EMS World Expo After Action

Hello! Long time no see. I’ve been dealing with site issues for a while now, and I’m happy to report that I am now officially SELF HOSTED. That’s right, this blog exists on it’s own, which means it doesn’t have a ring to belong to and no advertisements or fillers. I wanted to hold off an official announcement till after I attended the expo in Nashville, so now here it is, a week later. I’m going to try and post maybe once a week, if not a clinical pointer or something I’m famous for then it’ll just be me.

Anyway, EMS Expo

I was disappointed. Lots of the topics I saw being presented I am well versed in. There was a lot of offerings in respiratory emergencies, and I got to one presentation by a Vanderbilt flight nurse that had shown a BVM technique I had never seen before (which I got a chance to use my FIRST day back to work) and some pointers on teaching and defining intubation skills and practice.

The topics I didn’t get to see were along the instructor and management tracks primarily, and they were cancelled. I was interested in accident prevention and quantification methods as well, which I was very pleased in the both the instruction.

To explain my disappointment, there really wasn’t any topics that piqued my interest and there really weren’t any new and exciting products on the floor. It seemed to be a rather “blah” year in EMS innovation.

I wasn’t disappointed in the opportunities to see old and new friends. The last time I had seen any of them in person was back in Baltimore in 2011 just before my cancer diagnosis. New encounters included William Random Ward and Amy Eisenhauer from The EMS Siren. I hadn’t met Ben Neal from Louisville in person yet.

It was good to reconnect with Chris and Anne Montera, Jamie Davis, Carissa Caramanis O’Brien, Scott Kier, Charlotte from Zoll (I can’t remember her last name), Dave Konig, and a few others that got me through the year of cancer treatment from afar. It was good to return handshakes and hugs for all the support and encouragement and kindness that seemed to be never-ending.

It got a little spark going to rekindle the burnout I went through over the past couple years, but, more on that later.

Just Like Detroit – Repost

Repost from a few years ago…

In a round the room conversation at the our house yesterday, we were discussing the latest round of proposed cuts to the fire department here and a statement came up that I thought a lot about last night.

We were discussing the possible closing of fire companies (and possibly stations) and one of the guys said that he was talking to another friend higher on the chain. They both agreed that things were getting bad. Morale was dropping below an all time low and the overall job satisfaction and desire was plummeting. One of the guys said that he was talking to another friend in Detroit about what had happened to them years ago, and that what was happening there was happening here and if things weren’t done to correct it, Memphis would be “just like Detroit.”

I wish I could say he was wrong. But I can’t.

Our tax base is dwindling as Memphis has become a victim of the welfare system. No one owns anything and hence, no one is responsible. Things are going along as if no one is in charge. And that’s probably correct. The few taxpayers that remain will eventually be tired of having to pay property taxes out the nose (Tennessee by law outlawed any payroll tax or income tax, and Memphis city has the highest property taxes in the state) and leave. When that happens, I only see it happening one way:

The city will collapse under it’s own weight. Tax revenue will shrink and in response the city will raise and levy MORE taxes on businesses, which will them leave. The city will virtually dry up. Crime and poverty will swallow up the remainder of those unable to leave. The Police and Fire Department will be cut to the bone as the city levies it’s heavy handed tactics against it’s own people, without first cutting their won salaries. The politicians will get richer but everyone around them will get poorer. This happened in France one time, and the arrogant and defiant Queen, Marie Antoinette said “let them eat cake.” The rest is history.

Those employees that have no marketable job skills will be trapped. Those with skills will flee to greener pastures or to other lines of work, never to return. Lay offs will claim those that can’t escape, furthering the cycle of poverty.

Fire stations will close, EMS will be so short staffed that it takes forever to see a response. Streets once guarded by the police will be reclaimed by the gangs. Those firefighters, paramedics, and police officers that remain will fight the good fight with no chance of help ever coming. There will be blood in the streets so deep you will need hip waders to get from your door to the parking lot. That is, if you can ever see the streets due to lack of basic sanitation and street repair.

It would be the most heart breaking thing ever seen. A city once hailed as the jewel of the Mississippi Delta will burn out, with no firefighters or police officers to stop it.

It would be like Detroit.

I can assure this, that those of us that remain will do what we can with what we have for as long as we can.

But even we have breaking points.

The Title or What’s Probably Best

I rarely post about my own personal feelings on my blog. Lately some of my stuff has been introspective, but to a point. Recently I have had the desire to vent some thoughts I’ve had just to get them out there.

For the first time since August of 2002, I feel alone. In August of that that year I moved to Oklahoma, leaving everything familiar I knew behind, and learned how to survive on my own (albeit with a few training wheels), and chose my path in life. Made friends that endure, at a distance except for 1 but her and I don’t talk for more complicated reasons, and even she would be welcome if it helped blunt the sting. The reason I feel alone is because my more recent friends have left, or are leaving, the Memphis Fire Department.

