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...

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...

Tuesday afternoon at 3:30pm, there will be a meeting held at Springfield City Hall to discuss American Medical Response and their ability to provide prehospital care to the citizens of Springfield.  Below is something I would like to share with the City Councilors who will be in attendance Tuesday. City Councilors of Springfield, Despite the favorable findings of WGGB in their investigation on emergency response, you have decided to hold a forum to discuss potential short comings of the current EMS provider to the City of Springfield.  Yes, that is right, I said it was favorable.  Although the ebb and flow of the story might not have showed it, all of the information provided shows that AMR exceeds the expectations set for it.  But maybe you should dig a little deeper.  Prior to walking in the door to Tuesday’s meeting, I would like to urge you to do a little research and maybe expand your vocabulary a bit. For instance, for just a second, let’s forget about response times.  They don’t nearly matter as much as you might think.  Try researching what a ROSC rate is, or how CPAP has reduced the mortality of shortness of breath patients, particularly in Springfield.  Ask Baystate Medical Center about the success of their ST-Elevation Myocardial Infarction program (STEMI for short) and ask them how many of those patients are delivered by AMR. Still not convinced?  Why not take a good hard look at other communities around the country and see for yourself how good you have it in Springfield.  An ambulance is on scene in a preset amount of time or less 97% of the time.  How do you think that compares to communities like Detroit, Washington DC, or Philadelphia just to name a few? Or how about closer to home?  Ask around to some of the neighboring more rural communities and see what their response times are like.  I guarantee that some will be longer than the average time publicized by AMR in WGGB’s article, but the patient outcomes will still be favorable. Just like with in-hospital medicine, perfection will never be obtained in prehospital medicine.  Errors are going to happen because not only are the...

I recently read a story that came across the EMS wire about an EMSA paramedic in Oklahoma City who was assaulted by a patient and as a result, she lost her unborn child.  Last week, I read a story about a politician or lawyer (forgive me, I cannot find the actual article to reference it) who assaulted a medic and was not charged.  Over at Rogue Medic, Tim brought to light a man who assaulted a Chicago medic who got off easy. Our job can be dangerous.  Sure, for the most part, our calls are routine, and we are not at risk, but then there are those cases, like the ones referenced above, where we are put at risk.  When these incidents happen, I’d go as far as to say that paramedics and EMTs are more at risk than doctors and nurses who have other staff there who could potentially back them up, and police officers, who are trained to deal with such situations.  When a provider is one on one with a patient who could potentially become violent, or does become violent, there is not a more dangerous scenario that we as prehospital providers are put in. Some of these tips are my own.  Some of them I picked up from Mike Taigman and the street safety course he was teaching through EMS1.com a couple of years ago. First of all, each of us needs to remember that scene safety carries into the back of the ambulance.  Next time you’re in the back of your truck, take a look at your surroundings.  Where are the potential “weapons” kept?  Are there sheers or IV needles in the cabinet right next to the patient?  Are they accessible on the bench seat?  What do you keep on your belt, and how well is it secured?  Make sure your sheers are always fastened if you carry them.  And although I have not found much of a use for them in my years as a medic, make sure your knife is discretely tucked away. Work a “pat down” into your assessment.  It can be as simple as a head to toe assessment, and can be very discretely done. ...

I posted a question on my Facebook page asking my followers what they felt the “most innovative change” was that they have seen during their career in EMS.  To date, I have gotten 26 responses of varying degrees of seriousness but the most common one that I have seen is prehospital CPAP.  In fact, one nurse even weighed in with that answer.  I decided to do some research and see what else I could find out about the topic. I remember being an EMT in New Jersey home for the summer back in 1999 and watching the LIFE paramedics pull out a large bag with their CPAP setup out of the trunk of their unit.  It was admittedly an intimidating piece of machinery to me.  CPAP in my home system in Massachusetts was as foreign as prehospital 12-Lead EKG’s were at that time.  We did not get LP-12’s until 2002 or 2003. When I did a Google search for prehospital CPAP, I found an article from EMS World written in 2005 by my good friend Bob Sullivan outlining its use, why it is effective, and why it is so important to start CPAP sooner rather than later.  Some of his references in the article date back to as early as 2000.  The proof has been in the pudding for years, CPAP works. Why then did it take a special project waiver and two years of evaluations to get it approved for use by paramedics in Massachusetts?  Randy Cushing, a paramedic with the Agawam Fire Department was one of the leaders in the push for prehospital CPAP and his efforts finally paid off in 2010 when the change went through in the state protocols giving paramedics standing orders for prehospital CPAP.  Eleven years after I was seeing it used in New Jersey.  Five years after the article, one of many, was posted about its effectiveness in prehospital care.  This leads me to make the broad conclusion that in 2013, there are still probably some systems out there that don’t use it, or haven’t gotten full approval to use it yet. This makes me think about studies such as the one that compared usage of IM...

