Category Archives: EMS 2.0

Morpheus is fighting Neo!

In 1999 we were introduced the concept of the Matrix.  An electronic dreamland wherein machines of the future have enslaved human kind and keep us around as power sources.  Since the body can not survive without the mind, the machines have created an elaborate computer world that we all live in, oblivious to the truth.

A select few humans have discovered this fact and escaped, creating an underground resistance to fight the machines in the future and free human kind.

Spoiler Alert: I kind of doesn’t work.

Every time I hear someone in EMS complain about kidnapping, or having their chart blown up in court for all to see or some other urban legend of our Profession, I have to wonder what they would do if Morpheus arrived to show them the truth:

I picture Kelly Grayson sitting in a leather chair in some sweet shades and a fancy coat, holding out 2 pills to new EMTs.

You can take the blue pill, go along pretending this is all there is.  Backboards for everyone and NRBs at 15 liters per minute,  partners who torture with 14g catheters and refuse to tuck in their shirts, merit badge refreshers that rehash what we think we know and another conference class on how things used to be.

OR

You can take the red pill, and see the truth.

We are keeping you poorly educated and poorly paid because we need a steady stream of adrenaline junkies to replace you when you get burned out in 6 months.  You’re living in a dream world, new EMT, a dream world where the bare minimum is acceptable, even encouraged, and we make sure you’re just happy enough to accept it.

You go to work, collect billing information, treat from the cookbook, follow your patient’s every demand no matter how outrageous and it bothers you.

But what to do about it?

You’re here because you know something is wrong, but you can’t seem to put your finger on it.  No matter how many conferences you attend, magazines you read or managers you talk to, the answer seems to be the same:

“The future is now!”

But you don’t see it.  How can the future be here if it looks just like the last 30 years of guessing at science and pretending that taking them all and letting the MDs sort it out has ever worked?  When will you realize that “that’s the way we’ve always done it” is the last excuse of the desperate?

Take the blue pill and you’ll wake up tomorrow thinking your desire to improve was misguided, a waste, a dream.  You’ll strap up your boots and go to work, still wondering what is bothering you about what you do.

Take the red pill, stay with me, and see just how far we have to go.  Learn more about why, expand your horizons and seek out solutions.  I can show you the truth behind the lies, but you have to forget everything you know and trust me.

I offer only the truth.  Nothing more.

Morpheus: I imagine that right now you’re feeling a bit like Alice. Tumbling down the rabbit hole?
Neo: You could say that.
Morpheus: I can see it in your eyes. You have the look of a man who accepts what he sees because he’s expecting to wake up. Ironically, this is not far from the truth. Do you believe in fate, Neo?
Neo: No.
Morpheus: Why not?
Neo: ‘Cause I don’t like the idea that I’m not in control of my life.
Morpheus: I know exactly what you mean. Let me tell you why you’re here. You’re here because you know something. What you know, you can’t explain. But you feel it. You felt it your entire life. That there’s something wrong with the world. You don’t know what it is, but it’s there. Like a splinter in your mind — driving you mad. It is this feeling that has brought you to me. Do you know what I’m talking about?
Neo: The Matrix?
Morpheus: Do you want to know what it is?
(Neo nods his head.)
Morpheus: The Matrix is everywhere, it is all around us. Even now, in this very room. You can see it when you look out your window, or when you turn on your television. You can feel it when you go to work, or when go to church or when you pay your taxes. It is the world that has been pulled over your eyes to blind you from the truth.
Neo: What truth?
Morpheus: That you are a slave, Neo. Like everyone else, you were born into bondage, born inside a prison that you cannot smell, taste, or touch. A prison for your mind. (long pause, sighs) Unfortunately, no one can be told what the Matrix is. You have to see it for yourself. This is your last chance. After this, there is no turning back.
(In his left hand, Morpheus shows a blue pill.)
Morpheus: You take the blue pill and the story ends. You wake in your bed and believe whatever you want to believe. (a red pill is shown in his other hand) You take the red pill and you stay in Wonderland and I show you how deep the rabbit-hole goes.

 

It should be noted that many Matrix fans believe that the “real world” and Zion are also parts of the Matrix used to control the radical element and that the machines have anticipated their desire to rebel.

EMS doesn’t need a Neo to come and save us, or even a Morpheus to show us the way to the Oracle to hear what we need to hear.  But what we do need to do is wake up, look around and stop taking half truths and scare tactics as solutions for our patients.

Which will it be?  The red?  Or the blue?

