If anyone ever asked me what the internet was, I would tell them that it is a series of fads.  Ideas, popular websites, and social media networks come and go sometimes at the blink of an eye.  Does anyone remember Myspace?  I didn’t think so. . . There is one fad though that has come about in the last three years that needs to be recognized, and people need to be reminded that it is still there.  While some might say it is not for them, the EMS 2.0 movement actually lives in all of us.  Any EMT or paramedic who has ever said “I think I have a better way to do this” deep down shares his or her beliefs with Justin Schorr, Chris Kaiser, and everyone else who had input into that initial manifesto. I was reminded the other day that although it might be quieter than it was a few years ago, people are still talking and sharing about EMS 2.0.  I was in a uniform shop in a remote town getting fitted for my new threads, and there, in a cabinet with about forty or fifty patches from police departments and fire departments from the surrounding states was an EMS 2.0 patch.  I do not know how it got there, but I do know that it was not from Justin, Setla, Random or myself.  Someone walked into that uniform shop, and said “hey, I’ve got a patch for you.”  And knowing the people that carry those patches and pins around with them, that was followed with “Let me tell you a bit about it.” Currently, the blueprint for the rebooting and redesign of EMS is a simple one.  All we need to do is find what works for our particular system.  Start with something simple.  Explore alternate treatment options, or rethink staffing and response.  Realistically, it could be anything. There are questions to be answered about the future of our profession, and it is our responsibility as the current crop of prehospital providers to decide for ourselves where we want to be in the next ten or fifteen years because in ten to fifteen years, we are going to be...

Please be advised that the video does contain some language which might not be suitable for all viewers. In case anyone hadn’t realized it by now I am a huge fan of the HBO series The Wire.  I think it was one of the best directed, written, and acted shows I have ever seen.  I own every season on DVD, and I think I’ve been through every episode two or three times.  This is one of my favorite scenes, and I feel like it presents an interesting metaphor. Think of the desk as the current state of EMS today.  Everyone has an agenda for it, and has the intention of moving it in the direction that they feel it should go, whether that is where it belongs or not.  The one person who has the knowledge for the desk’s proper destination fails to speak up simply assuming that everyone else around him is already in the know, which they aren’t.  So he starts pushing.  From the opposite side, they start pushing.  More people arrive and decide that they know what is best, they take up their positions and start pushing as well.  What are you left with?  One big stalemate.  No progress. So what’s the answer?  In the video it is simple: everyone needs to shut up and decide as a group what needs to be done, and how to do it the right way.  In real life it is a bit more complicated.  We need a unified direction, and we lack that.  The NFPA sets one standard while evidence based medicine suggests another.  Some preach prevention and proactive medicine while others still insist on code 3 responses by multiple agencies to nearly every request for assistance.  Which is it going to be?  Do we want a fast, timely response or one more gauged towards what is medically efficient? Let’s pick one and stick with...

For the past two semesters, I have had the pleasure of doing the opening lecture to an EMT class at a local college.  This means I get to stand in front of a lecture hall of enthusiastic and often terrified EMT students who have no idea what to expect.  My lecture is called “So, You Want to be an EMT?”  Its purpose is to give the students an idea of what to expect out of EMS both as a career and as a provider.  I do not talk about patient care all that much, the lecture is more about stress management, the qualities that an EMT needs, what calls are really like, and also a generalized 50,000 foot view of EMS. In addition to all of that, I also talk about finding the right fit.  I explain to them that one of the beauties of EMS is if you don’t like the system that you are in, all you need to do is drive down the road and you can find someplace else to start over that might work a little better for you.  In the recent months that has been something that I have had to tackle as well, and it has left me asking myself a simple question: “what is the perfect EMS system for me?”  What I have tried to do is sum it up into five qualities.  Here is what I came up with: 1.  EMS centered – I want a system that is dedicated to EMS.  They need to be focused on patient care and encouraging the growth of their providers.  The focus cannot be on profit, justifying call volume or fire surpression.  It needs to be all EMS all the time. 2.  Horizontal career opportunities – This was a term that I heard Skip Kirkwood use a couple of years ago during a lecture at EMS Today.  The career path in EMS cannot and should not be solely vertical.  There needs to be opportunities for the street level providers to contribute to the organization with steering committees, study groups and assignments beyond the street.  This creates an environment where paramedics are encouraged to be involved with the growth...

