Category Archives: Patient Care

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.

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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EMS Flashmob

Eli Beer formed an all volunteer First Aid/EMS group when he was 17.  In the process of developing the program he volunteered on an ambulance and was always upset when they would get stuck in traffic.

Eli attributed his dying patients’ demise on the extended response time and wanted to do more for them in the time between when they needed help and when help arrived.

This video goes directly to the core of the Response Time argument and it is important to make a clear distinction between first response and ambulance response times.

We can all agree that getting someone in the door quickly can help guide the rest of the system’s response.  This can be a fire department engine, an EMT Police Officer or perhaps a third service handling first response.  What we don’t need is to send a reclined cot van on every call, nor does it need to get there in 4 minutes most of the time to make a difference.

In this TEDMED talk, Eli talks about how he came to found United Hatzalah and send motorcycles he calls “Ambucycles” to the scene of an emergency to help until an ambulance can arrive.  He touts a 3 minute response time to over 207,000 incidents last year and is using mobile technology to achieve it.

The phone app broadcasts the medical incident to the 5 closest volunteers in the same way CPR needed apps do so in the states.  When he mentioned it was kind of like an EMS flash mob he had my attention.  We’re locked into some old ideas and this one breaks the mold.

 

Why aren’t we as communities encouraging this kind of organization?  Sure there are volunteer First Aid Squads all over, but this is far far simpler than that.  And don’t wave the liability flag here, those folks would have to be trained to get access to the app and with the right kind of basic QA program built in you’re golden.

What do you think of the various things mentioned in this video?

  • Motorcycle first response
  • Volunteers
  • Phone App dispatching

 

Response Time or Patient Outcomes – How do you measure your EMS system?

I know it’s been quite around these parts lately but a recent article caught my attention this morning.

High Performance EMS posted “Does Response Time Matter?” and it got me thinking.

The author states an example of a patient being “treated” by fellow citizens at an airport and having to wait 20 minutes for an ambulance to arrive.  The author goes on to describe how we need to arrive quickly to save the public from themselves.  After 30 years of telling them to call 911 for anything and convincing them that “seconds count!” what did we expect?  While I agree that a delayed response to certain patient presentations could result in an adverse outcome, that points out a glaring omission from the story.  Missing from the story is the patient outcome.  The outcome will allow us to marry all the data from the response to determine the answer to the author’s question in the headline.

The short answer is no, response times don’t matter.  And no, I don’t have to pee.  I have data that does not have any correlation between quality of treatment, outcome and response time.  From my perch here at the data hub of a quite busy EMS system we have been trying to determine the quality of our EMS system and we rarely look at response times.

Don’t get me wrong, we look and our Department statistician collects, quantifies, qualifies and reports to regulators the 90th percentile of all code 2 and code 3 calls to meet their requirements.  We report it, they receive it.  The document says nothing about the quality of care or patient outcome.  The reason being that we can not guarantee a positive patient outcome, but can measure when we left and when we arrived.  Imagine if we had to treat 90% of symptomatic asthmatics with oxygen within 5 minutes of arrival and document an improvement in condition.  Can your system guarantee that?  Why aren’t EMS systems measured by the quality of their care instead of the quality of their response?

Apply this metric to any other industry and it fails.  Industry is measured by their quality and efficiency, not the speed in which they complete their tasks.  So long as we only look at one metric with any regularity we will continue to shuffle ambulances 2 blocks at 5 minute intervals to meet an average instead of realizing just leaving them still would bring the same outcome.

That’s where I come in.  My Medical Director and I, unhappy with the lack of actual patient care quality metrics, created our own in an effort to determine the quality of care being provided.  We learned very quickly that our ambulances do not respond in a vacuum.  Each patient receives a call taker, dispatcher, first response, ambulance response, assessment, treatment and some get transported.  Once at hospital they receive a whole new level of care and review until they are finally sent home.  It is hard to argue that the time it took to get an ambulance from point A to B has an impact on this outcome without any review of the call taker’s coding of the call, the dispatcher’s assignment of the ambulance all the way to the destination hospital capabilities and location.

We can all sit at the Pratt Street Ale House in Baltimore and discuss short times that had a bad outcome and long times that had a good outcome, but the worst part of all of this discussion is that so few systems measure anything more than response time.

If you consider response time your metric of success you have already failed.  You have failed the patient who improves when you arrive “late” and discounting that response as a failure, yet trading high 5s when a 2 minute response yields a call to the Medical Examiner’s Office.

