The blinders are off and I have seen the light! For the longest time I had a very closed-minded view of EMS and how it should be run. Having worked in a single-medic private based EMS system my entire career, I haven’t had much opportunity to see other ways of delivering patient care. While I still remain partial to my system, I have a new found respect for the many differences and similarities that we all share. Ever since I started this blog and started yapping away on Twitter, I have met many respectable EMS professionals and have had the opportunity to share and listen to great ideas.

Happy Medic’s Blog opened my eyes to a fire-based EMS system that is actually quite similar to the system that I currently work in. Until recently, I would cringe at the words “fire-based EMS”. Well…..I still kinda do, but I have a lot of respect for Justin and the work that he has done to promote the concept of EMS 2.0. He has shown me that it is possible (although difficult) to be a good paramedic and firefighter at the same time.

Reading Ambo Driver’s blog has made for some good laughs and valuable lessons learned. For example; his article about spinal immobilization made me read further on the subject and really rethink my “c-spine everyone” mentality. I have been able to use his many years of experience and expertise to improve my practice in the field.

Mark Glencorse has really opened my eyes to a different kind of EMS system with his Medic999 Blog. For the first time, he showed me that other systems have options to advise and even deny people transport to an ER by ambulance! This is something unheard of in my area. Reading his blog has shown me that patient advocacy doesn’t always consist of transporting everyone to the hospital. I have also found it very interesting to read that while fire departments in the United States are standing in line to start providing paramedic-level service, fire departments in Europe are doing everything they can to stay out of EMS all together! It’s just another example of people working differently to achieve the same goal.

I recently started to read MsParamedic’s blog, which grabbed my attention when I read her article about scene safety. It really drove home the fact that we are not invincible. I was able to relate as I had a very similar experience. Her post brought me back to that time and made me remember how important it is to make sure that myself and my partner are safe and make it home at night.

Having the opportunity to be a guest on the EMS Garage (or Happy Hour if you will) was a wonderful experience. I learned a lot by speaking with all of the experienced EMS professionals on the show. Hearing everyones takes on fire-based EMS and the future of EMS in general was quite the experience. It is something that I hope to do again in the near future.

Last and certainly not least, I must give major thanks to hard work put into the Chronicles of EMS. Following the project has really shown me that we are all after the same goal. I think that it is a wonderful way to connect EMS professionals from around the globe in an effort to perfect the important job that we do. It is truly the beginning of a new era. As the project grows and more people become involved, we will see EMS 2.0 transform from an idea to reality.

I read so many blogs everyday that I would be nearly impossible to list what I have gained from everyone. I can only hope that my posts and contributions will someday attribute to another EMS professional’s knowledge base. Thank you all for everything you do for not only EMS professionals, but the patients that you serve as well.

Keep up the good work!

I just finished reading a great guest post on “Everyday EMS Tips” by Steve Lichtenberg about teaching CPR to kids. He gives some great advice about teaching to a younger audience. But more importantly, he makes it clear that kids can be taught to save lives. This post really hit home, as I am living proof on how teaching kids to perform CPR or First Aid can really make a difference.

When I was 12 years old, I took a health class in school to get out of having to take Spanish. For 2 weeks, we learned CPR and first aid. We were also certified in the skills once we showed our instructor proficiency. To me, it was more of an excuse to goof around and pretend to make out with the CPR dummy and make people laugh. It still didn’t change the fact that I had to learn the skills in order to pass that part of the class. I actually did find the first aid part of training to be interesting. So after I passed the class, I had 2 neat cards to put on the refrigerator and show off to my parents. I never thought I would use any of those skills, especially as a child.

A couple days after I completed that class, I was riding bikes home with a couple of my friends. One of the kids that was riding with us decided to take off across traffic and was hit by a pickup truck. I watched him fly over the handlebars, hit his head on the windshield and fall off the side of the truck to the street. After a couple seconds of watching him lay motionless, I ran over to him to see if he was ok. He wouldn’t respond to me and basically laid there limp.

