Feb 3, 2015

Throughout the years, I have received a lot of advice from a lot of people.  I thought now would be a good time to share some of those quotes with you so that you might have the chance to learn from them as well. “If they’re bloody, clean them up.” – John Glowacki I’ve written about Big John before.  He was one of my first EMT instructors and had a major influence on my career, and how I practice medicine even today.  I was on a crash with him that was relatively minor, but the patient that were caring for was fixated on all of the blood covering her hands.  His point was a simple one.  Cleaning her up a bit not only would give you a better idea of where the blood is coming from, but it would also make the patient feel a little better not having to stare at what belonged on the inside that was now on the outside. Put the clipboard down.  Don’t worry about your tablet.  Leave the laptop closed.  Don’t touch any of that stuff until your patient is completely taken care of, and trying to clean them up a bit is part of that. “Rule number 1: People die. Rule number 2: Paramedics can’t do anything to change rule number 1.” – Bob Moore This is something else that I have talked about in the past.  As you may remember, Bob was one of my paramedic instructors and this was part of the speech that he gave us on the first night of class.  A few years ago, I wrote about accepting mortality and quoted Bob.  He commented on the post and shared the origin of it: In the fall of 1983, I was a NU medic student and not to brag but I did very well in class. Near the end of class we had an instructor named Joe Duecy run one of our last mega codes before exams. He put me through each and every rhythm known to man and I hung in there with the correct treatment and got the patient back with a pulse. After 30 minutes of playing with me Joe...

Jan 7, 2015

A couple of years ago I read a great article by Kelly Grayson on EMS 1 that talked about patient refusals and more specifically a person’s ability to refuse.  I liked it so much that I adapted parts of it into a refresher lecture that I did for a couple of years up in Massachusetts.  Now, almost five years later when I am back on the street, I still use portions of it as part of my refusal assessment. Kelly talked about orientation, memory, cognitive ability, and recall as ways to expand upon the old adage of “alert and oriented to person, place, time and events.”  On every patient that is going to refuse my care, and often on almost every patient that I do any sort of orientation assessment on there is one simple problem solving question that I ask them: “If I gave you two quarters and a dime, how much money would you have?”  The answer, of course, is sixty cents.  Easy, right?  I’ve run into patients though who were able to tell me who they were, where they were, and when it was, but were not able to answer that question. It also gives me another leg to stand on if someone misidentifies “time” for whatever reason.  I’ve found through the years that time is the one that is most often missed.  How many times have you asked a patient, “can you tell me what day it is?” and had them giving you a correct answer that had you looking at your partner for confirmation because you are not completely sure what day it is?  I’m a forgetful person, and it happens to me quite often. Take, for instance, a retired patient, or a patient in a nursing home.  Days might blend together for them and while they might be able to correctly identify the year, or tell you what holiday we just had or are going to have, correctly identifying the day of the week, date, or month might not be as easy as one might think.  Of course, you might ask a patient for a recent holiday, and have them answer “Christmas” and then ask them the month and...

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 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...

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...

Aug 29, 2014

As technology evolves so does the user.  The problem, however, is after a while, the user tends to become reliant on the technology.  For example, I remember when I was handed my first pulse oximeter.  It was a great new toy that I added to my BLS bag.  Boy, I thought, what did I do before I had this neat little machine?  The answer was simple though, I looked at my patient, assessed their capillary refill, and their work of breathing.  As my career has progressed, I have become less and less dependent on pulse oximetry and more dependent on my assessment.  But this post is not about pulse oximeters, it is about automatic blood pressure cuffs. Have you ever walked in to an emergency room bay with an agitated, hypoxic patient and turned them over to the ER staff, and seen them slap on an automatic cuff only to get a reading of 160/120?  What do they do then?  Document it and move on with their treatment.  Is that BP true?  Probably not, since your ears got 140/90 the whole way to the hospital.  The fact is, many ERs that I have been in have become reliant on their auto cuffs, and EMS is following in suit. LP-15’s, the Zoll X-Series, the new Phillips monitors, they all come equipped with auto cuffs and personally, I have never found one that I liked.  In a 15 minute transport time, especially when I am giving medications, I would much rather take a blood pressure with my own ears than rely on a machine that in my experience, more times than not gives me an inaccurate reading. Some people have developed a system for using their auto cuffs.  If the BP is close to the one they got manually, they’ll go with it.  But what happens when you are bouncing down the highway with a chest pain patient giving nitroglycerine to a chest pain patient?  Are they still hemodynamically stable or did that second sublingual bottom their pressure out? You might think you have the full story, but that auto cuff could be lying to you. The reasons for an inaccurate reading on an auto cuff...