I’ve been thinking a lot about cardiac arrests, CPR, and the barriers that I face in the system that I work in.  Chances are, if it is a problem here then it is a problem somewhere else, which makes it worth talking about. In the system that I work in there are two types of dead people: people who are not workable; that is to say, they have some injury incompatible with life, or conclusive signs of death.  The second kind is one that ends up on a stretcher in an emergency room.  That’s right, if you get CPR, you get a ride to the hospital. After doing some research earlier this year for a class I was teaching about running a better code, I found a clip from Wake County, North Carolina where their medical director Dr. Brett Myers talked about the key points to the quality of cardiac arrest that they provide.  The one big one that stuck with me was “Don’t move them.  Work them where they drop.”  I realized very quickly that Wake County had one very important component to high performance CPR that my system lacked. Over the last two years we have learned a lot about quality of compressions and their importance.  Anyone who has taken ACLS or an ACLS refresher has heard that you never stop compressions, or at least you greatly minimize interruptions but what they fail to address is the importance of knowing when to say when and affording us enough options and guidelines telling us when to stop CPR.  Actually, let me rephrase that.  The content and evidence is there, but a few systems have chosen to ignore it. So am I saying that knowing when not to do CPR or when to stop doing CPR is an important piece to improving ROSC rates?  You better believe i am.  Let me describe a common cardiac arrest in my system: The crew gets on scene to a confirmed code with fire department first response and more times than not, a second ambulance is coming behind them to assist.  When that truck arrives, the patient is loaded into the best way to extricate them from where...

How good of a paramedic are you?  Have you ever wondered?  Well, lucky for you there is some proof in the numbers.  Getting an idea of how well a paramedic does their job is not as hard as some people think, and with a little bit of research it is easy to figure out how successful your patient care is.   With data collection what it is today, one can look at things like their IV and intubation success rates, or their time to STEMI recognition or even their scene times for trauma calls to make sure that they are, in fact, within the Platinum Ten.  The rest of the job though you are going to have to judge from yourself, from your gut, or simply ask your partner: “how good am I with my patients?”  Bedside manner might be the most vital skill that we all possess in our toolbox and while tools such as patient surveys might give a single provider or a service a better idea of how much compassion and empathy their employees show towards their patients it is largely immeasurable. When talking about employee surveys with a colleague a few years ago, he told me that from his experience with them they were largely polarized.  The surveys that were returned from patients usually either gave a glowing, favorable review of the providers or a scathing dissertation of how poorly they were treated.  Those people who fell largely in the middle rarely said that the care was “just okay.”  One is left to assume then that all of those unreturned surveys, sometimes three out of every four, reflected that the providers did in fact do nothing more than an adequate job. Adequate should not be viewed as a bad thing, and don’t think that I am trying to paint that picture.  Lets face it: you are not going to be able to please everyone, and someone who is sick or injured will most likely be exponentially more difficult to satisfy.   When reviewing patient feed back, I have seen all sorts of complaints: “The ride was too bumpy” “the driver took a longer route to the hospital than he had...

