Croakers EMS Blog

I am changing platforms

2017-08-20T12:05:00.002-07:00

I am changing platforms to wordpress.

My new page is here:

https://croakerems.wordpress.com/

The argument for EMS Degrees: Bandwidth

2017-08-18T11:50:00.004-07:00

https://nemsma.org/

I repeatedly keep hearing on how "we" as an EMS profession need a degree to advance up the chain. This is 100% true and is reflected in the National Emergency Medical Services Management Association (NEMSMA) Officer Credentialling framework. (Which, BTW, is excellent). But I think this viewpoint, while accurate, is also outdated. I think this is no longer a question of leadership, but clinical expertize as well. Everyone focuses on the money and management benefit of degrees and that other professions (i.e. nursing) have left us behind in this regard. But I say that without degrees we are about to be left behind clinically as well. Let me explain. Right now we (as a profession) are trying to play Call Of Duty over dial up internet. we are lagging. We are the 1976 small pickup truck exceeding its gross vehicular weight by 10,000 pounds We are sagging. While other professions are embracing vents, many of us are still bagging. (See what I did there?) We are exceeding the educational capacity of the certificate and associates (2 years) model of education.

I think we have reached (and are exceeding) the maximum bandwidth for our traditional paramedic pipeline. We NEED a 4 year, science heavy, clinical heavy program to keep up. And with very few exceptions, we don't have it.

King County Medic One trains it's medics through the Harbor View?University of Washington's School of Medicine. It is arguably the best program for paramedics in the country, perhaps the world. It is 3,000 hours of medicine in a year (double the national norm at 1,500 hours). This is roughly the same as a 3-4-year degree solely in clinical time. And I would argue that it is perhaps over-focused on Seattle's systems needs and not what the professions needs.

http://www.kingcounty.gov

If Paramedics (not critical care or flight paramedics, or even community paramedics but regular everyday paramedics) are to remain relevant and effective in healthcare, we need to increase our educational depth and breadth now. We are hidebound to think of our profession in the silo of skills and "area's" like cardiology or pharmacology.... many of which are taught the same way they were to 18-year-old combat medics in the 60’s and 70’s. That blue print for making medics is no longer enough. If we look at the abysmal airway management in some agencies, poor cultural and professional ethics in others, and our knuckledragging image among other medical professions, It has failed us. In 2010 Dr. Ecksten reported to the Gathering of Eagles (or Ego's, depending on your perspective. ) on paramedic initiated refusals, he reported alarming failures in the ability of paramedics to determine the need for hospital admissions. This is supported by a meta-analysis from 2009 of five separate studies. The issue isn't whether paramedics can or cannot provide an alternative destination. The real issue is that we as a profession was not prepared educationally to make that decision. This is not the only example. If we are to move potentially meaningful interventions to the most critical patient’s in the field, such as better multimodal pain management, pre-hospital screening for mental health patients, etc., etc, we need to increase the educational capacity to accommodate that. And that means a BS at a minimum.

Many providers think additional education is a waste.

And that does not even mention the future of resuscitation, such as EMS-POCUS, EMS ECMO-CPR, REBOA, etc. Then there is already our critical care and MIH/Community paramedic initiatives all of which would likely require or benefit from an as yet undefined mid-level EMS specialist in the next 10 -15 years….all in a profession where TODAY we have a hard time convincing our own rank and file that we need degrees at all.

The other specialties (critical care, community paramedicine, etc) can evolve into post BS and MS level programs, and they will be better for it too. The rising tide raises all boats.

Educationally we are sharks. If we stop moving we die. We need more bandwidth.

Yes, I realize that some of the above things are just now entering the ERs in the US…but there is active research to make these things feasible for the field. And if we wait for that to happen, some other profession will already be doing it and “we” will simply be taxi drivers with advanced first aid.

http://digitallanding.com/the-revolution-of-the-computer-modem/

Because : Blood Pressure...or somthing...

2017-04-16T08:45:00.005-07:00

How this started...

In a recent pathophysiology class , I was asked the age old question to define, compare, contrast shock. This led me on a mini-essay/rant on shock, and how it is taught in EMS programs compared how it should be taught in EMS programs. After some cut/copy/paste/editing, I repost the meat of the discussion here.

What is SHOCK?

At its simplest, shock is a resultant hypoperfusion state. It is actually much more complex, but let’s run with what we teach every EMT in the 150 hour course. Shock = Hypoperfusion.

WRONG

Shock is way more compex than blood pressure. It involves multi organ perfusion, inflamatory response, coagulation, and many other factors.

In any event, the best description of shock I can imagine dates from 1872 (now that is “old school”) .

""a manifestation of a rude unhinging of the machinery of life.”

S.D. Gross

Dr. gross I think best captured the systemic chaos that shock (in all its mariad variety) inflicts on the body.

And how do we teach / gauge hypoperfusion?

Well, for entry level providers we tell them it is the patient's blood pressure. We proabably teach an arbitrary a blood pressure like < 90 mm HG systolic.

If we are especially ambitious, we inform them about Mean Arterial Pressure (MAP) as well. Mean Arterial Pressure is a better goal, but not perfect. In most cases (excluding head trauma) we want a minimum MAP between 65 mm Hg and 70 mm Hg. For many patients this would mean a minimum systolic blood pressure above 90 mm Hg, although that is not absolute.

But what does that mean at the EMT level? How can we relate a very complex compensation process to entry level students? In many cases we use a simple equation called the FICK Principle. Remember this?

Stroke Volume (SV) * Heart Rate (HR) = Cardiac Output (CO).

CO * Systemic Vascular Resistance/Tone (SVR) = B/P

So, looking at the above figurative equation, we can see the various factors that can affect blood pressure, as our indicator of perfusion (or lack thereof). We can increase how hard the heart pumps (Inotropy), how fast it pumps (Chronotropy) to improve cardiac output.
We can increase vascular tone (vasoconstriction via, Alpha dominant vasopressors) or fill up the vascular tank with volume ( via crystalloids, blood products or colloids with colloid pulling pressure).

Seems simple, right? All you have to do is affect one part of the equation and you can affect all of it.

Wrong (AGAIN) .

There are two issues here. The first is compensation and artificial inflation. The second is misplaced validity.

Compensation and Artificial Inflation

Simply put Epinephrine and nor-epinephrine (or Adrenaline and Nor-adrenaline for you aristocratic types in the UK) are the bodies “shock troops” and can cause radical/extreme short term responses to compensate for blood pressure. We see the responses often in the above equation. Increased HR, Stroke Volume, and Vasocronstriction . This is why HR and Blood Pressure are indicators of shock, even theough they are not great surragates.

The problem is that we can see severe microvascular hypoperfusion due to pre- and post-capillary sphincter dysfunction even though the blood pressure may be “normaL”.

Artificial Inflation is a variation on that theme, also known as sympathetic tone. Simply put, pain responses can mask shock. This, also via the sympathetic nervous system , can artificially inflate blood pressure, with similar microvascular problems as above. For this reason, analgesics, sedatives, and paralytics should be used sparingly (but not neglected) in major trauma. You remove the pain (sympathetic tone) from the equation, you can lose perfusion.

Misplaced Validity

The issue is that while blood pressure (and MAP) are important, they are also just BSS’s or BSE’s (Bullsh*t surragates or Bullsh*t Endpoints). They have limited, somethimes misleading validity. They are easy to measure, however, so we rely on them. Probably too much.

What is more important than blood pressure is actual perfusion, or more specifically perfusion of vital (perfusion sensitive) organs like the brain, heart, kidleys, pancreas, gut, and liver. In fact, Hypoperfusion (and by extension shock) is more accruately defined as:

“ a condition of reduced perfusion of vital organs leading to inadequate delivery of oxygen and nutrients necessary for normal tissue and cellular function.”(Krausz, 2006)

So if we really want to “Gauge” hypoperfusion, we need to gauge organ function. Therefore blood pressure should be only one of those measures, and a secondary one at that.

We should gauge the function of those vital perfusion sensitive organs.

They are:

Organ	Indicators of shock
Brain	Mental Status, Cerebral edema from anoxia
Heart	Ischemia,
Kidneys	Urine Output
Pancreas	Blood Sugar, Production of Insulin
Gut (intestine)	Gastric Motility, Signs of sepsis
Liver	Jaundice, Liver failure

In other terms, we cannot worry about hypoperfusion without worrying what is being hypoperfused.

If we are to address “hypoperfusion” in the prehospital setting , we should probably have a goal. Frankly, Blood Pressure is a rather crappy “goal”.

How do we treat this shock/perfusion/ cellular dysfunction thing....

We generally would treat that by STOPPING (or failing that, minimizing) loss of life sustaining blood out of the vasculature via tourniquets, wound packing, hemostatic agents, and pelvic splinting. We would then temporize the effects with crystalloid (carefully), TXA, and in some settings blood products.

Most have heard of the “3 to 1 rule” whereas for every three units of fluid to replace one unit of blood. The new current strategy is the “1:1:1” rule as the new standard in trauma resuscitation (Miller, 2013). Specifically Plasma: Platelets: Whole blood and crystalloids relegated to a secondary resuscitation role only. Permissive hypotension, albeit debated, remains the rule. It is believed that the 1:1:1 rule is better at preventing the “lethal Trauma triad”.

Finally, we would addresss the lethal trauma triad of trauma mortality by preventing or mitigating hypothermia, acidosis, and coagulopathy. So warm them, oxygenate them, ventilate them, and don't fluid overload them. For some reason we often forget the hypothermia part in EMS, but that is a topic for another day.

Citations

Philadelphia (PA): Elsevier.

Krausz, M. (2006). Initial resuscitation of hemorrhagic shock. World Journal Of Emergency Surgery, 1(1), 14. http://dx.doi.org/10.1186/1749-7922-1-14

Miller, T. (2013). New evidence in trauma resuscitation - is 1:1:1 the answer?. Perioperative Medicine, 2(1), 13. http://dx.doi.org/10.1186/2047-0525-2-13

Millham, F. (2010). A brief history of shock. Surgery, 148(5), 1026-1037. http://dx.doi.org/10.1016/j.surg.2010.02.014

The Vomikin (SALAD Airway Trainer)

2017-04-10T18:07:00.001-07:00

The Vomitkin and me. A love story.

OK, hopefully if you are ANYWHERE on the FOAMed (Free Open Access Medical Education) internet, you have heard of SALAD and esophageal diversion. In the off chance you have not, I have some links to some excellent overviews below at the end of the article.

Today, however, we are going to discuss how I built my own SALAD Airway Trainer (AKA the VOMITKIN). In essence this sis a low budget, low fidelity manikin that vomits to simulate those nightmare airways that keep us up at night. You know, the GI Bleeds, the College alcohol overdoses, and the esophageal vertices.
Why is this important? Well , I personally believe that every parameic service can easily afford to bring a little bit of difficult airway management to every member of their department in the name of clinical improvement. You dont need a $60,000 high fidelity Sim Man to do it either (although those do have their place).

There have been a few different incarnations of this on the web, and even submitted to the journals. What I describe below is simply our version, hopefully an improvement on lessons learned from others. I hope you can take this and improve on it further.

In the beginning:

There was a lonely Leardal Airway Skills Trainer (AKA "Fred the Head").

After many years of rough service in the name of god and country, he had been retired to the back of a equipment closet and would likely have made the lonely journey to the island of forgotten EMS training equipment.

The Lungs

I removed the old lungs as they would be increadibly difficult to keep clean. In stead I took a single Bicycle inner-tube and cut it in half, one for each lung.

I took a simple connection elbow (Home depot, 79 cents each) that would fit the end of the "Main stem Bronchi" friction tight. I wanted to be able to easily remove them. Then I applies a little bit of "Shoe Goo" to the inside of the inner-tube and then a metal clamp to the outside to seal it.

I folded and then I clamped off the end of the bicycle tube so that they will inflate like lungs. This is better than sealing them. All I have to do is release the clamps for when it's time to clean them (hot water through a hose or sink). And then I can roll them up again when I'm ready to use them again.

