The Myth of Culture

Over the past couple of years I have read a few articles about the importance of living in the community that one serves.  I have seen articles championing volunteer organizations because “people like being cared for by their neighbors” or implying that those who do care for their neighbors would do a better job because of their proximity both physically and emotionally to a patient. Other articles about fire based systems for example talk about how being part of a community can allow one to know the back roads and short cuts that might shave precious seconds off of response times thus saving countless lives.  Further reading will reveal criticism of private EMS departments that come in from outside of the area and know little about the people that they are caring for.  Some feel that not living in the area that one practices medicine in can result in them caring that much less about the people that they are providing medical care for. Based on some personal experiences that I have had, I fail to see any of these as being an absolute that one should lead an argument with.  My first EMS position was in the town that I grew up in.  Island Heights, New Jersey is small, populated by maybe 1,200 people during the summer months.  It was impossible for me to go into a house on a call and not either know the patient or one of their relatives.  From there I moved some 250 miles away for college, and spent the first twelve years of my career in Springfield, Massachusetts.  I was a transplant, and as a white kid from suburbia, I did not fit the cultural makeup of the city that I worked in at all.  Neither did the vast majority of my coworkers.  Much like the majority of the workforce in EMS, we were Caucasian and majority male. Although I was not from the area I was able to learn the streets, and learn a lot about the culture as well.  Working in Springfield pushed me to improve the quality of the Spanish that I spoke, and learn a little bit about the cultures that I was...

Testing Stinks

Years ago, when discussing the precepting program at my division, somebody said, “I don’t know why we are taking so much time to evaluate these people.  They were able to pass the paramedic test that right there should tell us that they are ready for the field.”  What this person did not understand is that testing that takes place in the written and practical settings have very little to do with.  Our testing, which has evolved very little in the fifteen years that I have been a paramedic, has become so disconnected from what our profession actually does, and we need to start reevaluating it. Granted, my frame of reference is about three years old, and I am otherwise going by what I have heard third hand from people, but I can say, without a shadow of a doubt, that the practical stations that I went through in 2012 for my National Registry certification almost matched the stations I participated in back in 2000 when I received my certification in Massachusetts, the exception being the two oral stations that NREMT has added to the testing. I guess most of the credit for my performance in 2012 goes to the staff at Springfield College and the meticulous teaching of Gary Childs who was the head instructor back in 2000 who spent more than a year instilling on me the importance of things like memorizing the critical fail points of each station, ripping the tape before starting an IV, and making sure that I verbalize every single step as I do it in case an evaluator is not watching. I did, however, have to break a number of bad habits to get myself ready for the 2012 test.  I found as I walked into each station that a number of steps that I was asked to do had little to do with how I perform as a paramedic.  For example, as I freely walked around a patient and worked from all angles to apply the KED to the volunteer who was my patient, I could not help to think about not only how impractical this was, but I also wondered how many items I would have...

Video Clip: Bystander CPR

Video Clip: Bystander CPR

Apr 15, 2015

This weekend a number of friends on Facebook linked a video that was making the rounds of a person presumed to be in cardiac arrest in a car in front of a bus stop.  This scene provides with a number of important lessons.  First you see an SUV in the middle of the road with people yelling at the driver asking him if he is okay.  9-1-1 is called and somebody starts doing chest compressions on the person before removing him from the car and placing him in the road.  CPR is continued until EMS arrives.  At the end of the video you see the driver being wheeled to the ambulance sitting up appearing to be conscious on the stretcher. The video itself spans about seven minutes and I encourage everyone to take the time to watch the entire thing from beginning to end.  Some content might be difficult to watch and there is some language that might be considered offensive used by those watching the scene unfold.  Regardless of that though, there are a few lessons that I think both the EMS community and the general public can learn from this. http://medicsbk.com/wp-content/uploads/2015/04/Street-CPR.mp4   There are still people out there who are willing to help – In a world dominated by social media, Twitter and cell phones people seem to either want to record or just call for help and make a potential emergency somebody else’s problem. Seeing this video is reassurance that there are still people out there who will get their hands dirty to benefit another person.  They saw somebody in distress and they acted.  They realized that doing something is better than doing nothing. When you call 9-1-1 help is on the way almost immediately – Confusion is common. People misidentify locations in fact, I can tell you that happened here.  Once a location is confirmed help is on the way but for dispatchers that is not where their job ends.  If there is one place that a dispatcher’s role in providing prearrival instructions can save a life it is in the case of a patient in cardiac arrest.  The bystanders can insist that the caller “just tell them to come!” until...

Ethics and Cardiac Arrest Management

Ethics and Cardiac Arrest Management

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....

BLS Defibrillation: Are We Doing Enough?

BLS Defibrillation: Are We Doing Enough?

