The Silver Lining of Epi

I was out with some coworkers for some frosty beverages last night in celebration of a friend’s birthday, and of course, predictably, the conversation turned to our profession.  We got talking about how we handle and respond to cardiac arrests, and mainly the medications that we give.  While we are all proud of our 40% ROSC rate, one of my friends made a bold, and not complete unexpected comment, “I think we need to get rid of epinephrine.” It is an argument that has been made by numerous people, including my friend the Rogue Medic, and it is one that is not completely unfounded.  Patients who receive epinephrine in cardiac arrests have worse outcomes.  To me, that is not completely surprising.  Personally, I feel that patients who we save with epi are people we would have not gotten back without it.  That statement might be slightly confusing, but as far as I am concerned, people with better outcomes without epi have those improved outcomes because their cardiac arrest was intervened with sooner, and the underlying cause was one that made them an easier save. So now we have these ROSC patients who end up with poor long term outcomes and some who might not even make it out of the hospital.  We are saving people only to put them in a vegetative state, or only prolong their lives for a short time, right?  One might think so. . . Then I looked a couple of seats down at the bar, and the whole purpose of epi, and the entire argument became clear to me.  We were joined that night by and celebrating the birthday of, a former paramedic who gave up her career to go into organ procurement and transplantation.  When we brought in one of these patients that was expected to have a poor or short outcome, which is when her company got involved.  They match donors to transplant recipients and get the ball rolling with screening and dealing with a family.  Her company and profession have saved countless lives over the years. If our documented ROSC rate tells us we are “saving” four of out every ten cardiac arrests, let’s say, for...

“Send Them In”

By now, the New York Times article from last week has made its rounds in the EMS online community.  If you have not read it, I will give you the short version.  Based on the response to the Boston Marathon as well as some other high priority incidents, Federal Emergency Management Agency released new guidelines this past September in regards to the response of first responders to active shooter incidents.  The new recommendations revolve around what FEMA’s fire administrator Ernest Mitchell Jr refers to as “risk a little to save a little, risk a lot to save a lot.”  According to FEMA, risking a lot means sending EMS responders into the “warm zone” of an incident to treat and extricate patients. Most of the article revolves around one particular paragraph of the seventeen page document: b. While the community-accepted practice has been staging assets at a safe distance (usually out of line-of-sight) until a perimeter is established and all threats are neutralized, considerations should be made for more aggressive EMS operations in areas of higher but mitigated risk to ensure casualties can be rapidly retrieved, triaged, treated and evacuated. Rapid triage and treatment are critical to survival. Rush in, keep your heads down, and get out safe.  They have not completely ignored our safety, however, adding a few lines later: d. If exposed to gunfire, explosions or threats, withdraw to a safe area. e. Consider/Investigate the use of apparatus’ solid parts such as motor, pump, water tank and wheels as cover in the hot zone. Understand the difference between cover (protection from direct fire) and concealment (protection from observation). f. Remove victims from the danger zone in a manner consistent with predetermined agency training and standards of practice. LE officers may bypass casualties in order to eliminate the threat. Recommendation “f” leaves me with some hope that there eventually will be more mandated training and education for EMS providers, but the document seems to largely ignore any mandation of this.  There are, however, recommendations made in regards to what FEMA feels should be addressed when planning, and developing standard operating procedures.  For example, much of the treatment modalities recommended revolve around tactical emergency casualty...

A Question About Violence

I have been giving some thought to the recent events in Springfield involving an ambulance being struck by bullets, and a rather real looking BB gun being pulled on a tech in the back of an ambulance.  That, along with the law passed this year in Delaware got me thinking, and i figured I would pose a question of the readers. If an EMT or paramedic is assaulted, where should the responsibility of filing charges fall?  Should services have a zero tolerance policy regarding violence against their employees?  Should they be encouraged to strongly advocate for their employees with law enforcement and encourage their people to file charges, assisting them along the way?  Or should they take a hands off approach and leave the decision and procedure of pressing charges to their individual employee? So, what do you think? Share...

Washington, DC – The Struggle Continues

This past week, Washington DC finally took a step in the right direction by hiring what they call “civilian paramedics.”  While I am not a huge fan of the term they use for their new employees, I cannot help but stand up and applaud their move to hire staff that can be 100% dedicated to addressing the department’s shortages. I have seen a lot of numbers of the past week: 38 paramedics on a shift with only 14 in ambulances.  80% of the department’s 160,000 calls medical in nature.  Trucks out of service.  Running out of gas.  Catching on fire.  Lately, it has been one horror story after another for DCFEMS.  While hiring paramedics seems like a logical move, one city councilman went as far to call it a “step in the backwards” for the department.  City Councilman Phil Mendelson was part of the Rosenbaum Commission which, in response to the assault and death of New York Times reporter David Rosenbaum.  That commission was a driving force in the cross-training of EMS personnel, and the overall integration of the fire and EMS systems in the nation’s capital. The circumstances surrounding Rosenbaum’s death seem more to me to be driven by complacency and burnout than the failure of the EMS system.  The EMTs involved failed to recognize a serious medical emergency and wrote the patient off as being drunk.  Because of this, he did not get the care that he needed.  The only place where the system failed was by not having the EMTs that initially responded to the call properly prepared for what they encountered. Now, almost six years after that committee’s recommendation, it is easy to see that the changes that were aimed at improving the system have failed.  The biggest sign of this is not the response times.  It’s not the number of trucks out of service.  It is the number of overworked and underappreciated paramedics who carried 80% of the department’s volume who have left the department because they have seen the writing on the wall.  The time for change clearly is now. Many have called for the firing of Chief Kenneth Ellerbe.  Some would even argue that due to his...