The Esophagus

I had some difficulty finding a good conenction to the esophagus. This may be because it was an older manikin, so your experance may be different. At the end of the day (after many frustrating and failed attempts) I simply cut off the connection to the stomach, jammed the clear 5/8 inch diameter tube into the esophagus until "snug", then "shoe-goo"-ed all around it until it was secure. I let it "cure" overnight.

The reservoir

For the resovoir of vomit I used a 5 gallon bucket. For some this may seem excessive, but it serves two purposes.

Obviously, to hold the "vomit". We intend to use this trainer over 10 days straight with about 500-600 providers. The large reservoir is a good idea.

The second purpose is to provide a base of the pump. For this I used two U clamps to secure the tubing to the top of the lid. Otherwise the "pump" likes to rotate and twist. I used simple 5/8 inch clear tubing (.94 / foot at home depot) to suck the vomit from the bucket and send it to the VOMITKIN.

I read that the pumps are pretty cheap and wear out easy, so I put simple hose connections so we could swap them out without much hassle.

The "outgoing hose" is only a foot long and attaches to the "esophagus hose" which is about 2-3 feet long. Again I used simple garden hose connections for easy set up, tear down, and cleaning.

THE PUMP

For the pump I sued a cheap 150 GPM fluid transfer drill powered pump like this:

I have found these under various brands between 10.00 and 15.00 dollars, so they are not horrible expensive. You should be able to find them at any major home improvement or hardware store.

For the vomit I used chicken bullion, cranberry juice, and coffee grounds. I was going to add a few old cans of PBR but was overruled by my "bosses" for obvious reasons.

The Bill comes due:

And that is it. I actually spent about $68 fiddling around with it but I'm pretty sure I could do it for about $40 now that I know what I am doing. Far better than the $1,275.00 for this S.A.L.A.D. simulator new. https://www.enasco.com/product/LF03500UG

How was it received?

Overall very well. We set it up in the bay of one of the stations. The station was part of a larger airway-centric training and crews "round robin'ed" through each lesson. Not only did the EMT's and the medics hurry to give it a try, but even a couple of Battalion Chiefs took a turn. And you never see those guys smile about anything!

I would have them (as a team) perform the following skills/tasks in sequence:

SALAD decontamination
Esophageal Diversion
Intubation with Bougie around the esophageal diversion tube. NTE: I would have them use a meconium aspirator on the #9 ETT instead of simply sticking the suction tubing in the ETT.
Apply in line suction for tracheal suctioning.

Al in all it was/is very rewarding to push the medics and EMT's one step closer past proficiency and towards mastery.

Resources

(Original Paper) Novel Airway Training Tool that Simulates Vomiting: Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) System: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5226742/

https://airwaynautics.com/2015/10/04/recipe-for-salad-suction-assisted-laryngoscopy-airway-decontamination-simulation-aka-vomiquin/

http://www.emsworld.com/article/12277918/what-you-need-to-know-about-salad-a-new-airway-management-technique

http://www.tamingthesru.com/blog/airway/puke-with-jim-ducanto-md

http://www.anesthesiologynews.com/Multimedia/Article/09-15/Vomiting-Simulator-Adds-New-Approach-to-Difficult-Airway-Management-Training/33743/ses=ogst

http://www.jonathandownham.com/salad-mannequin-construction-by-james-ducanto/

https://prehospitalmed.com/2015/03/26/suction-assisted-laryngoscopy-airway-decontamination/

https://www.facebook.com/pg/SALADSimulation/videos/?ref=page_internal

And of course:

https://emcrit.org/podcasts/having-a-vomit-salad-with-ducanto/

https://emcrit.org/blogpost/ett-as-suction-device/

Zero to Hero?

2017-02-10T11:07:00.003-08:00

Question: Can a new EMT fresh out of school go straight to Paramedic School and be successful? should they?

This question has been hotly debated, and there is no universal answer. In the "old days" going straight to medic school was unheard of. The process was competitive, there were only so many medic programs, and if you didn't have 3 or more years experience you simply were not in the running for the few slots.

Since then we have seen an explosion of medic programs. This resulted in the phenomena known as the "medic Mill" that would crank out newly minted medics barely able to pass a test for about 10,000 each.

Fortunately, the requirement for accreditation that occurred in the late 2000's thinned the herd a bit, but there are at least double (or more) the number of medic slots every year compared to even 10 years ago. As a result, we are seeing younger and younger students in college programs going straight into a paramedic program. On the good side we are seeing more and more new medics with degrees (2 and 4 years), but the new medic with 5-10 years experience is the exception rather than the rule (military medics are a special exception).

Personally, I have (and do) worked with medics from both sides of the discussion. I think largely due to our extensive FTO process, many (most) are very good and some are great. I have also seem medics from both sides of the discussion fail horribly.

A lot of things can affect success/failure. In broad strokes they are::

Amount of pre-hospital clinical hours and quality of clinical hours on in paramedic school The more prehospital hours working with ALS crews, the better. I would say this even with a wealth of BLS experience because working on an ALS ambulance has a different workflow, different considerations, and different learning opportunities. Not better, just different.
Quality of the FTO program at the employer
MOST IMPORTANTLY: Work ethic, diligence, and personality of the new medic in question. Let's face it. We all own our own successes and failures. Even the worst programs have some standout students, and even the best ones will always have "that guy". It is the character of the new medic which is the only universal predictor of success.

Another factor is the quality of the EMT experience, just like the quality of the clinical. It is entirely possible for an EMT with 2–5 years experience to pick up a lot of bad habits, heuristics, and biases that will sabotage their career as a medic. Experience can work both ways.

The only firm conclusion I can make is this:

As someone who has FTO’ed both types of medics, I can say that the ones who go straight to medic school from EMT do have a steeper learning curve, but it is nothing that cannot be overcome. I would go so far as to say anyone who states that EMT experience is an arbitrary predictor of failure or inability to be great is mistaken. But it does make the learning curve for the first 3–5 years a bit harder. After that first 3–5 years, the playing field evens out.

What is Resuscitation?

2016-03-15T14:58:00.002-07:00

A post in the FB group "resuscitation" asked the question "What is resuscitation".

This was my response:

"OK, I am not going to take the time to quote physiology. Most know it on here, so that will be wasting time. If you don't, I can't really explain it in a simple FB post.

Instead, I am going to quote my first Shao Lin Master when talking about Kung Fu. Kung Fu loosely translated means time and effort. When someone says your Kung fu is weak, they mean the time and effort you put into "it" (whatever "it" is) is weak.

Resuscitation is part luck, part uncontrollable circumstances, but mostly Kung Fu. It is the sum of the time and effort you take to master it.

That's how it "works". It worksd based on the time and effort you put into it to master your craft. And when it doesnt work...it fails for often the same reasons.

How strong is your EMS Kung fu?

What Phil taught me...

2016-01-23T09:41:00.003-08:00

Honor Guard stands ready to present and fold the flag

So, yesterday we said goodbye to yet another medic. This was bitter sweet, as usual. Our EMS family, even by EMS standards, is tighter than most. it seems we only see the "old timers" (or "good timers” as one corrected me) at events like this.

I am grateful this is not another suicide. going to two of those within 6 months is sobering. But this is no less hard. Our friend was taken from us too soon after a sudden and unexpected illness, at a relatively young age for such things.

I would rather focus on the impact he had on me personally.

Many of the core of my agency "grew up" under his tutelage and mentorship. In obituaries people often talk about an infectious sense of humor, and this was no exception. But it truly was an understatement with Phil. Phil had humor in spades, and even the stories at his funeral had us laughing like like goofy kids. He was an eternal prankster, and an was often described as having people laugh the entire shift to the point of spontaneous urination. Only in EMS would that be considered OK.

Later, when health forced him out of EMS, he naturally went to PA school. But, he was still part of our family. That is why I love where I have been for the past 17 years. Family. Real family. They even accept me. Weird. But I digress.

I didn’t have that experience others have had, though. My arrival at my agency 17 years ago was at a time when he primarily worked during the week, and I on weekends. So while I worked with him, it wasn’t on a weekly basis. He wasn’t my partner, supervisor, or FTO.

But that is not to say he didn’t make an impact or teach me anything. Unlike my coworkers, I don’t have a funny "Phil story". I do remember all his funny voices. I especially loved his spontaneous "creepy old man" voice he would use, or the ways he would poke fun at the fire department (well-deserved at the time), But those were small things.

Where he impressed me was his people care (to use Thom Dick's term for patient care). I had just come from EMS in the south, a much faster paced, somewhat gruffer "take it or leave it" approach to EMS. Completely different that my new work environment.

What Phil gave me (along with others, I might add) was modeling what caring really looks like in EMS. I was amazed at the endless faucet of compassion, empathy, and kindness he could muster seemingly effortlessly. Don’t get me wrong, he was not a doormat, a cream puff, or any of the other descriptions we sometimes use for overly empathetic and tearful healthcare providers. He was truly compassionate. At 3 am or 3 pm, it was the same.

He was an excellent medic. And that meant a certain indefinable toughness to get the job done, no matter what. He loved the challenge of the work that set it apart from other health care occupations. He loved helping people and solving problems. Don’t all great medics?

I remember also was amazingly intelligent, and could apply that intelligence immediately to the clinical situation at hand. He could speak on equal footing with any of the doctors we worked with, and had their respect. But we worked with dozens of equally amazing Paramedics. We were known for hiring only the most clinically minded.

In short, Phil was excellent in so many ways, but where he truly was amazing was his compassion. He showed me it was perfectly possibly, and even essential, to balance competence and intelligence with compassion and care. Because of him (and others like him, a lost generation it seems), I tried to do the same.

I will remember that lesson from Phil to the day I die.

Thanks Phil, you creepy old man.

#LAUGHQD

#deathisawanker

Understanding Career Suicide by Social Media

2015-12-14T08:50:00.003-08:00

OK, in full disclosure , I wrote this post to complete an assignment for a class I am taking.

Now, on with the show:

It's probably worth recognizing that “social media” is a broad, far-reaching term. Most of us would recognize that Facebook and Twitter are social media sites. But what about Youtube? Pinterest? Linkedin and Slideshare ? Blogger or Wordpress? Foursquare? All of these are social media platforms because they allow us to share media (text, video, images, documents, etc) with society (the world at large). And, we are all held accountable for that sharing , right and wrong.

Good use of Social Media

Social media is a tricky animal, and what is ‘good use” for one post can go south real quick. It's probably important to realize that not all social media is created equal for every task, nor is it equally pervasive in society. For example , if you are announcing a senior citizen B/P check station, putting it on TWITTER probably isn't going to draw much response as simply posting it to the bulletin board of the senior citizen center.

Let's look at some good use of social media by tasks. Let's say there is an active shooter at a school. Cross Posting to twitter and facebook would look something like this:

“ATTENTION PARENTS OF WEST COUNTY SCHOOLS: REPORT OF ACTIVE SHOOTING AT WEST ELEMENTARY. STUDENTS WILL BE BUSSED TO FAIRVIEW CHURCH WHEN CLEAR”. #countySherriffs, #county911, #countyschooldistrict. #countyEMS

and

“ATTENTION , PLEASE DO NOT SHOW UP AT THE SCHOOL< KEEP ROADWAYS CLEAR FOR EMERGENCY RESPONSE. NO REPORTS OF INJURIES AT THIS TIME.

and

“ATTENTION , ALL INFORMATION ON SCHOOL SHOOTING WILL BE DISTRIBUTED FROM PIO AT FAIRVIEW CHURCH” #countySherriffs, #county911, #countyschooldistrict. #countyEMS

By using social media, the responsible agencies work to limit confounding factors at the scene (concerned parents and media).

Let's say you start a blog for your agency? You could start an educational blog (AKA FOAMed) for your employees, along the lines of www.Emcrit.org ro http://www.tamingthesru.com/ .. You could do a week in review or a Chief’s address to promote communication in your department. You could even do a bog of health and safety tips for your customers and patients.

