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.

 

 

I’ve seen it all, we’re done here

I thought I had seen it all until today.

Every manner of injury, illness, presentation and patient seen, noted and documented.

Oh universe, I love it when you mess with my mind.

 

THE EMERGENCY

A bicyclist has been hit by a car

 

THE ACTION

Well, not exactly “hit” and not exactly “by a car” but at least there’s a bicycle involved.  Units are approaching from all directions downtown and traffic is thick as it is almost 330 on a Friday afternoon.  The bicycle messenger rider is standing, rather clamly, on the sidewalk near a stretch of street with cars inching forward, but none of them stopped.  At least not stopped as much as you’d expect for someone who just hit a bicyclist.

As we approach he’s holding his right arm with what appears to be a napkin, likely from the Chinese take out place behind him.

The assessment begins and we’re hard pressed to find any injuries consistant with a vehicle versus pedestrian.  We are allowed to get so deep into the assessment before discovering what happened because, as always, our question of “what happened?” is met with a 25 minute slide presentation about how he was following all laws, riding this direction from this place as he always does, blah, blah blah.  I used my patented “skip to the part where it’s an emergency” more than once and finally he explained the napkin on the arm.

He got bit.

By a dog.

While on his bike.

I did a quick double take.  On the bike, even crouched over his shoulder is a good 5 feet off the ground.  How did a dog-

And that’s when the delivery truck in the far left lane, the one right in front of us hit a pothole, tilted and gently scraped a no parking sign.  Judging by the sign and the scratches on the truck, not to mention the truck not stopping, happens all the time.

The dog was in a car.

It was hard not to stifle the giggles and my partner is a pro at getting the giggles out, so my next question was tough.

“Did you get a look at the dog?”

He suddenly had somewhere to be and rode away before we got his signature on the form, but I imagined him on his hipster bike, riding along in traffic and some dog out for a joyride just sniffing the air decided to see what the City tasted like.

 

That was a first.  And it reminded me that as soon as you think you’ve seen it all-BAM-sumpin’ new.

 

Sideways

I am a big skeptic of putting the 2 people with the least ability to assess a situation in charge of the system’s response to a reported emergency, but until we change things they can only code what they are told, right?  And the caller is never, ever, EVER, wrong.  Especially when describing technical rescue.

 

THE EMERGENCY

A caller is reporting he has fallen over 50 feet and is unable to walk.

 

THE ACTION

I had to read it twice too.  First party caller has fallen 50 feet, unable to walk.  Should be unable to do most things after that fall, especially when he would have hit the ground at a decent pace, then suddenly stopped.  Stranger things have happened, right?

The dispatch rounds out, after us in the engine, the truck, medic, Battalion Chief and Captain, with the Rescue Squad.  Further questioning suggests the patient is trapped.  Never before have I wanted the TV version of EMS to be true so they could patch me directly through to the caller and figure this all out.

 

Arriving on scene my firefighter and driver are grabbing some hand tools and a long spine board when we all look around the address for a second, an old habit of sizing up burining buildings.  None of the surrounding structures, trees, even light poles are more than 20 feet off the ground.

Something doesn’t smell right.

The balance of the assignment arrives as we head inside, ready to treat trauma.

We found drama.

A middle aged man is sitting on a chair still on the cell phone with the call taker, no apparent injuries.  He is inside a single story building and the folks standing around him seem confused as to why so many firemen have arrived.  The rest of the units are cancelled as we begin to learn the tale of the “long fall.”

This gentleman tripped on the sidewalk and would like to know who he can complain to after we take him to the hospital.

“Why would you goto the hospital?” I asked, already knowing it was a mistake.

“For my injuries, of course.  I must be hurt if the ambulance took me in.  I’m on disability already and can’t be expected to get around on my own all the time.” Was his response as his cell phone rang.

The caller on the other end wants to speak to “whoever is in charge over there” and I LOVE these calls so as the EMT confirmed the appearance of non-injury I spoke to the patient’s wife who also heard what our call taker heard.

“He says he fell 50 feet!  He needs to be taken to a hospital or something, he could die!”

“Sir?” I was embarased it took me this long to put 2 and 2 together, “Where did you trip on the sidewalk?”

“50 feet up the block!  I couldn’t walk!  Go look at that crack!”

He kept giving the distance TO the fall, not OF the fall, hence all the confusion. GIGO.