We all know the stories of companies staffing ghost cars near the end of the month to bring down the monthly response metric to meet guidelines.  It happens.  But I also wonder if that flood of ambulances to help more people had any other impact.

The complication in tracking outcomes is the relationship your agency has with local hospitals.  We may never have a seamless transfer of data but what we can do is pull data from the PCR to determine if the patient received the indicated treatments for the recorded chief complaint and observed complications.  By reviewing your policies and protocols as well as your patient demographics you can quickly spot your core performance indicators and design tools to track them.

It may be nice to know that we make our 90th percentile in 8 of 10 districts on a regular basis, but what if those 2 districts happen to have the highest number of cardiac arrest survivals to discharge?  Are they still a failure?

Widen your view to include more than how quick you can put the ambulance in park.  This goes far beyond the lights and sirens System Status Management debate and speaks to the core of the reason we’re out there to begin with:

To make someone’s bad day better

Delays can hurt, but not unless you look deeper into your system to find out if that is the case…or not.

999

You got WHAT stuck in a bowling ball?

In my memoirs of EMS (Working title – My Life in CQI: Kill me now, just document it properly) some calls will stand above all others.  This, sadly, is not one of mine, but from a friend overseas.

No, not Mark.

I got an email about a curious rescue his agency was called to and was wondering what I would have done.

So, here is the scenario:

 

A 19 year old male has gotten his finger stuck in a bowling ball.  He somehow wedged it in there so far, it up against the webbing of his hand with very little wiggle room.  Rotating the ball is out of the question as he seems to have the finger next to it wedged in almost just as bad.

25 minutes into the call you’ve tried gel, ice, lubricants of questionable origin (who carries that stuff into a bowling alley?) and brute force.  Prayer is taking place and all options seem exhausted when the decision is made to simply move him, and the 16 pound bowling ball, to the hospital.  What will they do there?  Dunno.

 

What would you do?

“You should read this blog…” said the Medical School Professor

Our local teaching hospital / trauma center / STEMI center / stroke center is putting on a new lecture series which focuses on STEMI and ROSC patients.  It is very similar to the trauma seminar I’ve mentioned before and has a wealth of information.

It starts with our pre-hospital radio report and continues through the balance of care for the patients.

 

My favorite part was when the MD leading the presentation suggested everyone in the hall go to a blog for ECG knowledge.

Mine?  Of course not, not until the seminar on fart jokes and grammar mistakes.

No, he directed us all to “Tom Boot-hill-aye” and his excellent work at EMS 12 Lead .com.

I will admit I sat a little taller in my chair when someone I know was mentioned as an expert in his field…and uses a blog to disseminate it.

Sure Tom Buothillet speaks nationwide about the importance of pre-hospital 12 lead ECGs, among other things, but also uses social media and video to make his message more powerful.

Tom recently debuted the London Ambulance Service episode of CODE:STEMI where he travels the world talking about EMS systems and their reaction to sudden cardiac chest pain and arrest.

 

Good work Tom, keep it up!  I think you’ll get a few more hits from today’s session!

Our Caridac Arrest Survival Rate is 100%

You read that right.  San Francisco has a cardiac arrest survival rate of 100%.

Does that mean that everyone who suffered a sudden cardiac arrest survived?

Of course not.

But our survival rate is still 100%.

That’s because today my numbers for witnessed Asystole with ROSC and cooling measures look really good.  So, our rate is officially 100%.

Hogwash you say?  How is that any different than some communities who bend their inclusion criteria to give the impression that they have an amazing rate of survival when their overall numbers are a complete unknown.

I rub my temples when editing our CARES registry, not because the data fields seem unending, but because there is one that I’m not sure we should be editing until long after the event:

“Suspected Cardiac.”

This term sits in a line with others such as drowning, respiratory, trauma etc.  Since our cardiac arrest patients seldom tell us what led to their arrest, we have to make a HUGE assumption and hope the hospitals update the information accurately.  That is also assuming that the hospital was able to discover the cause of the arrest.

It would be refreshing to be able to determine the cause of cardiac arrest and only count the patients we were going to be able to help at all, but that should not be taken into account when reporting survivability.

Imagine it this way: Our major trauma survival rate is 99% because we don’t include patients who had a BP of less than 50/P in the field since our efforts are unlikely to impact them.

Insanity, right?  If trauma care and survivability from injuries is our population, why exclude those who are less likely to make it?

Because it makes us look bad.

