Jun 22, 2017

There has been a lot of buzz over the past week about California’s EMS Bill of Rights.  Dave Konig has a great take on it over at The Social Medic that I encourage you to read.  American Medical Response has even launched a counter campaign to it complete with the hashtag #LivesBeforeLunch.  While that makes me cringe a bit, I want to touch on one line of AMR’s response to the bill that stuck with me. “As written, AB 263 is an unprecedented political power grab, and will heavily penalize private – but not public – employers of EMTs and paramedics.” When I look back at my career with AMR that spanned more than twelve years, I had a lot of ups and downs.  Had busy shifts and I had slow shifts.  I found myself mandated to work despite being sick, or just needing a day off.  Through the highlights and the lowlights of working in a busy 9-1-1 system that amassed roughly 40,000 calls per year, the instances where my 12 hour shifts hit double digits were rare when compared overall to my full body of work. I have friends who work in the “public” sector in some of the busiest EMS systems in the country.  One who works in a fire-based EMS system routinely does more than 20 calls in a shift.  In fact, the overwhelming majority of medic units in their system far surpass the volume run by their busiest suppression pieces, and you know what the response from some of his coworkers on the suppression side is?  “I know I occasionally get a full night’s sleep while you are out running, but you chose your career and I chose mine.”  They are under represented by their union and are the medics who really need protecting, not the EMS based paramedics and EMTs of the private sector, yet that is who this bill is targeted as. In all my years involved in EMS, AMR has never hidden what it is.  They are a for profit company.  They are a place for EMTs and paramedics to find a job, and rarely a career.  The higher that you go on the food chain,...

There were few things that I have been more proud of than when I passed my EMT and paramedic exams.  For the former, I was a 16 year old high school kid.  I was taking my EMT class two nights a week while going to high school during the day.  My parents had to drive me to my exam, and to the post office daily so I could check the mail hoping and praying that the right envelope would be shipped to me by the State of New Jersey.  When I was in college, passing the paramedic exam was arguably the whole reason that I was there.  That card would let me get my foot in the door, and my management education would give me the opportunity to climb the ladder when the chance arose.  Medic school was not easy, but I did it. Coming out of medic school, I still had a lot to learn.  I have talked about before here, but it took me a good couple of years to really feel comfortable in my skin.  Colleagues who I got my medic with, and some who got their medics after me passed me by in a lot of ways, but eventually I caught up.  The streets were a great place to hone my skills, and Springfield offered a lot of opportunity to do just that.  It was busy, aggressive, and when I got in over my head, I was close to a hospital.  A lot of people will say that EMS is generally like riding a bike.  In the years that I was promoted, I still practiced medicine, but not nearly as much as I used to.  When I moved exclusively back to the field it took me a little time to shake the rust off, but I got back to where I was relatively smoothly.  I had practiced medicine before I got promoted, so when i got back to it, I had already laid the groundwork for my care. There are some out there who think that simply holding an EMT card in one’s pocket makes them an EMT, and I call bull on that.  The things that one learns in...

On an almost daily basis, an irrational, irritating debate seems to break out within the online EMS community.  Typically it has to do with one of two topics, arming EMT and paramedics, and the debate on the ethical use of Narcan.  While I would love to open two cans of worms today, there is only so much ranting that I would be willing to subject you, the reader to, so we are going to stick with the discussion on Narcan today. It is no secret that we are giving Narcan to patients at an alarmingly high rate.  Compound that with the amount that the public themselves is using, and the number gets even higher.  But there are some things that the EMS community needs to concede and understand about Narcan use, addicts, and ethics when it comes to administering the medication. Giving Narcan kills more people than it saves A few years ago, there was somebody who I will classify at this point as an “online EMS personality” who shared his thoughts on the use of Narcan, feeling that bringing addicts back over and over again would result in them pushing themselves closer to the edge because they knew that we were going to be there to save them.  I shared my thoughts on that topic then, and my feelings have no changed because the evidence has not changed.  There are a lot of things that are making the opiate addiction problem in this country worse, and EMS giving patients Narcan still is not one of them.  Narcan is nothing new.  It has been in our toolboxes for a lot longer than most of us have been in the field.  And its not going away. “All that we are doing by making Narcan available to these people is enabling them to use heroin” This argument always leaves me scratching my head.  Recently, I gave D50 to the same patient for the 5th time in two weeks.  Once conscious, I asked them “did you go see your doctor like you said that you were last week?”  Their response was, “I was going to but I did not have time.”  I asked if they had plans...

In my defense, there are two videos posted below. These are the first two EMS Week videos created by a department that is very near and dear to my heart. Watch....