What about Youtube? Making PSA’s is nothing new, but putting the videos out there for your employees and/or public to access at anytime? Perhaps something like this:
https://www.youtube.com/watch?v=ieQTBHvFsnY . These videos, posted to youtube, can be shared across multiple social media platforms. How about recruitment? This police department did an excellent job of not only highlighting their department but what they want in their next Chief. https://www.youtube.com/watch?v=0i7yjabtBs8 . One of my personal favorites is this physician who uses Humor and music to make some of the most important points in healthcare: http://zdoggmd.com/ .

Bad Use of Social Media

Who hasn't seen a tale of “career suicide by social media”? Raise your hand, class. Oh you? Where have you been living, amazon? Oh, I see. You're over 70 and this “facebook thing” is just a fad, just like VCR's?

For the rest of us:

Facebook and Twitter: Perhaps a “standout” of a facebook- faux pa is the tale of Tatiana Kulikova, the Russian paramedic who took derogatory pictures with dying patients.

I just have to comment on this: How bad do you have to act to get fired for disrespect in “Mother Russia”? Well, now we know. We can thank Ms. Kulikova for that. What is interesting is that in many of these cases, the unanticipated consequence is not just loss of job, or even loss of respect from your peers or family, but the world-wide shaming that results. The hate mail, death threats, and other consequences. Rolling Stone even gave this case a mention. In the end, social media cuts both ways.

Blogs are no exception to the rule. We all have enjoyed sites like The Duffle Blog (a military satire site http://www.duffelblog.com/) or the G.O.M.E.R. Blog (a medical satire site http://gomerblog.com/ ), Call the cops (www.callthecops.net), of course, the Onion. There is a fine line between satire and career suicide. Satire is best left to the professionals when it comes to EMS. In the case we used in module 2 (http://www.emergencymedicalparamedic.com/mental-illness-or-just-bad-people/ ) Where a paramedic flirts (but doesn't actually commit) with HIPAA violations by describing a case and his specific actions in what could be considered a derogatory way. Taken out of context, and linked to a particular employee, this blog post could result in suspension or worse.

Youtube is a tricky medium: You want to make the video’s fun and informative so that it gets “shared” but not too “fun” that it sends the wrong message, or gives a perception of inappropriateness. For example, what would make a funny “college humor” video (https://www.youtube.com/watch?v=LlDjFn60rrI ) would not be devastating if it was associated with your agency or your job. Here is a great example of what NOT to do: https://www.youtube.com/watch?v=3JRA8mo6saE .

Best practices in Social Media

I am not going to post “how to fix it”because the diversity , complexity , and evolution of this medium is kinda like medicine itself, highly variable. Instead I will post best practices.

Have a policy for Employees

This sounds simple, but it often isn't. So many agencies simply say “don't use facebook” without understanding how broad (and useful) the entire realm of social media is. FOAMed (Free Open Access medical Education) is the latest in EMS education, and is entirely dependant on social media for distribution. Entire generations of EMS employees are social media users with over a decade of daily social media experience. Taking a hard line policy only means your policy will likely be ignored (until someone screws up and you have to fire them). instead, HARNESS social media and set REALISTIC and HIPAA COMPLIANT expectations.

Have a designated PIO and a policy for them as well.

A seasoned supervisor may still need guidance on using social media. Have a written and clear (in layperson peak) policy for how to use approved social media to further the department's mission. And before you adopt the “next facebook”, consult some tech experts on the pro’s and con’s of each medium.

Use technology smartly. Consider the medium AND the message.

Understand that privacy and confidential do not exist in something posted to ANY social media. Snapchat was considered a “safe” way to share things you didn't want others to see, but there is ALWAYS a way around privacy, as this EMT found out. https://www.ems1.com/ems-social-media/articles/2006949-EMT-quits-over-social-media-booty-dancing-video/ If it is private, HIPAA protected, propriatary, or otherwise classified, there are far more secure methods of distribution. Even email is more secure than facebook, but there are programs such as policy tech (http://www.navexglobal.com/products/policy-management) and even Department of Homeland Security (DHS) web based ICS programs for these purposes.

References:

Friese, G. (2009, September 1). Social Media in EMS | EMSWorld.com. Retrieved November 2, 2015, from http://www.emsworld.com/article/10320124/social-media-in-ems

Another brick in the wall...

2015-12-14T08:50:00.001-08:00

Ok, a recent Facebook post prompted me to write this post.

A fellow medic (from another service somewhere in the USA) posted:

"I've been doing this for 10 years, but how do you get the image of a 10 year Olds broken body out of your mind. Especially when your kids are 9 and 11. All I keep see is their broken body in the place of his."

OK, So I have 25 years “in” and counting. I have kids too. And I have had similar problems. Mine were visions of my kids lifeless at the bottom of a pool or ran over by cars at the end of the driveway. These were anxiety inducing. I mitigated them by tonnes of swimming lessons and a gate/fence around my yard. That helps. Kinda anyways. Even my other half, who is also in EMS, sometimes thinks I am over-reacting. But that said, the struggle is indeed real. Don't let anyone discount these feelings, as they are a normal reaction to abnormal situations that we are exposed to over and over again.

So lets just say/admit/understand that even the most resilient will have this happen. Instead of denying it, we need to meet it head on and understand it is "normal". It is a part of our system of "walls".

We all build walls. Walls serve to provide emotional distance from the situation at hand. We can build them tall and build them thick. But walls are still made of bricks and joined by mortar. And sometimes that mortar has cracks, and sometimes the bricks crumble.

Those cracks our loved ones, the things we hold dear. Those bricks are our own emotional resilience and physical health. And while the “wall” of emotional detachment is very effective, once something gets past that wall, it usually has free run inside our head.

Don’t get me wrong, the wall is sometimes necessary. The emotional weight of dealing with people in despairing situations, sometimes life-threatening situations, is cumulative. We need the wall just to survive under the weight of the job.

But what do we do when the wall fails? This is not an "If" but "when". How we prepare for this is the topic of this article.

In broad strokes, we have two choices.

Choice 1:

We can adopt a scorched earth policy. Leave nothing for the "enemy" to grown in. To avoid the situation above, we can become so detached from the inherent repetitive trauma of the job we become dead inside. Make our inner most thoughts such a barren wasteland of bleakness that there is nothing for those images to take root in. No fertile soil for fear and PTSD to grow.

Now there are several problems with this scorched earth policy:

First, it doesn’t always work. In fact, sooner or later it is destined to fail. The very self-talk and mental state that supports this bleakness is usually false to our own human condition, and can also lead us to alcoholism, depression, and other self-destructive behaviours. Remember how I said the bricks were our emotional and physical health?

Second, it makes us assholes to be around.

Third, it makes us piss-poor providers. As Thom Dick said, 90% of this job is about CARING for people. If you have no soul inside, you can not care genuinely for others. You can be technically very proficient, but still you ring "hollow". People/patients will pick up on this subconsciously, and this will effect their response to you. It's that simple.

Choice 2:

The second choice is that we nurture ourselves mentally and spiritually, and hope that the wall works. This makes us healthier, happier, and also makes us better providers, more compassionate and caring. The problem is that when the wall fails, our greatest strengths as healers can become our downfall. This fertile soil of compassion also overwhelms us if we are unprepared for the emotional weight of the job.

https://lovsnmua.files.wordpress.com/2010/11/lifedeath.jpg

I propose a third option.

First, we must understand that the "Wall" will not keep everything out. Using the "wall" analogy, a wall is made up of bricks, mortar, and cracks. Something will get through.
in my experience, it likely will not be the major multiple casualty incidents with 50 critically ill haemophiliacs. It is far more likely to be the sad, destitute, grandmother who dies alone in filth, forgotten by all, yet who looks like your own grandmother. Or the injured child who reminds you of your own son at that age.

The stuff that gets through the cracks is the stuff that "connects" with you. And the older you are, it seems there is more stuff you are connected too, and therefore more susceptible. And, depending on how much stuff the wall keeps holding back, depends on what happens when it comes crashing down. Of course, this is all based on my own, unscientific, unresearched, opinion from the past 25 or so years.

Second, understanding that it will happen, we must share that knowledge with others. A wiser than I mentor from LE and military circles spoke once about the benefits of sharing our experiences orally and informally. He spoke about how, since the dawn of time, seasoned warriors and veterans passed on words of wisdom to the next generation. In contemporary terms, letting the next generation "know" what it was really like, and honestly speaking about it, helps them prepare for it. It lets the next medic know it is normal to be scared or to be upset. Understanding it is a normal response to an abnormal situation is often the first step in preventing or treating PTSD.

I propose that in EMS we do the same thing. Instead of fostering a macho culture of “the wall is all”, we embrace that we are human. LTC Grossman, when talking about law enforcement lethal force encounters and the PTSD officers suffered afterwards in his books “On Combat” and “On Killing” , discusses that lack of mental preparation for the "events" leads to the after effects as much as the events themselves.

He goes on to say that when officers discuss not only what happened but how they truthfully felt during and after lethal force encounters , it helped other officers prepare mentally and understand afterwards the effects. This in return reduced the lasting effects and allowed officers to cope better.

We must understand that sometimes the wall will fail, that we will experience spill over at home and the rest of our lives, and understanding that will mitigate the effects on our lives.
Talking about it, laughing about it (and not at it), will take the stigma, and the fear, away. When we share with other medics, it will help them as it helps us, and in turn, they will talk to others and that will help those too.

http://cdn.ipernity.com/112/19/39/5471939.96384bf0.640.jpg?r2

I know its tough, though, as we are all judged by our peers, and we don’t want to be judged as “weak” or “soft” against this imaginary wall. But it’s a needed discussion, and by stepping forward with our own “events”, and how we were successful (and not so successful) in dealing with them shows a true resilience and courage, not the false bravado we see too often in Fire and EMS. Especially since it will help others survive as well.

Thoughts welcome.

Until next time...

- Croaker

A very old overview of SOAP charting

2015-09-23T22:28:00.002-07:00

Even my daughters best friend hates chrting.

No one likes to write charts. Not really. Sure some hate it less than others, but between writing charts and being out there on the streets, writing charts loses. Well, on one site or another , someone was once again asking how should he/she write a chart. Everyone chimed in, not a few recommending the most painful, useless, and abhorrent method ever: the chronological narrative.

Of course, just in that last statement, I am sure I have pissed someone off. At this point there will be a few who will say: " OK, Mr. Wise-ass, how do YOU chart?"

And here is where I lose all credibility.

I like SOAP. Subjective, Objective, Assessment, and Plan/Progression of call.

Yep. That's right, The most antiquated charting method still in use.

Its my go-to method. I believe it helps you organize your thoughts in a logical format. It is organized so if you adhere to it strictly, you will not forget to document anything. and its thorough. And that is never bad.

And even more telling, when I read the modern swill that passes for a comprehensive narrative, I feel my seizure threshold lower. I wish more people documented in SOAP format. Or at least used E-PCRs that did.

A little background is in order.

At one time, not so long ago, my service strictly adhered to the SOAP documentation format. As I also cut my teeth on SOAP in the military, I still have a very fond place for it. Many (read everyone but me) despise it as a charting format, but I still believe it is one of the most professional, bomb proof ways to compose and record a patient encounter.

Many years ago, a new trainee of mine named Karen Powers was having trouble writing her charts. Well after my guidance and some trial and error she finally got it. This was in the early days of the modern internet, and she ran a small website for new EMT's. What you find below is one of the few of that original work, as she lost her battle to cancer in 2006. She was one the best EMTs I have ever worked with, and I still miss her.

Anyway, below is the document I essentially still give every new trainee I see, to help them compose their chart. I still believe that if you can write a good SOAP chart, you can write any format out there. I know there will be haters, but I base my experience on 25 years (and counting) EMS experience, as an educator, a FTO, and doing QA/QI for many years as well.

Well, here goes:

EMT-I Karen Powers , Circa 2004.

SOAP Report Guidelines for EMS

By Karen Powers, EMT-Advanced

Adapted from Temple College's "Key Elements of SOAP Report Format."

When I was struggling with the chart-writing part of my training, one of my Field Training Officers suggested that I use the SOAP portion of the run report to "paint a picture." This helped me to focus on describing the call well enough that the reader could see what I saw and hear what I heard. However, make sure you don't include things that are irrelevant or judgmental. Thanks, Steve!

