Category Archives: EMS 2.0

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.

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

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 Comment on Typical Idiot EMS Managers by Burned Out Medic.

Burned Out Medic had a post up recently I thought I commented on, but apparently you have to hit ‘submit.’  Who knew?

The post is in reference to a Call the Cops story about an ambulance crew being reprimanded for going 90 MPH even though the vehicles govern out at 70.

Have a read and come back for my comments.

Well let me start by saying I agree 100% and that I’m going to have to disagree 100%.  Typical EMS Manager, right?

 

The trouble with the situation mentioned in the Call the Cops story is that there are no facts.  There does not appear to be any investigation policy or framework, nor is there any documentation confirming the speed of the vehicle, the exact location, time of day, etc.

Most field crews believe EMS Managers are sitting in the office hoping beyond hope that someone calls in a complaint so we can puff up our chests and assert the hair’s width of authority we have.

Let me confirm that that is not the case at all.  In between phone calls from hospitals, regulators, our own managers, chart reading, report filing and other mundane tasks involved with making sure you can still practice, citizen complaints are taken very seriously.

I used to get weekly calls from a fellow who swore up one side and down the other that a crew raped him*.  Same crew, every week. Seriously.  For over a year we were on casual conversation terms each time he called.  Heck one week he didn’t call and I was actually worried.  But the first time he called it was taken very, very seriously.

The conversation was recorded, run data was pulled, AVL signals gathered and only after confirming details from the caller was I able to conclude his complaint to be without merit.

The crew accused wasn’t even working that night but had transported this individual a number of times.  That same crew had recently been accused of other things by other members of the public and medical system.  Each time he called I’d pull the AVL map as we spoke to confirm the crew in question was in the clear.

You see my friends, complaints do not happen in a vacuum.  They are most often the result of someone getting a bill for service or just plain not liking EMS in general.

The example given by Call the Cops that Burned-Out references is hilarious because it can be easily disputed:

  • Obtain complaint in writing or verbally recorded.
  • Pull the unit history for the ambulance in question.
  • Pull AVL data for location.
  • Access maintenance data to ensure governing device installed and properly working.
  • Access previous violations for pattern behavior.

That’ll take maybe an hour.  The thing most field crews don’t realize is that good people can still do bad things.  If you’re a 5 star crew and get a complaint I handle it the same as a complaint about the crew that was in my office yesterday for what ever other frivolous thing the rumor mill says they were in for.

The tough call comes when the AVL data shows the unit traveling on the roadway in question, at the time in question, at the speed limit, but 3 hours earlier data show the vehicle traveling above the speed of the governor.

Now what do you do?  The crew has been proven to not be guilty of the accused offense, yet we now have data that show their defense is faulty.

It’s easy to sit in the rig and gossip about how the managers are out to get you after what happened to so-and-so but just remember it’s a lot of work to get you in trouble, and you know how we pencil pushing EMS Managers hate work.

If your managers are so bad at what they do, promote.  Nothing in EMS is easy, even sitting in a little room with a tie on reading charts and going to meetings.  The ultimate answer to bad leadership is to become a leader yourself.  Show me you can do it better than they can and your service will be the better for it and, as a result, your patients will have a better experience, which is all that matters in the end.

 

EDIT – *Forgot to mention, not the real reason he called, but just as unusual and hard to believe.

Now at Uniform Stories

Your pal Happy is proud to be included as a guest blogger over at Uniform Stories.

Uniform Stories allows you to upload a video about your experiences in uniform, no matter the type, and you know I’ll tell you that is a powerful medium.

Head on over and take a look at the site and watch a few videos and I invite you to upload your own.

If your uniform could tell 1 story, what would it be?

See you there.

A Big Move

I’ve been cryptic about things recently, and for good reason.

Those of you following on Facebook noted last week that I was preparing for an interview, but never explained for what.  Yesterday I got word that it went well.

Starting July 1st I will be assuming the role of EMS Director for the newly formed Detroit Unified Healthcare Service which will rebuild Detroit’s EMS service from the ground up.

Plagued with difficulties for decades the DUHS will erase the problems of the past and build on an EMS 2.0 platform of prevention, home visits and has already connected with a vast network of secondary transport facilities.

Upgrading salary, training and service levels are just the beginning!

More details are to follow as the official announcement will be made on Friday at a joint press conference, we’re still working on getting the house sold here, didn’t expect this to happen so quickly.

This is an exciting time to say the least and I’ll miss the SFFD but this is an opportunity not to be missed!