May 21, 2017

EMS Week 2017 is upon us and as always there are a lot of positives that need to be pointed out.  Its a time to recognize the little things that people do, and more importantly the people behind the uniform.  It is the week of the year that should be about us, because the other 51 weeks out of the year should be about the patients that we serve.  With taking all of that into consideration though, this is not going to be one of those positive posts. Last week, there was a call for articles and posts related to the tagline “EMS Strong: Always in Service” for this week’s message to providers.  It asked for people to talk about what it means to them.  Well, here you go. I grew up in a heavily volunteer driven community.  When I started EMS, every BLS unit on the street was staffed by people dedicating their time.  Much like myself, many went through their day to day activities with a Minitor II pager strapped to their hip, waiting to hear that rhythmic beeping that still gives me palpitations more than 20 years later.  Day or night, weekend or weekday, on school vacations or snow days, it did not matter.  I was always in service. At the time, I was a young, naive teenage EMT.  I was happier on the ambulance than I was on the high school basketball court.  I did not care if I got home from my summer job at 2am, if the pager went off at 3, I was going.  I did not have a care in the world.  EMS was what mattered to me.  I was always in service. In college, I sacrificed many Friday or Saturday nights where my college friends would be out drinking and partying to throw on a uniform, turn on the radio and go trucking out of my dorm to take care of the sick, vomiting, and ETOH students of Springfield College.  I cleaned vomit off of my boots.  I cared for people that I might see in my economics class come Monday morning.  I was ready to go at a second’s notice.  I was always in...

As we start to dive down the rabbit hole of what makes an effectively run cardiac arrest, it is important to understand the roots of what we are actually doing.  Personally, I could go back some 23 years to 1993 when I received my first CPR card.  I learned the importance of opening the airway.  Looking, listening and feeling.  If the patient was not breathing, and I could not give a rescue breath, I had to reposition the airway.  Simply put, until the patient had a patient airway, and was effectively being ventilated or breathing on their own, not a single compression was done. If I had somebody with me, for every five compressions that were done, a ventilation was given.  If it was just me, it would be 15:2.  Sometimes I am amazed that we saved anyone at all following that.  In the system that I started in, I feel like we were ahead of the curve.  CPR calls were commonly not transported to the hospital.  We would work them at home and leave them at home. Fast forward now seven years to my time as a paramedic student and my early days as a paramedic.  Not much from that airway focus had changed.  ROSC was rare.  Survival to discharge was even more rare.  Every workable cardiac arrest was transported to the hospital regardless of rhythm or downtime. The success and failure of the care provided rested on two factors: whether the patient was turned over to the emergency room staff intubated, and whether or not the call time was short.  We would walk away from a code high fiving each other for delivering a dead body to the ER in 30 minutes or less, like we were some glorified Dominos delivery drivers. Throughout my career, my views on EMS and the impact that we have on the general public has swung to both ends of the spectrum.  I’ve felt that we were completely necessary for the well being and survival of every single person that we encountered, and I’ve felt used and abused by the system.  As I enter my 16th year as a paramedic though, I can without a doubt say...

One of the things that amazes me about this field is how tightly we hold on to our beliefs.  It does not matter if it has to do with oxygen management or medication administration, or even C-Spine.  People always seem to revert back to how they were taught the first time that they learned something presumably because it is uncomfortable.  Maybe it is time to get comfortable with being uncomfortable.  Make it is time to make change a way of life. It has been my experience that people seem to base a lot of decisions that they make off of one negative experience in their career over a more frequent positive one.  We balk at giving pain medications to some patients because we believe that they are lying to us thanks to that one addict that we feel pulled a fast one on us in the early days in our career.  Or we put the nitro aside on an inferior MI because this one time a medic that you met told you about a medic that they knew who dumped the pressure on a patient who then coded on them.  The truth is though that the person in pain, regardless of their background, could benefit from that fentanyl, and chances are, that person having the MI will maintain their pressure and could greatly benefit from the treatment that you are so reluctant to give them. Or take response times as another example.  Despite evidence to the contrary, and despite studies that have been conducted, there is little correlation between response times and mortality in a majority of the emergencies that we as EMS providers respond to.  I happen to know of one rather large service that despite having an excellent ROSC rate they see a lower percentage of CPR saves in the more densely populated section of their service area with considerably lower response times than they do in the more suburban or rural areas.  While the difference in miniscule, it is further proof that despite the fact that somebody gets on scene more quickly than in other areas, speed alone does not constitute more lives saved. I have always found the concept of...

