  If you tell the story wrong they might launch a helicopter (or 2).

 

This tale began as a near drowning in a pool to see who would board him, but after running a guy hit outside a crosswalk I decided to change it.

As always, regardless of how archaic our protocols may seem, follow yours.  If you don’t like them, get them changed. On scene is no place to challenge established policy.

Michael Morse is hiring for The EMS.

 

I don’t swear often, but when I do, I say:

“Michael, Hells yeah I’m in!”

No, this isn’t a post about the Golden Gate Bridge.

Although it could be.

More a comment a bout blind allegiance without question.

I think everyone’s mother at one time uttered the phrase “If all your friends were jumping off a bridge would you do that too?” when our defense of a choice was “But all my friends are doing it!”

I was wondering recently why so many systems are running full speed towards certain treatments that have a great effect, but not necessarily pre-hospital.  If the beneficial time of application is within 3 hours of illness or injury and my average time from patient contact to hospital is 30 minutes, is that worth the investment for the system?

What if the time of application is 6 hours?

If studies show that applying treatments within 6 hours is beneficial, is that a good investment for my system?

So many systems are running towards therapeutic htpothermia and judging by the studies it is a beneficial treatment.  But do we need to be starting it immediately?  From what I can tell systems with prolonged transport times, only Intermediate Life Support, most rural areas, could see a great improvement in patient outcomes.

But in the urban settings, when even the ER could wait to apply it, is it something we need on the rigs, in our continuing education, and yes I’ll go there, additional opportunity for misapplication (liability)?

When does the risk/cost outweigh the benefit?

I think it is similar to the decisions I make in starting an IV pre-hospital.  We have nifty little saline locks attached to tubing for “gaining access.”  With the risk of infection in the back of my rig, or worse yet in the street, I will only take that risk if the benefit is there.  Why am I breaking the skin simply to attach tubing?  If I am not anticipating the administration of life saving fluid or medication, then why even do it?

When these pricey little guys arrived in our bags there was a training session and now 4 saline tubes and tubing are in my overflowing 40 pound bag.  In the early days someone (I don’t know who…) put a little paper in the baggie with the saline lock that read:  “Peripheral venous puncture is not a benign procedure.  If you do not anticipate the administration of life saving fluid or medication, does the benefit of administration outweigh the risk of infection?”

I still don’t use them and am quite within policy, protocol and the one that should be first on the list, the patient’s best interests.

BUT, on the other side of the bridge jumping argument, I like to think I surround myself with people who are like minded, forward thinking individuals.  If Ted Setla, Radom Ward, Chris Montera and Jeremiah Bush jumped off a bridge I would have to ask some serious questions as to why.  Or trust my friends.

I have made some blind leaps in the past that I now find foolish, probably still a few left in my future, but a blind allegiance is the thing I want to bring to your attention.  It is said that the most dangerous person is the true believer and someone who will blindly jump off that bridge with their friends no questions asked is the same in my mind.  However, a constant doubter, someone who refuses to jump or stay, but wants to see what the majority of folks do first is equally as foolish.

So when Mom asks  ”If all your friends jumped off a bridge, would you jump too?”

I’ll answer:

“Well…is there a train coming?”