 

Interested in coming along?  We’re hiring! Detroit United Healthcare Service info

Mixed Signals at Youth Detention – NOMA

I was asked to accompany my supervisor to the local Youth Detention Center where they’re running a couple weeks of a modified almost career day program. They’re bringing in trades and professions from TV makeup to EMS and showing the kids that they don’t have to give up the hopes of moving on with their lives when they get out.

I think it’s a great idea since simply putting someone in a room and waving a finger at them seldom produces change in behavior. My 7 year old could have told you that.

We had a presentation prepared about the history of EMS, local and State requirements to achieve licensure and what to expect on the job. We had pros, cons, salary expectations and, most importantly to them, what your background needed to look like.
They were very interested in learning about the sliding scale of background infractions that will still yield a job taking care of people on their worst days. This many years without a conviction in this, that many years without 2 or more convictions in that…they were riveted and you could see them doing the math in their heads. “If I get out this year and don’t re-offend I can be an EMT in 4 years!”

The Company Man in me was on board with the message of inspiring these youths to look beyond their transgressions and wipe the slate clean. An opportunity awaits them to possibly get a job with me helping people.
Everyone deserves a second chance in life, especially the young.

Not on my ambulance (NOMA).

That’s what the EMS 2.0 inside me said. During the presentation I did my best to explain to the class just how easy it is to get an EMT cert.
“Only 120 hours of class needed guys!”
“2 days a week for 1 semester at the community college and you’ll be able to take the test. Pass it and you can apply to work on an ambulance!”

The conflict within me was well hidden I assure you.

While I agree that these kids need this message of how easy it is to get into EMS, I don’t want it to be so easy.

Taking care of people takes blind trust on their part assuming that the agency responding has done something to make sure you are a trustworthy person and are trained to take care of them. We extend our message of EMS with the promise of lights and sirens, driving on the wrong side of the road and try to temper that with tales of 911 abuse, vomit, urine, blood and guts. All this group seemed to be interested in was why my stripes were silver and my boss’s gold.

They’re kids.

We need to take this message to EVERY school and get kids excited about helping people and being selfish about it.

Yes, I said selfish. I don’t do this job to help people, I do it because the feeling I get from helping people is addictive and better than anything I know. I help people because if I don’t I don’t feel right. Trying to convey that message to a group of young men already 2 strikes down and out of their league doesn’t translate as well as one may hope.

One of them asked how we handle dealing with sick people and I told them it’s easy. It’s taking care of the people you shouldn’t want to that is hard.

I told the story of the child abuser that was confronted by a neighbor. The child had been transported by another crew and I was called to deal with the abuser and his mild injuries. That man got the exact same high level of assessment, care and transport as my mother would have received. Not because it was the law, or policy or the right thing to do, but that’s what I was there for. My sole purpose was to help those who asked and I did it with a smile on my face. Maybe not the biggest smile, but I helped and I felt better.

I wanted to share more about the realities of EMS with those kids but we ran out of time.

We didn’t talk about burnout, divorce, poor dietary habits, the sedentary lifestyle of 12 hour system status cars or the fact that in most communities you’ll need a second job to make ends meet.

In the end I don’t think it will matter.

The Company Man in me will apply whatever standards my employer sets forth when considering candidates, regardless of personal belief or Professional discretion. But if I was the boss, even if you carried the same license and all other things being equal, I’m hiring the kid that WANTS to be here, not one who took the easy road and wants to give it a shot because it took less hours than welding at the local college to get qualified.

Am I wrong? Maybe, but at least then I’ll know and can move forward.

What are your thoughts on reaching out to troubled youth about jobs in EMS?

Hate Firefighters that complain about EMS? You might be one. I was.

It is no surprise that anyone working in the Fire Department who hates EMS is in for a generic cialis rough career.

I have met many a “Basic for Life” who groans everytime the bells ring and it is not a fire.  Some even groan at building alarms.

I was talking with a colleague recently and we stumbled into the problem most in EMS struggle with and one I built this platform on:  BS calls.

You might be thinking “Justin, calling them BS calls isn’t respectful.  It’s that kind of attitude that encourages less than Professional actions by our low information voter EMS types.”

But they are BS calls.  The scraped knees, the MVCs without injury some passerby called in, the headaches after slurpees and stomach aches after a seafood dinner, all BS calls.

And if you agree then you still have a lot to learn about modern, and I’ll argue future, EMS.

If you argue that you only exist for emergencies and the other calls waste your time, your argument is no different than the firefighter claiming they are there to fight fire, not wipe asses.

So let’s rename BS calls as Basic Service Calls.  Not EMT Basic, but Basic care.

