Oct 7, 2014

As I mentioned last week, I had the privilege of teaching a fully sponsored, free pit crew CPR class to about 90 EMTs and paramedics. The class was so well received that I was approached by a couple of departments who were interested in bringing the training as well as the policy and procedure to their department.  There has been an aggressive push to improve cardiac arrest survival in our system, and it is great to see the leadership of many of the BLS services taking a proactive approach to be part of it. The desire to change a mindset of what people view as a “traditional” cardiac arrest is extremely encouraging. There is a genuine want to learn and do better. In fact, I was recently on a CPR that ran very smooth from beginning to end, complete with an EMT using his iPhone’s stopwatch to call out changes in CPR. It was the true embodiment of “EMTs owning CPR” just like the Seattle Resuscitation Academy talks about.  If our compression fraction was less than 90%, I would be surprised.  It is amazing how far we have come when running a typical cardiac arrest. I remember the very first cardiac arrest that I worked as a cleared paramedic. Airway was king. Nothing else seemed to happen until that tube was in.  Do compressions but they are not that important. We need to get oxygen into the body before we can think about pushing it round and round, and passing an ET tube, well, there is no better way to do it than that, right? My bag was filled with antiarrhythmics. We carried bretylium, for example, and if you encountered one of those rare refractory v-fib patients who remained in that rhythm amidst the long pauses in CPR to get that patient intubated, then you might actually give it. Then there was post resuscitation care. There was not much stress on it because we did not get people back very often. If it happened, you threw up dopamine on a hypotensive patient. If you gave an antiarrhythmic like lidocaine, for example, you hung a drip of the same medication. My Lifepak 10 was not...

Oct 3, 2014

In a lot of ways, I equate being an EMT to being like riding a bike. You can step away from it for a bit, but once you do it, that mindset is always there. You’ll never forget it. You’re more apt to pull over if you see a wreck. You are the one your family and friends call when they have a medical question. As a couple who have been EMTs for more than twenty years in a small town, that is pretty much how life is for my parents Peter and Karen Kier. Last weekend, my mother and father were away visiting close family friends in Pennsylvania. My mom went out to dinner with some of the family that they were visiting intent on seeing one of their uncles play saxophone at a jazz club. They were sitting around the table enjoying a drink when the uncle suddenly collapsed. Instinct took over for my mom and she immediately stepped in, checked for a pulse that was not detectable, and began chest compressions. Within a minute of her starting CPR, he took a big gasp of air, more than an agonal respiration, and began to improve. He was transported to the local hospital, and I am happy to report that he had an internal defibrillator and pacemaker implanted, and he will soon be discharged with no neurological deficits with the expectation that he will make a full recovery. Looking back on it, I am extremely proud of her. At the same time though, I am not surprised at all. When pushed, she has always stepped up in those situations. Over the last twenty years, she has responded to thousands of calls. She has done CPR more times than I can count. Personally, I remember my very first CPR call when I was 15 years old. She was on it too. It would be short sighted to say that last Saturday night’s events defined her career as a volunteer EMT, but saving the life of a friend, well, that is on a completely different level from any other call that a prehospital provider will do in his or her career. I was going to...

Oct 1, 2014

Over the years, we have talked a bit about intubation.  We have talked about whether we should be doing it, and more recently, we made an argument to reinstitute studies on success rates based on our technological advances.  As I have stated before, I am far from an “airway guru.”  I am an average intubator, but I feel that I am successful more times than not because of the process that I use, and some of the pieces advice that I have gotten over the years.  Since we just recently talked about some finer points of intubation, I thought now would be a good time to share a few key pieces of advice that I have gotten over the past fourteen years. 1.  Use the smallest blade possible – Like many paramedics, my “go to” blade has been the Mac 4 since I was in paramedic school.  I always felt that bigger was better because if I did not need quite so much blade, I could always pull out just a bit.  If I decided to go right at the epiglottis and pick it up instead of shooting for the valecula, I could do that too.  That remained true until I watched this video: Using the smallest blade possible means that you do not work as hard to visualize the cords.  It makes sense, and more importantly it works.  In the last couple of months I have been using a Mac 3 more and more, and I find intubation considerably easier as a result. 2.  Elevate the head – In more difficult intubations, the first thing that I do is elevate the head.  While lifting the blade with my left hand, I put my right hand under the patient’s head and pick it up by an inch or two.  I find this is extremely effective when trying to bring the axises of the airway into alignment.  The downside is I end up needing a second set of hands to get the patient intubated, however with the number of people that we have on cardiac arrests, I usually have someone on airway with me anyway. 3.  Develop a process – As I stated in a previous post, my partner...