The lady driving the truck got out and started screaming at me to get out of the road so that she could pull him off to the side. I knew that we shouldn’t move him, although I didn’t exactly know why. I just remembered that we should keep the head still. I held his head and told the lady to call 911. This was before cell phones were popular, so there was really nothing she could do. I yelled at my friend to ride to his house that was only a block away and call instead.

Several people stopped to help, and pretty much everyone wanted to pull him out of the road. I was adamant that we couldn’t move him and I tried my best to convince the adults on scene that I was doing the right thing. It basically came down to the fact that I refused to let go of his head, so they really had no choice. I had one of my friends hold pressure with a towel on a large laceration that he sustained from the accident in attempt to control the bleeding. He too had just taken the same class.

The ambulance (the same one I work for now) arrived on scene first and took over care. I don’t remember much of what they did, but I do remember one of the crew members thanking me and saying that I did the right thing by holding his head. A couple months later, the kid returned to school. He suffered minor brain damage and a spinal fracture. He had no lasting neurological deficits and pretty much made a full recovery. I’m sure his helmet probably did more of the life-saving than anything, but It’s nice to think that I may have actually made a difference in his outcome.

So yes, I do think that kids can and should be taught to perform life saving interventions. Image how many victims of cardiac arrest would survive if we taught all high school students to perform CPR? We make them learn to use a computer and type properly on a keyboard. Why not teach them how to react in a life-threatening emergency? They may never take another CPR class for the rest of their life, but they will always have at least some of the knowledge in the back of their head. Bad CPR is always better than no CPR. I wonder if the American Heart Association has tried to approach programs that would teach young adults CPR before graduating high school?

If anyone knows of such programs, I would love to hear about it.

Your ambulance is dispatched to a scene for a complaint of seizure activity. You are arrive on scene to find a young male in his 20’s shaking violently on the floor. Your initial reaction is to protect his head and place him on high flow oxygen. You instruct your partner to place him on the ECG monitor and get your narcotics. Your just about ready to start your IV when you glance at the ECG and see a rate of 60 beats per minute. “Wait a minute, 60?”.  You then tug at his arm and pull it towards you with little effort. He then pulls it back with a few second delay. Having a pretty good idea of what’s going on, you stand back and say out loud “well I can’t find a vein, looks like we have to give rectal valium!” Suddenly his “seizure” stops and he immediately starts talking.

Obviously the patient above was not having seizure. Luckily you were able to figure this out. Had you have just assumed he really was seizing, you would have administered a controlled substance for no reason. Sometimes knowing when a life-threatening illness is not present, is just as important as knowing when one is.

Emt and paramedic school is great at telling you what to do when a patient complains of chest pain or has a seizure. Unfortunately, nobody really tells you the reality of treating patients in a pre-hospital setting. The fact is, people lie. People want drugs and people want attention. I really think that we need some some emphysis on teaching paramedics to detect when someone is “faking”.

In my opinion, part of doing a thourough assessment is determing whether or not the patient’s complaint is ligitiment. I wouldn’t give atropine to a patient in SVT, and I wouldn’t give nitroglycerine to a patient that was hypotensive. So why would I want to give valium to someone that wasn’t having a seizure?

Any seasoned emt or paramedic knows when a complaint is real or not. But this comes from experience in the field, not from training. At some point, we all had to learn our lesson from the one guy that fooled us. Why can’t this be taught as part of our detailed assessments?

I really think that we need to start training our paramedics the reality of working in the field. We need to promote having an open mind and realizing that things aren’t always as they seem.

Before I even begin this discussion, I am going to come right out and say that I carry an EMS field guide with me on every single call. Now I’m going to spend the rest of this article defending my position on it!

I heard many people argue that field guides or “cheat sheets” are crutches. I can certainly understand how someone could become dependent on having the information in their back pocket. I have heard plenty of stories of medics flipping out after getting on scene only to realize that they forgot their field guide.

I will say that I have been that guy. The first time I forgot to pack my guide, I ran an infant cardiac arrest. Even though I got nervous, I was still confident that I knew my dosages. I treated the kid without delay and the call ran as smooth as it would have if I did have it.