What vs Why – Ramsay vs Hunter

In the 1995 submarine film Crimson Tide Gene Hackman plays experienced Navy Captain Frank Ramsay assigned to the nuclear missile submarine Alabama.  Playing opposite him is the younger, up and coming Lieutenant Commander Ron Hunter played by Denzel Washington.

I enjoy the film and constantly find myself watching the battle of wits between “Old School” and “New School” often wondering who will win the upper hand.

Ramsay is from the Old School of Navy warfare and he knows it.  Hunter is the new Executive Officer (XO) on the boat and one night at dinner the conversation turns to the glaring difference in style between old and new.  Ramsay mentions that the Navy doesn’t want him complicated, but simple.  With just a hint of sarcasm the young Hunter replies that Ramsay has the Navy fooled, indicating that he is indeed more complicated than he’d like to let on.

“Be careful there, Mr. Hunter. It’s all I’ve got to rely on, being a simple-minded son of a bitch. Rickover gave me my command, a checklist, a target and a button to push. All I gotta know is how to push it, they tell me when. They seem to want you to know why.”

The conversation continues to explore the reasons for war and the different views on the subject which I won’t go into here, but it’s a great back and forth.

“They seem to want you to know why” sticks in my head though.

I see this conversation all the time in Fire Stations and Hospital ambulance bays.  The salty old anchor who is good at what they do questions the up and coming schooled rookie, assured that simply knowing what to do is better than worrying about why.  The rookie, educated and trained far beyond the salty anchor lacks experience and needs to find a balance.

Cut off from command, their last message was cryptic and incomplete.  Nuclear war is feared and the two schools are pitted against one another.  Old school sees it as an order to fire while the new school sees it as a chance to get more information.  The What vs the Why.  Ramsay orders a launch, Hunter refuses and the battle of wits has begun.  Old school bends the rules to meet their ends and new school tries to outwit him at every turn.

Throughout Crimson Tide we see a struggle between old school and new school during a crisis situation as each of the leads falls back to their comfort zones for support.  Ramsay leans on loyalty while Hunter seeks out new members to join him in opposing the Captain’s actions.

Don’t get me wrong, knowing what to do is important, but I think you know I’m a bigger fan of knowing Why.

One of my instructors used to say “I can teach a cat to intubate, but I can’t teach him when not to.”  He was the same instructor that, when faced with a scenario in lab and someone would initiate a treatment he would always ask “Why?”

BP is low, start a  line.

“Why does their blood pressure bother you?”

We’re here to fight.

“Why do we fight wars?”

Pulse is 50, hand me the atropine.

“Why is Atropine indicated here and why will giving it make things worse?”

I don’t think this is a good idea.

“Why can’t you just do what you’re told?”

 

In the end of the film, we discover that Why wins the day as the information was incomplete.  Had What been victorious a bad decision would have been flawlessly executed.  You can perfectly intubate every time, I get it, you’re a salty dog, but the last 4 you got were completely unnecessary.

 

Let me show you Why.

 

Which one are you?

 

Paramedic – A look back at the first 100 years – Part III

Now that the solar flares have passed and we’re all back topside we can continue on our jaunt through the history books looking back at the first 100 years since Paramedics were born of necessity and grew into the most valued public service since the Post Office was reinstated.

Today we look at the early use of the pre-cortex for Paramedics of yesteryear to check their work with Physicians.

 

Online Medical Control

Before the Cortex people accessed a maze of sites with conflicting information, often having to enter queries using digit tabs called “keyboards” which allowed them to access information.  From my research I have discovered that early Paramedics were rarely trusted to make decisions on their own and would access online medical control.

Since the Paramedic’s searches were based on their own impressions of what was happening, it was very easy for them to access the information they needed for the proper treatment of their patients.  It was not the same as today, where Paramedics are trained to act in all situations, but instead was a way for our lesser educated predecessors to ask for help on difficult cases.

This was also referred to as “WebMD” and was accessible from any screen in any community.  Before screens contact was made via telephone line or by radio.  I know it seems odd to call a WebMD for Online Medical Control without them being able to see the patient but apparently it was done quite often.  Some systems were very strict and even required Online Control for some medications.

You see, before Paramedicine was recognized as a specialization it was often relegated to those who could not afford to attend Medical School but still wanted to make a difference.  This WebMD allowed them to be trained quickly and work for far less than their skills were worth to the greater medical community.

After the influenza their value was recognized but up until then Paramedics still accessed the world web when needed, not unlike a wave consult for surgical consults of decades past.

It was a good tool for the time but seems to have held Paramedicine back in some communities for reasons I can’t discover.