We can argue the semantics of statistics, reporting and the like for decades, we have and we will, but make sure when someone reports 60% survivability from a condition that kills more than 90% of those who suffer it, ask what they mean by “survival” “cardiac arrest” and “witnessed.”

It’s all in who you place in the denominator that decides your final answer.

So when I neglect to tell you our survivability only includes tourists with witnessed arrest who received bystander CPR and an ALS intervention within 4 minutes, am I really telling you the chance of you surviving cardiac arrest in my community?

Nope, but it sure is fun to say.

What is our actual rate?

We don’t know, some of our 2012 patients are still in the hospital.  Some communities might count them as survivors and move on, but we’re looking for total survivability, not simply a target some time after admission.  It will also help us guide future interventions if we can wait to learn exactly what happened to cause the arrest in the first place.

Sub point being that putting all your efforts into community CPR may seem like a fantastic idea, but if none of your survivors received it, will it make a difference in your community?

None of your survivors received cooling measures…does it still have an impact in your community?

No one who had a transport time of less than 5 minutes survived…should we slow our response?

 

Asking questions like this comes from looking at the data with too fine a comb.

1/2 of 1% (.5%) of the patients seen by my system are in cardiac arrest.  Of that group upwards of 90% do not survive, many of them being beyond our help before we arrive.  So now look at the subset of the population we’re observing. 10% of .5% means .05%.

That’s 50 cents out of a $100 bill.

Are you willing to change your system, your community, your children’s graduation requirements… for .05% of your patients?

While I’m a big fan of community CPR, I’m also a big fan of community asthma programs, community hypertension screenings and community programs to reduce unnecessary 911 calls.

Those programs impact a far greater population and while there are not immediate results, like in ROSC, we are preventing far more cardiac arrests 30-50 years from now.

Which is better: Preventing an arrest, or classifying one so as to show success?

Hard to prove a negative.

 

EDIT – I was contacted by someone I respect very highly who informed me my stance has been misinterpreted (ie I didn’t get my thoughts out the way I thought I had.  Not the first time either, go figure).  I am not calling for the muddying of the waters when it comes to Cardiac Arrest Survival rates, simply that agencies know what they are reporting and, more importantly, WHY!  I’m aware I come off as a non-believer in this post, implying that all the new fangled stuff doesn’t work, I just want to make absolutely sure we don’t all focus on one outcome at the possible expense of others.  My views may be confrontative, ill-advised and downright wrong, I’ve never claimed to have the answers, but in my current position of gathering and interpreting data I see how easy it is to steer the results in my favor.  It’s tempting when someone survives cardiac arrest and goes home mere days later…yet doesn’t fit the Utstein numbers, so doesn’t “count.”  It’s also frustrating when we have an Utstein case arrest in the ambulance and not survive.  The one person we think we have the best shot with and there’s little we can do or learn from it.  Agencies like Medic One and Hilton Head Island, with impressive Ustein results should be admired. They’re using their data, learning from it and applying it.  Good for their patients (and good for them) but if you are not part of the CAREs registry make damn sure you know your metrics and are reporting apples to apples, otherwise you’re not only fooling yourselves, but doing your patients a disservice.

-HM

 

Code 3 for the Headache – Sudden

…and it’s contagious.

 

THE EMERGENCY

A headache!  Won’t someone think of the children?!

 

THE ACTION

I’m cooking tonight and the chicken enchilada casserole will be OK cold I guess.  The bells ring and we’re out the door code 3 for a headache, sudden, worsening.  It suddenly occurs to me that the sensation that develops behind my eyes between the kitchen and the engine is likely worse than what we’ll find on scene.

She’s in her mid 50s and is quick to mention her disability status (we noted the handicap placard in the BMW in the driveway) and her husband confirms it.  The disability status that is, not the headache.

Not one to take a patient at their word we do a full work up including 12 lead ECG which aquires a normal tracing just as the ambulance I downgraded arrives.

The patient’s headache seems to have subsided.  The pain that was an 11 is now a “tolerable” 7 although we all know that means nothing without knowing her 10/10, which she refuses to share…none of my business and all.

Turns out she had a bad tooth and got some medicine for it.  I know what you’re thinking, but no, she actually filed the prescription.

It was when the pain remained 30 minutes later that 911 was called.  And the call made it through the call center because of the words “dizzy” and “can’t think straight.”

 

Thanks MPDS, you win again.

 

Back at the house the casserole was cold and I lost the dinner shake, meaning I had to cover the cost of everyone’s meal.  That was a sudden headache.  I did not call 911.

 

 

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