I was working at my part-time job the other day, and we got into a lengthy discussion about Do Not resuscitate orders and when to honor them versus when to treat a patient.  Today, the conversation continued and we came up with an interesting scenario, and I wanted to see what everyone out there thought both from a moral/ethical stand point as well as a legal one. Here’s the story: You are called to the home of an 80-year-old male who lives alone.  His neighbor frequently checks on him.  Today, his door is locked, which is unusual.  Your unit arrives at the same time as the fire department who is there to help you gain entry and assist with patient care. You enter the patient’s apartment and find him supine on his couch.  His breathing is clearly agonal and you cannot detect a pulse.  In plain view sitting on the coffee table in front of him are the following: A bottle of hydromorphone which was filled two days ago.  The cap is off and the bottle is empty. An appropriately filled out Do Not Resuscitate order which clearly states that the patient does not wish to have CPR performed on him. A suicide note stating that he had been recently diagnosed with cancer and does not want to live anymore.  It outlines what he would like to be done with his personal effects. What would you do?  Would you start CPR on the patient?  Would you honor the DNR?  Does the suicide attempt void the presence of the DNR? Normally, I would expect a bunch of comments on this topic to say “I would contact medical control to see what they would like me to do.”  While I understand that, I would like to know what YOU would do as a provider. Also legal folks, I know you’re out there, what do you...

As EMS providers, we deal with tragedy every day.  We see people at their worst and are expected to put on a stern, professional face and take control of each and every scene, but what happens when the person that you are dealing with is one of your own?  Emotions run high, and while the expectation should remain that we put those feelings aside we are, after all, human. Throughout my career, I have had to care for colleagues who have had medical emergencies.  I had to do CPR on a past fire chief from the town I grew up in.  I’ve transported an old crew chief of mine when his heart rate was 40 and he was on his way to get himself a pacemaker.  Tragedy can strike at any time, and although we look at ourselves as impermeable to it, we are just as mortal as everyone else. What it comes back to is knowing our own limitations.  When it is in the best interest of our patient, there is nothing wrong with “tagging out” and letting someone else take control of a call that has a clearer head than you might at that moment.  It takes a clear mind to properly care for a patient and we need to remember that as paramedics and EMTs, we need help sometimes too, and we just need to be humble enough to ask for it. There is a lot of pressure on prehospital providers, and I do not think that many people in the public safety and medical communities realize and accept that.  Often, an EMT or paramedic is expected to deal with a patient on a one-on-one basis.  Take, for instance, a STEMI patient.  Quite often, a single paramedic is expected to obtain baseline vital signs, perform and correctly interpret a 12-lead EKG, give medications, start an IV, reevaluate the patient, and make the proper notifications to the emergency room. If that same patient walked into an ER, the tech would perform the EKG.  One nurse would administer meds and start that IV while another one charted.  The secretary would make the notifications to the cath lab, and the resident or attending physician...

I am sure that most of you have noticed that I have been wading my way through another bout with writer’s block.  It happens, right?  I’ve beaten it before, and I will beat it again though.  I’ve gotten some great support from some friends who have suggested topics, and offered ideas for future posts.  The one I am sharing with you today though is one I find interesting. Last week, I was complaining on my Facebook wall about my struggles with writer’s block, and my friend friend sent me an interesting question: “I saw that you had writer’s block the other day and was curious to know if you’d be interested in running an informal and non-scientific survey of your faithful readers. Here’s what I am curious to find out: I have the opportunity to watch hundreds of transfers by the various private services in RI take place at various hospitals while I am posting. It seems as though virtually all of the techs riding with their patients sit in the airway seat behind the patient, usually entirely out of view of their patient. About the only time that I sit in that seat is when I have a backboarded patient (so my patient can see me) or a patient with an airway issue, at all other times I am either on the bench or in the “captains” chair, in full view of my patient. I wonder if this is generational/experiential/company SOP, etc. and why so many EMT’s now choose to be out of view of their patients? Just a thought, I am sure you have your own feelings and experiences from Springfield, and maybe this will help break your block.” Personally, my answer is simple, but it comes with an “*”.  Although I often tell people that I am only 5’9” the truth is I am actually 6’5”.  When I am working on a truck, they are 99%-100% of the time, van ambulances.  With my long gangly arms, I can reach everything in the truck from the comfort of the bench seat.  When I say everything, I pretty much mean everything.  Its freakish.  The only time you will find me in the airway...