After refusing to listen to our reassurances that an ambulance ride was not only unnecessary but would end up costing HIM money, he was taken to the local ED “to get checked out.”

While loading up the gear the engine boss decided to go have a look at the crack in the sidewalk that could end up being a killer.  About 25 feet up the sidewalk we saw a slightly raised seam that someone could indeed trip over.

So we taped it off.

Tragedy averted.

 

Of Blankets and Discipline

A very eye catching story has been circulating for a few days involving everyone’s favorite EMS system to hate, Detroit and a Paramedic who claims to have been reprimanded for giving a blanket to a person who was cold after a fire.

I was waiting to comment until the Detroit EMS Administration commented.  Let’s just say I’m glad I wasn’t holding my breath.

As a Quality Manager I see this differently than most line medics might.  On the surface a medic was doing the right thing giving a blanket to a cold person.  It’s what we do most: Make bad days better.  We all know most of the attaboy letters don’t involve medicine but instead note demeanor and comfort measures.

Seems like a non starter.

However, it seems there were some policies in place, whether you agree with them or not, regarding dispensing agency property.

Take a deep breath…I’m getting to my point.

Most Vice Principles have a list of trouble makers who are just under the disciplinary surface and are watching them like a hawk waiting for a reason, any reason, to bust them on a black and white policy violation.

I don’t know enough of the facts to pass a decision regarding the blanket, but I can tell you that if this was brought to my desk I’d ask how we solved all the other problems to be able to spend time on this.  If there had been a decision to reprimand based on the Rules and Regulations, in my experience, there is more going on than meets the eye.

I wander the halls looking for my borderline crews to screw up on something so I can have a chat with them, sure, but more often I’m wandering looking for any chance to talk with them about how things are going.

This could have been a policy enforcement or the straw that broke the camel’s back.

Let’s just hope the camel doesn’t need a blanket.

You Make the Call – Handcuffed

Man it sure has been awhile since we fired up the ol’ You Make the Call Machine here at HMHQ, but I thought it’s finally time to get back on the posting circuit.

 

For you new people, I post a situation, you answer it based on your local policies.

 

Dispatched in the first response vehicle of choice for your agency, the local PD has detained a man who assaulted another person.  The other person is receiving care from your partner and is stable, bleeding controlled and has agreed to transport.  PD presents you to the window of the patrol car where you can see a superficial laceration to the forearm just distal to the left elbow.  There was a small drip of blood that appears to be dry, no other injuries are obvious through the window.

After repeated pleas the officer agrees to open the door and remove the patient but warns that he became violent when they took him into custody.  He stands and allows a brief primary and secondary exam and you note no other deformity or injury.  He is refusing vital signs, treatment and transport in colorful language, but denies alcohol or drug use.  When asked if he understands the risks of refusing assessment and treatment he replies in the affirmative and states his reason for assaulting the man and the police is his business, not yours.

 

Is he able to refuse service?  If so, who signs the form when PD tells you there’s no chance of him removing the cuffs to allow for a signature?

 

You Make the Call.

When a complaint is a cry for help

I absolutely LOVE answering the complaint line here at HQ.  Not HMHQ, my real HQ gig.  The complaint line at HMHQ never rings.  :P

 

Many may not want to hear the public rattle on about how we stole tens of thousands of dollars from their wheelchair or lifted a priceless piece of art the last time we were called code 3 for a spoon stuck in the disposal, but I LOVE it.

My pencil jots notes as I listen to the complaint in it’s entirety never once asking for clarification.  I get the entire story out and make sure they say everything they want to say.  90% of their complaint is usually because they want to be heard, not because they have a legitimate complaint.  They want to hear that it’s not cool that they don’t have as much stuff as I do or that spoons fall into my disposal all the time.  The venting is the powerful process here, I should know, right?

 

However, every now and then I get a call from someone unclear on the concept.

 

THE EMERGENCY

Not sure that heading still fits, but we’re almost 4 years into this thing, why change now?  A woman has called me requesting the ambulance crew who transported her 2 days ago be fired.

 

THE ACTION

OK…

Her story goes a little something like this:

The ambulance crew was late, rude and refused to help her.  They didn’t carry her into the ER and refused to give her to a nurse.  The ambulance crew then pointed at her and make remarks that I won’t repeat here.  Her language was colorful and hurried while I made notes and pulled up the chart from that day.

When she was finally finished I assured her I would look into her claims and explained the process.  While I was doing so I returned no records of a her being transported that day.

