Category Archives: EMS

All Stop! Quick Quiet!

It’s been a while since I took one of those famous blogger breaks and considering the time between posts these days you may not have noticed me stepping away from the keyboard for a bit, but I need to do so for a little while. I’ll leave it vaguely there.

-HM

Up to and including death

This is a phrase I see a lot in my line of work.  There are a number of variations including another favorite “seizure, coma, death” that are designed to cover the hind quarters of the author in some half cracked attempt at documentation.

For you folks out there who will swear up one side and down the other that you were told by an EMS Anchor that if that phrase isn’t included you’ll goto court and get sued for malpractice, just take a deep breath and relax, Sparky.

Your local policy likely includes guidelines for patients to be eligible to refuse transport, care or a combination of both in certain circumstances.  For example, the patient must be alert, oriented and not under the influence of alcohol, understand the risks involved with refusing an assessment or transport and sign acknowledging that they understand…you know, the basic stuff.  When I see so many less than EMT-Basic calls being completed and the risks of refusing transport for a hand abrasion include “patient advised of all risks including seizure, coma, death” I have to shake my head and laugh.

Funny part is that this blanket statement calls into question the rest of your document most times.  Do you really believe the hand abrasion will lead to death?  In what fashion?  If it is such a risk, why isn’t the patient being transported?

A more accurate statement could be “patient advised of risks of infection and advised how to avoid repeat injury.”  BAM!  That simple statement covers you far more than the giant heavy blanket of death.

So dial back the drama and have an honest discussion with your patients, otherwise get ready to explain to me or someone like me why you were worried this was a possibly mortal wound.

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?

Ambulance Response Time Resolution Theater

A Paramedic I work with in CQI and I were having a conversation that was originally aimed at discovering the best way to handle complaints that had no merit.
You know the complaint:
“your paramedics stole $8000 from my wheelchair when they took me in for a swolen toe”
or
“I was almost late for my podiatry appointment…”
We also discussed how to respond when someone mentions a minor issue and follows it up with “II don’t want to get anyone fired or anything but…”
Apparently telling them “Oh, no one is getting fired. Not for using the siren on your street when you told the call taker your husband couldn’t breathe.”
But our conversation yielded a brilliant idea I don’t think anyone has tried before:
Ambulance Response Time Resolution Theater.
Here is how it works:
Someone calls in complaining about the time it took to get an ambulance for a minor issue, that they were taken to the wrong ED even though transport was not indicated etc etc. In other words, most of our clients.
When they call in, tell them to come by at 4:30 on Friday for a formal apology. If 4:30 isn’t when your cardiac arrest survivor comes in to meet the crew that saved them, then adjust as necessary. Tell the complainant they can sit in if they like but you’ll need to address the heart attack first.
They may not connect the dots but it sure will make you feel better.

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Talk about tough luck

I actually got to do some patient care this morning.  Calm yourselves.

 

A car locked up their brakes on the Bay Bridge and the following motorcycle did his best not to hit it.  In the process he got hurt a touch.

It happened just ahead of me around a turn near a tunnel (Yes we have a tunnel in the middle of our bridge) so when the lane stopped and a person ahead got out and ran ahead, I knew I had to help.  That’s just what we do, right?  I carry no kit, so as cars go around I pull forward, hit the hazard lights, change out of my driving slippers (Yes, I wear slippers when I make my 3 hour daily roundtrip) and approach the bike.

 

Secondary assessment is being completed when over my shoulder I hear “Justin!  What do you need!?”

“Wow” I think to myself, “48′s got here freaking fast!”

I turn to look and who’s coming up to help?

My CQI counterpart from one of our competitors/partners.

2 CQIs alone in a tunnel on a bridge.  Sounds like a bitchin romance novel, but no, it was all this person had for a few minutes until the engine and medic units arrived and were able to complete a full assessment and render care.

 

As the patient was loaded in the ambulance I gave him my info and told the medic “I’m reading this chart later.”

