Most of the time when we see change, our gut reaction is to resist it, and do what we can to poke holes in it.  At least that has been my experience at many EMS services.  I guess I am just not lucky enough to work in an environment where fluid change occurs. Some change is really for the positive, and there is no more positive change in EMS that I can come up with than the new ACLS guidelines prioritizing chest compressions.  The problem though is breaking old habits. For my entire EMS career, it was always drilled into our heads that we “must get the tube” and we must do it well or someone would take the ability to intubate away from us.  Since the beginning of time, paramedics have seen their “right” to intubate patients as this sacred lifesaving skill that they must have and that no one should touch.  Through progressive thinking though, it has become more and more evident that intubation is not a lifesaving skill, but it is actually more of a life sustaining one.  In most instances, intubating a patient will help keep their airway patent and keep them alive, especially when sedated. I have studied up on CPR in Seattle and one thing that they discuss at great length is the importance of chest compressions and the minimization of interruptions.  We all need to keep that in mind and we all need to adopt that.  Nine out of ten times, airway is not important.  Early CPR, early defibrillation, and the minimization of interruptions are what are proving to be lifesaving interventions, not pauses in compressions to get a tube or vigorous bagging of a patient to get oxygen in.  Blood needs to go round and round in order for that air going in and out to be effective and measuring end title CO2 proves that. Have you ever had your APNEA alarm on your monitor go off?  The cause might not be a bad tube; it might actually be inadequate compressions.  Low CO2 output is a sign that there is little to no gas exchange at the alveolar level because there is not enough blood going...

Friday afternoon while I was checking my email I that I had a new e-mail from the Commonwealth of Massachusetts’ Office of Emergency Medical Services.  Every year around this time they like to send out any pending protocol changes that are being released with the annual March 1st updates.  Version 10.01, due go into effect on March 1, 2012 has a great new edition that I am very excited about. On the summary sheet of expected changes, protocol 1.6 for Post Resuscitative Care had the following addition: Mandating therapeutic hypothermia do not delay transport.  hyperlinked to Appendix V. While the state might need some work on their punctuation and capitalization, I was excited to see that Therapeutic Hypothermia was being added to our scope of practice.  I moved down to Appendix V to see what was in store for me in the coming year.  The new protocol describes the implementation, necessity and reasoning for the use of prehospital hypothermia in the following way: Cardiac arrest patients of medical etiology, who have responded to ACLS resuscitation efforts of any rhythm and demonstrate restored cardiac output and hemodynamic stability, but subsequently display signs of severe ischemic brain injury or coma, are candidates for instituting therapeutic hypothermia. Statistics show a significant number of those who survive out of hospital sudden cardiac arrest suffer from residual ischemic brain injury following cardiopulmonary resuscitation. The return of spontaneous circulation (ROSC), while resulting in the reperfusion of vital organs and the re-oxygenation of tissue, is thought to trigger destructive chemical reactions within brain cells limiting neurological recovery. The process of instituting early external and internal cooling efforts and maintaining mild hypothermia (32-34° C) in the first 12- 24 hours has been demonstrated to be a beneficial treatment adjunct in protecting the neurological function of cardiac arrest victims and improving patient outcomes.  Therapeutic induced hypothermia has been shown to be of significant benefit to select patients; continuation in-hospital is essential to its benefit, and may be a factor in hospital destination decisions by medical control. They get it.  All of the work done by services such as Wake County EMS, MedStar in Fort Worth, Texas and countless others is finally making a...