“Could this have been yesterday?” I ask seeing her name pop up on another day, then another.  In fact the software we use turns grey days blue if a patient is contacted on that day.

 

There are more blue days than grey.

 

I also notice that today is blue so I pull up the chart.

While I’m doing so she continues on that after the rude evil paramedics left she collapsed and had to spend 2 days in ICU.  She then described the pile of bills she is already receiving.

I noted her concerns for the file and asked the only question I needed to ask:

“Were you transported to St Closest today at 10 AM?”

“What? How do you know that? That’s a violation of my privacy!  How dare you access my medical record without my permission!” a brief pause… “Well?”

“Ma’am, if you’ll permit me..” and I restated her clinical concerns and her destination concern, and the claim that she was not delivered to a nurse, all of which is directly connected to her medical record.  And although I had no way of confirming her identity, no PHI was exchanged and clearly she knows most of the fleet and they know her.  As I scan a few of the charts looking for patterns of behavior I find what I’m looking for.

Most of the crews are using her statements in quotes and they match almost to the word:

“Patient states she will file a complaint if not transported to Saint Farthest, Saint Farthest is on divert, patient ambulated away angrily with steady gait.”

 

When I asked if she had been transported to her facility of choice and if the Paramedics had actually been rude to her, she began the back track.  She didn’t really want them fired, maybe just talked to, or even just mention that she was not pleased with the level of service she received.  Then we talked for a good 20 minutes about her medical conditions and her use of 911.  I offered a few contact numbers for local resources and even threw in a few breathing exercises for relaxing after a long day as an urban outdoorswoman.  She thanked me and in the end apologized for taking my time.

“That’s why I’m here, Ma’am.  If my Paramedics ever do anything you don’t like you call me right back, OK?”

 

That was in January.

Today I noticed her name on a chart where she was transported for a chronic condition, but the colorful language was gone.  I had to go back and check the name to be sure.

Her blue squares have decreased significantly since and I’d like to think I had something to do with that.  It wasn’t a rapid response car, or an advanced skill set, it was taking the time to listen and offering support.

 

Try it.

Just because it’s right…

…doesn’t mean you can do it.

We’ve had some confusion around the yard as to just what we’re supposed to be doing when it comes to assessing the car rather than the patient.
We all know to assess the patient, not the car, the patient, not the monitor etc etc.

At a recent training evidence was presented that contradicts our current protocols as set forth by our regulators.
It seems a number of folks took that training to heart and are trying to apply it to the patients they encounter in the field.

Problem is, the treatment, or omission of treatment in this case, is causing trouble for me in the CQI office since I now have to talk to folks about doing the right thing and breaking the rules.

First a note on one of our favorite terms: mechanism.

Motor vehicles today are designed to crumple, absorb energy and disperse it around the passenger compartment. This design allows for a great deal of damage to be incurred prior to the passenger, if properly restrained, is injured. This is the reason that recent CDC wording of field trauma triage criteria specifically mentions intrusion into the passenger compartment. Your protocols and policies likely have a similar clause.
The problem is when the protocols and policies start making assumptions about the possible damage to the car and how it relates to possible damage on the patient, then prescribes treatment based on the car, not the patient.

Rollovers used to be a big deal. If everyone is belted chances are they’re self extricating before you get there and strap their curved spine to a flat board. You know…just in case.

Even more frustrating is when you finally convince the patient that the hospital will take careful care of them in case they have a back and neck injury only to arrive to a triage nurse removing the collar, performing the same assessment you did, then removing the board if your treatment was based only on mechanism.

Even worse is when you convince them to be seen at the trauma center based on damage to their car, only to see them moved to the hallway prior to your chart being completed…no board, no collar.

I asked a few of my crews to think of the worst Paramedic they had ever seen and if they would want that person “clearing” C-spine injury in the field on them. The point set in that most of us can barely get our noses out of the cookbook long enough to do a complete assessment now. Those folks have no future in EMS if I have anything to say about it.

So what to do?

Attend the meetings of the groups that make the rules. Get on the agenda and speak. Bring research, evidence, examples from other systems already doing what you want to do.
You get a lot more attention when you bring in a multiple page presentation on Community Paramedics rather than complaining in the yard that we need more training to be able to do more.

Follow the policies. If they aren’t what your patient needs, lobby to change them. Don’t ignore them in the field or your next patient may suffer when you’re on suspension and that medic you despise has to treat them.

Which is worse?