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...

You are the medic on a busy urban unit dispatched to a serious call of your choice (cardiac arrest, shooting, STEMI, you pick it).  You arrive on scene, and get straight to work on your patient.  IV’s are started, maybe the patient is tubed, a 12 lead is done.  Holes that were not there before the incident that are not a direct result of actions of you and your partner are plugged.  You feel like time is dragging on, and you need to get going.  The patient is loaded, and your truck rumbles off lights and sirens blazing to the closest appropriate facility. Once you arrive at the ER, the patient is turned over to their staff, and you retreat back to your truck to write your run form.  All that is going through your head is “boy, we were on scene for a while, I need to justify this.”  You sit down in front of your onboard computer in your unit and wince as you bring up your times. Your eyes, however, get big as you do the quick math, and realize that you were actually only on scene for 8 minutes.  You share your surprise with your partner and move on to your run form. Anyone who has been in this field for any amount of time has experienced an incident similar to the one above.  When an emergency happens, time just seems to slow down.  Everything moves in slow motion.  If the experience of that sensation is true for someone who is a trained medical responder, imagine what it is like for someone who has no training.  Seconds feel like a minute.  A minute feels like five.  The perception of time is so incredibly subjective.  The reality of time, however, is not. This is why we have dispatchers who track times.  This is why most of the cardiac monitors out there today have event logs that allow you to track what you do and when you do it.  This why when you arrive at the ER with just about any critical patient, there is one nurse who is dedicated to charting.  Accuracy is so important, and one must overcome that perception...

Sometimes I wonder if the debate about whether or not paramedics can and should intubate will never end.  I am happy to say though that I have successfully intubated six out of seven people since I started at my new service back in December.  They were all cardiac arrests.  Not a single one of them had a pulse at the time that I tubed them. Coincidentally, with the tools I have at my disposal, I have yet to have a patient that I have said, “Boy I really think I should intubate this person right here and right now.”  I have, on the other hand said “this person might by a tube once we get to the hospital if what I am doing doesn’t start working soon.” Every one of us has worked with an airway “guru” at some point during our career.  You know who I am talking about: that person who can tube anywhere at any time by any means necessary.  Right side up, upside down, nasally, digitally.  You name it, they have done it.  I, sadly, am not that person.  In my twelve years at a paramedic, I would best describe my ability to intubate patients as “satisfactory.”  I can get the job done.  I know enough about anatomy that I can find my way around a patient’s airway and get that tube.  I could certainly be better though. Personally, in twelve years, I can say that I can count on one hand the number of living patients that I have myself intubated.  For me, it is a practice that I have always been more conservative with.  In my old system, we were 10 minutes or less from a hospital from just about every place in my coverage area, so it was always a risk vs. benefit of the time it took to get a successful tube on the patient.  The call had to be made for the meds.  The meds had to be drawn up and then administered, and then the tube had to be passed.  In the time that all of this was taking place, the patient was being ventilated, good or bad, and time was ticking away most...

In response to a number of major incidents over the last couple of years, active shooter, WMD, and terrorism classes are once again all the rage.  I wonder sometimes though if we are putting our eggs in the right basket.  These are not the incidents that are injuring and killing providers in the field as often as altercations with a single patient, lifting injuries, and motor vehicle accidents. Maybe we need to shift our focus back to scene awareness (not scene safety).  Some of the incidents, namely the hostage incident in Georgia, was a response to a routine call that went horribly wrong when the crew arrived.  I wonder if they looked back at it though if they would identify any warning signs that they missed.  I wonder if they walked into the scene with the level of complacency that many of us do when responding to a ‘routine” emergency.  It is something every one of us have done, myself included.  We get tunnel vision.  We forget to really get a look at the room we are walking into, or ask where that vicious lhasa apso is when we see the “BEWARE OF DOG” sign on the door.  Or even something as making sure the keys are out of the ignition on the call for the unresponsive or disoriented person behind the wheel. We rely far too often on the police and assume that their presence alone means that a scene is safe when that could not be farther from the case.  I have had plenty of “we need to get out of here right now” moments on scenes that were deemed “safe” prior to my arrival.  Now that statement does not exist to take anything away from the job that they do, because personally I rely on the police for a lot.  They often are able to offer a lot of information, and while maintaining a scene is their prime responsibility, our own safety needs to be our responsibility regardless of who else is there, or what the nature of the call is. Sometimes it just takes a few simple approaches to our day to make a big difference in its outcome, and...

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. ...

Back when I was in high school I was an extremely active member of the Island Heights First Aid Squad.  Summertime was no exception.  I spent many days when I was not on the water on the ambulance running calls.  One call just before the start of my senior year of high school is a memorable one, and I was not even on it.  I think now more than ever though, it bears mentioning. There was a rather serious traffic accident on the highway that ran next to our town.  Due to a shortage of daytime crews, just like many other days, our squad was called upon to respond.  The patient was a middle aged male with shortness of breath, and belly pain.  Since he required extrication, the decision was made to fly him to the trauma center rather than drive him. From what I was told then, and can better comprehend now, he was hypotensive and had a significant amount of internal bleeding.  As with any other trauma patient in a similar condition, he got two large bore IV’s, and a boat load of fluid as he was transported by medivac to our regional trauma center.  The area of New Jersey where I was raised was very small, and through the grapevine, word came down that after his arrival at the trauma center he had passed away. We were told that due to the patient’s religious beliefs he refused a blood transfusion.  Because of his depleted volume and the seriousness of his internal injuries, without the assistance of blood products the trauma team was unable to save him. The reaction from some of my fellow EMT’s was one of sadness and anger.  Many could not understand how this man could possibly put his religious beliefs and his expectations in the afterlife above that of the life that they had worked so hard to try and save that late August afternoon.  But that is what he wanted, and the trauma center was willing to honor and respect it. A few weeks later my squad held an in-service in which they had someone of the same religion come in and answer questions about the how’s...