Subjective - What You Are Told

1. Describe the patient, specifically age and gender.

2. Chief complaint.

3. What the patient tells you, including history of the present event and answers to your OPQRST questions. Guess what ... if the patient has a potty mouth and this disposition is important to the situation, go ahead and include the quotes, but don't forget quotation marks!

4. What other people at the scene tell you: other responders, witnesses, police.

5. Previous medical history.

6. Current medications, physician(s).

7. Allergies.

Objective - What You See/Hear/Feel

1. Description of the scene, such as amount of damage to the vehicle's windshield, steering wheel and passenger compartment.

2. Initial impression of the patient, including his or her location and position.

3. Vital signs, including breath sounds.

4. Physical exam findings and level of consciousness. It can be separated into primary (ABCDs) and secondary (body systems head to toe, so it's easy to remember).

5. General observations and other noteworthy information such as environmental conditions, patient behavior, etc.

Assessment - Your Diagnosis

1. Diagnostic conclusion(s) based on the patient's chief complaint and your physical exam findings.

2. You may have more than one problem listed and can qualify each with "possible" or "rule out."

Plan - What You Did

1. This is the only portion of your patient care report that should be chronological.

2. Describe what was done for the patient and how he or she responded to treatment. This should include what was done prior to your arrival, how care was discontinued or transferred, and the condition of the patient upon departure.

You may want to include information about who had control of the patient's personal belongings upon your departure or where they were left. For example, if you left her purse in the tray underneath the hospital bed, make a note of it so you aren't to blame if the purse disappears.

Always keep in mind the importance of this document:

It is a medical record that must be treated confidentially, as defined by HIPAA regulations.
It is a legal document you may have to defend in court much later, after your memory has faded.
It is an historical record of the event from which a bill of service will be generated.
ALWAYS BE SURE YOUR RECORD DOES NOT CONTRADICT ITSELF

Other things to remember:

n  Often Legal action is taken because of Act of Omission, no Commission.
n  We are (most often) sued because of something that was not done.
–        We didn’t treat a condition
–        We didn’t provide transport
–        We didn’t take time to…(insert basic treatment we forgot to document)
n  Many times this results in a underlying perception that we didn’t care enough to do our job.
n  It is important that our patient chart clearly shows that we were not just bystanders to the patient’s condition, but we took a pro-active part in being a pt advocate.
n  This changes the perception from us being a lazy medic who didn’t take the time to transport (or treat) the patient to a caring individual who tried to take care of a patent but the patient (or situation) prevented it.

I hoped that was a good review. I realize it won't change any minds. Thats OK. Below is the basic template I would use if writing a stand alone SOAP note.

The following is an example of a (complete) SOAP template I use for stand alone documentation.

Medic XX dispatched to

S) Pt is a (age and sex) with a complaint of (XX.).

Remember OPQRST and 1-10 scale of severity.

Remember Pertinent Negatives (“ Pt denies…”

Include AMPLE if not included elsewhere. It is appropriate to repeat important facts about PMHx if it pertains to the call, even if noted elsewhere.

O) GENERAL- (Enter scene info, who attended the pt on your arrival, and interventions actively in place when you arrive)

VEHICLE- (Specific Vehicle damage info)

PRIMARY-

Initial presentation and distress level:

LOC: (Mental assessment to include cognition, affect, and comprehension)

A: (Airway, snoring, ect)

B: (Labored, non labored)

C: (Skin pallor, pulses, ect)

D: Mini Neuro

SECONDARY-

HEENT: (Head-Ears-Eyes-nose-Throat)

NECK/BACK: (includes spine)

CHEST: (lung sounds, excursion, ect)

ABD: (soft, tender, masses?)

PELVIS/EXT: Stability, distal motor function and sensation, etc.)

NEURO: (Detailed)

Cardio/Vascular Status: (Initial Baseline Vitals)

DIAGNOSTICS:

EKG: (Limb and 12 lead)

BG: mg/dl

SPO2:

SPCO:

ETCO2:

LACTATE:

(Other Lab Values if available)

A) This is your working field diagnosis

P) Chronological and itemized (with times if required by policy) list of interventions and Events throughout course of patient contact. Ongoing Vitals go in this section as itemized line items.

To Vent or Not to Vent, a chest seal question?

2015-09-22T10:06:00.001-07:00

An example of a commercial chest seal, the HYfin Chest seal.
This is one of several options available in the market.

Introduction

There are a number of small, seemingly routine questions that come up time and time again when I teach CE classes. One of them is the chest seal question, 3 sided (vented) or 4 sided (not vented)? Frequently students seem to want an either/or answer. Instead, I thought I would spend a little time giving you my answer, for what ever its worth.

A little background:

First let me say that I am talking about occlusive dressings to the chest cavity. Occlusive dressings to the neck serve several purposes, and should be the discussed separately.

The purpose of the occlusive chest seal (any type) is to seal the chest cavity from the outside environment in the event of an OPEN (or potentially open) chest wound. So before we apply a chest seal, we should understand WHY we are doing it.
A common misconception of the occlusive dressing is that we are preventing air and contaminates from entering the chest cavity. While this is a benefit, it is a secondary one. The real benefit is to facilitate the mechanics of respiration. Hopefully, you recall that we breath (normally, anyway) by negative pressure mechanics. In other words, our chest wall expands, making the atmospheric pressure inside the chest cavity relatively negative in relation to the atmospheric pressure outside the chest cavity.
When we have an open chest wound however, the patient loses a lot of the benefit of that negative pressure to assist in the mechanics of respiration. By restoring the integrity of the chest wall via an occlusive dressing, we mitigate that issue.

The largest concern with a non-vented chest seal is of course that we may facilitate or promote a tension pneumothorax. While justified, this concern must be put into context.
Most open chest wounds are penetrating trauma from sun shots or sharp objects. With rare exception (close range wounds for example) , these tend to leave relatively small holes. Therefore, chances are the "open" chest wound has actually already self sealed with clotted blood, adipose tissue, or simple position of tissue, and the occlusive dressing is a formality.
The second consideration with sealing open chest wounds and a tension pneumothorax, is that the tension pneuomothorax tends to be a relatively moderate progression. In other words, in most (not all) cases it does not magically appear. You have some time to assess, intervene, and manage the injury. A major exception to this rule is high speed blunt trauma and positive pressure ventilation. The latter deserves some discussion. Nothing will convert a simple pneumothorax into a tension quicker than positive pressure ventilation. So once you begin to bag a patient, especially with an ETT or SGA, your vigilance for a tension pneumothorax must be increased ten-fold.

So where does this leave us with the vented vs. non vented discussion?

http://www.mirror.co.uk/news/uk-news/tyler-gane-picture-shows-how-5396389
An example of an open chest laceration that would
definitely benefit from an occlusive dressing,

Keep in mind that we should be applying some kind of occlusive chest seal in the first 2-3 minutes of patient contact, during our rapid trauma assessment for life-threatening injuries. If you are in a combat situation, or work on a tactical team, you probably have commercial vented chest seals anyway as your "go-to" equipment, so this discussion is mute. But for the rest of civilian EMS, who d not have vented chest seals at the ready, this discussion is for YOU.
In 2015 the NAEMT's Tactical Combat Casualty Care Course (think PHTLS for soldiers and law enforcement) recommended that a vented chest seal be used for open chest wounds. For the most part I agree with T-CCC. Over time, such as seen with prolonged evacuations, a vented chest seal is an absolute must have. But what about in the first 5-10 minutes? UNLESS you are using positive pressure ventilation, I don't think it matters.

Therefore, what I tell my students is that I would rather have a provider spend 30 seconds getting an non-vented occlusive dressing in place during your rapid trauma survey and moving on to other injuries, than spending 5 minutes trying to make a perfect vented chest seal. So if you have a commercial chest seal, great. if you don't, just use what you have (expired defib pads work great for this.).

THEN...5 minutes down the road in the ambulance, when you go back and revisit your interventions, THEN you can spend time screwing with it to make a vented chest seal. Considering that most GSW's soft seal themselves, the vent is likely academic anyway. IF...you decide to provide positive pressure ventilation at any time, then you need to make sure yoru chest seals are vented as well, regardless of the time frame.

Wrapping up

In closing, I don't think this is an either/or proposition. I would recommend do something simple and quick now, and revisit it to make it more definitive shortly after when you have some "breathing room" (pun intended). I hope this discussion makes sense. Thank You, and of course follow your local protocols.
For more information, I highly recommend you take the NAEMT's Pre-hospital Trauma Life Support (PHTLS) course, or the Tactical Combat Casualty Care (T-CCC) Course or the Tactical Emergency Casualty Care (T-ECC) course. Information available at www.naemt.org I should point out that there are other course are available as well, such as the International Trauma Life Support (ITLS, formerly BTLS) Course (www.itrauma.org) or the Advanced Trauma Life Support (ATLS) Course. Having participated in all, and been an instructor for BTLS and PHTLS both, all are worthy courses.

References

NAEMT. (2014, June 2). Tactical Combat Casualty Care Guidelines. Retrieved September 22, 2015, from http://www.usaisr.amedd.army.mil/pdfs/TCCC_Guidelines_140602.pdf

EMS Thoughts: So, today a medic died...

2015-09-10T13:19:00.000-07:00

So today a former medic died.

It wasn't surprising. He wasn't in the best of health. And he had a MI a few years ago as well. He was found down today and was worked by a couple of our younger medics who didnt know him.

But I knew him. But back in the day when we were all younger we all ran a bunch of calls with him. Back in the the "guts and glory" era of EMS. Stayed up all night running calls, laughing with him, meeting with the crews for midnight slurpees at one of the down town gas stations,etc. Lots of memories. He was a very funny guy and a good medic.

But that was then. This is now.

So, today he died. there wont be a funeral. No honor guard. No wake. You wont see a bunch of medics at a local bar telling stories about him from yester-year.

You see, his (then) wife, also a fellow medic, found out he had child porn and turned him in. This was probably 10 years ago. the revelation hurt everyone in the department. I was mad at him then because he violated the first two rules of EMS (1- Don't be a dick, 2- Don't make the rest of us look bad) His actions were shameful and horrendous. It made all the good times a lie.

Haven't thought about the guy in years. Until today when I heard about the call.

And now I am mad again.

Now I am mad again because after all these years, his actions have deprived us of something else, the ability to say goodbye. We cant toast his memory, have a laugh, or tell a story, or even have a Slurpee in his honor because he took that from us 10 years ago as well.

I really wanted a slushi to remember and laugh.

Fucker.

Hyperoxia? A contrary view....

2015-02-20T12:22:00.001-08:00

Recently there has been quite a lot of huff and puff about over administration of oxygen. Tell me if you have heard this one before....

We (EMS) will bring in a patient on oxygen, a rather grumpy nurse would rip it off, put on an SPO2 and if it read anywhere near >94% for a fraction of a second, would leave the O2 off regardless of the patients overlying condition. When asked, the nurse would mumble something unintelligible about "hyperoxia" and "The AHA says...." and stomp off.

Well, like many things, a short couple of recommendations about oxygen have , at least in my opinion, been broadly misinterpreted and misapplied in ways they were never intended. So, lets take a look:

The actual recommendation is:

" EMS providers administer oxygen during the initial assessment of patients with suspected ACS. However, there is insufficient evidence to support its routine use in uncomplicated ACS. If the patient is dyspneic, hypoxemic, or has obvious signs of heart failure, providers should titrate therapy, based on monitoring of oxyhemoglobin saturation, to >94% (Class I, LOE C).36"

The new recommendations coming out later this year will likely read something along the following guidelines:

"We suggest against routine oxygen supplementation in comparison to air in normo-oxic patients with acute coronary syndromes (weak recommendation, low quality of evidence). "

So why am I bucking the flow on this? Well, lets first look at what the concern is: Hyperoxia.

So, what is HYPEROXIA?

Hyperoxia is technically defined as >300 mm Hg (Critical Care 2011) , a parameter that is only achievable with (reliable) SPO2 readings in the 99-100% range. Thus, titrating O2 downward based on SPO2 reading in the 93-97% range in the acutely dyspniec patient is not inline with the current concern about hyperoxia, and thus also not advisable. The concern around hyperoxia is
primarily directed at neuro outcomes post cardiac arrest, and CVA , and similar
ischemic issues.

