Just Like Riding a Rigged Bicycle

This video swam into my feed recently and the click bait was well written.

“See why no one can ride this bicycle!”

OK, internet, what’s the catch?

 

Smarter Every Day

Not only is it fascinating that the welders threw this bike together, but watching the host try to ride it, and everyone else try to ride it, really hit home for me.  There is the old saying that you can’t teach an old dog new tricks.  I’ve always hated that phrase but in many respects it is true.

Most times we are so engrained in the way we learned something that learning a new way of doing it is not only difficult, but could be impossible.

Training and education can challenge the old ways.  Heck it should, but we need to use caution in moving forward with new ideas that change the way we’ve operated in the past.  For whatever reason we think changing the system may be better, there will be those who will need time to adapt to the changes.

Indeed it is easier to change your ways when they are fresh in your head, hence why the child in the video was able to learn in a few days what took the adult 8 months.

While riding a bike is a great metaphor for EMS (We train, rehearse, drill and train again until we can’t get it wrong) it is important to remember that there are those in our field who still ask for Lidocaine on an arrest, reach for the MAST or go for a pulse check after a shock.

They are still riding the way they were taught, wobbling unsteadily trying to adapt to the new settings in front of them.  Some things can’t be unlearned, simply archived and new pathways used for new concepts.

However, just like in the video, when challenged we will revert back to what we have known the longest.

 

Hey, it happens.  Just be ready to admit when you’re wobbling and don’t be over confident in your ability to suddenly be able to adapt to change.

After all, it is just like riding a bike, right?

State Bill allows Nurses to Staff Ambulances

In an interesting twist the state legislature in Texas is considering staffing ambulances with nurses.

And I’m for it.

Let me explain:

There is a place for nursing pre-hospital but we’re going to need a complete retraining for the nursing staff.  Focusing on decision making without physician approval as well as adapting to adverse conditions will be needed and we in EMS are more than willing to help them prepare for this change in role and responsibility.

We need more specialized help in the field and nursing can help fill that void.

See Texas ENA, that wasn’t hard now was it?

For those of you not in the know, head over to Unwired Medic’s post for details about the Texas nursing group spreading lies to prevent medics from practicing in the hospital.

Before you grab a pitch fork to tear apart their hilarious claims, let’s turn the tables for a minute.

Could a nurse staff an ambulance?

The short answer is no.  The nurse has no extrication training, no patient movement training and no idea how to react to standing orders.

But if I needed their expertise in the field I’ll be the first in line to help them get trained up.  I certainly wouldn’t be the first to write a letter about how placing a nurse in the field would be unsafe and endanger patients.

That’s exactly what the Texas ENA did without thinking about, or researching, the capabilities of modern Paramedics.

We aren’t simply techs wandering the halls performing IV sticks and other random tasks.  If the Texas EDs need practitioners with experience giving medications, performing intubations and other advanced procedures and reassessing complex patients, why not choose a Paramedic?

We do those things in low light with little rest and no back up as it is.

Texas ENA seems to think that giving us comfortable shoes, bright light and a room that doesn’t move will somehow endanger patients.

Adorable.

Texas ENA is worried a technician with an associates degree can outperform their Nursing degree when the cards are down in a time sensitive situation.

You played your hand too early Texas ENA and are drawing for the inside straight.

We’re holding the Royal Flush.

We’re all in.

Do you call or raise?

PS – You should fold.

the Crossover Show Returns May 1!

This is not a delayed April Fools joke.

The Internet’s best (and only) Fire, EMS, Police crossover podcast triumphantly returns May 1, 2015.

Your hosts, the ruggedly handsome fire and EMS expert (yours truly) and the Po-po a go-go Traffic Enforcement guru Motorcop, are still in their beer drinking, opinion slinging moods but this time with intent.

We actually started planning out shows, guests, schedules…seriously, we even wrote stuff down.

Check your itunes feed as the first 51 episodes are down to make room for the glory that is the return of the Crossover Show!

Have a listen, give us a review on itunes or whatever other podcast player you use and enjoy the hilarity that is only possible when a cop and fireman don’t have to play nice.

Details on topics, guests and overall shenanigans in the coming days, but get ready internet…

They’re baaaaaaaaaaaaaack.

Informed Customers and the Irrational Medical Marketplace

Leonard Rodberg PhD, penned an article in July of 2013 discussing why Healthcare in America costs so much.  His take on the system boils down to an often overlooked glitch that is required for a market to thrive the way we are told the Healthcare market should:

The customers have no idea the cost, the options or the necessity of the products they are being sold.