Apr 16, 2013

First of all I want to send out thoughts and prayers to everyone involved in yesterday’s explosion at the Boston Marathon.  It is a shame that we live in a world where we even have to deal with these incredibly tragic events, however, they also show the resilience of the American people.  We will recover, and we will overcome. In the wake of yesterday’s tragedy one thing I think everyone needs to realize is how lucky Boston is to have the men and women of Boston EMS caring for the people of their city.  In the days leading up to the Marathon, the Boston EMS Twitter was extremely active talking about the immense amount of preparation leading up to Monday morning.  From the looks of it they were ready for almost anything.  And kudos to Boston EMS for sharing that fact with the world. If nothing else, those of us in the EMS community need to walk away from this with recognition of how important preplanning is.  None of us should ever take for granted our own personal safety or the safety of any event that we cover.  No one should ever utter the words, “that will never happen here.”  Instead, take the extra time to draw up a detailed plan.  Know your staging areas, know your egress routes, and make sure that every single provider involved is aware of them as well. Another thing that needs to be pointed out that I think many people not involved in public safety lose sight of rather quickly is while this large response was going on in Copley Square the rest of Boston was still calling 9-1-1.  Boston EMS, Fire, and Police were just as busy as they were on Sunday, and just as busy as they will be today.  In my eyes, that is one of the most remarkable things about incidents like this.  Not only does the public safety community step up to deal with a major crisis at hand, they also continue to handle those routine emergencies that so frequently flood communities. While watching the news, I saw a number of different ambulances down at that scene: Cataldo, Lifeline, McCabe, AMR, and Professional...

  I was cleaning out my phone the other day and I found some pictures that I took back in November before I left Massachusetts.  On December third of 2012, Baystate Medical Center opened its new emergency room.  In the weeks prior, they were inviting paramedics and EMTs from the area to come and take tours so they would know a little more about the facility before it opened.  I attended one of these tours, and took a few shots. First of all, I have to say that the facility itself was beautiful, and while I always liked Baystate’s old ER, it was a clearly an upgrade.  While this was close to six months ago, and I am sure some might feel that the pictures would have been more relevant a post then, as I reflect back on them the staggering thing about them to me is the actual status of the emergency room when I took the shots. Much of the ER was ready to go, and probably could have taken patients that day but the place was empty.  Patient rooms were vacant, no one was in any of the nurse’s stations or pods.  Everything in their trauma room was neatly put away, and in two week’s time it would never look like this again. Baystate can be a pretty chaotic place.  As the only level 1 trauma center west of Worcester, and the region’s premiere STEMI and pediatric center it was constantly full and many times overcrowded.  To see this brand new state of the art ER completely empty was a sight to behold. In the months since it has opened, the transition has seemed to go relatively well, at least according to some of the folks that I have spoken with about it.  That is not at all surprising to me considering the quality of the nurses, doctors, and staff that work there.  Still though, kudos to them.  ...

Apr 2, 2013

First of all I would like to make it clear that what you are about to read is largely driven by my own opinions based on what I have read, and what I have seen in my years both as an EMT and a paramedic.  With enough research though, I feel confident that I could present a substantial amount of “facts” to back this up. Response times DO NOT improve ROSC rates. Directly. In article after article about response times, there is always that little asterisk that says “in MOST cases response times do not matter.”  Well, I am going to go as far to say that in ALL cases response times do not matter.  There are far more important things than response times in providing a high quality Emergency Medical Service.  I say specifically Emergency Medical Service because Skip Kirkwood made a terrific point in his comment in a recent blog post: “(An) ‘ambulance service’ is not the same thing as ‘EMS.’” Now, let’s just suppose for a second that we go with the common statement that response times improve outcomes.  An ambulance pulls out of their station or away from their street corner and goes flying across a city, or through suburbia, lights and sirens blaring, and they pull up in front of the address of a patient in cardiac arrest.  Then what?  If that ambulance makes it there in 8 minutes and 59 seconds or less, do the EMS gods simply smile, say “job well done!” and your patient is magically resuscitated?  No.  Far more goes into it than that. So if response times do not improve ROSC rates, what does make a difference?  Well, let’s start from the beginning: 1.  Public CPR education – Seattle has proven that when trained, people are willing to help.  The rest of the country should follow their example and push public education.  That does not exactly mean putting a CPR card in the back pocket of every citizen, it might just mean educating them on the importance of compressions only CPR. 2.  Public access AED’s – Again, here is another piece in the pie that rests mainly on the public.  Since I have been...

. . . And I have a picture to prove that this is not an April Fool’s joke. Twelve years as a Massachusetts paramedic.  As tough as it was to let it go, I had to do it.  That National card is in my pocket now though, which is quite the feeling of accomplishment.  If I had one piece of advise to give anyone getting into this field, or anyone who is already in this field, get your National Registry certification if you don’t already have it.  It’s worth it. But I digress. . . Thanks for a great twelve years, Massachusetts!  Best of...