My name is Scott, and I’ve made mistakes. There. I said it. The medical world is one where we strive for perfection. That seems to be multiplied ten fold in the world of EMS. We expect ourselves to be perfect. We expect ourselves to be better than nurses and sometimes doctors as we stand back and watch residents and attendings make mistakes that we feel we are immune to making. We can point them out or cite the newest evidence but for some reason when it comes to our own industry, we are prohibited from pointing out those same mistakes. Some think that in the absence of protocol or knowledge, a good ol’ diesel bolus is the answer and should continue to be the answer when reeducation and more training would be far more appropriate. “Do no harm” is significantly different from “no harm was done” and we need to realize that. Just because nothing bad happened does not mean that something good happened. The key to success in this field is learning from the things that don’t quite go as well as they should have. When I hit the streets fifteen and a half years ago I was terrified. I made a lot of mistakes, and when things were not going well my partner’s foot had better be getting heavy. Through the course of my career, I have grown and I’d like to think today that I’m a better paramedic. In all of the intricacies of medicine that I learned, and all of the journal articles I have read the biggest lesson that I have learned is humility and the ability to admit when I was wrong. When things do not go well, the first question that I ask myself, or someone who takes my patient over is “what could I have done better?” how could I have improved my patient’s outcome? Which brings me to my ultimate point in this post. The internet has been on fire lately after a Virginia volunteer fire department was cited for transporting a pediatric seizure patient in the cab of the fire engine instead of providing care and assessment and waiting for a responding ambulance to...

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...

Last month I headed down to Baltimore for an afternoon to visit the exhibit hall at Firehouse Expo.  While I was there I had the chance to sit in on a class about leadership on the fireground that raised some interesting questions for me about the safety of responders and more specifically our regard for that safety. The instructor took a considerable amount of time out of the class to question the “culture of safety” that we operate with feeling that you need to be willing to sacrifice more to save more, likening his battlefield experience in an extremely admirable and heroic military career to his time on the fireground.  To sum up what I, as an attendee in the class saw as his message, you need to be willing to sacrifice more to save more.  He was saying that many were too cautious by putting the concept of “at the end of the day, everybody goes home” above the mission of the department which generally is to save as many lives and as much property as possible.  He disagreed with the “nothing is worth your life” concept of the culture of safety. Now, let me start off by once again stating, as I have many times before, that I have zero experience in firefighting.  My personal participation on a fire scene consists of me standing around, waiting for a patient to be delivered to me, or handing out Gatorade and water in an attempt to keep those on the fireground from not becoming my next patient.  What goes on inside that house is something that I have no knowledge about. What I do have, however, is a great respect for those who do put their lives on the line in those situations.  The angle of this class that I want to discuss is the bleed over from the fire side to the EMS side of the profession since in many communities the two are so closely tied.  Some firefighters might sit in on a class such as this and receive and honor the message that “when you’re on the engine, you need to be willing to risk it all.”  Then, the very next...

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...

Jun 6, 2014

Did you know that this week is National CPR Awareness Week?  In some places, people are celebrating it the right way.  Earlier this week, Governor Quinn of the State of Illinois signed into law a bill requiring high schools to add CPR and AED training to their curriculum.  The bill was created in response to the death of Lauren Laman who died while practicing with the school’s dance team.  Lauren received no prearrival CPR, and although there was an AED nearby, no one received it or thought to use it. Obviously, no one can really know if CPR and the AED would have definitively saved Lauren’s life but at least we would have given her a fighting chance had the skill and the device been used.  The creation of this law is a great thing, and it’s about damn time that somebody somewhere finally got this one right. I remember back in the (late) 1990’s when I was in high school, our junior year health semester was dominated by first aid training.  We learned CPR, but if I remember correctly, while we received the class, we did not receive cards in our pockets.  Looking back, I guess it was better than nothing and a step in the right direction. Think about many of the cardiac arrests that we run.  Someone has to call them in, right?  Whether it is someone at home with the patient or someone in the street with the patient there is someone else there more times than not.  Now, compare that number to the actual number of people who receive pre-arrival CPR.  Emergency Medical Dispatch’s version of pre-arrival instructions are great, but there is nothing better in a situation like that than having the knowledge in your own head of what to do. With the introduction of cell phones, we have conditioned society to call in incidents and make them somebody else’s problem.  It all led to what I liked to call the “third party caller not minding their own business” job.  You know, those calls for the person sleeping on a park bench, or someone who “looks like” they might be in distress.  Occasionally, that caller will stick around...

