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!

In any type of business there is a chain of command. If you are self-employed, you answer to your customers. If you work for a large corporation, then you probably have several levels of management. EMS is no exception. We all work for somebody.

If your an EMT, you probable answer to your paramedic. If you are a paramedic then you probably answer to your supervisor. If you are a supervisor, then you probably answer to an operations manager. If you are an op’s manager, then you probably answer to the owner. So now comes the big question. Who does the owner answer to? The owner answers to the people making his/her business possible. The customers, AKA the patients.

I’m sure that I will get some coments explaining that this doesn’t apply to government-run operations. That is actually far from the truth. Government-run ambulance services usually answer to either a city counsel or a county board of supervisors. They of course answer to the tax-payers that utilize your service. See where I am going with this?

The moral of this story is simple. Your patients are ultimately your boss. You work for them. They don’t work for you. Think of them as your bosses, bosses, bosses boss. Without them, you don’t have a job. They are what makes this wonderful thing called “EMS” possible.

I was teaching a CPR class a couple days ago to a group of EMT students. While I was explaining the 30 compressions to 2 breaths ratio, a student raised her hand and asked me if I actually count or even follow the AHA guidelines when working in the field. Believe it or not, this is the first time any student ever asked me that. I was honest and told the group that I do not always follow compression ratios. As a matter of fact, I probably never do. As you can imagine, the class was full of comments and questions after that answer.

Of course, I explained the science behind the AHA guidelines and why they recommend fast and hard compressions. The hard part was explaining why me and most of my coworkers don’t follow them. Being a paramedic, It’s easy to explain that my focus is around ALS interventions. Being that I have plenty of BLS providers on scene with me, I don’t typically have to worry about doing CPR. However there isn’t really a good excuse as to the large number of EMS providers that just “pump and blow”. It kind of makes me wonder how much of the Heart Associations studies actually included pre-hospital cases. More importantly, it makes me wonder if it really makes a difference.

….which brings me to my next point.

It seems like every time I teach a class, whether it be CPR or an EMT class, I always find myself having the “when you get into the field” talk. There seems to be this big separation of what you learn in the classroom and what you learn on the streets. I get that there are many things that experience teaches you that a textbook just cant. But why can’t our education be more realistic? It almost seems that we do everything BUT prepare our EMT and Paramedic students for real life scenarios.

We don’t tell people in CPR classes that bagging patients for any period of time usually leads to abdominal distention and regurgitation. Sure if you “properly ventilate”, that shouldn’t happen. But throw in the “bouncing ambulance” factor and the “2 people trying to do five things” factor and you got yourself a gurney caked with used hot dogs.

We don’t seem to tell our paramedic students that Mr. Homeless on 4th street only calls 911 complaining of chest pain because he knows you will give him Morphine, a bed and a hot meal. Is it that the people writing the books are so far disconnected from pre-hospital medicine? Or do we just think it’s too “politically incorrect” to tell our students that our patients lie to us?

All I’m trying to say is that we as EMS educators and providers need to put more emphasis on teaching our students the reality of working in this field. I would like to see us try and close this gap between classroom and field learning.

Anyone beg to differ?

Once upon a time lived a boy named Sue. He was well known as the bully around town. Sue was quite the perfectionist. It was understood that when you are in Sue’s territory you play by his rules. One wrong look and you better hold on to your lunch money for dear life, because Sue would have you roughed up and broke before you even knew what hit you.

On the other side of the neighborhood lived a boy named Doc. Now Doc was quite the opposite. He spent his days helping people with their various issues. A problem solver if you will. As a matter of fact, other kids were willing to pay Doc to help them with their problems. He was good at what he did and had a heart of gold. Unfortunately Doc wasn’t perfect. Sometimes he made mistakes, and that often made the other kids mad.

One day came and a kid named Pat had a problem that Doc just couldn’t solve. Pat became very upset as he paid Doc all of his lunch money and didn’t get what he wanted. Pat decided to track down Sue and see what he could do to help. Sue assured him that he would get his money back, as long as he got to keep half. Pat couldn’t resist the offer and decided to take him up on the deal. So Sue tracked down Doc, roughed him up and took all his money. As a matter of fact he took more money than Pat gave him to begin with. Pat ended up getting all of his money back and Sue kept the rest.

Now Doc eventually recovered and went back to his business of helping people. That is until one day Pat returned and requested his services again. Not really sure what to do, Doc agreed to help him. Once again Pat wasn’t very happy with the service he received. Pat once again called upon Sue to get him his money back. Only this time Doc called upon his friend Sharky to defend him in his time of need.

Sharky stood up to Sue and saved Doc from losing all of his money again. This continued until one day Sharky realized that he was providing a valuable service for Doc. A service this good was worth some form of reimbursement. After all, if Doc didn’t have Sharky to help, then he would lose all of his money every time Sue came around. Eventually it got to the point where it cost more money to have Sharky help, then to just give Sue what he wanted. This of course made for hard times with Doc.

More and more kids were getting the idea that they could just call Sue to get what they wanted out of Doc. Of course Doc couldn’t stand to lose all of his money as he had to have something to buy his lunch with. So Doc decided to ask for more money in exchange for solving peoples problems. As the cycle continued, many people couldn’t afford to pay Sue anymore and therefore would not seek his services. Even with the small number of kids that were actually paying Doc for his services, his high prices still provided for enough money to buy lunch.

Times were tough, but Doc managed to eat everyday. That is until the kids that didn’t have enough money to pay Doc called upon Sue to help them with their problems. Sue then told Doc that whether or not the kids had money, he was going to help them unless he wanted to get roughed up and robbed again. Unfortunately it got to the point where Doc was helping every kid in the neighborhood and only a couple kids were actually willing to pay him for his service.

Eventually Doc just couldn’t keep helping people. The constant fear of Sue coming around finally got the best of him. He had no choice but to quit trying to help people and find another way to earn his lunch money.

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.

Lately I have participated in many discussions regarding fire-based EMS. As we all know, there are very good arguments to both sides as to whether EMS should be run exclusively by the fire department. So rather than argue about whether or not it should be done, I am going to express my opinion on how fire-based EMS should be run.

Having worked in a single-medic service for my entire career, I tend to favor that type of system. I truly believe that 1-2 paramedics for each call is really all you need. Any more than that and you are just wasting resources. At minimum 1 paramedic on the ambulance would be sufficient. Depending on ambulance availability I suppose having a medic on the engine would be beneficial too. You can refer to my article “Two paramedics are not always better than one” for more on that subject.

I believe that the paramedics assigned to ambulance duty should play a single-function roll. It is very difficult to keep up your skills as a paramedic if your job responsibilities are split between patient care and firefighting. I also say this because I don’t believe that paramedics should have to become firefighters in order to practice in a 911 system.

One big problem with having multiple paramedics on scene is establishing who is in charge. It needs to be made very clear in writing who runs the show. I feel that this responsibility should be given to the transporting paramedic. If they are going to care for this patient all the way to the hospital and have to answer to the doctors and nursing staff, then they should have the final say in how the patient will be cared for.

Being the conservative that I am, I don’t really believe in “special taxes”. Having said that, I do believe that if a community wants to vote to impose such taxes to provide fire-based EMS services, then more power to them. If a special tax is imposed to provide the service, then the department should not be billing the patients. Departments that tax and bill their patients are just asking to be shut down and replaced by a private ambulance service who collects no tax dollars.

I truly do believe that efficient and effective service can be provide by fire-based, third service or private-based EMS, it’s just a matter of doing it right.

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!