Outside of neurological outcome post cardiac arrest, and a few other neuro related studies, there is little evidence against O2 administration prehospitally. Certainly Hyperoxia over a prolonged period may be a precursor to several adverse sequela (i.e. ARDS) , but at the point in the treatment process where this is a concern, the patient is monitored over multiple parameters in the ICU setting with a careful measured risk benefit analysis. I would argue that the use of SPO2 alone in ANY setting , in hospital or out , to titrate O2 administration in an acutely SOB or potentially unstable patientis not only imprudent, but perhaps irresponsible. Despite the advances of SPO2 in sensitivity, it can still be spoofed. In addition it is only a 1 dimensional view of a very complex physiology and a complex decision.

"...I would argue that the use of SPO2 alone in ANY setting , in hospital or out , to titrate O2 administration in an acutely SOB or potentially unstable patient is not only imprudent, but perhaps irresponsible."

Conversely, administration of supplemental O2 in any SOB patient may reduce O2 deficit, reduce anxiety, resolve nausea, and generally support oxygenation and better gas exchange to perfusion dependent organs, despite normal SPO2 readings (for the purposes of this lets call normal >94%).

Then there is the question of SPO2 lag, where the SPO2 has not caught up with the patients deteriorating condition. A situation where you would be treating an arbitrary number that is not even representative of the patients current condition.

Most of the (very limited) studies took an all or nothing approach to oxygen administration, as if the only option available to prehospital providers was a NRB blasting at .15 LPM. Reality is far different. Supplemental O2 at 1-6 LPM is far more common in 99% of the real world calls out there.

Where does this put CPAP? Most (not all , I admit) prehospital CPAP is O2 powered and therefore running near 1.0 FiO2. Do we have to wait until the patient is bad enough to warrant CPAP before they get oxygen, even though they may be hovering right at that 94% mark (but still be severely dyspniec)? Of course not.

Then there are the concerns on preoxygenation in the run up to RSI type apneic periods. I can think of cases of impending but not yet evident airway failure where preoxygenation is not only prudent, but the standard.

There are patients who are hovering right on the clinical cliff, yet still may have an SPO2 in the 94 range..until they drop. Excited delirium, restraint, unstable morbidly obese, and other patients fit this bill.

In the end, blanket recommendations on foundational treatments tend to cause more problems then they solve. In this case, the research is :

1) Out of touch with reality of current prehospital care (there are more options than 15 LPM via NRB).

2) Limited in its scope and relevance to prehospital care (researched post cardiac arrest and very few other conditions, where the scope of O2 administration is broad).

3) Has the risk of being broadly applied and broadly misinterpreted, causing substantial risk to a broad variety of patients suffering from Dyspnea, Shock, trauma, and other conditions; without really benefiting more than a very very few.

4) Is based on technology (SPO2) that can be problematic, especially without reliable pleth, or in shock states...or in hypothermia... or in anemia... or pregnancy... or in "days that end in Y".

SO, DOES THIS MEAN THAT HYPEROXIA IS NOT A CONCERN?

No. Hyperoxia is a concern, but a secondary one in most situations (post cardiac arrest, CVA, and possibly MI being exceptions). But even in those situations, it does not mean "do not give O2". An understanding of "Hyperoxia" leads us to believe that it is ONLY going to happen with HIGH CONCENTRATION of oxygen.

So, Croaker's perfectly contrary and debatable recommendation(s) is as follows:

1) Use of SPO2 without a pleth should be limited to those agencies who are not going to make clinical decisions based on the SPO2. In other words, for documentation and monitoring purposes only. If you are going to use SPO2 in any decision making process, you should be assessing the quality of the data (SPO2) you are receiving as well as the final number.

2) The decision to withhold or administer O2 in a potentially unstable patient should be a multi-dimensional assessment, also involving other tools like ETCO2, SPCO, and of course old fashioned physical assessments, rather than an arbitrary number.

3) In patients who are hemodynamically stable, without signs of SOB, without a time sensitive emergency, or an ischemic condition (i.e. CVA, MI); it is perfectly reasonable to titrate or omit supplemental oxygen based on SPO2 as a benchmark as well as patient comfort, IF a reliable PLETH is present and SPO2 is >94%.

HOWEVER, in patients who are hypotensive, at risk for hypotension, otherwise unstable, suffering an ischemic event/condition, dyspniec, in respiratory distress, or otherwise at immediate risk for imminent morbidity/mortality; then it is generally wise to administer oxygen regardless of the SPO2 in the prehospital and emergency setting until the patient can be stabilized.

After stabilization, supplemental oxygen should be based on PaO2 and clinical judgement rather than arbitrary SPO2.

4) Oxygen is tirtratable, and should be in 99% of cases. It is important to note that "administer O2" does not mean a NRB. The route, flow rate, and methods used are subject to titration, clinical judgement, and circumstances.

Thank you for listening.

References :

O’Connor R, Brady W, Brooks S, et al. Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S787–817.

The One Stethascope

2014-03-11T18:25:00.005-07:00

http://www.youtube.com/watch?v=igFhhByIOLo

Three scopes for the medics who fly the sky,

Seven for the nurses with their hearts of stone,

Nine for firefighters with their nose so high,

One for the Doc on on his porciline throne

In land of EMS where the patients lie.

One scope to hear them all, One scope to find them,

One scope to take their money, and in the darkness bind them

In the Land of EMS where the patients lie.

- Johnny Tolkien, NREMT-P

The most dangerous thing in EMS is...

2013-12-19T08:48:00.000-08:00

Fatigue Kills

Anyone who has ever sat in my full EMS courses has heard me say this: Fatigue is the most dangerous thing in our profession. Beyond domestic disturbances, infectious diseases, flying bullets, Ambulance accidents, or bad bosses. Being tired kills more patients, paramedics, firemen, police officers, and other critical cogs in our public safety wheel than anything else.

I am not talking about the long term effects of fatigue on cancer risk, heart disease, obesity, social relationships or sexual drive. All of which are true, by the way. What I am taking about is known as "Sleep Debt".

Sleep Debt

I am talking real time, point of care, on the street, in the blood and mud, being fatigued. Now we are all tired in this job from time to time. That 3 AM call always sucks. But Sleep Debt is different. Dr. Dave Grossman, PHD, (and retired US Army Ranger) is a (very) well-respected lecturer in public safety topics and particularly in the law enforcement community. He has too book I recommend highly. One is "On killing", the other is "On Combat". This last one particularly pertains to our discussion today.

Sleep Debt is the cumulative loss of quality sleep over a period of time (days). There are two major points here. Cumulative and Quality. Your 20-minute cat naps you grab in between your cups of coffee and cans of MONSTER/ENERGY/BULL SEMEN/EXPRESS don't cut it. You have to sleep long enough, and deep enough, to gain deep REM sleep. This restores vital neuro-transmitter levels in your brain-pan and are essential to higher functioning under stress. You know, like lifesaving and hero-shit and stuff.

Now there are different types of sleep deprivation. Total and partial. Most EMS providers "live" in a state of partial sleep deprivation. We brag about it. We are proud of it. And we are stupider for it. Sure, there are legit reasons to work in sleep deprivation. Rangers in combat have to. We do not. And for the record, even the military's own studies have shown that the effect on sleep deprivation on pain levels, reaction time, combat effectiveness, and PTSD are all dramatically worsened when we are sleep deprived.

Why this happens

Sleep deprivation happens for a wide variety of reasons. I will hit on a few:

1- There are no uniform mandates for rest periods for EMS workers. There are for truck drivers, pilots, medical school interns, and other professions where decision making and cognitive function is a life or death issue. But not in EMS or Fire? Why?

2- We are "proud" of our ability to work without sleep. 30 years ago, only "pussies" wore gloves on calls. It was a mark of prestige to have a bloody uniform. we wore our gore like a red badge of courage. Well, several epidemics of AIDS/HIV, Hepatitis, TB, and herpe-syphla-gonorhea later, we finally wizened up and now only the "rookies" get their uniform spooged. when we will think the same thing about those idiots who work two full time EMS jobs back to back, a part time one, and also party every night when they are off? (Disclaimer, once I was one of those guys too).

3- It is cheaper to put employees on 24 and 48 hour shifts than 12 hour ones. Less employees means less benies payed out, even if you pay a little more on OT. So many less scrupulous employers love the idea of 24 hour shifts.

4- And lets face it, we (the EMS providers) let it happen. We like having the time off that 24 hour shifts allow us, though all we do is fill it up with more sleep depriving activities and jobs. And then the simple truth is most of us love this work enough (for a variety of reasons, some good and some not so good) that we continue to work for everyone who will have us, whenever they will have us.

The results

Now , I know, what's a little sleepiness, right? Here are some of the things I have PERSONALLY witnessed.

1- Micro-sleep: More like petite mal seizures than cat naps, this is where you find your self in a sleep state for mere seconds..."nodding off", despite outside stimulation and energy drinks. Not too bad if you nod off while writing a chart. Lethal if its behind the wheel, or hanging on a rope belaying your friend.

2- G.A.S. Factor: No, I am not talking about the ratio of flatulence to nose equation, I am talking about your ability to "Give A Shit" (GAS). Weather you are checking out the rig, doing station duties, driving appropriately, providing patient care or getting a refusal. Your G.A.S. about the quality of your job is superseded by an overwhelming need to get back to sleep, and it taints all your decisions You are less likely to provide treatments (like pain relief) if it means you will be out of your bunk longer (like restocking the same narcotics or writing a longer chart). You will be more likely to get a refusal , even on someone you know you probably should transport, all because the very real need for sleep is clouding your judgement.

3.- Reaction time: Many studies have tried to qualify the exact effect of sleeplessness on the human body and performance. its a tough nut to crack, but generally speaking a 24 hour period without meaningful sleep is equivalent to between 0.5 and 0.8 Blood Alcohol Content (B.A.C.), only without the bad karaoke and the one night stands. Now, go into that same 24 hour shift with a building sleep debt, and its a wonder we don't have more bad outcomes, and near misses. Or do we only they are seldom reported?

What to do?

1- Use coffee and energy drinks as an occasional supplement to get over a hump, not as a daily ritual. The long terms effects of stimulant tolerance and consumption on hypertension and heart disease is worrisome, but even more worrisome is the tolerance that builds to coffee. When you really need it, it won't be there.
Energy drinks are even more troubling. Kidney stones, strokes, and other metabolic problems are all increased risks.
In the context of this blog, the issue is that these drinks prevent quality sleep. they make it harder to restore those vital neuro-chemicals you need during sleep, and therefore contribute to partial sleep deprivation and sleep debt, even if you are sleeping. So only use these drinks when you need them. And if you need them every day...then you need to look in the mirror sirenhead!

2- Sleep more! As a parent, a boyfriend, and a long time medic, I know this is harder than is sounds. I also know that it seems the only time to get any adult time (what ever that means to you) is AFTER the kids are asleep. This means late nights working, gaming, socializing online, watching movies, etc. All that is fine in moderation. But in the 2 days before your shifts...get full deep sleep.
Limit alcohol consumption before shifts. while a sedative, it also interferes with sleep patterns.
Some people use meditation, sound tracks, and other neuro-linguistic programming to help this. It works, and you should do your own research and try it out.

3- Plan safety naps: Some services have strict rules about when you can and cant sleep. I want you to listen closely on this one. If you are falling asleep in front of the computer writing a chart, or otherwise getting "micro-sleep" periods. TAKE A NAP NOW. or you will be taking a dirt nap later. Most supervisors will understand. Just don't make it a habit.

4- Cut back on the work and live more. If you must work, do something different that allows sleep before shift. Working back to back EMS shifts, compounding sleep dept , is a recipe for disaster.

Is this a common , everyday issue?

