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...

Late night I was shown a very public reply posted to a very private email circulated by management in a New England ambulance service expressing displeasure with the performance of many of their employees that some have interpreted led to the loss of a 911 contract that they have been given a second chance at.  Although the original email was never posted, the reply made on a craigslist page and signed by an “anonymous employee” called out management for their practices.  I read it, and I cringed. The post itself was flagged for removal within the first eight hours of it being posted online which is fine, because I would not have linked it here as I personally felt it was in poor taste.  While there is a time and place for sharing with the outside what goes on in the inner workings of an organization this was a lot of dirty laundry to hang on the line for everyone to see.  Quite often they are posted too quickly with the thought that “if I let the public know what is going on here things are sure to get better!”  In actuality, all this does is increase the gap between the field and management. As someone who has, in the past, pulled the pin on a grenade and tossed it into the fray, I can testify that actions like this do not help as much as many think that they will.  As my career progressed, I found it easier to write the email or memo and let it sit on the computer for a good couple of hours.  Then, I would come back and take a second look.  More often than not, my opinion would have evolved to an “it’s the same old complaint, it won’t help anyway.  I’ll keep it in my back pocket though.”  The draft would then be saved, and the window closed, as some fights are just not worth it. The anonymous writer of this post clearly was upset, and I doubt that his or her intentions were completely malicious, they should realize that the damage they did might be irreparable.  While it might be fun for some people to...

Over the course of the last year I have developed an established morning ritual.  One piece of that is sitting down and reading a series of links for the day that include local and national news sources as well as posts from selected blogs.  It helps pass the time in the morning, and it is something to do while I enjoy my coffee. Last month, I read a very moving post by Chris Kaiser over at Life Under the Lights about provider suicide.  That particular morning I was teaching at my department’s monthly educational day for one of our platoons, and one of the topics that I was tackling was stress management.  The post made such an impression with me that I included it in my lecture while describing the “code of silence” and how it applies to EMS professionals. It was a blunt reminder of the stress that each of us in this field deal with both as a provider and as a person.  We are not only expected to shoulder our own problems but we are expected to tackle the problems that everyone else around us has as well.  The result is us burying and burying and burying until our own feelings are so suppressed that when they do surface they are so overwhelming that they are that much harder to deal with. Sad to say, I am seeing more and more cases of provider suicide in the field.  It is a problem that is not going away.  In fact, my whole reason for writing this post is because I recently learned of the passing of someone that I met a number of years ago.  He was a hard-nosed paramedic who was never afraid to speak his mind.  Although he was one of those people who could clearly be a thorn in your side it was obvious to me that he had his peers’ and his patients’ best interest in mind.  Much like my other experiences with provider suicide, the news that I heard came out of the blue and based on what I have heard from friends, while there were some warning signs out there no one ever thought that he...

Through my career I have worked in a couple of different style of EMS systems.  I started out in a volunteer system that commonly saw anywhere between 2 and 4 people riding on an ambulance, cramming themselves in back with a medic and a patient for transport to the hospital.  Despite how big our ambulances were (and granted, they were smaller than many of the ones on the street today) things still felt cramped.  I must admit that from my BLS stand point things seemed to run smoothly.  It was all that I knew.  Everyone had their role.  Things seemed to go well, however, now, twenty years later I can certainly see where things could have been frustrating for an ALS provider. Fast forward a few years to my tenure in Springfield.  There was no predicting who I would be in an ambulance with, and more importantly, how much help I would get if I asked for it and it was actually granted to me.  Sometimes I worked with another medic, sometimes an intermediate, and sometimes an EMT.  I did not mind the work load that was generated by not working double medic because such a high volume of our runs were BLS runs anyway.  Admittedly though, there were certainly some frustrating times in the early years of my career as I felt like I could never get enough done.  I was and am my own worst critic.  When things don’t go how intend them to, I beat myself up.  That seemed even easier when I was the only medic there. On most cardiac arrests, we had a fire engine or ladder company with us ready to do compressions, but they were not always the easiest to give feedback to if compressions weren’t being done well enough, or there was something that needed to change.  Don’t get me wrong, many of them were fantastic but it was certainly a barrier we encountered.  Finally, the question of “how many EMTs do you need to run a code?” was a common question that was asked.  A lack of recognition for the evolution of medicine was something that constantly held us back.  My opinion was always that...