Recently, an article was posted about a group of Prince George County, MD firefighters who violated policy and transported a child in cardiac arrest to the hospital in their fire engine with what was described as “limited medical supplies” instead of waiting for an ambulance that was less than five minutes away.  The child, who was reportedly having an asthma attack, arrested in front of the crew.  The paramedic who was on scene made the decision to start transporting in their fire truck after getting what can only be assumed was an unacceptable ETA of five minutes.  According to the Prince George County Fire Department, the patient regained pulses prior to arrival at the emergency room. The firefighters who were involved were not suspended without pay.  Their medical control was not pulled.  They do not even appear to have been reprimanded by their department.  Instead, they have been given valor awards for their life saving actions that day. First, I do not want to overlook the miracle that took place on this call.  A life was saved albeit using very unconventional and potentially dangerous actions.  Effective CPR was done, and the girl lived, without any residual neurological deficits.  I give them credit for their care, but only to that extent.  This does not mean, however, that these firefighters should not stand and explain their actions. As I stated previously, the fire truck that was used on the call had limited medical equipment, and according to the press release, it was not one that was typically used for medical calls.  This leads me to believe that the life-saving actions taken by the paramedic that day was effective CPR which could have been done just as well, if not better, on the patient’s living room floor until a transport capable unit arrived. What about the large amount of departmental liability this crew put their employer under?  The girl had no neurological deficits but if she came out of this with so much as a limp or maybe slurred speech, her family could have owned the entire department, and potentially taken that paramedic for everything he had because of what would have only been described as “gross...

I recently read a story in EMS World about a paramedic who has been placed on administrative leave for failing to treat a patient.  According to the article, he arrived on scene, assessed the patient, and despite the requests of the BLS ambulance on scene, he decided to go back in service and triage the call to the BLS unit.  The patient was transported to the hospital where they subsequently died. I am not writing this to debate whether any ALS interventions would or would not have made any difference in the patient’s outcome.  There has not been enough information released to even dip one’s toe into that debate.  I am also not going to debate the “liability” issue of a lower level of care taking care of a patient when the higher level of care is present because I feel that quite often, if a patient can be triaged, and the BLS unit willingly accepts to take over care of that patient, then there is no issue with doing that.  I am writing this to discuss comfort levels. Throughout my career, I have viewed ALS as serving many different roles in prehospital care.  They are there to provide ACLS care, pain management, and trauma care just to name a few, but they are also there to be a safety net for BLS providers who may or may not be comfortable with a patient that is in front of them.  With three times the training that a BLS provider receives, sometimes a more knowledgeable presence when caring for a patient rather than a brief pat on the back and a polite “you’ll be fine” is what that lower level provider needs. In the system that I work in, I often work by myself in a fly car (or interceptor, or QRV depending on where you are from).  The majority of the patient contacts that I have are while intercepting with an ambulance staffed by EMTs.  Throughout the course of my day, I will see a variety of complaints from stubbed toes to cardiac arrests, depending on what I am sent to.  After my assessment is done on my patient, and I am comfortable with...

Some posts are more difficult to write than others.  This is one of them. Coming from a volunteer background, I have seen a variety of levels of abilities in EMTs.  Some can’t hear a blood pressure.  Others just seem to say the wrong thing at the wrong time.  Some are just plain unreliable, and still others are downright negligent.  Sometimes, people tried to make excuses for these people by shrugging and saying “they’re doing this out of the kindness of their heart.”  That argument never seemed to hold much water to me. I came to the conclusion early in my career that not all EMTs are paramedics are created equally.  This should not be anything anyone considers earth shattering, some people is better at things than others.  As an industry though we seem to have taken this “all for one and one for all” mentality and it is hurting us. “A paramedic is a paramedic, and an EMT is an EMT.”  Have you ever heard anyone say that?  Unfortunately, if they don’t say it, many people think it.  There is no differentiation between a good provider and bad one, and there needs to be.  It is time to work with those who might not be cutting it.  It is time for them to get on the bus or move on. How much of the problem comes down to our reluctance to be educated?  Our view that continuing education is the two or three year grind that we have to do.  I think many providers might get a decent education under their belts right out of the gate, but once the reeducation or discovery of new educational opportunities is put in the hands of the “responsible” provider, we fail.  Miserably. But I digress. . . The first step to dealing with someone who is not cutting it is to correct them.  Be blunt about it.  Let them know that they are not getting the job done and show them the right way to do it at the right time: away from the patient.  Let them know what they are doing wrong, and tell them, no, show them how to do it the right way. When...

