Oct 30, 2014

This morning I saw a video come across pretty much all of the major EMS related news sites about a fire crew from Glendale, Arizona who were filmed while restraining a patient.  I fired up the video and sat there watching saying to myself over and over “it looks fine to me. . . still looks fine. . .” and then one of the firefighters opened his mouth, and lost his cool.  He informed the patient that he was “dead meat” and began swearing at the patient and the family.  Have a look at the video, but be aware that there is potentially offensive language used in it.  It might not be suitable for work. The backstory on the call is sketchy: a patient who had a “seizure” after overdosing on medications who first punched his father and then assaulted the crew.  During their restraint of the patient, the stretcher ended up on its side, and at least two firefighters ended up on top of the patient.  Operating in a vacuum, and putting the video on mute, the crew did a pretty good job retraining the patient.  He was being held down by an adequate number of people leaving other responders to watch the scene, and monitor bystanders.  If two people can effectively hold a patient down, then there is no reason to have five people on top of him, so kudos for that.  Keeping with the desired online theme of not armchair quarterbacking this call, I feel that this is a good time to touch on a couple of different points that we can remind ourselves of after watching this video. In the world of power stretchers, we no longer have to lift it to its highest level right off the bat to prevent repetitive lifts. Keep your stretcher at a manageable level especially when you have a patient on it who might become combative.  If you start off at a level higher than your patient, then they will be easier to control, and while you might put yourself at risk for strikes to some areas that men specifically might be more protective of, you will prevent yourself from being struck in the...

Oct 29, 2014

Anonymity on the internet is a powerful tool.  Some use it for good, and some use it to put their coworkers, colleagues, and services on blast.  When I started writing almost five years ago, I first started perusing blogs like Kelly Grayson’s and Justin Schorr’s.  Justin had recently gone public with where he worked with the release of Chronicles of EMS right around the corner.  I always looked at Justin as one of the lucky ones because his service so openly embraced his writing. When EMS in the New Decade was started, I had hopes that I would get it to where it is today, but looked at things more realistically in that so many blogs are started on the internet but not followed through on.  While my name was made public i did not mention who my employer was, and i did not talk about my writing at work.  I maintained this stance for more than a year, mentioning it to some people here and there but for the most part I kept my social media life divided, not discussing my writing very heavily on Facebook, and promoting the heck out of it on Twitter.  Once I did start letting people know what I was doing, the response to me was overwhelmingly supportive.  It is not that I doubted my friends and colleagues, I just did not know that the response would be so overwhelmingly positive. If you met me, it was not very difficult to figure out who I worked for, but I never said it, keeping my description of my employer to “a large national ambulance service in the United States.”  Heck, it was not until I gave my two weeks’ notice that I stated publically that I worked for American Medical Response.  I did not do this out of spite or disrespect for the people that I worked for.  Truth is, if you did know who I worked for, or figured it out, it was pretty easy to put names to a lot of the examples that I gave.  I used this blog to arm chair quarterback a lot of what I saw as failures in the system that I worked...

Oct 22, 2014

In the first part of this series, we took a look at the disease of Ebola itself.  In the second installment we looked at the disease’s signs and symptoms, and took at look at how we as prehospital providers could be put at risk.  In this final part we take a look at the role EMS will be paying in the battle against Ebola. The EMS Response to Ebola In a recent EMS1 article, Dr. Alex Garza took a look at Ebola and how it will affect EMS responders.  One of the first things that he pointed out was the need for specialized air ambulances to transport these patients.  Personally, I feel that we need specialized responders as well.  Dealing with highly infectious diseases such as Ebola requires specialized training and treatment for the patients.  The infection control training that EMTs and paramedics receive is usually focused on “universal precautions and Body Substance Isolation” heck, if you don’t say that at the start of every National Registry station, you’re most likely going to have to retest, but I digress. . . Much like we have specialized HazMat technicians in many systems, and SWAT medics maybe we need specially trained medics and EMTs to handle specifically the interfacility transport of potentially contagious patients. I also spend a lot of time reading the National EMS Management Association (NEMSMA) ListServ on Google.  There has been a lot of talk over the past couple of weeks about different services developing policies and procedures for dealing with patients who possibly have contracted Ebola.  If your department releases anything, read it.  Memorize it.  Make sure you know what your point of entry plan is.  Is one hospital being designated as an Ebola receiving facility?  Who do you have to notify if you have a possibly infected patient?  Are there any radio codes that you need to be aware of?  Also do not be afraid to ask your leadership for answers to any of these questions.  If they don’t have them, suggest that they might be important.  If they’re resistant go higher up the chain if you have to, or at least as high as you are comfortable going. The Center...