My post today is loosely in support of one called “EMS Week Resolution” that went up this morning at The Ambulance Chaser.com.  Have a look; it is a good read essentially about “growing up.”  My take on it though is slightly different, and is something that I am not alarmed about because it is a trend that I see from system to system and while attending EMS conferences. Our friendly neighborhood Ambo Chaser points out to us that he was involved in a message board discussion about a state that was mandating all paramedics who were even short a half a credit on their continuing education to retake their National Registry exam.  How dare a state demand that?  How dare they penalize their paramedics and jeopardize the infrastructure of their EMS system over a half an hour of training?  While our favorite attorney/paramedic makes some great points about accountability and professionalism and (yet again) personal responsibility, I want to look at it from a slightly different angle. Why the heck is anyone even close to the minimum hours when it comes to training?  How could you let that happen?  We are surrounded by education in this field.  You can get it online through great sites like MedicEd and CentreLearn, and you can find enough educational classes that both provide and don’t provide CEU’s that there is no excuse to even be near that bare minimum that we all seem to try to strive for when thinking about getting ourselves educated in our chosen profession. A friend of mine once used a great saying which I have used many, many times since hearing it and frankly, it seems to fit perfectly here: “Don’t shuffle your feet you’ll trip over the bar!”  We set the bar so low that there is not only no excuse to clear it but there is absolutely no excuse to even be close to it.  If you want to talk about professionalism and being responsible for our patient actions, well, this is where it starts. Greg Friese pointed out in a class of his that I took at EMS Today one year that free pizza brings in more students than good...

By now, the New York Times article from last week has made its rounds in the EMS online community.  If you have not read it, I will give you the short version.  Based on the response to the Boston Marathon as well as some other high priority incidents, Federal Emergency Management Agency released new guidelines this past September in regards to the response of first responders to active shooter incidents.  The new recommendations revolve around what FEMA’s fire administrator Ernest Mitchell Jr refers to as “risk a little to save a little, risk a lot to save a lot.”  According to FEMA, risking a lot means sending EMS responders into the “warm zone” of an incident to treat and extricate patients. Most of the article revolves around one particular paragraph of the seventeen page document: b. While the community-accepted practice has been staging assets at a safe distance (usually out of line-of-sight) until a perimeter is established and all threats are neutralized, considerations should be made for more aggressive EMS operations in areas of higher but mitigated risk to ensure casualties can be rapidly retrieved, triaged, treated and evacuated. Rapid triage and treatment are critical to survival. Rush in, keep your heads down, and get out safe.  They have not completely ignored our safety, however, adding a few lines later: d. If exposed to gunfire, explosions or threats, withdraw to a safe area. e. Consider/Investigate the use of apparatus’ solid parts such as motor, pump, water tank and wheels as cover in the hot zone. Understand the difference between cover (protection from direct fire) and concealment (protection from observation). f. Remove victims from the danger zone in a manner consistent with predetermined agency training and standards of practice. LE officers may bypass casualties in order to eliminate the threat. Recommendation “f” leaves me with some hope that there eventually will be more mandated training and education for EMS providers, but the document seems to largely ignore any mandation of this.  There are, however, recommendations made in regards to what FEMA feels should be addressed when planning, and developing standard operating procedures.  For example, much of the treatment modalities recommended revolve around tactical emergency casualty...

Well, here we are, it’s October and in just ten days, I will be back in Massachusetts standing in front of what will hopefully be a room full of people giving a new lecture for the first time: The Solution is Pollution.  It goes without saying that I am quite excited.  I am hoping that this will be the first step for me, and maybe someday, AJ Heightman or Scott Cravens and their teams will see fit to bring me in as a speaker at EMS Today or EMS World Expo. For a long, long time, I was completely terrified of public speaking.  Now, I love it.  I do not know when the change happened, but it did, and hopefully I’ll be able to capitalize on it. The conference is scheduled for two days, October 18th and 19th, and it is being held in Springfield, Massachusetts at the Mass Mutual Center right in the heart of downtown Springfield.  There are hotels just a block away from the convention center, and plenty of places to eat and drink just a few blocks away. Over the last four or five years, the Massachusetts EMS Conference has grown exponentially, and this year is no exception.  They are expanding their exhibit hall, and continue to bring in high quality speakers to lecture on the topics that their audience wants to hear about.  This year, I am lucky enough to be in the company of people like Dave Aber, who had to put up with me as my Field Training Officer for my first six weeks at my new job, Jim Politis, and someone I think very highly of: Dr. Ed Racht, the national medical director for American Medical Response.   Unfortunately, due to my travel schedule I will most likely miss most of the lectures from Friday, but I will be there all day on Saturday, as that is the day that I am presenting. Registration for the conference is not closed yet.  You still have a chance to get in there and not only get some credits but have the opportunity to take control of your field and be a better provider for you and your patients.  Just click...

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...

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...