How does a paramedic handles those three words says a lot about the kind of provider that they are.  Despite all of the training and continuing education one might seek out, there are still going to be situations where we just are not sure what to do.  We will encounter conditions we have just read about and never seen firsthand.  There will be tools in our bags that we might never pull out during our careers, and in many cases, never having to use something like a Quick-Trach or a needle crich is never a bad thing.  None the less, we need to be ready for anything. This is where personal responsibility comes into play.  If someone does not understand something, they need to speak up when asked if they have any questions.  They need to be ready to seek out the answers if they do not understand.  For example: CPAP is still relatively new to my service.  We have had it now for just about a year, and as a supervisor, I am not getting nearly as many patient contacts as I used to.  In the course of my field time, I have had to use CPAP six times, and on three of those, I did not feel as though I had done as good as I could have.  I did not feel that the seal was tight enough, and as a result, the device was not working as well as it could. I decided it was time to ask a respiratory therapist that I know if he had any tips for how to achieve a better seal, and he was able to give me some great advice: “if the patient is able, let them control 90% of the mask when it is being applied.  Get it tight and comfortable for them, and work on tightening the straps when they have it placed.”  On the next CPAP call that I had, I gave this a shot, and it worked really well. I had identified a part of my patient care that I was not doing as well as I could, sought out advice, applied that advice, and was now a better provider as...

Communication is such a huge part of this job.  We need to be able to communicate with our patients and get information out of them, we need to be able to speak on a radio (which is sometimes easier said than done) and we need to be able to translate what our patients say into medical jargen so the doctors and nurses we give report to fully understand what they are going to be dealing with.  In addition to all of this, we need to be able to communicate with our partners as well. Jamie was my third partner in my career, and she was the one that I worked with the longest.  The two of us were partners for close to two years, working evenings and weekend overnights.  We had some great times, and did some really good calls over the years.  Our styles were completely different.  I was more aggressive medically, where she was quite a bit more on the conservative side, but because of that I learned a lot about holding back, and what to treat and not to treat. We would seem to commonly encounter a problem in the street though: while our silent communication skills, we were not always able to read each other’s minds.  It was on a slow shift that we solved this problem.  Jamie and I decided that we were going to create our own language, one that was spoken by touching different parts of our face to let the other person know what was needed in more of a silent fashion. For example: there is a crying woman sitting on a bed, not talking with her boyfriend/husband looming over her.  Jamie might tap her temple with her index finger which, according to our silent language dictionary, says “let’s clear the room so I can talk to her alone.”  I’d say to the husband, “Sir, can we go take a look at her medicine?”  or “Can you hold the door for me while I get the stretcher in?” At its peak, we had just about fifteen different silent phrases we’d “speak” to each other on calls, covering everything from “This is ridiculous, why are we here?” ...

For the last couple of months, the term Personal Responsibility has become one of my favorites.I think it’s the answer to many of the questions that we ask day in and day out not only on the streets as we take care of our patients, but in life in general. I constantly struggle with how to provide effective QA/QI and where Chart Review falls into that whole mix.Now, I haven’t done a ton of Chart Review in my day, but I’ve read some truly bad ones, and I’m sure I’ve written my share of less than desirable charts in my day, but does it go without saying that a poorly written chart means substandard care was provided?I don’t think that is always the case.A strong argument could be made that the quality of the chart written can be a direct reflection of quality of care, just like the cleanliness and readiness of one’s ambulance could indicate the same, but ultimately, what is a Patient Care Report? That PCR isn’t just the picture that we paint for those that we turn care over to, or those that review our charts in the Chart Review process.Ask yourself this: Do you think James Patterson, Stephen King, or your favorite author could write an effective chart?I’d say they could probably paint a pretty clear picture of what happened.Does that mean they have the patient care to back it up?Absolutely not. Effective documentation shows a person’s ability to tell a story and craft words.Don’t let the term “Craft words” confuse you.I’m not saying that people are not truthful, because I have a lot of faith in the people that work in this field.I think that a majority of the time, what is documented is an accurate account of the call, but we need to start looking at patient care beyond the chart, and beyond the capacity that an English Professor, or a Math Teacher would look at it from. How do we do that?Well, that’s the difficult question.When practicing medicine in the pre-hospital setting, we often act alone, in the back of an ambulance, or with one other knowledgeable person present to help us.Random visits on calls by Supervisors,...