Recently there was an Air National Guard F-16 pilot who had a preventable mid-air collision. Unlike many of our fellow EMS providers, he is (by the nature of his job) acutely aware of the effects of sleep debt and deprivation on performance. I promise you that. yet he allowed himself to be sleep deprived over a relatively short period ( 3 days, only half the normal sleep recommended). The amount of sleep debt built up is something that most EMS providers do every week! His decision caught up to him , and about 22 million dollars damage occurred between both aircraft. What's worse is that he almost killed one of his fellow pilots. One of his friends.

Sleep debt catches everyone...

For my EMS friends and non-EMS friends alike. I have never been a pilot but I have been exactly where this pilot has been, and made the same decision over and over again... . I was lucky and no-one died..but I had my share of close calls. There were days/nights where I literally could not make myself give a crap because I was so tired. There were days and nights where I was snatching 5 minutes of extra sleep on the way to the call when even the siren and my partners driving could not keep me awake. There were days and nights where I had to pull over and make my partner drive because I was seeing shadows move I was so tired. This is a dangerous situation for someone who literally may have to make a life-saving decision. And it is occurring every shift or every day, I promise you.

Sure, my service pays fair wages and provides good benies/retirement...but for every one service like mine (fire based, third service, or otherwise) there are 20 that do not. This forces many providers to to work themseves to death to make ends meet. Chances are your local EMS or EMS employer is one of them.

And now there are fire agencies going to 48 hour straight shifts! As Gordan Grahm would say..."WOOOOOOHOOOO! Hear that sound? Its a train and its coming! Its going to derail reeaaall soon!"

I don't know how to make these crappy services treat their employees better. Only when there is a shift in what we as employees demand, will there be change. STOP GIVING AWAY YOUR PRECIOUS TIME, DEMAND SAFER EMPLOYERS. Citizens, stop letting your emergency responders work these long shifts as a matter of routine. Everyone: In the end, work less, sleep and laugh more. Both you, your patients and the communities you serve will appreciate it.
So look around, do a self-assessment. Everyday in this country EMS personnel are working two and three jobs, back to back, to make ends meet ..often still barely making it above the poverty line (while burger flippers are making more) The self-sacrifice is noble as a grape, but the result are catastrophic.

In a very real sense: WAKE UP, SLEEP MORE!

The Triple Check for safety: Is it time?

2013-07-13T15:53:00.003-07:00

Man its a rough world in EMS today....

Violence, trauma, intoxication, anger and strife have always been at the heart of EMS responses in the modern era. Every EMS provider, regardless of private or public sector, has encountered someone who wished them ill. Some of those people, patients or bystanders (and even rarely...other providers) actually act on those impulses. Others, in their states of confusion, anxiety, or delirium, simply lash out at anyone in reaching distance. Often that is "us", those who are trying to help. Since the beginning of EMS, and even before, it was often considered "part of the job". The 1971 movie, Mother, Jugs, and Speed, while a foremost a comedy, underscored this when one of the supporting characters (Leroy) was killed responding to an unknown medical.

Over the past decade, and especially the past year, there has been a significant rise in violence against EMS providers. In response, most agencies have instituted new policies on staging, co-response for law enforcement, and training on cover and concealment. Other agencies issue vests, and some agencies are even allowing EMS personal to arm themselves (to see my discussion on this, look here: http://croaker260ems.blogspot.com/2012/11/ems-thoughts-arming-emts.html )

States have enacted stiffer regulations on those who assault and batter EMS workers similar to penalties for assaulting a Police Officer. The National Registry of Emergency Medical Technicians (NREMT) has even partnered with the National EMS Management Association (NEMSA) and the Center for Leadership, Innovation and Leadership in EMS (CLIR-EMS) to form a National Violence and Safety reporting database to track and collect data on these occurrences (http://event.clirems.org/ ).

Let me go on record to say that all of these measures are worthy, worthwhile, and frankly...long overdue. But is this enough? Ultimately, WE are responsible for our own safety, and the street level practices that we develop ourselves, and then train the next generation in, will ultimately be what saves lives.

I have long believed that EMS leadership and educators have (with some exceptions) been reluctant to adopt proven techniques and practices from other industries into our own profession. For example, Law Enforcement Officers have long been taught to incorporate "Threat Cues" (body language, behavior, etc) into their daily practices, as well as regular "defencive tactics" training as part of their core skills. EMS administrators, because of budgetary constraints, fear of liability, and misconceptions of what EMS providers should and should not be doing scene, often balk at such talk. The same could be said of the use of checklists such as used by the aviation industry, or the "Pit Crew Approach" used by NASCAR.

As I write this, there have been at least two notable events in the past two weeks of violence against providers. Both of these events share a common trait. they BOTH involved situations where Law Enforcement were already on scene, and we know had searched one of the suspects and presumably searched the other. Both of the assaults occurred when the EMS providers were alone in the back of the ambulance, during transport.

Let me put it another way: In both cases, the none of the common scene safety tactics would have worked. Staging, Law enforcement "securing" the scene, etc... all were ineffective.

They share one other commonality, in both cases the patient attempted lethal assault on the EMS provider with a previously hidden weapon ( A gun and a knife respectfully).

I am not going to say someone slipped up, because that is obvious. But what is not obvious (until you think about it) is that it is predictable. And it will happen again. Why? Because we are people, and only through use of certain practices consistently, will these events be reduced (but never eliminated).

One of the major issues is that in these cases, these subjects were subject to "pat down searches" by law enforcement, rather than "full custody " searches. Many EMS providers are unaware of the difference. Due to constitutional issues related to privacy, as well as simple practicality, most LEO's cannot perform a detailed search unless the subject is placed in custody (as in arrested, as opposed to being detained while things are getting sorted out). This "weak link" and misunderstanding often leads EMS providers to a false sense of security.

Unfortunately, there is no easy remedy to this. I do not advocate in engaging in unconstitutional behavior, or unreasonable searches. But I do support reasonable safety checks and practices.

Therefore, I think its time for EMS providers to adopt and adapt another principle and make it a safety practice. The "Triple Check".

The Triple Check

The "Triple Check" is a safety practice that is used (along with the six rights of medication administration) in medication administration. In short strokes, you check the 6 rights at three different times. That's all fine and good for patient safety, but how does that apply to EMS safety?

I propose that we practice "safety checking" (i.e. searching) the patient three times. The chance that a hidden weapon will be missed on three separate searches by different people as opposed to a single one is unlikely.

The first "safety check" is by Law Enforcement before we arrive. We should ALWAYS ask if this has been done. Often you will be surprised it has not. Even when it was, there are many reasons it may have been done sloppily.

The second "Safety Check" is when we stand/assist the patient up to get on the gurney (or walk to the rig). Often our very proximity this puts us in a better position to observe and notice dangerous items.

The Third (and most important) Safety Check is before we begin transport. This is the most important because in most circumstances we are ALONE in the back of the rig with the patient.

Should it be done on everyone?

That's a good question. There is no good answer. Take a look a the TSA. Widely despised, yes, but you have to admit even when they do something right someone is saying they are doing something wrong. They are the best example of how NOT to implement a searching policy.

I think that the medic should exercise some common sense and leeway, but as a general rule I think this policy should be applicable to the following patients:

Anyone who was detained/in custody of law enforcement: They were detained because at one time or another, an LEO with a lot more training than us in these situations...thought it was a safe thing to do. That's good enough for me to do a safety check.

Anyone who is altered in mental status: I really really hope this one is self explanatory to the reader. If not, you may want to avoid EMS as a career choice.

Anyone with a known history of violence: We see many repeat customers, and LEO's even more so. When a patient assaulted another crew the previous week, or has a record of domestic violence...even if he is being nice today, he should be searched.

Anytime a paramedic can demonstrate an articulatable concern for safety: This is a key point. I don't believe in the validity of saying "I had a hunch". In reality, something, often very subtle and unrecognized, was processed by your brain to produce that so called hunch. We need to articulate that "something" into words before we search someone.

A couple of tips from a streetwise medic:
A lot of hassle and heart ache can be avoided by explaining your self and what you are doing prior to conducting a safety check.

Be aware of your body position to the patient. A safety check is irrelevant if you put yourself in a position to be harmed by the patient.

All safety checks should be done by two or more people. If the patient is hiding a weapon, they are most likely to be violent with it at the time of its discovery. Having a witness, preferably the same sex as the patient, reduces liability.

All safety checks should be with gloves on.

All safety checks should be in the best lighting possible.

All safety checks should be done in a respectable manner. Putting someone spread eagle against the rig looks bad on youtube, and is likely to provoke non-compliance. Being respectful and discrete will prevent a lot of problems.

Before you start feeling up every hot chick in the planet in the name of safety...talk to your local LEO agencies. See what their policies are. See what their training is. Then BUILD ON THAT. Write a policy. Do some annual training. Be credible and professional in your approach to this topic.

So what do you do if the patient refuses to be "Safety checked"?

Well, a significant portion of issues can be avoided by simply being "nice". When doing this , interjecting a little humor "Sir, do you have any knives, guns, sharp sticks, needles, or bazooka's in your pockets I need to worry about?" ), being friendly, and not acting like a badge-heavy-know -it-all will go along way. Remember we are stealing safety practices from the cops, not becoming cops. There is a difference.

I would also say that if a patient absolutely refuses to be searched, you should ask him why, and explain your reasoning and the extent of your search.

Thirdly, I would have serious reservations about transporting the patient who is acting like he has something to hide. Transport is the patients choice, but if he refuses to follow simple safety practices such as wearing a seatbelt, not groping the paramedics, or consenting to a safety check, then he may also be defacto refusing treatment. While this is a legal minefield, no hospital would allow a patient to remain in the ER who refused to obey "the rules". At some point, we should take a similar stance. After trying alternative remedies of course. In reality though this would be the very rare event.

Finally, the routine use of metal detecting wands on ambulances would have prevented both the gun and the knife in the recent events as well.

Thank you again for reading my rant, and in the words of Sergeant Phil Esterhaus:

"Hey, let's be careful out there."

For your casual reading:

http://www.kmtv.com/multimedia/videos/?bctid=2520912236001

http://www.firehouse.com/news/10495630/new-york-emt-shot-and-killed-by-patient

http://www.nypost.com/p/news/local/law_enforcement_officer_wounded_DP3D0RTEXihzhLeBSYz0sN

http://event.clirems.org/

EMS Thoughts: The Vacancy of Death

2013-04-12T09:36:00.001-07:00

The vacancy of death.

I am a paramedic, and I am scared of the dead.

Truly afraid. Not the “Ewww, I think I might hurl because it smells bad” type of fear. True fear. I have to deal with this regularly. I think I do well. Gloves, training, experience, emotional detachment are my tools. But after it is all done, when I lay down to bed, I have to do some critical assessment and thinking to deal with it. And for the most part I feel I am successful.

"There's a big difference between mostly dead and all dead.
Mostly dead is slightly alive. " - Miracle Max
The Princess Bride (1987)

I’ve seen hundreds of dead people. Perhaps over a thousand. Personally, up close, over my years as a paramedic. In all manner of death. I am not talking the mostly dead (Thank You Miracle Max) , or the almost dead.. what I sometimes refer to the “Peri-mortal”, but the truly dead. The post-mortal. The (insert southern accent) “ D-E-D” dead.

People think its emotional, dying. That at the moment of the passing of those close to us, the earth weeps a little. The sun shines a little less, or a little more ...on the moment. The clouds darken ..or clear. We expect SOMETHING to grieve, just a little bit, for the passing of someone’s life. The reality is, we are just imposing what we think should happen, perhaps the human emotions of the survivors, on a very no-longer-human and impartial remains.

Now at this point you would think I am going to rant about how death is impersonal. It is but that’s not my point. The earth doesn’t grieve, the sun doesn’t change, the clouds go on being clouds…but something else does happen. Something, perhaps , much more profound.

We don’t notice it as paramedics when we are busy with the newly dead. We are usually busy trying to hold it at bay. We are personally involved, we are busy and intensely focused. And I think… weird as it may sound....the really good paramedics give a little of their own essense in some unknown way to the newly dead… to keep them lifeful for a little longer.

But once that moment has passed, and there is nothingmore to be done....or when the body has been down a while, there is something empty about what remains. A black hole of nothing in even the most lifeless of environments. Its not just human beings, but animals too. Something has …left.