Jul 23, 2014

Recently, on the Resuscitation Facebook group, a discussion started regarding time on chest, time off chest, and the safety of defibrillation with active CPR being performed by a rescuer.   While the core of the debate and the reasons behind why and why not one would voluntarily subject themselves to an electrical shock is one that really needs more research to validate, it became clear that reducing the peri-shock pause (the time with no CPR prior to and immediately after defibrillation) could actually make the concept of receiving said shock a non-factor. The discussion quickly turned to how long five seconds was, and how long three seconds was, and how with proper training and practice, a shock could almost be delivered on an upstroke with little to no pause in CPR.  It goes without saying that time on chest is vital for cardiac arrest survival.  Pit crew CPR teaches us some techniques to best deliver effective emergency responder CPR, but I feel like we can do better. What about the other lengthy hands off time in the pre-shock period?  I am talking, of course, about the time that it takes an AED specifically to analyze the heart rhythm of a patient in cardiac arrest.  Usual analyze time for a monitor in my experience has been around 5-7 seconds depending on the model.  Once analysis is complete, many AED’s continue to announce “Stand Clear!” and start “spooling up” to their preset energy setting to prepare for a shock.  When it comes to dealing with the general public, this is, in my opinion, appropriate.  I do not expect some “Average Joe” who pulls an AED off a wall at the Mall of America to have the same ability to use it as someone who spent months (in some places a year) in an EMT class.  Public AED’s are a great thing, but why are we not putting better training and maybe simple EKG recognition skills in the hands of our BLS providers? The first time I encountered an AED was in 1994.  It was a big deal for our town.  We had one for our two ambulance first aid squad and would switch it back and forth...

Let’s Train Them

CPR is increasingly becoming a requirement for high school graduation throughout the country, and personally I could not be happier.  I love seeing news stories about this topic. When we are dispatched to a cardiac arrest in our system, one of the first questions I ask myself is “is anyone doing CPR?”  I usually find that compressions are being done in about one out of every three “workable” cardiac arrests.  More times than not, the thing most often preventing CPR being done is the fact that the caller has difficulty getting the patient from where they are to the floor. The second most frequent one is that the caller is too scared or just unwilling or unable to do it because they are too hysterical.  I completely understand this.  EMS professionals walk into these situations with training and the expectation that they will be there to bring order to the chaos.  It is what we do.  It is part of who we are and what our profession is all about.  One cannot have that same expectation of the general public. Should a bystander be willing to do CPR, and they are untrained, they will get a crash course on the phone of how to do hands only CPR in the form of prearrival instructions from an Emergency Medical Dispatch certified person on the other end of the phone.  It is virtually impossible to make sure that the person on the other end of the phone is following the instructions as they should.  Of those one third that get compressions, probably half of them are done well.  The plus side though is something is better than nothing when it comes to cardiac arrest care. Here we sit in 2014 with a generation of people (that arguably I am on the older side of being part of) who are consumed by their cell phones.  People live in their phones, and use them to make potential medical emergencies someone else’s problem.  Gone are the days of people moving away from these sorts of things.  They call, and then they stand around to see what happens.  Rarely do people get involved and try to help.  We need to...

Why So Serious?

Why So Serious?

Jun 13, 2014

This is going to be my last post on this topic.  I actually intended on posting this about a week ago, but so much has come up over the past week that I kept pushing it back.  In fact, I was going to push it back even more with my Belchertown post that I released yesterday but I figured that this one could not sit any longer. The events of the “smiling and posing” paramedics in Detroit got me thinking back to a call that I did a few years ago. We were dispatched to a very well-known diner in the city I was working in at the time.  It was one that I frequented both while at work and occasionally off the job since it was close to my house.  That morning, we were dispatched to the patient having a “diabetic issue.”  The waitress told us that our patient was a regular in their establishment.  He was an elderly male who would walk down every morning for breakfast, and was a known diabetic.  Today, he came in sweaty and disoriented, and just was not himself. While the patient could follow commands, he was just “off.”  His sugar came back at 30, so we continued where the waitress had led off: we fed him glass after glass of orange juice and some toast as well.  As our treatment of the patient progressed he became more and more alert to the point where he was conversing with and joking with us.  We laughed as he jokingly told us how much he hated needles despite having to check his sugar multiple times a day. Being a busy Saturday morning, and this being a small diner (I’m sure many of my readers from Springfield know exactly the spot that I am talking about) we were the center of attention.  I’m sure people wondered what was going on as we cracked quiet jokes and then collectively laughed.  While the digital age was just starting to really take off, not many people had cameras, and the voyeuristic society that we live in today was not yet dominating the news and the Interwebs, so no pictures of the laughing paramedics...

