Nov 17, 2014

If you ever want to get under an EMT’s skin, call him an ambulance driver.  The resulting rage, either in front of you or via social media later will tell a lot about them.  I was having a discussion last week at EMS World with a couple of friends kicking around a silly idea to host a bar crawl that required everyone to either wear one of those god awful EMS slogan t-shirts, or make their own to be able to participate.  My nurse friend who was part of the conversation just shook her head and said, “and people wonder why EMS struggles as an industry to get ahead.” I understood what she meant, we have always been, and seemingly will continue to be our own worst enemies.  Then, while waiting in the airport with a friend, the two of us were flipping through some industry centered Facebook pages having some laughs over some of the comments that people were posting on shared articles.  “I don’t know if I am reading comments from EMTs or YouTube comments,” is what he likes to say. We sat there over lunch and tried to figure out where this attitude is born from.  Is it a product of people’s environments and predispositions?  Is it due to people just being Type-A personalities in this field?  Or is it just general immaturity? Maybe we are over-recruiting.  It is no secret that if you are an EMT with a card in your back pocket for twenty years or twenty minutes, you can find employment somewhere.  It might not be the greatest job in the world, and it might not be an endpoint for your career but the opportunities are out there, it is just a matter of what a person is willing to settle for.  Its not really an industry recruiting problem, it is more of a lack of standards when it comes to recruiting.  And exposing impressionable younger people to the folks who have the wrong attitude just makes it more difficult to break this cycle of disrespect and immaturity. Anyone who knows me personally will confirm that I am, in fact, a huge goofball.  I can be inappropriate with...

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 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 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...

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...