Even if you carry a guide, it shouldn’t replace your core knowledge. You should have no problem figuring out a dosage or doing drug math. Carrying the guide should be a way to double check your work. You shouldn’t have to rely on it 100%.

The popular field guides that are on the market now have tons of useful information. Poison information and prescription drug information are just 2 examples of things that are nearly impossible to accurately keep in your memory bank. Having the information in your back pocket will be extremely beneficial.

My personal favorite guide is the “ALS EMS Field Guide” by Infomed. I never leave home without it. I also carry a nurses drug reference book and a medical dictionary in my backpack. If nothing else, they can be used to research a patient’s medical history and medications during long transport times and learn something new.

In conclusion, I feel that the field guides are a great tool, but can easily turn into a crutch if you don’t stay on top of your core knowledge. The guides should be used to add to your existing knowledge, not replace it.

If anyone knows of any good field guides that I didn’t mention, please let me know. I’m always looking for new tools to use at work.

As I sit here reading through Happy Medic’s Blog, I came across a very interesting post regarding billing, and refusal of treatment. He made some very valid points when it comes to fraudulent practices seen amongst many EMS providers. For the purpose of this post I am going to focus on legal issues when it comes to having patients sign AMA (against medical advise).

The Scenario:

You arrive on scene of a 26 year old female complaining of abdominal pain that started 2 weeks ago. After you start your assessment, she asks you if the ambulance ride is really necessary. You respond by telling her that her vital signs are all stable and that she looks fine. You explain that abdominal pain that started 2 weeks ago is non-urgent and that she should seek care with her primary care physician as soon as she can.

She accepts your advise and decides against transport to the hospital. You then ask her to “sign here” to release you from any liability SHOULD anything happen after you leave. She signs the form, apologizes for calling you out and wishes you a good day.

Here’s the problem with this scenario. You just had her sign a form that states that she is “refusing treatment” against medical advise. Well your medical advise was to stay home and seek care from her physician at her convenience. I’m sorry but Larry H. Parker is going to eat you alive in the court room.

Just because you got someone to sign a piece of paper, doesn’t mean your legally off the hook. Someone signing out AMA must give you Informed Refusal in order for the form to actually be legal. Just like Informed Consent, the patient must verbalize that they truly understand the risks from REFUSING TREATMENT. Tossing them a piece of paper and saying “please sign this” isn’t going to meet that criteria.

As EMT’s and Paramedics, we should not be giving medical advise unless it is in the form of convincing a truly ill person to go to the hospital. The proper way to address the “do I need to go” issue is to explain that it is not your decision to make and that if they want to go to the hospital, you would be more than happy to take them. I’m not saying force everyone to go, because that will get you in trouble too. Just be very cautious when expressing your opinion on their condition. We are not physicians and we cannot truly rule out a life threatening illness.

If you felt so strongly that the patient didn’t need to go, then why did you have them sign an AMA? Why not just leave them and call it good? There shouldn’t be a need to “cover your ass” if they really don’t need medical attention right?

If you want to play it safe, then don’t advise patients that their condition doesn’t require medical attention. That old lady with the stubbed toe just might have broken loose a clot from the DVT that you or her didn’t know she had (a stretch, I know). I’m not saying that you have to force everyone to go, but rather be careful of what you “advise” people before you have them sign a refusal of treatment. Lets try not to give the lawyers any more money than we have to.

We get dispatched to a familiar address for “difficulty breathing”. As we pull up on scene, the fire captain walks up to the ambulance and says “he’s having another asthma attack, my guys are walking him out right now”. I wasn’t particularly thrilled with his decision to walk the patient, but at this point the patient was already walking up to the ambulance.

The patient is 67 years old, deaf and has a history of chronic asthma. He typically calls about once a week when he runs out of his Albuterol and gets short of breath. The call started out pretty much just like every other time I have transported him. I’m initially thinking “O2, monitor, IV and an Albuterol treatment and we should be good to go”.

I listen to his lung sounds and hear wheezes in all fields. This is pretty much normal for him as mild wheezes are pretty much his baseline. He happens to read lips quite well, but doesn’t really speak. I look him in the eye and ask, “are having another asthma attack?”. To my surprise he shakes his head “no”. A bit puzzled, I ask “are you short of breath?”. He motions “yes”. So now I start with a different route of questioning.