How an App Can Save a Life

Yesterday afternoon I received a press release from Physio Control in my email, and it is a story that I think needs to be shared.  PulsePoint, a revolutionary app designed to notify users that somebody nearby might need CPR played a key role in saving the life of a patient in Portland, Oregon. An off-duty firefighter was working out at is gym when his phone alerted him that somebody outside in the parking lot was unresponsive.  Scott Brawner of the Tualatin Valley Fire & Rescue followed the app’s map to the patient’s side.  57 year old Drew Basse was unresponsive in the gym’s parking lot and found to be pulseless and apneic.  Scott started CPR until paramedics from AMR and the Clackamas Fire Department arrived on scene. Because of the app, a trained provider of CPR was at the patient’s side in less than two minutes.  Firefighter Brawner’s actions, along with the paramedics from AMR and the fire department completed the vital chain of survival that the American Heart Association rightfully promotes as being so vital to survival in sudden cardiac arrest.  The actions of everybody involved in this call resulted in the patient, Mr. Basse’s expected full recovery. It is really remarkable what we can do with technology these days.  While there is a serious shortage of people who are willing to help in situations just like this one, there are still people out there who are willing to make a difference.  Apps like PulsePoint make that possible.  Without Scott Brawner’s presence on May 9th, there could have been a life threatening delay in an emergency where seconds truly count.  While most people would opt to call 9-1-1, and stand back to let someone else take care of the problem, Mr. Brawner allowed the trained he received as a firefighter which, coincidentally is training that anybody can receive, guide him through the treatment that his patient needed until more help arrived. It amazes me that PulsePoint is not in place in more communities around the United States.  Currently, there exists a huge gap in the chain of survival.  In-hospital care is improving.  Pre-hospital care is evolving.  The gap exists though in what happens before...

The DO’s and DON’Ts of ePCRs

I’ve been giving a lot of thought lately to what would make an EPCR system perfect for me. Most of these thoughts have stemmed from the last year that I have been using what arguably is the worst EPCR system that I have encountered out of the four that I have used. Yes, I know, four really is not that many when you consider how many products are out on the market still, the thing has a long way to go to reduce the frustration that I seem to consistently encounter. What I decided to do was create a few “Do’s and Don’ts” that might give someone developing or improving an EPCR system some things to think about when working on their product. DO have an open source coding system that will allow different products like cardiac monitors to upload their data to it with the greatest accuracy possible. Make sure that event markers line up with the wording in the monitor and if possible allow the patient information we put into the monitor (name, age, case number) to import into the chart so that it only has to be entered once. Also, allow preferences to be set for each person that can include truck number, crew member, and other information that is the same for every single shift. DON’T try to do too much of my job for me. I have never met an auto generated narrative that I like. It does not matter if it is CHART, SOAPE, or anything else that you can name, things just never seem to add up. Facts get missed, and what I see with my eyes is either left under described or completely missed. Anyone who teaches a PCR writing class will reinforce the concept that your narrative is your bread and butter. It is what will tell you the most about a call if you get called to the carpet for it years down the road. It is what will get you paid if there is a dispute with MEDICARE. Narratives are so incredibly important that they need to be left to the tech to write them, not the computer. DO have a repeat or...

I’ve Been Rogue Medic’d!

Right now, I feel like a minor internet celebrity.  I’ve been Rogue Medic’d.  That’s right, Tim Noonan, the Rogue Medic, has read one of my posts and posted a reply to it as one of his entries in his blog.  It all started last week when I shared my post as a comment to something he put up in regards to working a CPR with a LUCAS device and the relation of using epinephrine in cardiac arrests. The entry that I referenced was one that I posted a few months back about organ donation and how while not every ROSC will walk out of a hospital, we might produce the opportunity for organ donation for that patient.  While one life could be lost, others could be saved. Tim makes some excellent points in his reply to my comment.  Obviously, the job of every paramedic and EMT out there when working a cardiac arrest is to save our patient.  We want them to walk out of the hospital.  We want that chance down the road to meet them.  If that is even going to happen, we first need to achieve ROSC. My advocacy for epinephrine revolves around personal feelings based on my experience, I believe that the use of epi in cardiac arrests produces a higher ROSC rate.  More specifically, I feel that the effects of epinephrine produces ROSC in patients that we would not have gotten ROSC in.  I am mainly talking about those asystole patients and patients in an unexplained PEA.  Due to the fact that these people that are saved might not have been brought back otherwise, their long term outlook is poor. This differs from those patients that we encounter in v-fib and v-tach without pulses.  Those patients, again, in my opinion, should not get epinephrine.  The focus there should be solely on high quality CPR.  This part of my opinion is actually supported by studies. It was easy enough for me to find one from 2013 that states that while more trials are needed, detrimental effects post-cardiac arrest were greatest in patients who received epi and were in v-fib or v-tach.  So on that side, I fully support Tim’s repeated...