Aug 26, 2014

As if the debates about arming EMS personnel and merging fire and EMS weren’t enough, I decided to take a stab at sharing my thoughts on another controversial one this week.  Of all of the skills and medications that a paramedic possesses in their toolbox, there is none that they are more protective of than intubation.  There is an almost constant debate not only in the EMS community but the medical community as well as to whether or not paramedics are good enough at intubation to be proficient at the skill, and do they use it enough to make it worthwhile for them to keep it?  Last week, Sean Eddy had a great take on this over at Medic Madness, and I thought that I would add my two cents to the discussion. As our field has evolved, we are intubating people less and less every year.  I like to say that intubation has gone from a life saving procedure to a life sustaining one.  More times than not, on the rare occasions where I intubate non-cardiac arrest patients I find myself doing so to protect their existing airway rather than to improve their oxygenation.  CPAP has changed the archaic treatment of CHF patients particularly that used to result in paramedics high fiving each other in the parking lot of the ER as their field intubated patients struggled to ween themselves off of ICU ventilators.  We used to think that nitroglycerin, morphine, and lasix with some PRN orders for versed was the way to go.  It’s not!  Who knew? There have been studies done over the last fifteen years, many of them recommending the cessation of field intubations after having retrospectively looked at success rates particularly among those incidents where a patient was turned over to the ER with an esophageal intubation, or as one resident in my current system likes to refer to it, they “stuck the tube in the goose.”  While I realize that studies like these take time to complete, maybe they are looking at the wrong things. A better take on the intubation debate would be to look at not only overall success rates but how quickly missed intubations are recognized, and...

Aug 15, 2014

Is potentially not saving one patient a worthwhile sacrifice if that loss helps pave the way for future saves?  Is this ethical?  These are two questions that Warwick University in England is having to tackle as they prepare to involuntarily enlist patients in a study to find out how effective epinephrine is in helping achieve ROSC and favorable long term outcomes.  While long overdue, a study like this toes a fine line between what is ethical and the opportunity to answer a long debated question of whether or not epinephrine actually makes a difference in cardiac arrest.  The results of this study could pave the way for some major changes in cardiac arrest management. The study will evaluate 8,000 out of hospital cardiac arrests with patient either receiving epinephrine or a placebo with outcomes evaluated after the arrest.  The problem with studies on cardiac arrest is there will be a patient population that you just don’t get back and others where we achieve ROSC with very few interventions at all.  In other words, sometimes even if you throw everything including the kitchen sink at a patient who arrests right in front of you, you still might not get them back.  Still though, if things go as they hope they will, England could see an improvement on their dismal 6% out of hospital ROSC rate. I am sure that despite overwhelming support from the medical community in England, some will try and poke holes in the ethical aspect of this study.  When any medic hears the words “CPR in progress” we immediately shift gears, and many of us will turn up the intensity and focus a notch or two.  We know what the task at hand is.  This is our bread and butter, it is what we are trained for.  It is a true medical emergency.  The prospect of possibly not doing everything we can for a patient in cardiac arrest is one that some will struggle with.  When looking at the bigger picture though, with the right evidence the results of this study could be earth shaking. Personally though, I am happy that someone has finally built up enough guts to tackle this one....