11 years ago right around this time, I was spending every free moment that I had studying for my Paramedic Class Final. It had been 11 long months of work, where I had sacrificed time away from family and friends to help achieve a dream that I had: to be a Paramedic. That 250 question final was staring me straight in the face, and after that, it would be off to my Clinical and Field time. I had learned a lot in those 11 months, and had also learned a lot in my 4 and a half years that I had been an EMT prior to that. There were still plenty of lessons that were waiting for me on the road ahead throughout my career. If someone was to ask me what I thought some of the most important qualities that a Paramedic should have, some buzzwords that come to mind are “caring,” “compassionate,” “clinically competent,” and “hard working.” That would be my politically correct answer though. There are some other qualities that lie under the surface that are rarely discussed with the public that people should know about and be ready for if they choose to make EMS their career: Strong stomach — During your career, you will see and smell things that no person should ever have to. When you encounter them, you will be expected to keep a straight face, stay calm, and act like it doesn’t bother you one bit. Able to work independently — There will be times when that other truck, or even your partner might not be near by. You may have to work a cardiac arrest by yourself. You could pick up the radio and ask for another truck and hear those terrifying words: “No units available.” Above all else, be ready for as much as you can with little to no help. Innovative — In EMT and Paramedic class, you will learn about algorithms and what to do for a patient quiet often in the best case scenario, but remember what Murphy’s Law teaches us: “Anything that can go wrong, will go wrong.” You need to be able to think outside the box and adjust...

Think back through your EMS career, whether it is a long one or short one. How many times have you been dispatched to this call: “Unconscious in a vehicle” or “Person slumped over the wheel?” I know in my ten years a paramedic, that’s happened more than a few times. Today, however, those calls carry a great risk that could injure you, your partner, other responders, or the unsuspecting public. Back in 2008, Japan saw an increase in their suicide rate due to something called Hydrogen Sulfide poisoning. The person would mix household chemicals together into a potent combination that with just a few breaths can render someone unconscious, and put them into Respiratory Arrest. This also poses a risk to rescuers and bystanders, because often, these suicides take place in confined spaces, which does not allow the gas to dissipate. When access is gained to the potential patient by rescuers, they could also be overcome by the fumes. In the spirit of Scene Safety, what should you be looking for as warning signs? 1. The Dispatch — As previously mentioned, these suicides often take place in confined spaces, such as a bathroom or closet. Most often though, it is encountered in motor vehicles. 2. Warning “signs” — Thanks to the Internet, information on Hydrogen Sulfide poisoning is easily accessible. Many of the sites that advocate for this form of suicide also share the risks to those around them. Quite often, the suicidal party will place signs around where they are to warn potential rescuers of the risks presented before them. They will often say “Warning: hazardous gas” or “Do not open, HAZMAT team required.” 3. Rotten egg smell — Quite often, there is a detectable rotten egg or sulfur smell present, although if the patient is inside a car, you might not be able to smell it. 4. Presence of chemicals/mixtures — Take a good look inside the car before you open the door. Is there a bucket on the passenger seat? Are there any bottles visible in the car? If so, take a big step back, and wait for more help. Hydrogen Sulfide is created by mixing a Strong Acid source with...