Aug 29, 2014

As technology evolves so does the user.  The problem, however, is after a while, the user tends to become reliant on the technology.  For example, I remember when I was handed my first pulse oximeter.  It was a great new toy that I added to my BLS bag.  Boy, I thought, what did I do before I had this neat little machine?  The answer was simple though, I looked at my patient, assessed their capillary refill, and their work of breathing.  As my career has progressed, I have become less and less dependent on pulse oximetry and more dependent on my assessment.  But this post is not about pulse oximeters, it is about automatic blood pressure cuffs. Have you ever walked in to an emergency room bay with an agitated, hypoxic patient and turned them over to the ER staff, and seen them slap on an automatic cuff only to get a reading of 160/120?  What do they do then?  Document it and move on with their treatment.  Is that BP true?  Probably not, since your ears got 140/90 the whole way to the hospital.  The fact is, many ERs that I have been in have become reliant on their auto cuffs, and EMS is following in suit. LP-15’s, the Zoll X-Series, the new Phillips monitors, they all come equipped with auto cuffs and personally, I have never found one that I liked.  In a 15 minute transport time, especially when I am giving medications, I would much rather take a blood pressure with my own ears than rely on a machine that in my experience, more times than not gives me an inaccurate reading. Some people have developed a system for using their auto cuffs.  If the BP is close to the one they got manually, they’ll go with it.  But what happens when you are bouncing down the highway with a chest pain patient giving nitroglycerine to a chest pain patient?  Are they still hemodynamically stable or did that second sublingual bottom their pressure out? You might think you have the full story, but that auto cuff could be lying to you. The reasons for an inaccurate reading on an auto cuff...

Aug 26, 2014

As if the debates about arming EMS personnel and merging fire and EMS weren’t enough, I decided to take a stab at sharing my thoughts on another controversial one this week.  Of all of the skills and medications that a paramedic possesses in their toolbox, there is none that they are more protective of than intubation.  There is an almost constant debate not only in the EMS community but the medical community as well as to whether or not paramedics are good enough at intubation to be proficient at the skill, and do they use it enough to make it worthwhile for them to keep it?  Last week, Sean Eddy had a great take on this over at Medic Madness, and I thought that I would add my two cents to the discussion. As our field has evolved, we are intubating people less and less every year.  I like to say that intubation has gone from a life saving procedure to a life sustaining one.  More times than not, on the rare occasions where I intubate non-cardiac arrest patients I find myself doing so to protect their existing airway rather than to improve their oxygenation.  CPAP has changed the archaic treatment of CHF patients particularly that used to result in paramedics high fiving each other in the parking lot of the ER as their field intubated patients struggled to ween themselves off of ICU ventilators.  We used to think that nitroglycerin, morphine, and lasix with some PRN orders for versed was the way to go.  It’s not!  Who knew? There have been studies done over the last fifteen years, many of them recommending the cessation of field intubations after having retrospectively looked at success rates particularly among those incidents where a patient was turned over to the ER with an esophageal intubation, or as one resident in my current system likes to refer to it, they “stuck the tube in the goose.”  While I realize that studies like these take time to complete, maybe they are looking at the wrong things. A better take on the intubation debate would be to look at not only overall success rates but how quickly missed intubations are recognized, and...

Aug 25, 2014

What does it take to put a podcast together?  What are some of the important pieces of equipment that you need?  How do you upload a podcast and get it out to the masses?  This week, Scott takes a step away from EMS topics to give you a behind the scenes “listen” into what goes into the production of EMS in the New Decade! Blue Yeti Microphone Call Recorder for Skype Audacity free audio editor and recorder Libsyn Podcast Hosting Services To download the podcast follow this link. Or, use the player...

Aug 22, 2014

Every day, I try to put aside some time for combing the internet and reading a variety of industry related articles.  This week an older article from FireRescue1.com from July of 2012 that former Washington DC fire chief Dennis Rubin reposted called “5 reasons not to merge fire and police” caught my eye.  The article presents arguments against combining police and fire departments.  I read through the article and was able to draw a parallel between this topic and the argument against merging fire and EMS.  Keep in mind that this is in no way a reflection of every single fire-based system on the map.  Some do it very well but for each of those effective, progressive fire based EMS systems, I feel like I have found two who do it very poorly or worse, do not understand or care what they are getting into when they take over ambulance response.   I invite you to read the full article by clicking here  but here are some of the chief’s observations and my thoughts on them. “There are a multitude of examples where communities have fused the police and fire departments into one public safety agency.  The motivating logic seems to be that neither department is busy enough to command the tax share needed t operate separate agency. The initial belief is that merging two costly departments into one will create a more efficient department, thereby saving big public bucks.” EMS and fire are often combined for the exact same reason.  The fire departments are not busy enough so in theory, combining fire and EMS gives them the ability to handle an additional piece of the public safety workload.  The workload that EMS brings in, however, is often ignored or it is not realized to be as involved and time consuming as it is. However, the transition of police duties into the fire and rescue department comes at a steep price that you will not find on a budget line-item spreadsheet.  Intangibles such as organizational stress, personnel, resistance, and demoralization of the rank-and-file members of both departments are the major factors that will ensure this type of plan’s failure.” Take a close look at any fire and...