Since it is EMS week, I decided to take some time and look back over my career.  This is my nineteenth EMS week which is a staggering statistic for me.  I knew from day one that I loved this field, but there was a part of me that always doubted that I would stick with it as long as I have. I have picked up a lot of hobbies and side projects over the years but nothing has stuck with me the way that EMS has.  From the first day that I was eligible to get on ambulance that has been where I have wanted to be.  It is hard for me to pin point one reason as my motivation has changed as I have evolved and progressed in my career.  On that first call I think that it was the adrenalin rush.  It was being involved in that emergency and stepping up and seeing it through to the end.  I remember watching the paramedics working out of Community Medical Center and thinking of them almost as gods.  I was always amazed at what they were able to do.  They were larger than life to me, and I could never imagine myself being in their shoes. Once I got my paramedic card in the mail, I was motivated by all of the new things that I would be able to try, but I was also terrified.  I remember sitting in my car getting ready to head into work for my first shift as a cleared paramedic, dry heaving in the parking lot because I was so nervous.  I saw great opportunity in what I was doing, but I also saw great responsibility, and having that responsibility was very scary for me, and I feel like that showed through in my medicine for the first year or two that I was a practicing paramedic.  I could be quite high strung and on edge at times. As I got more comfortable though I feel like I progressed into a pretty decent paramedic.  I was not the strongest by far, but when I was unsure of something, I was always quick to ask.  I knew my limits,...

There has been a topic that has been bothering me for quite a while now, and I feel it is time for me to weigh in on it. One of my favorite shows that has ever been on TV was HBO’s miniseries A Band of Brothers, based on Stephen Ambrose’s book of the same name about Easy Company of the 506th Parachute Infantry Regiment in World War II.  In one of the show’s best episodes, the company’s medic is forced to ration medications and supplies so as to provide as best he can for The result is him having to hoard morphine for the more severely injured soldiers and carefully consider his treatments and who gets them and who does not.  I have watched that particular episode many times and thought to myself that I could never imagine having to make those decisions.  I always felt that in medicine, everyone deserved the same care, whether it be in the form of life saving medications, supplies, or pain management. Now, here I am, almost 70 years later, and I am on the verge of being forced to stare at a drug bag with expiring medications that cannot be replaced, and having to choose between morphine and the far superior fentanyl based on what I feel my patient’s needs are.  But who really is to blame? One of the greatest tragedies in this country is the profit machine that is health care.  It exists on every level from insurance companies to hospitals to manufacturers of medical equipment to the big bad drug companies and even to prehospital ambulance services.  In fact, I am not a fan of any ambulance service being referred to as “for profit.”  The fact is whether an ambulance service is privately owned, classified as a non-profit, fire based, third service, or any other model that sends out a bill they are, in fact, in the EMS business to make some sort of profit.  But I digress. Some drug manufacturers have decided to stop producing certain medications because regulations and quality controls have become so strict that without a significant price increase, the profit that they can make from these drugs becomes little...