Just a Typical Call. . .

Imagine if you will. . . It’s a typical day for you.   You came into work, just like any other shift, you got assigned your truck, and you hit the streets.  You did a few calls, here and there, mostly routine, you transported them, finished your paperwork for each, and got yourself back on the road.  Then, you are dispatched to a male in crisis. You arrive on scene, just like any other call to find the depressed, suicidal, and slightly intoxicated patient.  You put him on the stretcher, and place his bag on his lap and load him into the ambulance.  Initially, your patient is calm and cooperative, so you hop in back, sit on the bench seat, and get on your way to the city hospital, just like any other call. Without warning, the patient goes into his bag and pulls from it a black handgun.  A scuffle ensues, and you are able to disarm the patient, restrain him and finish the transport.  After removing your heart from your stomach, you inspect the gun and find it to be a BB gun.  Regardless though, you feared for your life, and you are assured that after being medically cleared, the patient will be dealt with by the proper authorities. This really happened to a good friend of mine.  Lucky for him and his family, he was fine.  The outcome of the patient, or rather the assailant, however, is unknown to me. Safety is a growing issue.  Recently, a Jersey City EMT had a knife pulled on them in the back of an ambulance.  They were able to dodge the first swipe, sustaining only a minor laceration, but the party they were transporting then impaled the knife in the EMT’s shoulder.  Fortunately, the injuries sustained by the EMT were not serious, and according to an article I read, they will be fine. An official in Jersey City made some eye opening comments in the article.  Robert Luckritz, the Director of Jersey City Medical Center Emergency Medical Services said that “some EMTs accept it as part of the job.”  He went on to add that “it is relatively common that EMTs are assaulted and it...

Is It All About the Money?

EMS is currently at a major crossroads as an industry.  Across the country requirements to become a paramedic are becoming loftier, and rightfully so.  In order to properly care for each patient we encounter, we need to be at our best, and the route to that is through training and that bar is being raised.  More education eventually should mean more pay, and some in the private sector are starting to realize that. This is evident from the recent well publicized labor dispute in Buffalo, New York and their eventual 10 hour work stoppage followed by a contract settlement.  From the publicity I have seen regarding those negotiations and others I have more intimate knowledge of, it leaves little to the imagination as to what is most important to EMS professionals: pay and benefits.  I know, that seems like a slam dunk, no brainer, but it also seems clear that at least in the private sector, purse strings are becoming tighter, and benefit packages are less and less appealing.  It’s quite the conundrum, actually.  Increasing educational requirements are driving paramedicine towards being a career, yet employers are still far too often looking at employees with the expectation that they have a job, and there is a divide the size of the Grand Canyon between the two. Now, the jury is still out for me on work actions such as strikes.  I do not really know if they truly follow the “spirit” of our profession and seem to do more of a disservice to the community than they do benefit the worker, but that is a debate for another time.  The fact remains that they happen, and there is certainly reason behind them, as evident by the Buffalo, NY Rural Metro incident. While the private sector is just one of a number of EMS models, it is quite often the quickest path of entry into the industry and employs more EMTs and paramedics than any other model, so discussing the big kid on the block is extremely important.  With health care taking on a huge for profit presence in the economic world, everyone wants their piece and if some of the bigger players want to...