He shook his hands in the “Ohhhh, I’m soooo scared” fashion and smiled, then got right back to patient care.

 

 

Halloween and Christmas rolled into one

In all the EMS debates over BLS vs ALS, evidence based cialis 20mg tablets vs anecdotal, public vs private is the real reason we do what we do.  I like to say that we make bad days better.  More often than not we ride the bench.  Sometimes we get the grand slam in the bottom of the ninth to win the game.

I got a facebook message from a reader who was looking for a spark to get out of a rut and gave the best advice I could.  My response included examples where we find joy in this work: The smile from the woman who’s hand we hold when nothing is wrong, the man who half smiles at his Buy cialis drugs wife when he sees her as we unload him at hospital having a massive stroke.  There are so many small victories in this world sometimes we miss them.  If you are looking for medals or public recognition in EMS I have bad news for you: It will be a long, lonely wait.

 

But sometimes that wait pays off.  I had no idea that the best motivation to be a good Paramedic or EMT would come in my email inbox early this morning.

8 months ago today a man died.  Dead.  Asystole.

Then some of my co-workers showed up.

This morning we got an email with a photo.  The photo showed our patient dressed up for Halloween with his young daughter.  He was Obi Wan Kenobi and she was Princess Leia.

His smile made me smile.

Her smile made me forget all the bullshit.

Although I keep a running tally of cardiac arrest saves on a white board in my office, this is my first photo of a smiling child.  And hopefully not the last.

Righty tighty…

Being back in the field is a wonderful thing.  The smell of week old urine on a regular, the thrill of getting the line on the recus patient and even just sitting in the buggy at a street corner catching up on QA.  But I was not prepared for what happened today.

THE EMREGENCY

A local clinic has called in a code 3 transfer for an asthmatic patient.

THE ACTION

Well, this sounds like a good one.  With at least one MD and a scattering of RNs in the office for them to call 911 before 5PM means it must be something serious.

Stop giggling.

I add myself to the run and head over the few blocks to the well known clinic as the engine company pulls up.  We head inside and are led, rather swiftly, to an exam room where our patient is working on sucking a non-rebreather bag back through the tiny hole in the mask.

“Hi there, what seems to be the trouble today?” I ask seeing a look of panic on the patient’s face.

“His sats are dropping and the albuterol isn’t helping!” a pajama clad medical office worker is telling me as she’s fumbling with the tiny O2 sat monitor on his finger.

“Well, let’s switch this to one of ours to start” the Engine Medic and EMT have prepared a mask on 15 liters with a well filled bag and the patient drinks in the fresh air, the look of panic quickly receding and relief taking it’s place.

“Thanks guys, the albutrol must have finally kicked in” the pajamas tell the room, hoping it will cover up the look on her face that she is still completely dumbfounded as to what happened.

“Here’s your trouble” the Engine officer says as if noticing an oddly shaped cloud, “Yer tank ain’t on.” And as soon as I can turn around to see the EMT still holding the clinic’s mask the officer turns the key on the top of the clinic’s O2 tank and air begins to flow.

“Beginner’s mistake I guess” he says as he shuts it off and looks to me barely holding my professional pose. “Unless you need us Cap, we’ll be on our way.”

I cleared the Engine and comforted the patient who’s “low sat” of 94% had risen to a comfortable 96%.  The ambulance arrived to take him in to Saint Farthest, per his request, and I relayed the situation.  The pajama clad person had left just after the engine and now came in with what was clearly an experienced RN.

“I think the tank is faulty.” She told the older RN.

“I don’t think it’s the tank, Dear.  Thanks, guys.” And down the hall they went.

“What was all that about?” the ambulance EMT asked as we wheeled the now calm patient to the elevator.

“She didn’t know how those tanks worked.  Can you believe that?” the patient chimed in with not a hint of distress.

And to their credit the crew kept a straight face as the doors closed.

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?