Recently, Austin Travis County started hiring EMT Basics to work with their paramedics in order to create more units in the system and reduce what is commonly referred to as “skill dilution.”  But what is skill dilution?  Does it even exist, and should we worry about it? I started my career in suburban NJ, a state that, at the time, mandated that every paramedic unit in the state be staffed by two paramedics, operating out of a hospital or under a hospital’s license as an intercept unit.  In my county there were five paramedic units which grew to six, and eventually seven during the summer months.  Seven units staffed for the entire population of the county.  The medics on the truck would commonly take turns tech’ing calls, splitting the work down the middle.  I must say, and I’m sure many would agree, the paramedics that I saw working over the years for LIFE EMS out of Community Medical Center in Toms River, New Jersey were some of the most skilled providers I have ever seen. As time has progressed though, and I have been exposed to different systems, I see paramedic/EMT trucks more and more.  Call them what you like: P/B; 1-and-1; Medic/EMT, but it is all done with a few ideals in mind: to expand coverage, and to give them more chances at patient contacts.  I wonder sometimes though if it really truly makes a difference, and I also wonder about the consequences. For example: if patient contacts are so important to the ability of a paramedic to be able to provide care, then does that mean that urban paramedics who may see as many as ten times the patients that a rural paramedic sees in a given year as superior providers? And what about burnout?  Those of us who work P/B often have had those days when 75% or even 100% of the patients require a paramedic’s care.  When those days turn into weeks, and the overtime mounts up, those borderline BLS/ALS patients can slip through the cracks.  Running P/P trucks gives a system the chance to have a paramedic at a patient’s side from contact to turnover on every call.  If...

No, this is not an article in favor of bringing back the Super Size to McDonald’s.  What I am talking about is creating a strong base for an EMS organization. What does it mean for someone to grow within their career?  In EMS, for the most part, that refers to any upward movement that someone might have.  For a field provider, that mostly means that they will end up in one of two places: supervision and leadership, or clinical services.  We either lead or we teach.  But is there enough for people who have no interest in doing either of those?  And because we lack options, are we losing people to other professions?  I’ve heard it before: when someone gets that rocker on their shoulder that says “paramedic” the immediate reaction is “I’ve made it.”  Well, why should being a field paramedic be the be all end all for someone who does not aspire for a life with any more upward movement.  It is not a glass ceiling that is holding us back in EMS, its glass walls. Some services have done a great job of developing what Skip Kirkwood refers to as horizontal employment opportunities.  That is to say: there are other opportunities for employees to use their skill at their level that does not require upward movement.  Down at Wake County EMS, they do a large number of standbys for some of the colleges in the area, and offer other options such as bike teams, tactical EMS, an increase in HAZMAT training among other things.  The hope is that it keeps things fresh and new for their field providers and keeps them from becoming stagnant in their current position in the organization. With these horizontal opportunities comes a chance to obtain continuing education credits on topics that were previously not available thus helping to solve the current often point and click or wink and nod status of many (not all) EMS educational opportunities.  Most of all, there is an opportunity to try something new and different.  It promotes growth, outwardly, much like the nursing field does.  Not every RN works in a nursing home, an emergency room, or a doctor’s office.  They...

As I sat having breakfast and reading through the previous day’s news on the internet, a Tweet popped up on my other monitor from Greg Friese about a news article from the Wall Street Journal with the title of The Ultimate Lifesaver about advances in prehospital care outlining how services themselves are the ones who are driving these changes for their communities.  The article, written by Laura Landro, is part of an ongoing series called “The Informed Patient” and I must say, I am impressed with what I’ve read. The most impressive thing about this week’s article is how much Ms. Landro immerses herself into the EMS on a nationwide level, outlining not only the accomplishments that we have made as an industry but also the challenges.  For example: in a video interview, Ms. Landro states that “If you see one EMS system you have seen one EMS system.” The reporting that often takes place when it comes to EMS is most often based on assumptions.  People do not know what happens in the back of the ambulance (because we fail to educate them on this) so they make it up as they go along.  Because of the fear of HIPAA laws, the view of EMS is often from the outside of the rig, and not where it should be: right from the patient’s side.  Without getting right in there and “gloving up” herself, Ms. Landro has succeeded in getting the right story about what is going on in EMS. Ultimately though, she has called us out in the article.  While a lay person might take a lot of positive from what they’ve read, what she has shown us is the gross disparity of what goes on around the country.  Seattle’s CPR save rate should never be five times that of Alabama’s.  Pro Ambulance in Cambridge Massachusetts should have every resource available to them that the Phoenix Fire Department does on the other side of the country.  The only thing different about a cardiac arrest in San Francisco and Springfield, Massachusetts is the way that we handle them. Best practices, folks.  That is what this article should steer us towards.  We need to look...