Oct 21, 2014

In the first of this three part series about the Ebola virus, we talked about the history of the disease, and a little about the pathophysiology of it.  Now that we have a little background about it, let’s look at its signs, symptoms, and talk a little about the treatment of Ebola. How Does a Person Catch Ebola? As we touched on in part 1, Ebola is transmitted through direct contact with body fluids of a living or deceased infected person or animal.  The list of fluids that traces of the Ebola virus have been found in it not a surprising one, and includes saliva, mucus, vomit, sweat, tears, breast milk, urine, feces, and semen.  According to the Center for Disease Control and Prevention (CDC) the virus can live in body fluids for “several days” at room temperature, which brings up some serious conundrums when it comes to the pronouncement of patients with obvious signs of death that are encountered in the field. This is why we need to stress the importance of universal precautions with every single patient that we encounter.  The CDC tells us that transmission occurs through “direct contact” with bodily fluids.  Direct contact means that “body fluids from an infected person have touched someone’s eyes, nose, or mouth or an open cut, wound, or abrasion.”  While alarming, contact of body fluids with unbroken skin is at a very low risk for transmission of the disease. The big concern right now that is being fueled by the mainstream media is the prospect of the Ebola virus becoming airborne.  While it is known that it has not currently taken on that characteristic, as previously stated, traces of the virus has been found in saliva and mucus.  While coughing and sneezing are not a commonly found with Ebola patients, should a patient with Ebola cough in the face of another individual, there is a risk that the disease could be transmitted. What are the Symptoms? Now that we know how the disease is transmitted, how can we tell if somebody has it?  The alarming thing about Ebola is the symptoms that you will see in patients infected with the virus are quite familiar:...

Oct 20, 2014

In light of all of the media attention being made about the most recent Ebola outbreak that has now spread to the United States, I thought it would be beneficial to put together a three part series about the Ebola Virus.  In this first part, we will talk about the history of the disease to help us better understand where it came from, and the impact that it has had over the past nearly forty years.  Part two will talk about what you as an EMS responder needs to know about the disease, and in the final part we will talk about things that you should think about after dealing with a potentially infected patient. The Discovery of Ebola Ebola was discovered after its first documented outbreak in 1976 which occurred from June through November in Nzara, South Sudan.  The World Health Organization (WHO) knew that they were dealing with some sort of hemmoragic fever but did not realize that it would be as deadly as the Ebola virus turned out to be. The first documented case of Ebola was discovered on June 27th when a Sudanese store owner became symptomatic and died just nine days later.  In total, the first outbreak of Ebola infected 284 people and resulted in 151 deaths. The disease was named nearly six months later for the Ebola River which is located near the location of the first documented outbreak.  With the disease becoming more publicized thanks to the WHO and Center for Disease Control and Prevention’s (CDC) involvement, an additional 318 cases were identified with 280 of them proving to be fatal.  The two departments undertook a combined effort to contain the disease and were eventually successful in doing so.  Interestingly enough, one of the most effective strategies that was used to contain the outbreak was the advocating of the discontinuation of reusing needles by local medical providers. Over the next nearly twenty years the disease stayed out of the headlines and off the radar of the CDC and WHO then in 1995, the second major outbreak of Ebola occurred in Congo infecting 315 people and killing 254.  Five years later, another outbreak occurred in Uganda claiming an...