Sean: Does this feel like your asthma is acting up?

Patient: No

Sean: Are you having pain?

Patient: Yes (and points to his chest)

Sean: Have you ever felt this way before?

Patient: No

So now my treatment plan completely changed from a respiratory emergency to cardiac. I wasn’t able to determine length of time or a pain scale due to the language barrier, but I did know enough to start treating him.

I placed him on oxygen, started an IV and administered 325mg of ASA. His bp was 98/palp so I did not administer nitro. His monitor showed sinus tach at 110 and an Sp02 of 99%. We arrive at the ER, place him in a bed and the staff does a 12-lead ecg. Sure enough, the patient was having an MI and was taken to the cath lab.

This call really got me thinking about how easy it would have been to just run with the asthma idea and completely mistreat the patient. Administering Albuterol would have increased the workload on the heart and potentially made the MI worse. Who’s to say that the hospital would catch the error?

If anyone else has similar stories, I would love to hear it.

The service that I work for recently made a rather large purchase of new heart monitors. We are switching from the Zoll “M” series monitor to the Zoll “E” series. This of course comes with a ton of neat upgrades. Built in c02 Capnography, NIBP, and 12-lead monitoring are all new features that come with the devices.

There is one feature that I forgot to mention…..

The monitors record the Sp02, c02, NIBP and ECG for the entire call. They also have Bluetooth capabilities and sync the entire call to our electronic PCR’s. You heard that right, big brother is coming to town!

Before I get to far into this post, I will say that I am 100% for recording and keeping the data, but I’ll get into that later.

I heard several people say that they are troubled by the new devices because they feel like they are being “watched” or “spied on”. Many paramedics fear that the feature will lead to a lot of “Monday night quarterbacking”, or questioning of paramedics practices if you will. I personally believe that the people that fear this system are just not comfortable with their own skills. I am actually quite bothered by this response and can’t help but wonder if it will have some negative impact on the care provided by the “affected paramedics”.

Ever get the feeling that your being watched? Have you ever noticed that you don’t act like yourself when you know you are being watched or recorded? Well imagine that feeling being applied to every ALS call you run. My fear is that some paramedics are going to second guess themselves to the point where nothing gets done. Unfortunately everyone always assumes that surveillance is a bad thing.

Lets look at an example on how closer monitoring of patient care can be helpful:

Have you had a patient present to you one way on scene, and completely change either en route or at the time you arrive at the ED? If you have, then you have most likely had the nursing staff or the ER doctor question your assessment or treatment. Rather than just saying “you weren’t there”, you can show them solid evidence and spare yourself from being the topic of their conversations for the rest of the day.

ECG recording can be used to improve QA programs, defend yourself in court and help the hospital staff continue the care that you started. Having someone review your calls and ECG interpretation will ultimately help you. It is far better to have someone correct an issue, than let it go without being addressed, and possibly harming someone. If you feel that uncomfortable with your knowledge or skills, then read up and get confident!

Don’t be afraid of big brother. He’s really there to help.

The other day I heard a couple coworkers talking about the calls they ran for the shift. One of them started to talk about a “BS” patient complaining of difficulty breathing. The part that caught my attention was when he said that he pulled out the “lie detector”, AKA the pulse oximeter, to confirm that the patient was indeed, “full of shit”.

Statements like this absolutely make me cringe. Perhaps I just like to live in my dream world where paramedics are professional and knowledgeable in their field. Don’t get me wrong, I hate transporting the “911 abusers” just as much as everyone else, but I also understand that it’s part of my job.

Now for the medical part of my rant……

I am 100% convinced that we as paramedics can perform our jobs and treat our patients effectively without ever touching a pulse oximeter. Sure it’s a handy tool and it serves it purpose, but it’s nothing more than a luxury.

If a patient presents to me with stable skin signs, clear and equal lung sounds, a good respiratory rate and speaks in full sentences, I can probably assume that they are breathing just fine. Likewise, if someone presents in a “tripod” position with wheezes and speaks in 1-2 word sentences, then I can definitely assume they are in respiratory distress. No pulse oximeter needed. Treat the patients people, not the monitor!