Revisiting Skill Dilution

A little over a year ago, I tackled the concept of “skill dilution” and its validity as a statement, and reality in the field.  My perception at that time was that a more important component to focus on instead of skill dilution was education for our paramedics.  While I still stand by the concept that we need to better prepare our medics for what they will encounter when they hit the streets, my views of skill dilution have changed a bit. The EMS system in Massachusetts is quite different from the one that I currently working in.  I know, that is no shocking revelation since it has been said to exhaustion that “if you’ve seen one EMS system, you’ve seen one EMS system” but I find the uniqueness of my current situation interesting in comparison to where I was.  The easiest way to look at it is by evaluating both environments on a county-wide basis. On a common day, Hampden County, Massachusetts has approximately 25 paramedic level ambulances protecting its citizens.  They respond to emergencies for the most part regardless of the complaint.  Everyone gets the same opportunity to have the most advanced care available to a sick person regardless of what the caller told the dispatcher, or what the Emergency Medical Dispatch (EMD) code says is the appropriate response for that incident.  Do you have a splinter?  You’ll most likely get a paramedic.  Are you having chest pain?  You’ll most likely get a paramedic.  That paramedic’s partner, however, could be an EMT, an intermediate, or even a paramedic.  All that Massachusetts requires is one paramedic to make an ambulance an ALS level ambulance. In the county I work in now, there are nine paramedic units for the entire county.  None of us transport.  We respond to only ALS level calls as determined by EMD codes, and we are supplemented by approximately 30 BLS level ambulances.  I do not know the exact number, but to me, that “feels” about right.  Every paramedic unit is staffed with two paramedics, and the state requires that each ALS appropriate 9-1-1 call gets at least two paramedics. According to the 2010 census (and Wikipedia), there were about 463,000...

Some Thoughts about EMS Week

I am writing this post today because I feel that I have been inexcusably quiet during EMS Week this year.  I do not want anyone out there to think that I am “anti-EMS Week” if you will.  Personally, I feel that we all deserve recognition year round, not just during one week out of the year.  We contribute to society every day, so why not recognize us more often, right? Throughout my years in EMS I have participated in a lot of EMS Week events.  I have been to banquets, had breakfasts, lunches, even dinners provided to me by employers and organizations to say “thank you” for another hard year’s work.  This year, I am with a different organization and my experience this year was a bit different and enlightening. Sure, we had a cookout, which was great.  Nothing like burgers and ‘dogs on a warm pre-summer day, but this past Monday, I got to dress up in my Class-A’s and have my mother pin my badge on me during an appointment and graduation ceremony put on every year for the new paramedics to join the organization.  It was a great experience, complete with bagpipes, drums, a color guard, and plenty of speakers, and I took a great deal of pride to have the honor to stand up there, but there was another group there that I think this event meant more to. The real winners Monday night were our families.  While the organization was saying, “thank you for being one of our paramedics” to us, the more important message was the “thank you” they were extending to our families for the time we sacrifice away from them.  They are the ones who have to put up with the time we spend working during holidays, and birthdays, and anniversaries.  I feel sometimes that our loved ones deserve the biggest pat on the back, so let this be my “THANK YOU” to all of you. It got me thinking about what other missed opportunities we, as an industry, have during each and every annual EMS Week and I can’t help but feel like taking the opportunity to educate the public is probably the biggest one. ...

Advocacy: It’s That Time

Another year has gone by, and it is time for the third annual EMS on the Hill Day!  Unfortunately, I am not going to be participating this year, but that does not diminish the need to stress the importance of advocacy not just this week, but year round. There are decisions that need to be made that are not made by EMTs, paramedics, or their services’ leadership.  They are championed, led, and voted on by senators and congressmen who act largely on their gut, and information given to them by their staff.  It is our responsibility as a community to make sure that they are getting the right information.  While year-round advocacy is vital, EMS on the Hill Day gives us a chance to take Capitol Hill by storm and share with them in one unified voice to talk to our representatives and lawmakers about issues that are important to us and our future. Take a look at this video from NAEMT about last year’s EMS on the Hill Day.  And yes, that’s me. Share...

Innovation

I posted a question on my Facebook page asking my followers what they felt the “most innovative change” was that they have seen during their career in EMS.  To date, I have gotten 26 responses of varying degrees of seriousness but the most common one that I have seen is prehospital CPAP.  In fact, one nurse even weighed in with that answer.  I decided to do some research and see what else I could find out about the topic. I remember being an EMT in New Jersey home for the summer back in 1999 and watching the LIFE paramedics pull out a large bag with their CPAP setup out of the trunk of their unit.  It was admittedly an intimidating piece of machinery to me.  CPAP in my home system in Massachusetts was as foreign as prehospital 12-Lead EKG’s were at that time.  We did not get LP-12’s until 2002 or 2003. When I did a Google search for prehospital CPAP, I found an article from EMS World written in 2005 by my good friend Bob Sullivan outlining its use, why it is effective, and why it is so important to start CPAP sooner rather than later.  Some of his references in the article date back to as early as 2000.  The proof has been in the pudding for years, CPAP works. Why then did it take a special project waiver and two years of evaluations to get it approved for use by paramedics in Massachusetts?  Randy Cushing, a paramedic with the Agawam Fire Department was one of the leaders in the push for prehospital CPAP and his efforts finally paid off in 2010 when the change went through in the state protocols giving paramedics standing orders for prehospital CPAP.  Eleven years after I was seeing it used in New Jersey.  Five years after the article, one of many, was posted about its effectiveness in prehospital care.  This leads me to make the broad conclusion that in 2013, there are still probably some systems out there that don’t use it, or haven’t gotten full approval to use it yet. This makes me think about studies such as the one that compared usage of IM...