Oct 16, 2014

One of the biggest sticking points that most EMS systems have when it comes to being overworked is figuring out what the definition of an emergency is. Right now, that definition is subjective, much like a pain scale. Just watch any social media outlet, and you will find some provider complaining about responding to some level of nonsense.  We forget that the patient or the bystander is the one who gauges how bad a situation is, not the person on the other end of the phone or the responding EMTs and paramedics. One of the best paramedics I ever worked with walked into every situation with the same calm demeanor because, as he would put it, “its not my emergency.” Currently, there are a number of EMS systems around the country that are plagued by lengthy response times. The public is outraged. Departments that hung their hat one the concept of “we can do it faster, so therefore, we can do it better” are scrambling to find answers. But really, the answer is right in front of them, and it starts with admitting that they were wrong. One of the most influential articles that I have read over the last five years was the one that I have quoted numerous times about response times and patient outcomes for MedStar Mobile Healthcare (formerly MedStar EMS) during the Dallas Super Bowl, which was accompanied by a snowstorm. They found that despite their longer response times, their mortality rates did not go up. Their patient outcomes largely were not affected. They proved the point that the paramedic caring for the patient was far more important than how fast they go there. Think about the anatomy of many of these runs that we go on. We response lights and sirens to the patient with flu-like symptoms because nothing is more important than getting an ambulance in front of their residence in less than 9 minutes. Not a paramedic at the patient’s side, but an ambulance, capable of transporting a patient to the hospital, parked in front of their house in a desired amount of time. We load this patient up into the ambulance and head off to the...

Oct 14, 2014

Once again, the topic of “should we strive for higher education?” has come up, and once again I need to come out in support of this. And it has nothing to do with the fact that I currently possess a degree. Many wonder what it will do for our bank accounts. They ask for evidence of how increasing education will result in increased income at the street level. To me, it is the simple concept of supply and demand. Currently, it is so easy to get a job in EMS. Look at larger companies like AMR, which almost have a revolving door of providers. We used to put on big recruiting class and would usually retain about 60% of our hires six months out. There never seemed to be a shortage of EMTs to staff trucks. Increasing the knowledge base of providers means that not everyone will want to invest the time into the field, and will result in the people getting into the field being the people who want to make a career out of the field. Fewer providers will be available at that level, so their skills will be more coveted. As a result, departments will pay more for their ability. In my eyes, there are three places that we need to increase our education. The first two have nothing to do with actually providing care but everything to do with understanding how our care affects our patient. We need more education in anatomy and physiology, and pathophysiology. Most paramedic programs that I have encountered do a barely adequate job with these topics. While most paramedics understand how diseases and conditions affect the body, we need more. Right now, most education revolves around that immediate emergency, as it should, but we could be well served with some additional knowledge about the body outside of our encounters with these patients. As we establish that stronger base, then we can expand the care that we provide, which is where my third topic comes in. With the growth and expansion of community paramedicine, paramedics need more education in after care. We need to understand what level of care goes into our patients after we intubate...

Oct 9, 2014

It is no secret that I am not in favor of arming paramedics and EMTs.  I let Chris Montera and Sean Eddy debate the issue a few months back and found the arguments from both sides very interesting but still, my position was not swayed. I have a tough time justifying putting a gun on the hip of anyone who gets into an ambulance intent on providing care to the sick and injured of their community.  This does not, however, diminish the need for ambulance personnel to learn about gun safety. I remember one incident in particular when I was still in Massachusetts.  It was a busy Saturday night, and right around closing time, a man stumbled out of a bar and turned down an alley way collapsing face first, prompting bystanders to call 9-1-1.  When police and the ambulance got there moments later, they rolled the patient over and found him without a pulse, not breathing, with a couple of gunshot wounds to his chest.  They started CPR and loaded him into the ambulance. Once there were enough hands taking care of the patient I was doing my usual supervisory thing, standing at the back of the truck making sure bystanders kept moving, and using my 6’5″ frame to block the window as much as I could.  Then, one of the medics opened the back door and said to me, “We need a cop back here now.”  I turned around and looked in the window to find that the crew had cut the legs of the patient’s pants and I was staring at the business end of the handgun that he had tucked into his waistband.  No one in the truck had any experience with firearms, and neither did I. An officer got into the back of the truck, disarmed the patient, made the gun safe, and took possession of it. What would have happened if the crew was just on the typical “man down” call with delayed or no police response?  What if they had done their pat down as part of their patient assessment and found the gun with no one to take care of it?  How do you know if it is...