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...

This past week, an article posted by EMS 1 caught my eye.  It tells the story of a Minnesota man who had his video camera confiscated and was eventually charged with “interfering an ambulance crew.”  According to the article he was videotaping the interactions between a man living in his building and sheriff’s deputies who were accompanied by EMT’s who intended to transport him to the hospital.  I am not going to get into the article and story itself, as I really truly feel like this should be a non-issue.  In the society we live in today people have video capabilities and use them on a daily basis to shoot a variety of things.  It is part of the social media YouTube society that we live in.  What I found truly alarming was the reaction from the EMS community. The article received over 150 comments on the EMS 1 Facebook page, many stating that there was a “HIPPA” violation.  First of all, it needs to be pointed out that the abbreviation for the law is “HIPAA” and not “HIPPA” and no, the headline of this post was not a typo, I meant to do that. HIPAA, which stands for Health Insurance Portability and Accountability Act, is a law that has multiple parts.  Title II which deals with health care fraud and abuse is the one that is most important to EMS providers.  Covered entities of the HIPAA laws are those who record, collect, or store a patient’s health care information potentially for billing purposes.  Most HIPAA education began in the early 2000’s but judging from the comments that I saw this week; I cannot help but feel like it might be time for some reeducation. Over the years, I have encountered HIPAA on a number of different levels.  I have been told by facilities that I “should not open the sealed envelope” that was containing a patient’s medical information because I would be violating their HIPAA rights.  I have heard HIPAA cited as a stumbling block for QA/QI officers in getting information on patients who were delivered to a medical facility.  Simply put, so many entities that are HIPAA covered keep the information more...

    LEVEL ZERO – The Movie from Thaddeus @Setla on Vimeo. Yesterday marked the four year anniversary of this blog, and what a ride it has been, and sitting here in a completely different system in a different state with different friends and colleagues around me, I cannot help but reflect back at how crazy this journey has been.  For me it all started with a trip to California provided to me by AMR, and a few conversations out there with a few paramedics about a little movie called Level Zero that I had stumbled across on the internet. For those of you who have read through the posts of this blog, you know where it went from there.  I started writing.  I connected with Ted Setla and Justin Schorr.  The EMS 2.0 logo and pin were created.  I came out of my shell and found a love for teaching and now, four years later, I am still at it. The road has not been without bumps, and times have not always been easy but ultimately I could not be happier about where I landed.  I wonder sometimes what i would be doing had Mike Taigman not reached out to the east coast for help, or had I not gotten a ride down to one of the southern hospitals in the county from one of their Clinical Specialists.  Any little turn in that road could have changed everything.  I was lucky though.  I have come out of this four year rollercoaster with some great friends who I would not trade for anything.  I have had a little hand in sparking change in my old system in Springfield, and still love following their accomplishments even now, over a year after I left.  I’ve sung Karaoke with people from EMS World and EMS Today.  I’ve sat down and interviewed a man who someday I hope to have a shred of his ability to lead.  Justin Schorr’s number is in my phone, although I don’t talk to him nearly as much as I’d like.  I’ve lobbied on Capitol Hill.  I’ve hosted a podcast that I used to listen to and wish that maybe someday I would...