 

Next time we’ll answer one of the biggest mysteries of early Paramedicine:  Was it really done by the Firemen?

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A new kind of intern

For the last two Tuesdays I have had an intern.

I can hear you now, “That silly Happy, he has a desk job, how can he have an intern?”

Well, a local High School has expanded and offered an EMS Intern position.  One of the local Rescue Captains has assisted in designing the program which will give this student an inside look at not just field time, but supervisor time, administration time, radio time and even a few days with the regulators (Remind me to ask her to ask about proof spine boards are a good idea.)

I am proud to announce she was officially bored out of her skull in the CQI office.  What we do can be distilled down to the high school level, but the finer points of QA (stop laughing already) can be lost.

“We apply the rules, regulations, policies and protocols to each chart and determine if variations warrant review, coaching, counseling or reprimand.  And after completing those reviews we analyze the results to determine trends and act on them.”

She was unimpressed (Seriously? Stop laughing.)

So we read a narrative I was reviewing.  It went a little something like this:

“Police activated EMS for man defecating on sidewalk.  Male present alert and oriented, steady gait near pile of human feces.  Male has no chief complaint and has no signs of traumatic injury.  Male states “Just cite me and go away” without slurred speech.  Male does not give consent to treat or to assess vital signs, threatens to pick up and forcibly relocate feces, EMS agrees male may leave area under own power.”

“Why did the cops call if he wasn’t hurt?” She asked.

“We’re working on that, but I expect your generation to get that sorted out for good.”

 

She had a chance to meet the Chief of EMS and talk to him a bit about what it means to be a Paramedic these days and looking forward.  He is of the same mindset as me, that we make bad days better and go home safe to our families who will never know the truth of what we’ve been through.

I told her that the gauge of a good EMS leader is someone who, when asked if they would go back to an ambulance answers “yes” without the slightest of hesitation.  You can be away from the ambulance for only so long I have learned and the farther away, the more you miss it.

 

Next Tuesday is her last day in the Administration track and we’ll stop by the fleet yard and let her observe a World Class System deploy to chaos.

 

Paramedic – A Look back at the First 100 Years – Part 1

2066.  100 years since the White Paper that solidified what some communities were already learning:  Paramedics were needed to help in communities that had no doctors.  We were born of trauma.  Accidental death was our crib and cardiac arrest our playroom.  In our adulthood we expanded into the community and dealt with chronic health issues.  Now reaching 100 years young there is so much farther we can go.  But to know where you’re going, you need to know where you’ve been.

It’s easy to forget where we came from.  Not just back to the ancient times when drivers had wagons and horses, or when the hearses (I still can’t believe we buried our dead) began to treat people, but at the decades that propelled Paramedicine into the respected Profession we practice today.

In this series I’ll be covering all manner of advancement in care, organization, education and funding, but I wanted to start off by clearing up some myths about the early days of Paramedics.  These are all 100% accurate, as I have referenced texts from the time.

Let’s start with one of the Urban Legends of Paramedicine:

Chemical reversal of death - It is true.  It can now be confirmed, based on texts from the day, that Paramedics (Often called EMTs back then) would inject patients suffering from cardiac arrest with cardiotoxic chemicals that they thought would mimic the heart tissue’s natural functions.  There were no balloon pumps back then and hypothermia had yet to become rapid onset using the sheaths.  Although they did begin to cool patients using cold packs and cold venous injections (transdermal fluids were decades away), many patients were likely inadvertently killed as a result of this practice.  Some research was recovered that showed dismal success rates, but it wasn’t until the H6N3 epidemic in 2023, when stockpiles of cardiotoxins were depleted and survival did not worsen, that the industry finally took notice and eliminated their use entirely.

It was the Paramedics that rose up during the epidemic that overwhelmed the hospitals of the day, which quickly became incubators for the rapidly mutating infection.  It was the mobility of the Paramedics that allowed for continued care when the hospitals shut down for months to be disinfected.

Combined with AEDs (ShockDocks) installed as frequently as fire extinguishers survival from cardiac arrest improved.  It was not the hospitals that led the change, but the Paramedics who fought for common sense technology in the community.  When MRI and Xray were still not in the patient’s home, they stood up and demanded change.

It is worrisome that it took something drastic for Paramedics to look at their own practices for efficacy instead of demanding proof before using it that it would do no harm.

 

Next time: A lead on the curious boards used to apparently keep drivers from falling into traffic.