Imagine you are going in to buy a television.  The clerk in the store has only 1 and there is no price listed.  He tells you there may be other TVs, but this one is the best fit for you.  You’d be out of that store in a heartbeat looking for a store with more choices, pricing information and make an informed decision.

Healthcare overall is still being treated like a product to be sold instead of a service to be delivered.  The Marketplace set up to handle payments for service can not work if the end user is purposefully being kept in the dark about pricing, options and alternate methods of care.

I’m not talking about healing crystals, but instead trying to focus on the actual end game for healthcare:  Healthy people.

A healthy population is more productive and costs far less in the long run in regards to care so why aren’t we making a difference?

Shouldn’t our goal be to prevent larger problems early?  What ever happened to an ounce of prevention being worth a pound of cure?

Turns out an ounce of prevention means a loss of billable services later on.

Jeffrey Brenner, Physician and co-founder of a group researching new methods of delivering care called the Camden Coalition of Healthcare Providers, was recently a guest on Freakonomics, a show about the hidden meaning of everything.

On that program he discusses his group’s efforts to find high users of healthcare and address their problems head on.  By making them healthier, they use less of the system.

From the show:

“So we learned that 1 percent of the patients is 30 percent of the payments to the hospitals, and that 5 percent of the patients is about 50 percent of the payments to the hospital. So a very small sliver of patients are driving all of the revenues to the system. … And you know, the question really is this the fault of the patients or is this a system failure? And I think our journey over the last couple of years has really demonstrated to use that it’s a system failure and that we could be doing much, much better for these patients.”

If we suddenly improve the health of 5% of the people visiting the hospital, just 5%, that hospital will lose 50% of their revenue.  There is no incentive to cure these people.  The same can be said for EMS.  If we actually start telling people they don’t need an ambulance we lose our revenue stream and can’t operate when someone does need it.  Of course that logic only holds if you consider EMS a product and not a service. (Here’s a hint…the word Service is actually in EMS.)  Until EMS is considered a service just like police, fire, animal control and the courts it will be driven by profit and profit alone.  New methods of care will be challenged with “What is the reimbursement model on that?” instead of “How many people do you think we can reach and improve?”

Sounds a lot like some programs sprouting up recently, doesn’t it?  Community Paramedicine needs to be that tool for EMS, but may get cornered into simply visiting folks post discharge.

In the meantime we need to change the way we deliver care.

We need to start educating our patients.

Ever been told by your managers or Chiefs not to discuss billing, costs or any other financial aspects of care?  Why do you think they do that?  Could it be that finding out the cut finger will be billed $1700 may impact the patient’s ability to make a good decision or is it that the manager and Chief need the $355 State payment for the transport to keep the system afloat?

You know it’s the latter but will still tell patients, like I used to, that worrying about money should be the last of their worries.

Or should it?

If patients knew the cost of the service they requested, were given options at various levels of cost that fit the situation and were able to choose a solution that met their needs, that would be a true marketplace and the cost of healthcare would fall dramatically while maintaining the same levels of care to those who need it.

We operate in a marketplace that hides cost, reduces choice and intentionally restricts access to services.

That is an irrational medical marketplace indeed.

Now in the Keg – Basic Ale

HA!  You thought I stopped brewing didn’t you?

 

No you didn’t.

A return to the basics this time.  An American Ale kit from More Flavor with California Ale Yeast.  No frills, no extra hops (Gods forgive me), just a basic simple beer brewed the week of bad news and ready to drink the day of worse news.

Sometimes the simple things are the best.

Slainte.

Basic Ale

An Unexpected Compliment

While walking through the kitchen to the comm room to talk to a co-worker, I walked past, and wished a good afternoon to, one of my co-workers.

She stopped me and said, “I have never seen you move without purpose.  You always have someplace to be and you’re going there like it matters.”

 

Possibly the best compliment I’ve gotten in a long time.

Cash on Delivery – American Healthcare from the Outside

Those of you following along know where I work and why I can no longer mention them.  For you new people, I work at one of the busiest airports in the Nation and the world.  I meet all types of people, from the college kid traveling home on the puddle jumper to the executive boarding early for champagne on the A380.

I meet them all at one time or another because of a tight travel schedule that didn’t leave time for lunch, a few too many $12 mugs of beer at the terminal, a bag falls from the bin or, on the rare occasion, their pilot isn’t able to bring the aircraft in for a controlled stop.

Most times we encounter a person dehydrated, intoxicated or suffering from a minor traumatic injury.  Like any other EMS service we respond, assess and offer treatments and transport options as appropriate.

It was the summer of 2009 when my discussions with Mark Glencorse, then a Paramedic in England, turned towards the American and NHS systems of care.  In the US we were being told the British were being turned away at over crowded emergency rooms and old women were laying in the street to die.  Mark was being told that in America if you didn’t have cash money the ambulance would not take you.  This opinion was confirmed on multiple ride alongs with Mark in England and, most recently, at my current job.