Sep 25, 2014

Recently, EMS 1 posted a story on Facebook with the headline “Equipment cutbacks put Chicago medics, firefighters at risk” with the subheading provided by EMS 1 of “What were they thinking?”  The short version of the story is that self-contained breathing apparatus or SCBA’s for short are being removed from all 75 of the Chicago Fire Department’s ambulances.  Furthermore, 70 paramedics getting ready to graduate from their academy will not be issued fire helmets, boots, and bunker gear.  A Chicago fire medic and their union want us to believe that because of this decision, people are at risk, and people are going to die!  As someone who has worked for 14 years in non-fired based EMS, I would like to share a differing opinion based on some of the statements made by various people in the article. First of all, let’s talk about what the presence of SCBA’s means for someone who might not be fully trained and acting only as a single role paramedic, and not as a dual trained fire medic.  The mere presence of this equipment encourages bad decisions to be made, either by “old school” leadership who doesn’t care what anybody thinks because they are “in charge, and we need people inside, now!” or by the medics themselves who take unnecessary risks because they think that they can handle something that they really cannot by donning this equipment that they have limited training to use. As someone who has worked many fire scenes both as a field provider and in an EMS leadership role, I have been in very few fire related situations that have required me to “stage at a distant location” or not have a stretcher right at the front of a fire scene as Pat Fitzmaurice, a veteran Chicago paramedic claims.  While we would usually park a block or so away from the scene we would do so to allow responding fire units to lay in with their 5” lines from hydrants because it was a common occurrence that if you parked your unit too close to a fire scene (maybe a half a block away) you were just asking to be boxed in by laid hose...

Sep 24, 2014

One thing that I have realized over my years in EMS is that the concept of a “typical day” is a foreign one.  There is something that we can pinpoint from just about every single shift that made that shift a unique one.  Sometimes it is a bizarre patient, or maybe a complicated medical call.  Other times, it is a major incident that gets your system talking for weeks and months to come. Earlier this week, my department had one of those calls that would occupy the last segment of shows like Emergency!, Third Watch, or Chicago Fire.  It was intense, with close to forty patients on scene.  While the call took a bit longer than the fifteen minutes that it would have on TV, it was well run, went smoothly, and for the most part was wrapped up in less than an hour.  The remarkable thing to me though is what happened after the call. There were no high fives from anyone.  There was no freeze frame of a group of paramedics with credits rolling over them.  Everything returned to normal much like it was an hour before the incident happened.  After that last patient was loaded into the back of the ambulance, everyones focus turned towards gathering up their remaining equipment, loading it back into their units, and going back in service. When major incidents happen, that does not mean that everything else going on within the system stops.  When the towers fell on September 11, 2001, people in New York City were still getting shot.  They were still having heart attacks.  When my staff and I were making our way through downtown Springfield after the tornado hit looking for patients, there were still psych calls and people with abdominal pains who had not even realized what happened in their own back yard.  And when we were tending to our forty patients, there were still calls going on in our coverage area.  A little more than an hour after our incident started, it was over.  My partner and I cleared up, and on our way back to the station, we listened to three more calls get dispatched that were your just run of...