Ambulance Facility Must Haves

Many an article looks at ambulance design, Paramedic training, policies and protocols but I’ve been wrestling with a different kind of barrier to quality: The Fleet Yard.

 

More specifically, I was wondering what your must have list is for an ambulance deployment center.

 

Is it indoors, well lit, vending machines, training on site, locker rooms, showers, supply techs, drive through ambulance wash…

Here’s my must haves if I could build a brand new facility:

  • Drive through restocking and shift change
  • Onsite mechanical repair
  • Onsite scheduling, CQI and training
  • Indoor secured fleet and employee parking
  • Vehicle Service Techs for restocking
  • In-unit mobile data gateway repair (after I get them installed that is)
  • Crew lounge
  • Locker rooms with full showers
  • Gym

Let me know what your must haves are, maybe you’re thinking of something I’m not.

 

The hour is late

Recently a close friend asked why we even try.  Why do we try so hard to achieve all the goals we have been chasing?  Who cares?  Isn’t there someone else who can fill in what we’re doing better?

No.

No there isn’t.

If there was something better that could be done, we’d be doing it.

This forum used to be updated every few days, some days even multiple times a day.  My duties have consumed my time, heart and vision.  Previous posts about not being able to change the system have turned into meetings that are changing the system.  For every crazy story I try to tell, I read an actual chart that mirrors my edited version and the tale can’t be told.

We’re on the verge of some major opportunities in my system and that seems to be monopolizing my time.

Go figure.

13 months ago my priorities changed and this therapy experiment has suffered.  It was created for one purpose and one purpose only and that was to serve as a pressure release valve.

Boy did it ever.

But the pressure might be too high this time around.  The troubles aren’t with those in charge of the system, or the system itself, but within myself.  My dreams of an EMS 2.0 world were destroyed by regulators, bureaucrats and the realities of a for profit system only to be rebuilt by a single EMT doing the right thing despite our policies to the contrary.  Our late night discussions in Baltimore, Vegas, Houston and other places all build into a mural of a future for our Profession only to be sidelined by technical issues and personnel conflicts.

We were dreamers.  We looked at a future that was built around quality patient care, not realizing the first question would be “how are you going to pay for all that?”

I checked…the Police Department has yet to post a profit.

It isn’t an uphill battle we in EMS are fighting, it’s an all out war.  There are those who wish to take over, give up, concede, demand even take a seat on the fence and wait to see who wins to declare their allegiances.  We can get frustrated, rant, moan and complain or we can give 100% to the one thing that matters:

 

The patient.

 

My posts may slow, my twitter may stagnate, but only because I have a chance to make a difference for more patients and I’m taking it.

Join me?

 

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Ellerbe may be ahead of his time

DC FEMS Chief Kenneth Ellerbe unveiled a plan for EMS redistribution in the Nation’s Capital and it is getting some nasty comments online and from the local Firefighter’s Union.

I can’t necessarily comment on Ellerbe’s reasoning for his move, since I don’t know what it is, but I can tell you that he’s WAY ahead of his time.  I just think he doesn’t know it yet.

You see, DC FEMS will be down staffing ALS transport units from 0100 to 0700, a time when calls for service are drastically less than the daytime hours.  On the surface, it makes perfect sense.  Cut extra resources when they’re not needed.  If it can be done and still meet the demand for quality ALS transport, great.  If it can be done while still meeting all the guidelines set forth by the local EMS regulatory agencies, great.  (Now our UHU calculations come in handy, don’t they?)

But what happens when your calls for service are ALS?

Ellerbe’s answer is to staff up that ambulance for the transport with one of the 21-25 ALS engine resources and 7 ALS supervisor units.   That also makes sense, until that fire engine is doing something else, like already transporting an ALS patient.  Forget being on a fire or an alarm or rescue, these resources will be BLS as their extra member attends another transport.  now units are scrambling to pick up medics at hospitals or BLS ambulances are out returning medics to their company.

My agency could consider such a move in the future, but it will be doomed for failure because of the high call volume of seemingly ALS calls as defined by the local EMS regulatory agency.  Without decreasing the number of patients, we can’t decrease the number of transports.

If DC FEMS can also flex their ALS Supervisor resources to augment the system of transports, they will also soon run out and someone from the engine will need to return their buggy to the hospital or the BLS unit give them a ride back to their buggy parked back at the scene.  More time will be spent returning units than responding in many cases.

 

Ellerbe’s plan is ahead if it’s time, but as far as I’ve been able to find it will not be as efficient as it needs to be.

Why you ask?