Aug 20, 2014

I was really happy when I started seeing chatter on twitter from Cherise Leclerc from CBS 3 after she read my original post Best in the Country that I put up on Sunday.  They were interested in Roy and Nick’s story and wanted to do a piece on it.  Over the course of the day on Tuesday, the whole thing was recorded, the interviews were done, and footage from the competition in Colorado was obtained.  I have to say Julia Leonardi did an excellent job with the story.  Have a look for yourself. . . CBS 3 Springfield – WSHM These are the kinds of stories that we as an industry need to make sure are told.  It shows the true clinical ability that service is capable of because Nick and Roy are a product of the environment that they are surrounded by.  Although people do not always get to see and hear about it, the staff at the Springfield Division of AMR does one heck of a job.  They are professional, they are competent and they bring a level of experience both collectively as field providers as well as a service provider in the area that cannot be duplicated.  A piece like this gives people an inside look into what happens after the time stops on the response time clock that so many people like to say is so important when it comes to EMS. To add to the press coverage of this story, Masslive.com reporter Conor Berry did his own piece based on the CBS 3 story.  Check it out here! Although Roy and Nick did not place, they had one heck of an experience in Colorado and I am proud of both of them and I know that I am not alone.  Well done, guys.  And thanks to Julia Leonardi, Cherise Leclerc and the team over at CBS 3 Springfield for telling a story that had to be...

Aug 18, 2014

This week, Scott takes some time to talk about the changes that have occurred to MedicSBK.com over the past couple of weeks.  He then turns to a couple of hot button topics that have come to head over past week, specifically the incident in Nashville, Tennessee where a group of paramedics were suspended and then reinstated after pronouncing a patient who was still alive.  Scott’s focus then turns to the announcement by a California nurses union that released their statement of opposition to Community Paramedicine.  The topic sparked an interesting debate on Scott’s Facebook page and he shares some of the views with you. Firefighters medics who left dying patient under investigation. An incident where Scott and some of his coworkers made a big mistake.  Full Disclosure. Paramedic vs. Nurse.  The Doctor’s Definitive Edition. To download this week’s podcast, click this link!  Otherwise, use the player...

Aug 17, 2014

Every year, American Medical Response holds a nationwide skills competition amongst their divisions.  Tryouts are held regionally and eventually the top six divisions in the country who scored the highest in the preliminary competition are sent to Colorado to compete for the right to brag that they are the best in the country.  For the second year in a row, the Springfield, Massachusetts division is represented in the finals.  Last year, it was a pair of paramedics Erin Markt and Kim Arnone who represented my old stomping grounds.  This year it is a pair of paramedics Nick Chirekos an Roy Rudolph who will be representing Western Massachusetts. The event is held in a large “simulated” city where a crew is given a fully stocked ambulance and asked to respond to calls in this mock setting where they are heavily monitored and thrown curve balls around every corner.  The stories that Kim and Erin told me last year were great.  It sounds like such a fun experience, and each of them took something from the competition. First of all, I want to to say how great it is to see AMR holding an event like this.  As the largest ambulance company in the United States, it rests on their shoulders to also strive for clinical excellence.  Putting their divisions in the spotlight like this is a great way to showcase just how good the company has become clinically.  While I am not surprised to see Springfield heading to the finals yet again, I feel like it is something that deserves quite a lot of attention. With the brewing turf war in Holyoke, Massachusetts with their fire department, and past investigative “reporting” on the division’s performance in Springfield that revolved around response times this is yet another example of how great the clinical care being provided in the greater Springfield area really is.  While some will complain about AMR as a corporation and their motives in the medical field which are occasionally driven by their need to be a profitable company for the stakeholder’s sake, the motive for the street personnel has and always will be to deliver the best patient care that they are capable...

Aug 15, 2014

Is potentially not saving one patient a worthwhile sacrifice if that loss helps pave the way for future saves?  Is this ethical?  These are two questions that Warwick University in England is having to tackle as they prepare to involuntarily enlist patients in a study to find out how effective epinephrine is in helping achieve ROSC and favorable long term outcomes.  While long overdue, a study like this toes a fine line between what is ethical and the opportunity to answer a long debated question of whether or not epinephrine actually makes a difference in cardiac arrest.  The results of this study could pave the way for some major changes in cardiac arrest management. The study will evaluate 8,000 out of hospital cardiac arrests with patient either receiving epinephrine or a placebo with outcomes evaluated after the arrest.  The problem with studies on cardiac arrest is there will be a patient population that you just don’t get back and others where we achieve ROSC with very few interventions at all.  In other words, sometimes even if you throw everything including the kitchen sink at a patient who arrests right in front of you, you still might not get them back.  Still though, if things go as they hope they will, England could see an improvement on their dismal 6% out of hospital ROSC rate. I am sure that despite overwhelming support from the medical community in England, some will try and poke holes in the ethical aspect of this study.  When any medic hears the words “CPR in progress” we immediately shift gears, and many of us will turn up the intensity and focus a notch or two.  We know what the task at hand is.  This is our bread and butter, it is what we are trained for.  It is a true medical emergency.  The prospect of possibly not doing everything we can for a patient in cardiac arrest is one that some will struggle with.  When looking at the bigger picture though, with the right evidence the results of this study could be earth shaking. Personally though, I am happy that someone has finally built up enough guts to tackle this one....