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...

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...

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...

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...

For the first twelve years of my career the answer to most questions was “just take them to the hospital.”  Don’t know what’s wrong with them?  Take them to the hospital. Paramedics and EMTs seemingly start to “over think” calls?  Stop thinking and take them to the hospital. A certain facility doesn’t want our medics to do anything for the patients?  Just get them in the truck and take them to the hospital. More times than not “take them to the hospital” is at least a functional answer.  Whether they need to be there or not a trip to the ER either delivers the patient to definitive care or makes them someone else’s problem.  Oh, and did I mention that taking them to the hospital allows a department to bill for the call as well?  It does.  Or at least it did in my former service, but that is another discussion all together. The big question though is what do we do when taking them to the hospital does not benefit our patients?  Who am I talking about?  Our cardiac arrest patients of course. By now many of the readers have seen Tom Bouthillet’s picture of the “Resuscitation Fairy” who magically revives our patients when we deliver them to the ER.   While Tom and I don’t always see eye to eye on issues in our industry, I feel like we are not only on the same page, but the same paragraph when it comes to running cardiac arrests.  I have been lucky enough to spend enough time with Tom that I have learned a great deal from him.  Changing how we do things can be scary.  It takes a commitment to do it.  We all have our comfort zones and stepping outside of that can be difficult, but we need to for our patient’s sake. Moving patients kills them, or rather prevents us from saving them.  Wake County has studied it and proven it.  The simplest thought processes confirm it.  A heart needs to beat in order to sustain life.  In order to get that heart beating again, we must work for it, whether that be manually or with a CPR assistance device...

With the general public clamoring for help, the debate over Narcan and who should have it rages on.  Recently, I read a post by EMS and fire author and blogger Captain Michael Morse from Rescuing Providence.  Michael relates some of his own personal experiences as well as those as a paramedic firefighter with the Providence, Rhode Island Fire Department to shape his opinion that making Narcan available to the public will allow drug users to “push their high to the limit and then return from the brink of death trough the judicious use of the miracle drug that they can now get as easily as they can their drug of choice.” While I respect Captain Morse and his willingness to share his personal experiences with the community at large, I think he is missing the mark here. There comes a time in medicine when we have to weigh the risks of the care and medications that we provide against its benefits and that is exactly what we need to do with Narcan.  I am sure that somewhere in the United States the scenario that Captain Morse has shared with us could happen.  Heck, I’m sure it probably has already happened, but we just don’t know about it, but making this argument is as absurd as saying that someone who is allergic to shell-fish would want to try lobster just once, Epi Pen in hand, ready to bring them back from the “brink of death.”  While I am sure that it has happened, it is the exception to the rule. “What if the drug is given too fast and the patient vomits?” “What if the patient is actually speed balling and comes up violent?” There could be a million and one “what ifs” that we throw out there, much like we could for C-Spining patients, or putting a patient on CPAP.  The medical world is full of “what ifs” which is why every drug commercial on TV is followed by a long list of side effects that I am pretty sure include spontaneous combustion. Rogue Medic will tell you that the problem with an opiate overdose is not Narcan deficiency, and that effective ventilation can...

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...

Recently I read a story from Alameda County, California describing the issues that they are having there particularly with responses to stabbings and shootings.  According to the article, the dispatch center in ALCO has abandoned their previous “send anyone to anything as soon as it comes in” system for a more nationally accepted system utilizing Priority Medical Dispatch. Priority Medical Dispatch, or PMD, is supposed to prioritize calls and tailor responses to those calls by classifying them utilizing a limited amount of medical information.  Calls are classified from the lower “ALPHA” level response to the most serious calls classified as “ECHO” level calls.  ECHO runs are mostly reserved for cardiac and respiratory arrests.  The purpose of the system is to get the most serious calls taken care of first.  It is a means of phone triaging.  Using a series of questions, call takers do their own little “choose your own adventure” flow chart and end up with a call’s classification. The claim made by paramedics and EMTs in ALCO states that on occasions since the change over from AMR to Paramedics Plus, runs that turned out to be fatal or serious shootings and stabbings were classified at the less serious “BRAVO” level.  Field providers are now demanding that prioritization changes be made to give these calls a quicker response.  I, for one, cannot help but feel like they are barking up the wrong tree. I feel like I have seen both the “very good” and the “just okay” of Emergency Medical Dispatch and PMD throughout my career.  I have seen it work well, and I have seen it misused.  Any system that gets used is going to be less than perfect, and utilizing Priority Medical Dispatch is no exception to that rule.  I believe it was Justin Schorr who once described Priority Medical Dispatch’s greatest flaw as the “least informed person (the caller) is talking to the least trained person (the dispatcher)” any anytime we discuss dispatch, or the prioritization of any calls, that needs to be kept in mind. The real issue in Alameda County, as is in most systems that have I seen struggle with the problems they are having, is a...

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...