A few weeks ago I was sitting around the station talking to a couple EMT’s about some issues that they had with the translation of a “lift assist” or public assist into a patient refusal.  It was not so much a personal problem since, as one of them put it to me, “If I touch them, I get a refusal” but it was more the actions that they had seen some of their coworkers take to minimize their own paperwork.  Interestingly enough, the debate of “what is a patient” and “who gets a refusal” was a long standing debate that I had with some people during my years as a supervisor. The scenario we most commonly encounter is a simple one.  It is like that old Life Call from the 80’s.  Mrs. Fletcher falls in her bathroom, pushes her pendant and moments later, she is telling someone “I’ve fallen, and I can’t get up!”  EMS, the fire department, the police department, and whoever else gets called is on the way to her in no time.  A few minutes later the crew gets on scene and finds Mrs. Fletcher as they would expect her to be: seated on the floor unable to get herself off the floor and back in her chair.  The responsible ambulance crew gets on each side of her, hooks their arm under hers, puts her back in the chair, and they’re out the door without another word spoken.  The paperwork is simple, and they’re back in service. That is how it happens, right? If they were my ambulance crew that better not be how it happened.  Anytime Mrs. Fletcher finds herself on the floor it is up to us to at least make an attempt to find out how she landed there.  The first question that should be asked is “what happened?  Did you trip?  Did you get dizzy?”  Follow that up with another simple one: “Are you hurt?”  I know, it seems like it would be a no-brainer, but that is not always true. You need to get a look at the medications that these patients take.  Is there a beta-blocker in there?  Are they a diabetic?  These patients need...

I try not to complain very much, and I think compared to most medics I don’t.  Mind you, that’s not a dig at my fellow caregivers, I just think that we are Type-A personalities who want it all, and we get vocal when we don’t get it.  That said. . . This winter, I have had a huge pet peeve of mine rekindled.  In all of my years working in Springfield, Massachusetts there was one thing that I always checked when I was putting my truck together at the start of my shift.  It was not the oxygen, it wasn’t my backboards, paperwork, or anything else like that.  The one thing that I always made sure that I had was a sheet or blanket sandwiched into my stair chair, especially in the winter time.  For me, there was no more necessary item to carry into a scene. I was what one might refer to as “stair chair dependent.”  Many people liked to bring their stretcher to the door and park it there, or leave it on the curb but frankly I did not and still do not like leaving it unattended.  For me it was always easier to carry a stair chair to my patient’s side regardless of their condition so I could have something to use to move my patient to the back doors of the ambulance.  It got used a lot, and there were a lot of butts of varying conditions that saw time on that chair.  For me, the blanket gave me a barrier for my patents to sit on. In the winter time, it helps keep the patient warm.  In every season it gives you a great way to move your patient if they are not able to get over to your stretcher.  Nothing is easier than scooping a patient up with a sheet and popping them down with a draw sheet.  It is one of the simplest and earliest taught “moves” in the industry. And let’s not lose sight of the “don’t reach out” factor.  We all give that speech to our patients about how important it is for our patients to keep their hands in, don’t grab hand...

As I was getting ready for my first day of work last week, I started loaded up my pockets with the usual stuff that I carry.  In my right leg pocket, I keep my shears strapped into their little holders.  I always crisscross the straps to their snaps.  In my left hip pocket I carry my gloves.  At my new job I was surprised to find that many people carry sterile exam gloves so I started doing the same.  (If we are ever partners, I am an 8 and a half.) I loaded up my belt the same way that I do every day.  Between the second and third belt loop on the left, the clip for my radio goes.  In the same spot on the right side I have a holder for non-sterile gloves.  I usually load it up with four pairs at the start of my shift all rolled a certain way so I can grab a pair quickly if I need them. I then got ready to pocket the last little trinket that I carry: my Smith & Wesson knife that sits clipped into my right front pocket and realized that I could not find it.  I slipped into a momentary panic. Although I have used it just twice in the four years that I have owned it the knife is always sitting there, just in case. Fortunately, I found it in my hamper.  Apparently, it fell out of my pair of pants from the previous shift but it got me to thinking about all of the little idiosyncrasies that I go through in my day.  I have a certain way of doing things in my job that makes me comfortable.  It is kind of my own personal way of holding on to my sanity I guess.  My GPS goes on the windshield a certain way.  I keep my traffic vest in a certain spot in the truck.  My bulletproof vest sits behind the headrest of the back seat on whichever side I am driving.  These things get done every shift.  The same way.  I end up almost unconsciously reaching for things just knowing that they are there.  it is comforting....