The pulse oximeter only measures a patient’s oxygen saturation in the blood. It cannot determine the metabolism or amount of oxygen actually being used by the body. This is why conditions like respiratory acidosis and carbon monoxide poisoning can give a high Sp02 reading, when in fact the patient is suffering from hypoxia.

So whats the moral of the story?

Do your job dumbass. Assess your patients, get a detailed history and for God’s sake, act professionally.

Being the geek that I am, I am constantly on the lookout for digital alternatives to things like calendars, checkbooks, and paramedic field-guides. Of course, being the not-so-wealthy-EMS-salary guy leaves me looking for cheap, if not free solutions.

My search for EMS-related applications started when I bought my Motorola Droid phone last week. After downloading the metal-detector (yes metal-detector) and internet radio applications, I began searching for apps that would be useful to an EMT or Paramedic.

I did my initial search was done using the built in app-market app that comes with Android. I searched various keywords like “EMS”, “Paramedic”, “Paramedic field guide”, “ALS Field Guide”, etc. I came up with 2 applications, however the results are not so good.

Here is a rundown of what I found.

BLS Drug Profiles:

The application comes with 6 drug profiles (Aspirin, EPI Auto-Injector, Activated Charcoal, Albuterol Inhaler, Nitro, Oral Glucose). While the information seems to be accurate, it’s not a very useful application for in-field use. I guess if you somehow forgot your doses or contraindications, then this might might be of some help. This app has been removed from my collection.

USA Drug Reference:

At first glance, this seemed like an extremely useful application. It’s basically an electronic version of a PDR or Nurses drug reference book. It has a really neat scrolling feature that makes flipping through the different drugs a breeze. It seemed like the perfect drug reference. That is until I actually tried looking at the information on the individual drugs. The majority of the categories are empty or have missing information. The program is solid, but the information is definitely lacking. This is quite a shame as the app has huge potential.

There are some applications out there that cost money. Skyscape’s “Rapid Paramedic” reference is basically a digital version of their hard copy pocket guide. I guess I would spend the money if I didn’t already own the pocket guide. Unfortunately, Epocrates does not have an android version of their program. It is available for Blackberries, iPhones and Palm phones. This, of course, is a major bummer. Hopefully they will come out with a compatible version soon.

The built-in GPS navigator is far superior to any GPS device that I have ever purchased. It utilizes Google Maps, which means that it updates constantly. I suppose it could be used to route yourself to calls, however I would check to make sure you aren’t violating any policies before you do so. I happen to work for an ambulance service that prohibits using personal gps devices. However, I have looked up random addresses in my area and compared the recommended routing given by Google Maps and my personal preferred routing by just looking at a map. I must say that I am quite impressed.

I must say that I am a bit disappointed in the lack of EMS-related apps for Android, being that the platform has been around for a while now. I will certainly keep my eyes out and post when I find any. If anyone knows of any that I missed, please let me know!

A common theme around hospitals and the latest ACLS guidelines suggest that intubation should no longer be considered a high priority. Instead it is now recommended that high-quality CPR and early defibrillation take priority over all other ALS interventions. I for one feel differently when it comes to pre-hospital care.

According to the American Heart Association, other procedures like IV access and medication adminstration can be performed before intubation if adequate ventillations are taking place by means of a bag-valve-mask. While I certainly agree with the concept, I do not feel that it is very practical for situations when EMS is involved. Unlike hospital settings, EMS workers have to deal with bumpy roads, tight corners, environmental factors and limited room in most ambulances. It can be extremely difficult to maintain a good seal and adequately ventilate a patient in those conditions.

Early intubation frees up hands, limits the amount of time suction is needed and allows paramedics to focus on interventions like chest compressions, defibrillation and medication adminstration.

I am not saying that I completely dissagree with the new ACLS guidelines. I simply feel that pre-hospital care was not taken into consideration when they were released. I would be interested to see how much of the Heart Association’s research was done on pre-hospital cases.

As always, feel free to e-mail me with any questions or comments.