There is no “peace” of death. Peace implies some life left in the body. There is none. Any peace to be had, is what is given to us as a final gift from those we loved. The body itself cools, and is inanimate in the truest since of the word.

Its intangible, it’s a void, undefinable but real. I sense it like the 800 pound guerrilla in the room. If there is a body in a part of the room, no matter which way I face I can feel it, or more appropriately, feel the absence of it. I used to wonder if others felt this, or if I was just weird (most likely both). I have observed my co-workers, doctors, nurses, family, and strangers. Police Officers, Deputies, and firefighters. Students and mentors. I even try to observe myself to understand if what I am feeling is real.

I’ve come to the conclusion it is real. Not everyone can articulate it, but most I think can feel it on some level. We use humor to cope with it as much as we use humor to cope with the situation. We will often put ourselves in contact with the living … no matter how awkward, to avoid contact with the dead, which among other absences… has awkwardness all its own. We will use technical talk and street slang both to try to breath some humanity into what is no longer alive and therefore no longer human. Failing that, to put some distance emotionally. Something to change the feeling of emptiness.

Sometimes we have to deal with the dead. For me its easier when I don’t know them, obviously. I can still check a pulse, move the jaw or wrist to assess rigor, or roll the body to look for livor mortis. But even this brief contact is disturbing. I have been told that some things, like black holes, can be so cold, so dark as to steal heat and light and prevent it from escaping. Sometimes I feel as if a tiny bit of life and light is sucked into that which remains, trying to fill the empty vessel left behind.

Numerous belief systems talk about the body as a husk that we leave behind, on to heaven, nirvana, another chance on the wheel, Valhalla, whatever. I think that they may have that part right. In my lifetime, I have dealt with the deaths of my great grandmother, my grandmother, my father, and my best friend. I have also dealt with the deaths of a handful of close co-workers and friends. It is the same feeling at the funerals, walking up to the caskets, I want to put my hand on theirs, plant a small kiss, some physical touch to say goodbye, but I cant. I cant touch the body. My hands sweat, my heart races, and my fight or flight response kicks in. SO I do what I can, and its OK, because they arnt occupying that space anymore.

This isn’t to say that I cant function. Often I will leave a memento, something to carry with them on to wherever. These were people I love, and I feel very very strongly that how we honor the dead is as important as how we honor the living. I find that comforting. I may even feel a spiritual presence of some indefinable sort. from the departed. But it’s not from the body. That is a shell, and no amount of familiarity with the deceased has changed that sensation. It is constant every time.

This is different than what I feel with the peri-mortal, the newly dead, the not-quite-dead we encounter in our jobs. In this case we are trying to resuscitate and restore life. Perhaps coax it into staying a while longer. I guess in this case if it takes a little of us to do so, I am OK with that. Perhaps that is why, more than the effort that often leaves me feeling emotionally exhausted afterward. We spend some of ourselves in our efforts. If so, I think that is OK.

What about those who don’t feel this? I have only met a couple in my lifetime who I feel like they were completely immune to this feeling. Not just insensitive, not just unaware, but immune. Strangely, when I was in close proximity to them, I felt the same emptiness, the same void, as I felt with the dead. They too were lifeless, soulless, and inhuman.

One was a convicted child molester. I was providing some basic care for him, and it truly was as if I was interacting with a talking, breathing, but equally lifeless mannequin. He sat there, looked around, and did not speak. He had a pulse and blood pressure. He was performing the mechanics of respiration. But if you made me take the stand I would swear I didn’t think he was alive. I think that is what true sociopath is, an absence of life as we know it, but walking among the living. Perhaps that is why they are able to do the things they do.

The other was a pathologist I met in a long time ago. He smiled, talked, carried on in a very macabre and patchwork simulation of life, but was still just as lifeless as the dead inside. I would stand beside him as he performed autopsies, and if I closed my eyes, I would feel as if there were two bodies in the room. I read later about a series of missteps and misadventures in that pathologist’s career that eventually ended it. People wondered how his life unraveled. I wondered if there was any life to unravel, or rather the charade of pretending to be alive simply fell apart. It should say something about how profound of an impact these (and a few others) walking dead made on my career that I still recall them after all these years. I think its because it is as close to true evil…in the preternatural sense, that we will ever encounter. Even bad people, many will have some small shred of good in them left. Even hatred, is a sign of life. But these people were truly empty, and I could feel it.

Return of the Living Dead. I think his line
was "Send more Paramedics"....

This absence scares me. It truly does. Anyone who knows me knows that I have always been afraid of Zombies. It’s the source of much amusement to those closest to me. One zombie movie gave me nightmares for two weeks. I swear I slept with a bot by my bed because of it. This fear predates my days as a paramedic. It goes back to my childhood. I guess I can thank Sam Raimi for that. I saw one of his movies (Return of the Living Dead I think) then I was about 10 or so. I think about why they scare me. Its not the virus, or the gore of the stereotypical zombie. It’s the absence of life. The true void, that is. And it frightens the shit out of me. Laugh if you want. Its OK.

I am not claiming any special empathy, or supernatural psychic ability. I am simply stating that there is something to being alive beyond that strange cognitive ability we possess and the complex body systems that support us. Whether it is a soul, or something else I have no idea. But I know exists, It has too, because I can feel when it is gone.

I have no idea if this makes me a better paramedic, or not, but there it is.

NOTE: Many of these photos were taken from "The Knife and Gun Club", an excellent photojournalist piece on Denver Paramedics and Denver General. http://www.amazon.com/The-Knife-Gun-Club-Emergency/dp/0871136236

EMS FTO: What is a Slovis Drill?

2013-02-01T08:13:00.001-08:00

Every FTO has a "bag of tricks". Little things that they pull out of their butt that can save a trainee from certain career ending doom. I have quite a few. I have mapping tests and drills, mandatory books to read, about 20 Gigs of medical articles and studies, and about 50 gigs of ppt presentations...even some guided imagdry magic tricks I can pull out of my ass to help (I recently used some simply guided imagery to help an AEMT student improve her IV sticks). By the way, big thanks to Brian Willis ( http://excellenceintraining.typepad.com/excellence_in_training/) for that last trick!

One of my favorites is the "Slovis Drill".

The origin of the Slovis Drills (also known as the 5x5x5) dates back to my days in paramedic school in 1994. Dr. Cory Slovis is a world renowned emergency physician out of Vanderbilt ER in Nashville TN. He was (and I assume still is) a very quirky individual.

Dr. Corey Slovis

http://www.vanderbiltem.com/corey-slovis-md.html

Photo from: http://www.mc.vanderbilt.edu/vumcpub/index.html?pubID=7&articleID=407

One of his many “quirks”, is a habitual use of the number “5”. We would sit in “morning rounds” as paramedic students on clinical rotations, in the same room as first and second year ER residents, as well as medical students…and we would review interesting cases. Usually from the previous night I assume. It was not uncommon to hear a very loud assertive voice… “Mr. So-and-So….Tell me the five things you have to do to treat a patient in rapid A-Fib…” . This was usually followed by some stammering, and then occasionally a puddle of yellow fluid on the ground. If “Mr. So-and-So” didn’t perform to a satisfactory level, we would then hear…”Paramedic Intern Cole….can you tell us what the five things you should do to treat rapid Atrial Fib”…and then it would start over with a new case. It became such a trademark part of his conversation on almost any topic.. I really believe he probably thinks in “5 essential steps”.

Over the years I have frequently found students who have the knowledge and skill, but somehow are unable to put it out in a coherent form on a call. The NREMT assessment sheets do not lend themselves well to the real world, and frequently scenes are dynamic with multiple things happening simultaneously. In these situations, it is important to organize actions into "whats "important now", "whats important next", and "whats important later". Many trainees have difficulty adapting to this fluid and rapid pace compared to the very linear method taught in school.

Pic found at:
http://ontariomedic.ca/2010/08/24/paramedic-rap/

Somewhere along the way I tapped into my experience to help these students. I will make them do a 5x5x5 for situations to help them organize their thoughts and approaches to the real world situations. Sometimes I will make them do it for for every protocol/situation in our standing written orders (SWO) book. Sometimes make the student do it verbally, sometimes on paper, sometimes as flashcards or as homework. It would look something like this:

Chest Pain:

5 essential questions

- OPQRST (Note? I only allow common acronyms like OPQRST and SAMPLE count as one question)
-Previous history of CAD/MI/Cardiologist? Previous Cath
- Check for increasing frequency and severity of s/s over time.
-Syncope/near Syncope?
-Compliance with meds?

5 essential assessments

-Lungs
-JVD
-Pedal Edema/Acites/Fluid retention
-12 lead
- Enzymes (if applicable)

5 essential Treatments

- Oxygen
- Nitrates
-2 plus lines
-TRANSMIT THE 12 LEAD (we have stemi systems here) /CALL A CODE STEMI
- Consider opioids

I generally allow some variance in what trainees chose for their "five" . I am sure even now, you are probably coming up with your own list. The point of the drill is to improve thinking under stress.

I want to make this clear, I am not saying that knowing each and every step for starting a line, setting up a medication or analyzing a 12 lead is not important. In fact it is essential to know the minutia of our job like the back of our hand. it is the DEPTH of understanding that will often enable a paramedic to salvage a call when something unusual comes along, which is quite often. But utilizing the "5 essential steps" is equally important. It is similar to a pilot and his in-flight emergency check list. A good pilot knows the principles of physics, aeronautics, and the exacting details of his aircraft. But when his aircraft stalls, the adrenalin surges and the "lizard brain" takes over...the in flight emergency checklists tear away all that to the "essential steps needed now".

That's what this 5x5x5 drill will do, is help train the brain to do that , on a scene, on a call, to give the new medic some "breathing room" to handle the more complex thinking. The "5 essential steps" approach makes sense to me. It strips away all the procedural stuff, the fine print, the "extra stuff" into a simple list that must be done right now.

And, out of respect for the man who directly inspired it.. and who was the medical director for Nashville Fire, and at one time the State EMS director…I name the drills after him. I have been surprised how useful it has been for me and my students. It has exceeded my expectations, when I thought it was just a random idea floating around aimlessly in my head ( I get a lot of those). Given the chance today, I would thank him (though he would not remember me) , as would several of my students (and now friends). The reality is he probably is singularly unaware of how such a little think has helped others. I am hoping that by putting these thoughts down , this idea may help many many more. In the end, I hope you and your students find it as useful in your practice of the art and science of medicine (and paramedicine) as I have.

EMS FTO: when your partner is on the wrong tract....

2012-12-12T16:07:00.005-08:00

When your partner is wrong....

I had a recent online discussion on what do you do when your partner (i.e. the trainee) is about to do something bad on a call. You don't want to tip the public or the patient off, but you need to intervene on some level. It was (and continues to be) an interesting discussion.

The problem:

One of the unique things that has developed in many 911 services is a concept of a "lead medic". (I am using the term "medic" universally here to include any provider). When you are in the passenger seat, everyone tends to know its already "your call". Some places call it "lead", some others (like my service) call it "your tech". The result is clear, your the main person interviewing the patient, and typically you are the one directing care.
Ironically, this is something that fades away and disappears in the critical care/air medical environment, as a more team based approach is embraced in that culture, but even there usually one person is "calling the shots".
The reason I bring this up is that in many ground based 911 services I have seen, if its not your "tech", then we tend to see other providers "check out". Sure, these providers will set stuff up, perform IV's, etc...but unless the call is "all hands on deck"... there is a definite disconnect.
So what happens when the lead is clearly on the wrong track? It is considered "bad form" to step in too assertively. and when you do you are usually met with "if you want to run the call, its your paperwork, and your chart!" type of conversation. because of this, in EMS-land there is a definite aversion to stepping on someones toes and stepping in.

But how do you handle this when "stepping in" is what you need to do? As a co-worker, saying "hey dumbass, you shouldn't do that" is counter productive on many levels. As an FTO, you want to redirect the rookie, without taking over the call, so the learning continues. In our society as a whole, we don't teach conflict resolution, or even how to handle disagreements. As a result both new FTO's, and rookies, may not know how to handle this. Its a difficult proposition.