THE EMERGENCY

A pilot has contacted the tower declaring a medical emergency, person unconscious and they are on final descent.  ETA to terminal, 5 minutes.

THE ACTION

My crews are at the jetway as it lurches to life to approach the aircraft that appears to be pulling into the gate rather quicker than most.  Sometimes the pilot will call in CPR, other times you are met with a door opening and the sound of “three and four and five…”

Meeting us at the door the crew informs us that the patient merely fainted at the rear of the aircraft after getting up from their seat after the final descent began.  She’s in good spirits, embarrassed, but in need of further physician evaluation and she agrees to it.

As the local ambulance company arrives she is digging through her purse rather intently.

“We have your passport if that’s what you’re looking for,” I mention to her, softly toughing her arm to distract her from the task.

“Oh, I know, but I need to pay for the ambulance.”

The looks that flashed around the room were of disbelief on all faces but one.  Mine.

I crouched down into her line of sight and held her hand.

“You don’t have to pay right now.  I wouldn’t be surprised if NHS picks up the tab, but they’ll take you in and get you well for no fee up front.”

Her face was considering my words when I realized some background was in order.

“I had the chance to serve a week in Newcastle Upon Tyne with the Northeast Ambulance Service and heard folks from that region concerned about American medical access.  Rest assured, you can get care without cash in hand.”

She sighed heavily as the cot finally reaches her side.  As she was covered with a blanket and my business card tucked neatly behind that of the airline supervisor in her purse I heard her tell the ambulance Paramedic very softly “He told me not to give you any money now.”

To his credit, the medic quickly whispered back “I’ll make sure the hospital knows to contact the NHS for you.”

Her smile likely reversed the condition she was suffering from while the rest of us packed up and headed back to get ready for the next call.

Preconceptions can cause trouble.

Remember?

When Does Intoxication become an Emergency?

Drunk Girl - Crossfirecw
Drunk Girl – Crossfirecw

I’ve been having a number of jabs on Facebook (2 or 3 comments in 2 or more places) about the all too common intoxicated patient.

There are those in our ranks who believe they have the ability to determine when a person is “just drunk” implying that no assessment is required.

We need to make a clear delineation on our terminology before moving forward.  First, notice in this post title that I do not use the term “drunk” but instead intoxication.

Drunk is the extreme form of intoxication.  Drunk refers to one affected by alcohol to the extent of losing control of one’s faculties or behavior.

While certainly not an emergency, a person who meets the definition of drunk is in no way, shape or form able to assist in an assessment for other mimics to intoxication such as stroke, hypoglycemia and sepsis, just to name a few.

A drunk person is likely to be semi-conscious or unconscious.  These folks are horrible at maintaining a clear airway and can get into trouble fast if not properly taken care of.  That may not always mean a hospital, however.  More on that in a moment.

How many times have you been called out by PD for the “alcohol poisoning” only to find someone alert, ambulatory and smelling of alcoholic beverages?  Is this person drunk?  Only after a complete assessment will we be able to determine if their level of intoxication meets the definition of drunk.

Here’s a quick tip: Your local protocols probably don’t have a section for this.  There’s an altered mental status section, but no, “He doesn’t need to go to jail but we can’t let him drive home, so take him to the hospital” section.

PD is adorable on these calls, often telling a patient they can either go to jail or to the hospital.  I often cal their bluff, when appropriate, and tell the patient they can still refuse transport (After my assessment finds them able to do so under local policy).

Intoxication is, technically, a poisoning.  All levels of alcohol ingestion constitute alcohol poisoning if you want to get down to the nitty gritty.  The key is going to be determining to what extent the intoxication is impacting your patient’s ability to make sound decisions regarding their care.  Plain and simple.

My local policy states that, among other elements, the patient does not appear to be under the influence of drugs or alcohol in order to be able to refuse care.  That’s a big gray area.  They may be intoxicated, but able to comprehend my questions, weigh their options and have a plan for decreasing the level of intoxication in the near future.

These folks should have a sober adult with them and not operate a motor vehicle, but they seldom need an ambulance ride to an ED.  Think about it.  What will the treatments be?  Fluids?  If they are able to sit in triage long enough they could drink more water than any IV could run in in the same amount of time.

Now, before you go running off to your next drunk call and leave someone lying in the street because of something I wrote, let me ask you this:

How do you know they are merely intoxicated and not drunk?

Remember the definition?  Losing control of one’s faculties or behavior.  We all have that one friend that overindulges and becomes an idiot, but are they drunk or intoxicated?