Sep 22, 2014

A few months ago, I was approached by some friends at a local fire department who were looking for some help developing and rolling out a pit crew CPR system for their people.  I was quick to offer my help after watching the success that Louisville EMS has had over the last year and a half since rolling out their new CPR program.  I felt like I had a good knowledge base and a number of resources, especially after the events of EMS World in New Orleans back in 2012. The EMS officers from the fire department put in a tremendous amount of work developing a new procedure that utilized the department’s strength in numbers, and played off their established fireground culture where every piece of apparatus arriving at the scene of a fire has an assigned role. After the procedure was developed, the rest of the project was dropped in my lap.  They asked me to develop a class that talked about the importance of high performance CPR, the pit crew mentality, and stressed the values that our state had adopted by adding pit crew CPR to the upcoming BLS protocol updates.  I took a couple of months, and developed what I felt was a strong presentation complete with evidence, videos, and plenty of theory. Last week, that fire department opened their doors to anyone who was willing to listen.  They put together a free class complete with a free dinner which, as Greg Friese will tell you, is a great way to get people in the door.  Much to my surprise, ninety people attended the class from a number of different departments.  The feedback from some of the attendees has been great, and I have even been approached by three more departments who want to develop their own SOP, and push CPR in their organization. The entire project was a lot of fun for me.  I have found a love for teaching, and being able to talk about something like running a better cardiac arrest is something that I have become very passionate about.  I could not have done the job that I did without the connections that I have made through...

Sep 17, 2014

As the debate rages on about whether or not “cookbook medics” are the new fad, an interesting question was raised on the Paramedics on Facebook page that sparked some interesting conversation.  The question was about deviation from protocol with an elderly patient that some could have considered a priority to take c-spine precautions on.  I’ll let you read it for yourself: You’re dispatched to the assisted living facility for a fall. You arrive to be met by staff who is escorting you deep into the bowels of the building. During the walk, she tells you that the patient is an elderly gentleman who is under comfort care only, DNR/DNI with all appropriate paperwork, for stage IV liver cancer with metastasis to just about every organ system in his body. He’s accepted it, as has his family. He just wants to die with a little peace. But tonight he tripped on the carpet, and when he fell, he hit his ear on the night stand. There’s a laceration that bled a fair amount. Facility requires his transport for a fall, though. You walk in the room to find the FD strapping him onto a backboard with a collar in place. The patient is alert and oriented. The only visible injury is the laceration to the ear, which has been controlled, but it looks like it needs a couple stitches. He has no signs of injury on his head, neck, or back. He has no neck pain. He had no back pain before the board. The patient says he is in incredible pain since being on the board, and wants off. He’ll go to the hospital, but he’s in agony. His GSC is a solid 15. He’s not stoned on narcotics, and he’s able to understand risks. No history of dementia. Here we have a patient who is alert, oriented and refusing a portion of the care that you are trying to provide to him.  Some will argue that protocol is protocol, and others that he should be taken straight off the board, and the evidence does not support taking spinal precautions of this patient.  Congratulations, folks.  You’re all right. . . kind of. Far too...

Sep 16, 2014

System design has always fascinated me. Throughout my career, it has become more and more obvious to me that design of an EMS system goes far beyond what trucks are on the road, and who is on each of them.  Each aspect of the system from top to bottom effects every other aspect of it.  Those who make the big bucks to make the decision need to find the best balance possible.  Need more medic trucks?  Push to run a “one and one” style system.  Short on units?  Investigate the possibility of first response, or downgrading calls to allow longer response times.  While some look at unit hour utilization and time on task as two of their biggest determinant for the effectiveness of their system it is starting to become apparent to me that much of the success of an EMS system starts at its base when that phone is answered and those first first units are dispatched. Both major systems that I have worked in have utilized Emergency Medical Dispatch (EMD) and Priority Medical Dispatch (PMD) to determine response.  Or at least they have claimed to.  I feel like at this point in my career, I have experienced both ends of the spectrum and I have seen both the good and the bad. Previously, the quality of phone triage was poor.  Even if the right questions were asked, much of the determinant of response rested in the hands of a dispatcher who would read the notes of the call, shoot from the hip, and make the decision based on what they felt was going on.  If the call was for a pediatric patient, for example, the response would almost always be with lights and sirens for no other reason than “because its a kid.”  Calls were rushed and pushed to the dispatcher’s screen in a minute or less in an effort to churn them out. The system I am currently working in has a perception that they take a bit more time when prioritizing calls.  They will sit on the waiting screen sometimes for as much as two or three minutes to allow the dispatchers to make the best decision possible in order...