Because it needs to be coupled to a “Respond Not Convey” program, or as we call it on the street, the Paramedic Initiated Refusal.  Refusing transport to certain patients who do not need it is the relief DC FEMS needs to better serve the population.  So long as every stubbed toe and runny nose that wants transport gets it, you will continue to have 4 person ALS engines or ALS supervisors at the scene of incidents waiting for an ambulance.  We call it “Medic to Follow” and it is the number one drain on our system. “But Happy, that’s a BLS run!” Not if they used the magic word “Chest pain” to get triaged faster.  And we all know that NEVER happens…right?

 

With the sudden interest in the Community Paramedic model, many systems will have to address the issue of Respond Not Convey if they want to increase services without increasing resources.  I would love nothing more than to deploy our fleet of ALS supervisors to handle community paramedicine, but we’re dealing with an increase in call volume and market share.  And we have less than HALF the amount of ALS supervisors DC FEMS deploys.

 

Ellerbe’s plan seems like a slap in the face to some, but I see it as a new way of deploying resources.  Thing is, it will work.  That is until a second call comes out.  Then a third, then a fourth and next thing you know Engine 99 is sitting on the curb IFO the clinic awaiting a second engine to respond with a medic so the BLS unit idling at the scene can transport.

 

Just a gentle reminder: These views are my own, not those of the SFFD, the City or any one else, just me.

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Control V

We have become a cut and paste society.  Not just us social media savvy kiddos either, oh no, no.  In a time when the conclusion that shapes your opinion has already been authored, why not just copy and paste it as your own?  Who will notice?

 

Probably me.

 

And not just because I can access all the same resources you can when you did the original search for your opinion, but because I have grown up on this technology and can spot certain abnormalities that many don’t.

Yes, I have these powers.

I can see the difference between MS Word 97 Times New Roman 12pt and MS Word 2003 TNR 12 pt when printed.  It looks the same on the screen and had you cared to standardize your document, maybe it wouldn’t have been so obvious.  How do I know this? I’ve done the same thing before, but caught it in time.  When copying references to cite on a page, most folks copy and paste, resize and move on, not even noticing the font is different.

So what does this tell me about your abilities in the field to which you are professing knowledge?  That I should be highly suspect and investigate ALL aspects of your findings.  And that’s when I get frustrated.  Nay, UnHappy.

There have been few documented cases of me being honsestly UnHappy.

 

Trying to trick me?  Try harder.

That is not a late run

A trend has spread through EMS that is causing a bit of a ruffling of panties in my neck of the woods. If the term ruffling of panties is upsetting to you relax, it’s accurate.

I hear a lot of “We got a late call” both in the yard and online as a reason folks dislike their shifts. Every shift seems to claim they are always held over because of a late call, that the next shift never has to hold over, it’s not fair, IT’S NOT FAIR! Then they jump up and down from foot to foot in a tantrum which causes the bunching panties mentioned earlier.

Complaining in EMS is remarkably easy. We apply anecdotal observations skewed by our own bias and apply it to everyday. Suddenly getting a call 35 minutes before the end of your shift is a late call and being sent to it is an affront to all things holy.

In response to just such a statement recently I was sucked into a common EMS Manager response that had me actually catching my words just before they left my mouth.

“Back in my day…” was how the sentence was going to start, but I was just able to catch it before I lost all credibility.

But then I stopped. It likely looked like a stroke, but the phrase was easy to say, yet lacked the true meaning I wanted to get across.

“You were closest, you got the job. You are assigned to the ambulance until 0300, not until 0230.” I went on to describe methods they could use to check the ambulance and plan their off duty chores in the 106 minutes they were on post prior to the “late call.”

I then told a war story about the call at 825, 25 minutes AFTER my sift was over and when I had been ordered by the Battalion Chief that I was not to leave my post until relieved. That the call ended up being a transport to Saint Farthest and that I didn’t return to the firehouse until close to 10 AM. They were unimpressed and still held on to the belief that they should get some wiggle room at the end of the shift to “wind down and restock.”

The film version of me delivers the speech far better than I do but the point gets across that we are on duty to answer calls for service and make bad days better. Sometimes that means we’re a little late getting home.

Sometimes we have to spend a few extra minutes doing this work that we have chosen, taking the time to do it right instead of half assing it just to race back and disappear, upset that we asked you for a little something extra. Especially when we’re paying you extra to do it.

A late call is a call that comes in AFTER your shift has ended folks, plain and simple. if you are due off duty at 0300 and dispatch gives you a code 3 call guess what? You have another chance to do something for someone who might need it. Be thankful it’s not the other way around.