Stop looking for zebras.  Sometimes drunk is just drunk but you won’t know until you assess.

Unconscious people are unable to make sound decisions.  Semi-conscious people are the same.  Ambulatory people who have been drinking may still be able to understand their situation.  Only after a complete assessment will you know for sure.

 

Response Times Discussion Continues

While I expected Scott and I to get into the ALS vs BLS first response debate a lot faster, we seem to have trouble moving on from the response times discussion.  Or, I keep getting distracted by great questions and comments.

Reader Florian commented on my original post regarding a large American City struggling to meet response times with a question about unit deployment and availability:

“WHY there are not enough units available? Cost, ageing fleet, retired staff etc were touched upon, but what are all the available transport units up to when they are unavailable for other calls? Are they on actual emergency calls? Or calls that could have, and should have been dealt by other services, e.g. community nurses, GPs etc? Should that unit have been dispatched at all, or could they have been given home help advice over the phone?”

Excellent points all Florian and you were right later in your comment that your views are skewed to the UK version of healthcare: Actually getting people the care they need.

When I visited Mark Glencorse in the UK my eyes were opened wide to a new model of delivering care – Respond Not Convey.  This simple program allowed medics to divert reclined cot 2 person transport units away from ambulatory patients and those who did not need transport via a reclined cot.

The system allowed for single paramedic resources to relocate patients to their GP, local clinic or even local A&E (ED) depending on severity of condition.

Because of the American system of health insurance those options are almost impossible.  While many communities are adopting Community Paramedicine with great success they may also still be locked into a rigid transport model that does not allow single practitioners to transport.

And all because of billing.

You can take someone to the hospital in a horse drawn wagon if you wanted to.  Perfectly legal.  Just don’t label it “Ambulance” and don’t try to bill for it.

But back to Florian’s comment in regards to the American City noted in the news story.

It is likely that those reclined cot 2 person transport units are busy taking folks to the ED who neither need the cot or the ED.  Most 911 calls require only BLS intervention following an ALS assessment.  So why keep those practitioners, equipment and units committed?

Billing and a warped definition of liability.

I can’t speak to the municipality mentioned in the story but it is likely that any system seeing an increase in call volume without an increase in patients who require intervention needs to address their patient population with alternate services.

Homeless outreach, community prevention programs, asthma programs and community paramedicine can all do a fair job at decreasing the calls to 911, but offer no help when a crew is on the scene of the cut finger who demands an ALS 2 person reclined cot van ride to an ED while the choking down the street gets no ambulance.

Florian, I would bet that this system could benefit from diverting appropriate patients to single unit resources for transport to clinics, urgent cares and EDs but the lawyers would never go for it.

After all, they would want to try to bill for it and you can’t bill unless you meet the requirements.

Is an ALS front loaded system with those options more efficient than throwing BLS fire engines at every call?  Most definitely, no question about it.

But what would we do with all the BLS resources in the community?

 

Great question, Florian.

Doctor on Board – Professional Courtesy

“Units responding to the unconscious, be advised a Doctor is on scene.”

Possibly the most feared words in EMS.  Not because we’re heading to a scene where a Doctor might be needed, but because finding a physician in the wild is unusual.

No, the most common “Doctor” to encounter on scene is a PhD or specialized MD.

Not unlike the scene in Mother Jugs and Speed when the Doctor on scene happens “to be the best dermatologist in all of Los Angeles.”

“Well, if acne breaks out, we’ll let you know.”

While all MDs have received more training than the average Paramedic, most of it was not geared towards the situation they encounter in the wild.

On a recent job we were told a doctor was tending the patient.  As the plane landed and the door opened the look on the Purser’s face told us all we needed to know.

Sure enough, a Psychologist a few drinks into the trip decided to help when a man was feeling dizzy.  No assessment was done and according to the crew he never even questioned the patient, but wanted to speak to the Captain about the need to land immediately.

Luckily the airlines have a beefed up dial a nurse resource who advised to continue to destination based on the assessment completed by the flight crew.

When we tried to begin our assessment he insisted we listen to his report prior to contacting the patient.  Luckily for the patient these folks are my specialty.  I gathered him to the side and took his rambling report, thanked him and sent him on his way while my crew made contact.  Then I leaned over to the flight crew who knew the patient’s name, vitals, history and everything else I needed.

Professional Courtesy dictates that I listen to your concerns and address them as appropriate.  I would only ask that if you have had a few drinks on the plane, haven’t practiced medicine in awhile or have a PhD in something other than medicine, maybe hang back and just make sure the flight crew does what they do.

Oh, and we’ll let you know if his dizziness makes him depressed.

 

I speak from experience on this topic from both sides, remember?