The brain drain is on.

Yet, I find it hard for me to print out my resignation letter and march down to city hall and turn it in with a big stamp that says “EFFECTIVE IMMEDIATELY.” I could end it just like that. No longer a firefighter for Memphis. In a larger sense, to give up that which I have sweat and bleed and sacrificed my body and at times, my sanity for. To give up the fulfillment of a desire that started when I was 14.

To work “the big time.” To leave the little sleepy town of 24,000 people and make it to a fire department with more than a handful of fire stations, that actually fought fire more than once every few months. It was a dream that I fulfilled, and now I’m having a hard time with the thought of giving it up just because I’ve worked for it.

Would giving it up because the incentive to work in government is being systematically and callously dismantled represent a failure on my part to be able to “stick it out?” Does it mean I failed the people that dedicated their time to get me here?

Maybe not. If I have no guarantee of a future here, why should I stay? If I get hurt, there will be no medical benefits if I get injured and if I die (God forbid) there probably wouldn’t even be a payout to my wife and if there was it would be a meager amount that wouldn’t replace me.

Can I give up the title, the one I’ve held almost consistently since 2002? Can I be “hybrid” no more?

Only God knows.

Cool The Jets

Be cool!

Easier said than done. Well, unless you’re me, and even I have to tell myself to be cool sometimes. It’s easy to forget.

So why is it so hard for the new guy to be cool? It’s pretty easy for the new to get flustered. The business of an emergency scene can be overwhelming for that person without much experience around them, so it falls to the more experienced to carry most of the way while a new EMT copes with the shock of the dead and the actively dying. Even EMT’s that have been EMT’s for a while but have never touched a 911 scene can get nervous when presented with a scene that involved the need for quick wits and thoughts. It can be exhausting and in some more seasoned providers it gets expressed as frustration.

I can see why those thoughts might be racing by. The directions of a seasoned EMT or Paramedic seem like commands from a god on high as they always have the right timing for a procedure or their own system of doing things that seems so organized it makes what the new EMT would be doing seem too easy.

The answer is simply exposure. The more memory cards a provider gets based on what he or she is exposed to, the faster their recall becomes, and the faster and better organized the thoughts come about what to do next. Especially if a new EMT and an experienced provider are paired together, if the senior provider is a good teacher then it’s likely that healthy habits will develop and continue on the health of the organization towards a more… sublime existence.

So, experienced providers, don’t get so frustrated with your green folks. Teach them and have patience enough to guide them towards healthy habits and patterns, you might need those habits in a pinch some day.

CPR Training in School

I noticed some churning articles about Illinois requiring CPR training as a result of stories with two different outcomes.

I like the idea, but can we really cram more on to high school students? And can we really expect teachers to deliver the material according to the standardized format like Red Cross or AHA with the required quality controls?

The thing is, those organizations already have materials to teach to high school students, and give a card for completion. It doesn’t measure competency in the way that other programs like Heath Care Provider or ACLS do with written exams and mandatory passing rates. In theory, one could ignore the video and associated sing-a-long and pass through and become “Peter Griffin Certified CPR” without ever actually learning the procedure.


Vezi mai multe din Desene animate pe 220.ro

I’m all for teaching more people CPR, but if it’s to be done with high school kids, they need to learn it the correct way in addition to learning basic first aid and how to care for minor ailments and when it is appropriate and not appropriate to use 911 and when to call their doctor.

EMS Dead Horses

We spend a lot of time beating the proverbial dead horse.

Seriously.

The trade mags and webpages and forums are full of those dead horses.

More recently we’ve seen a new article pop up in JEMS attempting to answer the question if we diagnose or merely form an impression. We seem to rehash the debate every 8-12 months.

My answer is yes we do in the legal sense of the word, but Medicare doesn’t pay us like they pay doctors for diagnosing a problem and fixing it. We get paid for transport and whatever we do during transport at significantly lower rates. The article in question seems to make an attempt to answer why we don’t get paid that way.

If you could answer that question it would be one for the ages. The answer to me is pretty obvious that in the eyes of the politicians that make the laws that we all have to follow to stay in business and out of prison that an ambulance has one purpose and that is to transport, and they assume that when someone calls 911 that they have a life threatening emergency that REQUIRES transport.

They don’t take into account that perhaps 10% of EMS calls in a certain place are really on emergencies, and most calls that result in transport are non-emergent or a result of neglect of a chronic condition. They assume that all 911 calls result in transport, even though most calls could do with a bit of education (albeit temporary) and maybe some advice. But we don’t get paid to give out advice.