You exist to assess.  So many in EMS list their abilities to treat as their claim to fame when we have all known for a long time that treatments are useless without a complete assessment.  That headache, stomach ache, every call you go on deserves a complete assessment to determine possible solutions to you patient’s chief complaint.  If your main reason for assessing is simply whether this will be a transport or not, perhaps we should get you an application at Dairy Queen.  I can say that, I used to work there.  If all you d is check your boxes on the ePCR and exclude the patient from your box of tricks are you even addressing their concerns?

Every single call you are sent to is someone who didn’t know what else to do.  What an amazing opportunity to help them.  Not with a 12-lead most times, or albuterol even, but listening to their concerns and reacting to them.

If the guy on 3rd street keeps calling every time he runs out of meds, can we possibly help him figure out why instead of getting upset he called again?  In case you haven’t noticed, getting mad and yelling at him only makes him call and complain in between calls for 911 to refill his meds.

Getting upset isn’t working.  So instead, get involved.  It will take just as long to complete a transport or refusal helping him or ignoring him so why not make the time you have with him useful?

You don’t need Advanced Practice, Community Paramedicine or (I can’ believe I’m about to type this) Integrated Mobile Healthcare (ewww) to make a positive impact while still acting within your scope of practice.  There is no law that keeps you from being a patient advocate.  Since he called you for medical care you are now able to access his medical record (as much as he gives permission for) to determine what may be the trouble.  Call his Doctor’s office and mention to the clerk who answers that you are on a 911 call and need to speak to his Doctor.  Dude will be on the phone in a heartbeat.  If the van service from the managed care service is always late or keeps skipping the house, make a call.  If the home care nurse isn’t doing what they are supposed to be doing, ask for their agency’s contact information and follow up with your concerns.

All of this can be done in the same time frame as your frustrated conversation with your regular that will end the same way it always does unless you change your perception.

He IS the reason you are here.

Like the Fire Service before us we are doing a great job at preventing major medical issues and because everyone seems so intent on getting to any scene as fast as possible, we see many conditions far earlier than before, meaning they’re not as dire as our 20 year veteran colleagues remember.

We are the safety net these people need when their insurance company fails them.  We are the number they call when Medicare can’t cover everything.  We can make a difference if we try and we don’t even need to try very hard.

These calls will frustrate you.  They frustrated me so much I wrote about them.  As I did I realized I was getting frustrated for no reason at all and that I alone had the power to help these people.  That’s where EMS 2.0 became a reality for me.  That’s when Chronicles jumped off and my perceptions changed forever.  Had I kept stewing in my frustrations there is no telling where my sanity would be.

If you disagree with me and believe the first word in EMS is more important than the last word in EMS give up ever becoming a Professional.  You’ll burn out in a few years and I hope you don’t hurt anyone between now and then.

It’s time to take the extra step so many think is not their job, not their responsibility or not in their power:  Help people.

 

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Kelly Grayson belly flops with cliches, proves he’s a Noob

“Ambulance Driver” Kelly Grayson proved his ignurences (aside from keeping us down by repeatedly refusing to stop calling himself an ambulance driver) in a recent column from EMS1.com where he “debunked” some EMS cliches.

This article proved to me that this Kelly person is not fit to write for any magazine or website.  Anyone who’s been in EMS as long as me and worked as many calls as me HAS to see just how wrong Kelly is.  I’ve taken his 10 cliches and written my responses:

10. “Paramedics save lives, EMTs save paramedics.” This is the #1 truth in EMS.  I can’t tell you how many times I get on scene and start an ALS assessment on a patient and an EMT swoops in and places the patient on 15 liters of high flow.  I forget all the time that O2 should be applied for anything.  My EMTs also remind me to recheck blood pressures and check my splinting.  EMTs DO save Paramedics Kelly, if you give them a chance!

9. “Here to save your ass, not kiss it.” We are being misused at an alarming rate.  I had a call just yesterday where a woman wanted us to refill her prescription.  “You call, we haul.”  I wish they’d stop calling us and wasting our time.  What does she expect me to do? Explain the basics on healthcare?  I don’t have time for that, we’re a 911 service.

8. “We cheat death.”  We do, daily!  I have a T-shirt with the Grim Reaper being slapped in the face by a bad ass medic with sunglasses and everything.  You are so narrow minded you can’t see how we bring the dead back everyday.  Epi works Kelly!

7. “Seconds count.” Try holding your breath for 3 minutes and see what happens.  I can’t stand it when some washed up middle manager tries to tell me that we drove too fast or opposed traffic to the IFT.  We are en emergency service and I took a 3 hour driving course.