Apr 24, 2017

As I said in last week’s article about Bob Harper, I am kind of playing catch up with a lot of topics, this being one of them.  In late 2016, the State of Rhode Island announced publicly that on March 1 of this year, there would be a significant protocol change to their cardiac arrest protocols.  Crews would be expected to remain on scene for 30 minutes prior to being transported. Topically, I applaud Rhode Island’s Department of Health for being as public and transparent as they were about this change.  Anybody who has been in the field for even a modest amount of time has been on a scene where they were asked “why aren’t you just taking them to the hospital?”  In some cases, there is some merit to that.  In some cases there is very little that we as paramedics and EMTs can do for a patient on a scene.  Cardiac arrest is not one of those emergencies. I saw some pushback online from some who consider themselves experts on the topic, but that’s neither here nor there.  One common complaint that I saw revolved around scene safety.  Obviously, scene safety trumps all.  If I am coding someone in the middle of a street with an aggressive or growing crowd, I am going to think about moving.  But on these calls are the exception to the rule, and on the vast majority of runs, even in the worst areas of someone’s coverage area, communication with families goes a long way. “We are doing everything for them right here that they would get in the emergency room.  It is their best chance to survive.”  That’s the common statement that I have made a number of times to families of patients in cardiac arrest. Maybe those dissenters failed to read the protocol, it states “Regardless of proximity to a receiving facility, absent concern for provider safety, or traumatic etiology for cardiac arrest, resuscitation should occur at the location the patient is found.”  Emphasis is mine.  Most of the write ups that I read from the online blogging community were written on or around the month of December.  It is certainly possible that the...

I wanted to follow up on my reply to Councilman John Bendel’s letter to the editor in the Asbury Park Press a little bit and talk about delivery and goals.  Realistically, regardless of what sort of department an EMT or paramedic works for, their goal should be the same.  We should be aiming to reduce morbidity and mortality of the conditions that we can directly impact and for those that we cannot have lasting impact on in the prehospital setting, we should aim to deliver them to a place where they can get treatment while doing everything that we can in our time with him to promote a favorable outcome in our limited time with the patient. Too often, when debating about what delivery method works best, we get caught up in the weeds of the minor details that have a greater impact on the provider than the patient.  We worry about the training that we must do and the time that it takes, or the unproven theory that people serving their own community has a greater impact on patient outcome than the ability of the provider.  We get hung up on the importance of response times when they have less to do with patient outcome than care provided in most cases. In Bendel’s letter, he touched on the fact that “MONOC can probably tell us how many lives were saved because a highly qualified EMT was on calls.  But no one can tell us how many lives were saved because a local squad got people to the hospital faster than MONOC would have.”  He’s probably right, but we need to ask ourselves why this is.  With a call volume that is often a fraction of what MONOC runs, why can’t volunteer squads better report their impact on patient outcomes?  I think that the answer to this is twofold. First, most squads probably do not possess the outcome data that a company that MONOC has access to.  That is partially the fault of the system for not including volunteer services in this feedback loop, and partially on the squads for not seeking it out, and creating the infrastructure within their organization to acquire it....

Apr 17, 2017

Read my Open Letter to Mr John Bendel here. For today’s post, we are going to continue to analyze the saga of the Asbury Park Press editorial battle regarding EMS in New Jersey.  The EMS Council of New Jersey has sounded off.  Last week on April 10th, the EMSCNJ’s president, one Mr. Joseph G Walsh, wrote a letter of his own in order to, as he puts it, “correct several points.”  So let’s fact check some of Mr. Walsh’s statements, and dig deeper into what the EMSCNJ has said in the past. “Paid or volunteer, every New Jersey EMT must pass the same certification exam. Volunteers conduct monthly drills, and education and skills sessions to stay current. The misleading editorial might have panicked some readers into falsely thinking their local volunteer squads are not staffed with properly trained responders.” It is true, indeed, that every EMT must pass the same certification exam.  So what?  I would dare to say that the ability to study and regurgitate information from a textbook is not the be-all-end-all in evaluating one’s effectiveness as an EMT.  I have worked with great EMTs, and I have worked with people who could not be trusted to work on a crew of two because they lacked the ability that they needed to take the knowledge in their head and apply it in a real-life practical setting.  They all had one thing in common though, they passed the same test. Then there is the other statement that Mr. Walsh makes here about proper staffing.  While all EMTs take the same test, that fact alone does not mean that every person operating on a volunteer ambulance in New Jersey is a certified EMT.  In actuality, many responders might just be certified at a lesser level.  How do I know this?  Mr. Walsh tells us. “Every one of our member squads is required to respond to calls with at least one EMT who remains with the patient. On many calls, two or more EMTs respond. The EMS Council of New Jersey (EMSCNJ) is unaware of any squad — member or nonmember — answering calls without such trained responders.” Currently, when a paid or career ambulance...