Not to mention a service that gives out advice and not a transport is sometimes open to civil liabilities when they get it wrong, which the fear of liability in leaving them there often spurs transports even for routine complaints that a hospital can do nothing to help like common colds and minor orthopedic injuries.

Any program to reduce non-emergent 911 calls would also require overcoming cultural obstacles. It is a relatively known fact that in places with high levels of generational or ingrained poverty that non-emergent 911 calls are often the only way perceived by that community to gain access to health care. So far, programs focused on education against that obstacle have been unsuccessful, and probably the only solution is direct and consistent intervention.

See? Plenty of dead horses beaten in any discussion about solving problems that faces the ways and reasons we get reimbursed as well as any problems we have regarding unnecessary transports and civil liability. The only way we are going to remove the beaten horses is to fix the problems, and with the way the power brokers in Washington are playing and us chasing our tails over semantics and identity, they are topics that will likely never get fixed.

Waveform Capnography Part 3

Wow, it’s been a LOOOOOOONG time since I visited this category. Sorry for taking so long with Part 3, if you need to knock the cobwebs out of what I’ve written on this topic in the past here is Part 1 and Part 2.

Ok, so what did I promise you the last time? Oh yes, patterns in different respiratory issues.

So the last time we talked about this we played with the normal pattern for a ETCO2 waveform, which is the equivalent of a plateau with fairly sharp delineations between phases and the normal values of exhaled CO2 being between 35-47 mmHg. So now that we’ve established what “normal” is, let’s look at some things that aren’t normal.

Abnormally High Numbers and Funny Looking Waves

“Hey RJ, the numbers were like 50 mmHg and up the last time I used capnography!’

High numbers indicate CO2 retention (bonus question: which is common found in what respiratory condition?) which means that the patient isn’t moving any CO2. You can fix this with mechanical means such as a BVM or CPAP (if the assessment indicates obstructive
pulmonary disorders) or if the respiratory depth is adequate, you can try using a non-rebreather mask.

I will tell a story. When I was a medic student riding at Xenia Township in Ohio, we responded to a report of an unconscious female out in the sticks. On arrival, we found a 60-some odd female lying on her couch. She was obtunded, with questionable pupil size, normal blood glucose, depressed respiratory drive, sinus rhythm, normal 12 lead ECG, and a slightly elevated blood pressure. We expedited her transport, and we couldn’t wake her up despite the use of naloxone (we suspected she had overdosed on recently prescribed pain medication) and a questionable CVA screen. Turns out, it was none of the above. Had we placed a capnography probe we would have found her PETCO2 to be in the 60-80 mmHg range and could have corrected her mental status change using mechanical ventilation.

Why tell you this? Because the technology was brand new to EMS then (it was a new feature on our recently upgraded LifePak 12’s) and if we had dug a little deeper we would have found COPD in her history, specifically chronic bronchitis. We could in-lined a breathing treatment through the BVM and created positive pressure in her alveoli and open them up, creating the release of trapped air and bringing her back to normal level. The next time we encountered her with the same issue (which was about 3 months later) I knew exactly how to correct her problem. 80% of all diagnosis is history related (and we do diagnose, don’t get me started) so make sure your history is as complete as the situation allows.

In bronchospasm (which is a form of pulmonary obstruction), the waveform, when analyzed closely, may look like something of a shark fin. Why is that?

Well, the Expiration phase (which is the Phase I and II waves) is prolonged due to obstruction. This makes the wave kind of smooth out a bit as the patient attempts to force air through the obstruction. This patient may exhibit the classic respiratory distress signs such as tripoding, nasing flaring, etc, and will appear in trouble before you even put the probe on. As you remember, those breathing patterned are typical when the patient is attempting to increase the PEEP (positive end expiratory pressure) in response to air trapping.

I’ve also seen the numbers high in a post arrest in the presence of DKA, the science indicates that PETCO2 is an accurate measurement even for regular patients in DKA for PCO2, which can help you determine if DKA is present.

This is kind of a quick end to a long standing series but I wanted to put out an ending like I had promised so long ago.

http://en.wikipedia.org/wiki/Positive_end-expiratory_pressure

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001153/

http://emscapnography.blogspot.com/

http://www.capnography.com/

Hell in a Handbasket

Ever had a run go to hell in a handbasket? The kind of run that makes you sit and stare out the window of the ambulance, with report finished, your mind trying to piece together the utter chaos that just unfolded? The job that made you work so hard you sweat soaked your job shirt? When you’re looking at a scene that looks like a bomb exploded and you’re the first unit to arrive with a serious mass casualty incident developing and your first thought is “man, someone should really call 911…”

If not, you ain’t doing this right.