6. “I don’t have X-ray eyes.” If they think it’s broken, what do they want us to do Kelly? Huh?  Guess what happened?  If I did have an X-ray machine would that change my treatment? I didn’t think so.

5. “They should have gone to medical school if they wanted to be a doctor.” I spent 6 months in EMT school and another 11 in Paramedic School.  If there was something else I needed to know to treat from my Protocols, I’d know it.  Protocols are laws written by Doctors.  If I step outside those protocols, no matter the outcome, I will get stepped on and fired, no questions asked.  If they wanted me to learn more, why are the renewal credits where they are?  You can’t answer that one can you?  If 24 hours is enough to keep doing what I’m doing, I’ll keep taking the same 5 classes and cheating death on a daily basis.

4. “Zero to hero.” Classroom and book learning is a start, but you need true street experience to be a real EMT or Paramedic.  Only in the truck, getting puked on and standing in blood everyday can you truly realize and understand what it is we go through.  When you see death first hand it changes you.  It hardens you.  That’s why I can’t stand all the BS PC talk on facebook.  If you can’t take a joke, get out of EMS!  What we see every day would leave regular people in a puddle of piss, so yeah, the street is the only place to learn what it is we do.  You could take a doctor and put them out here and they’d shit their britches.

3. “If it saves one life, it’s worth it.” What if it was your Mom?  What then?  The cost of 1 human life can’t be calculated, I looked it up on wikidepia.

2. “I save lives for a living.” Damn right!  I suit up against Death, kick the Grim Reaper in the ass and take names later.  That’s what we’re there for Kelly, not all this BS moving people around because they are entitled whiny losers.  I don’t remember the whiny brat portion of Paramedic School.

1. “Treat the patient, not the monitor.” All your fancy ALS machines don’t tell you squat if you’re not looking at the patient!  Get them on O2 and watch them change in front of your eyes.  Sat monitors are useless.  Just give them some O2 already!  EKG?  Not so fast!  Basic before Advanced!  Take a pulse, count respirations, give O2, check a blood sugar, get a BP.  Then and ONLY then should you be applying the monitor.

 

Kelly, your cliche list proves to me one of 3 things:  Either you are a Noob in EMS, have never done any time on the streets, or you’re burnt out.  Either way I’m not going to listen to you, whoever you are.  I just saw an update on a facebook group I follow that belittles patients, makes off color comments about death and shares other updates that I agree with.  Keep your fancy learning to yourself, NOOB!

 

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Are you ready for Evidence Based EMS?

Bad news for those finally jumping on the Evidence Based bandwagon, most of the things you love about EMS are going out the door.

Don’t get me wrong, I’m new on this Evidence Based roller coaster, but we used to call it common sense.  How can EMS take ourselves seriously when we demand research for a new toy while defending high dose Epi and backboards as witchcraft Standard of Care?  If something works once it does not guarantee a repeat occurrence.  Ask any married man with kids.

Where was I.  Ah yes…

Things you have to give up if you truly are “Evidence Based”:

Lights and sirens

Backboards

Refusal forms

Amiodarone

Epinepherine 1:10,000

Dopamine

Most of the rest of your drugs except benadryl, albuterol, epi 1:1000, Adenosine and Dextrose

ET tubes

Combitubes

Automatic CPR devices

ACLS recertification

PALS recertification

National Registry

Attitude

ED triage

System Status Management

UhU

The pre-packaged occlusive dressing

MAST (oh, wait…I forgot, are we in a 10 year MAST is good or 10 year MAST is bad time period)

The idea that transporting is the solution

Fee for service

Community Paramedicine (They’re calling it Mobile Integrated Healthcare now…you know…to make sure the word Paramedic isn’t in there and so nurses can do it and bill more)

The idea that “seconds count” (See no more lights and sirens)

The idea that putting a cardiac monitor on a trauma patient does anything at all (Thanks Ambulance Chaser for the reminder)

The idea that CQI is out to get you (Maybe yours is, but I’m not.  Unless you fracked up, then it’s on like Donkey Kong)

The idea that your manager was promoted for no reason but when you get the gig it’s earned.

The concept that being more like Seattle will save more lives

The idea that a new Medical Director, Chief, Manager or boss will change things for the better

The idea that you are too good for where you are

The idea that EMTs save paramedics

“BLS before ALS saves lives”

The idea that making anything that is red and costs over $200,000 ALS will save lives

The idea that thinking only ambulances can help people

 

 

Need I go on?