Friday afternoon while I was checking my email I that I had a new e-mail from the Commonwealth of Massachusetts’ Office of Emergency Medical Services.  Every year around this time they like to send out any pending protocol changes that are being released with the annual March 1st updates.  Version 10.01, due go into effect on March 1, 2012 has a great new edition that I am very excited about. On the summary sheet of expected changes, protocol 1.6 for Post Resuscitative Care had the following addition: Mandating therapeutic hypothermia do not delay transport.  hyperlinked to Appendix V. While the state might need some work on their punctuation and capitalization, I was excited to see that Therapeutic Hypothermia was being added to our scope of practice.  I moved down to Appendix V to see what was in store for me in the coming year.  The new protocol describes the implementation, necessity and reasoning for the use of prehospital hypothermia in the following way: Cardiac arrest patients of medical etiology, who have responded to ACLS resuscitation efforts of any rhythm and demonstrate restored cardiac output and hemodynamic stability, but subsequently display signs of severe ischemic brain injury or coma, are candidates for instituting therapeutic hypothermia. Statistics show a significant number of those who survive out of hospital sudden cardiac arrest suffer from residual ischemic brain injury following cardiopulmonary resuscitation. The return of spontaneous circulation (ROSC), while resulting in the reperfusion of vital organs and the re-oxygenation of tissue, is thought to trigger destructive chemical reactions within brain cells limiting neurological recovery. The process of instituting early external and internal cooling efforts and maintaining mild hypothermia (32-34° C) in the first 12- 24 hours has been demonstrated to be a beneficial treatment adjunct in protecting the neurological function of cardiac arrest victims and improving patient outcomes.  Therapeutic induced hypothermia has been shown to be of significant benefit to select patients; continuation in-hospital is essential to its benefit, and may be a factor in hospital destination decisions by medical control. They get it.  All of the work done by services such as Wake County EMS, MedStar in Fort Worth, Texas and countless others is finally making a...

    When I was fifteen years old, the first ambulance that I set foot on was a 1984 slant sided Braun.  That truck, 219, was a beast.  Gas powered with two tanks that it would guzzle on a Summer day, and to better make sure it was plugged in when you left the station because if you didn’t, it would be dead as a doornail for the next call and you’d be forced to take the van one bay over.  Nobody wanted to take the van. The back of the truck was typical for your smaller box truck.  The s tretcher was side mounted to the left hand wall with a bench seat running down the side and the airway seat where you would expect it to be.  There was really nothing unusual or breathtaking about the back of the truck.  About a year into my time, the dreaded van was replaced with a 1994 Horton ambulance with a center mounted stretcher, but otherwise nothing remarkable to it.  219 was remounted sometime after the turn of the century, and that 1994 Horton, 218, was replaced in 2007 with a brand new Horton ambulance, ready to keep the populace of Island Heights safe. Now, in 2011, 218 and 219 still sit in their respective bays.  219 is still that remounted 1984 box on a new chassis, and 218 is that pristine 2007 Horton, 23 years younger than its big brother just a few feet away.  Here is the problem: if you open up the back doors of each of the trucks, you will find that they are alarmingly similar.  That’s right: 23 years of history, zero progress.  218 still has that same center mounted stretcher, much like its 1994 predecessor did.  The bench seat is still running down the right side, airway seat still in the same spot that it was not only in the old truck, but also in 219.  No bucket seats.  No advanced restraint systems.  No harnesses.  No steps taken to make the providers safer in the back of the ambulance.  Just the same old lap belts.     Now, compare it to the back of an ambulance from “across the...