I’ve had 2 over the past few days, one at side job and one at regular job. Both times I was driving, and both times less experienced medics were in the back.

The first one was a seemingly simple CHF episode dispatched as respiratory distress. My partner picked up on it slower than I did (experience) and the transfer of care from basic providers to advanced providers was slower than I usually like (ride with me working by myself and you’ll see how quickly I like to move) so I decided to give my junior partner a few nudges in the right direction. We got CPAP and nitrates on board as soon as I was able, and we were packed up and ready to go. That’s when things went pear shaped.

The patient tripped out and started into a panic, ripped off the CPAP and was fighting my partner. I put the pedal as close to the floor as company policy would allow (see what I did there). Despite our best efforts, she went back on CPAP at the hospital. Current outcome is unknown.

The next one occurred VERY recently. In short, dispatched as a simple diabetic emergency. The first company to arrive, an understaffed engine (due to illness, not intentionally, yet) found a 500+ lbs patient full nude face down on the floor. Pulseless, apneic, blood glucose 420+ mg/dL, and the sheer mass and the engine company’s limited manpower had them call for a truck company for extra muscle.

We couldn’t get a tube, no IV access led to an IO, regurgitation from the BVM and simple adjunct, made this extremely challenging. Not to mention getting the massive man to the cot through a long twisty hallway. It seems that when you want to get the cot close in to make it easy the cardiac arrest is always in the farther point from the door and the cot doesn’t get closer than the front door. We didn’t get much traction, and despite the return of ROSC in the field, the patient died during a resuscitation effort by the closest hospital.

My partners were very dismayed at the outcomes, or how they felt about how the job progressed. Something that they hadn’t seen before was something go south that quickly, and from the 500 pounder, the medic on the engine even said “I’ve worked lots of cardiac arrests, but that one was near the top of the bad ones.” Despite the bad outcomes or issues, I think they are filled with teachable moments about the nature of our work.

Bad stuff is going to happen, lots of calls will come where we can’t get traction and we don’t hit all the protocol points or all the goals or benchmarks on the checklists. This alone can throw a new medic who’s been taught that those rules or rigid and are required for everything. I know, I once thought that way too. The bottom line is that sometimes we just start so far behind the ball or events occur that put us off track and the it snowballs and we never catch up. It happens in the so called invincible hospitals, it will definitely happen in the field.

My only advice is don’t let your mistake or how you felt about that call affect the next patient, have a short memory for the details but remember what you need to do the next time to catch up or get ahead. We all have jobs where we just never get caught up or we get set back or we forget something.

Go read what Kelly says. Relax. Breathe.

Some days will just go to Hell in a handbasket.

When that happens, well, I trust you will know what to do.

Just Testing

Bringing my public life back online has occupied most of my morning.

A protein shake, 2 cups of coffee, several bathroom breaks, and a shower later, I think I’m getting it finally configured.

Oh, this is just a test of how well my feed syndication settings are doing.

“Lookest thou over there…”

 

 

 

 

“HA! Madest thou look. Thus endeth the trick”

Up to and Including Death: A Variation on a Theme

Justin nails it.

I just wanted to add a few thoughts on the matter.

When I first started writing reports, this was a topic that was so glazed over that I hardly remember any discussion on the concept. Then again, I spent a majority of my EMT-Basic and Paramedic classes in a fatigue induced haze, and I’m surprised I remember anything at all.

I was no surprise to me that when I arrived in Memphis I had hardly done refusals, and I ended up doing a lot of them. People where I was from (and trained) only called an ambulance when they wanted to go to the hospital, and they needed to. Calls for service that basically amounted to basic first aid are common place here and in just about every major city. I got really good at doing refusals (declinations, as we are speaking in legal-ese, but it amounts to what is commonly known in the business as a refusal) and I was always sure to include that phrase “up to and including death” on all the tickets because it went the farthest in what could possibly happen.

As I matured, however, and I started blogging, I thought “how ridiculous is it to threaten someone that they may die from the blister on their heel?” So I sought about to change the way I thought. Sadly, there are ZERO models to chose from, so I basically had to invent my own. Justin goes far enough to explaining the consequences of the reason they called, and that is primarily what I do. It just amuses me that I had been taught wrong all those years by medics who sought only to reduce liability, but when you actually READ the refusal document it does that for you.

You really should read what you’re having people sign, by the way. I even had to explain it to a city attorney and you would figure that a lawyer would have read the document when presented with it.

So, when you do a refusal, not much further explanation is required unless you genuinely believe that this person may die. I’ve had chest pain patient refuse care, I had an old lady die 8 hours after refusing care from a massive MI. As my medical director said: “could we be more persuasive? Maybe. But we can’t force someone who is in their right mind from doing something they don’t want to do, even if we think it’s stupid.”