As an FTO, it is our job to maximise learning while protecting the patient from harm. This type of situation crops up more frequently with new employees and new medics, but it can happen even among long time partners.

Two different approaches:

There are two real issues/situations here. One that requires an immediate halt..i.e. safety issue, legal issue, etc....The other is a situation where the other rookie/officer is on the wrong track, and subtle "redirection" is needed "now" , before "immediate intervention" is needed later.

The Immediate Intervention

Is this an immediate safety , clinical, or Legal issue? If so , then an immediate intervention is perfectly appropriate. In those situations I think "Stop" is perfectly appropriate, point blank, and period. For example, if your rookie has an amp of Lidocaine in his hand, and is about to hook it up to the IV on a patient who is in a 3rd degree AV Block...then this is an immediate clinical situation. If you don't act immediately, then the patient may (most likely) die from an inappropriate medication intervention.

In this case clear, direct, and simple language is appropriate. Use the rookies name, and tell him to STOP. Then follow it up with the reason later. But the first statement should use the name to gain the minds attention, followed by the command. Any explanation can be done immediately after. If you dont, in the heat of the moment the command may be misunderstood or ignored.

This is easier said than done though. If the medic is a senior partner, older, or of higher certification, then stepping in can be difficult. This may be especially true in the fire service where the captain may be an EMT, and the rookie may be a medic. Of course this goes both ways.

The Subtle Approach

On our (EMS) side of things, the credibility of the paramedic providing medical care is very important, and a patient who feels the medic is off base, or doesn't know what he is doing, will often show signs of stress, etc. Obviously the last thing we want in a cardiac patient ... :). SO...finding a way to redirect the medic without stressing out the patient is paramount in all but the most urgent situations.

However, say there is an issue, but it is not immediate, but may soon be. In the above situation, your partner did not identify the rythm correctly and (for some unknown reason) thought that idioventricular rythm were malignant PVC's causing the patients chest pain. Say he does NOT have the lidocain in hand, but verbalizes hisintent to give it. In that case a more subtle approach may be warranted.

In the past, a simple " Are you sure?..." muttered under the breath is usually enough to cue the medic that he is on the wrong tract. If that doesnt a "If you dont mind, may I make a suggestion/ask a question (etc)?" is a definit cue to the rookie medic. "What do you think about ....?" also works.

If that doesnt work, Finally, "Paramedic Jones, could you run out to the rig and set up ...." is a very clear message that I am taking over the call. It helps if the FTO has a very frank conversation on day one on how he intends to handle the situation. Being open and communicating doesnt just solve problems, it prevents them.

Know When To Let It Ride

Sometimes no intervention at all is required. Sometimes the best thing you can do as an FTO is to step back and let the rookie stumble (but not fall).

Let me first say that at no time should an FTO allow his partner to set himself (or the FTO, or his agency) for failure, either clinically or legally. For example, I know some FTO's who let their trainees deliberately turn in poor charting to "let them get chewed our by QA so they learn". In this example, a poorly written chart has significant liability for all involved. A sub standard chart should never be submitted, and ruely dangerous care should not be allowed to proceed. If the rookie is not responding to the FTO's suggestions, then there are other more appropriate actions to take.

But there are slips , stumbles, and mis-steps the rookie should be allowed to experience. For example, perhaps the way your rookie interacts with the patient needs a little refining. Perhaps he is a bit " badge heavy" with the drunk. or, perhaps his scene management needs help, or the way he is positioning his equipment on a call..... As long as he does not step over into immoral, illegal, or dishonest behavior, maybe dealing with a self induced problem and getting nowhere is exactly what he needs. Then as an FTO it presents some teachable moments.

After all, our goal is to help the rookie eventually be better than us. And that will never happen if we make them do everything exactly the way we want.

In closing

It is important to use tact and subtlety far more than the weight of your evaluation and rank as an FTO. After all, if you embarrass your partner/rookie...even if absolutely justified...then learning stops at that moment and defensiveness begins. However, if you can protect your partner/rookie, redirect him, all without the public knowing, then its a win win for everyone....

Just my two cents.

EMS Thoughts: Arming EMT's

2012-11-26T18:06:00.002-08:00

To Arm or Not To Arm?

Recently a news article has become a hot topic... (for like a firestorm) in the EMS world. In Virginia (U.S.A. for any international readers) the rumor started that the Governor is giving Virginia EMT's the ability to carry guns on an ambulance. Other states are considering the same, and some prominent EMS'ers are coming forward and stating they have been carrying .. albeit covertly..for years.

Yes, that's right, arming EMT's and Paramedics. And YES, thats right, the second amendment debate has come to our front door.

HOWEVER, things are not as they appear. Despite what several sensationalist and alarmist have implied, no one is actually going our to arm EMT's. Instead , the governor is simply making it legal for Agencies to authorize it IF their unique situation makes this a reasonable option.

Background

You see, currently there is an obscure provision in Virginia state code that prevents EMS providers from carrying weapons. Many other states have similar provisions. Yep. According to one article it was a draft provision that was never intended to be in the final rule, but got left in by accident, and this revision by the governor is simply part of a larger attempt to tidy up the administrative rules. But , things have gotten out of control.

There is a common belief that by being unarmed somehow makes us better EMS providers and provides us with a "free pass" into unsafe situations. (http://www.ems1.com/ems-news/1353304-Real-protection-is-not-carrying-a-weapon-on-duty/?fb_comment_id=fbc_394749487265631_3418447_396711760402737#fc0c426cc ) There is also a belief that by arming EMS providers, we will suddenly become Rambo's rushing into every scene shooting our way to grandma and her broken hip.

Just the Facts, Ma'am,

Lets put aside the fact that there is no legislation mandating that EMS providers or their employers allow the carrying of guns. Put that aside...for now.

Instead, lets look at the facts.

1-Misconception: EMS providers are unarmed. Lets set aside the fact that EMS providers carry enough drugs to kill more patients than cops carry bullets. Most EMS providers carry weapons already, you just dont know it. Look at the pants pocket of 99% of EMS providers today, and you will see the familiar clip of a pocket knife. Technically these are verbotten as well under Virginia administrative law (and most other states too). Yet do a search for "EMS knives" you will find about 10,000 hits on google for companies selling them. (helpful hint: Most of these are crap. Truely crap, feeding of the need to "look" like a hero My personal favorite is the CKRT M-16 line of knives. http://www.crkt.com/tacticalknives if you want a good carry knife). A surgeon once told me that I could reach any cavity in the human body with an 1 1/2 blade. While I think he was forgetting that most of our patients have 6 inches of adipose padding, the basic principle is the same: EMS providers are already armed.

2- Misconception: Arming EMTs will change the way the public looks at EMS providers. Going armed will NOT change the perception of EMS providers in the public. Armed EMTs are common place in many parts of the world. Isreal, South Africa, central america are all examples. Granted those are all dangerous places, but that is not the point. The point is being armed will not change the way we are looked at. Currently, right now, in the US, there are plenty of agencies whose paramedics are dual role. Not firefighters, but cops. The Maryland State Police HEMS program, the Broward County Sheriffs Department, and many more are all examples of (Armed) Law Enforcement that function daily as EMS providers.

3- Misconception: EMS is not dangerous. Listen folks, we go to the same scenes that police officers do. Our pretty white shirts and "star of life" patches don't mean a thing to the confused, deranged, intoxicated, or simply stupid. And unlike law enforcement, ballistic vests are not standard equipment. EMS providers frequently assaulted or in danger. This doesn't matter is you are in the US or in the UK or South Africa. The facts are well documented. A NIH ( Prospective field study of violence in emergency medical services calls. ) study shows that violence occurs in about 5% of EMS calls and precipitation at least 14% of EMS calls. This study acknowledges that the numbers are likely under-reported.

4- Misconception: EMS providers are not targets of violence by the "Bad Guys" and arming them will change that. This is not TV. I don't know if gangs ever gave EMS a free pass on a regular basis (even the "Freedom House Ambulances got in tight spots) but it is clear that they don't anymore and haven't for quite some time. The military is again gives us a hint into the reality of this. For years, both because of the Geneva Convention and the general feelings of the military medical REMFS (look it up if you dont know what a REMF is) that a military medic ("Doc" if your worth a damm, Corpsman in the Navy/USMC) was somehow better protected if they were unarmed. There was a misconception that "First do no harm" somehow meant "Dont defend yourself".

Well, three plus wars and countless major conflicts later we know that is not true. In fact, as a recent event shows, medics are increasingly becoming targets (http://www.wane.com/dpp/news/crime/bullets-riddle-ambulance-in-transport) . EMS providers both in the US and abroad, as uniformed members and representative of society, are targets by the very nature we put on a uniform. to help others. As EMS providers we therefore straddle an invisible line in the eyes of the public, and often find ourselves opposite of the criminal and violent elements of society .

5- Misconception: If EMS waits for law enforcement to secure the scene, then EMS doesn't need to be armed. Scenes are dynamic and dangerous. The scene that was "secure" 5 minutes ago now has fighting family members. The crowd that was "controlled" now is not. Cops are outnumbered on most streets. If things get bad, they have their hands full.

I'll share another secret. Every time I have been assaulted on the job, either Law Enforcement was not on scene because it came in as a routine call, or Law Enforcement was on scene and simply busy with other tasks and were not on the ball. The "diabetic" pulls a knife out of the couch and comes at you with it. The mother of three who is post ictal has a rifle next to her bed.
The simple fact is that most lethal encounters with the public escalate and end in fatality in less than 3 minutes, many in less than 60 seconds. Right or wrong, the statement "when seconds count, help is only minutes away" is true.

So, are guns a good idea?

Now are guns a good fit for EMS? in most cases , no. But not for any of the reasons mentioned above. Consider this:

1- Distance: Most law enforcement agencies have a 21 foot rule. 21 feet is the potential lethal distance of a knife wielding bad guy. That is why police officers have specific tactics they employ when dealing with bad guys and potential bad guys. You better believe that when a law enforcement officer closes within 21 feet, it is on their terms. A cop can do most of his job at 21 feet. Command and control.
By contrast, our job requires us to be at what cops call "Bad Breath distance". At this distance, if a patient were to try to kill us we would have neither the room, not the time (granted to us by distance) to draw a firearm and employ it. Most lethal force encounters with us, that we would have time to defend against, will be decided "hand to hand". I can think of a number of weapons that would be better than a firearm at that distance.

2- Retention: Firearms retention is a big issue in law enforcement. In the "old days" there were reports of bad guys literally ripping the gun from the leather holster and using it on the cop. Good officers practice firearms retention daily through the placement of their body to the subject, arm position, and the use of good retention holsters. For EMS providers, we will need to change our tactics to allow for retention and safety of the firearm at the "close distances" that are required for us to do our job. I am not sure there is a good solution (currently) on the market for our specific setting.

3- Training: The liability of carrying a firearm as a representative of society the government or a company carries with it substantial risk and cost I am not sure most agencies want to bear. Before you see wide spread carry of firearms, I think you will have to see some sort of statuary immunity, and some kind of training standards established (similar to Law Enforcement Officers). Do I think there may be some out-liers and early adopters? Probably, but not very many.
I also think that while the training should be on par with law enforcement, it should also be somewhat different. We are not doing felony take downs, we (as mentioned earlier) would be deploying our weapons in a much different way. An example of the fundamental training differences can be found here: http://www.youtube.com/watch?v=ZdDEharvp0U&feature=related and a good discussion found here: http://www.policeone.com/columnists/lom/articles/1203276-Firearms-Training-for-Close-Quarter-Combat/

Are there roles for Armed EMS providers Yes. In fact, many exist already. We already discussed the dual role law enforcement.

Is there a need, and a desire for EMS providers to have the means to defend themselves today? Yes again.

Are firearms the best option, debatable.

Should it be an option, probably, provided the right training, and planning go into play. Is there a long way to go before this is a reality. Absolutely.

Until then, Stay safe, stay smart. watch the corners, and remember your best weapon is your brain!

-Croaker

Veterans Day and EMS

2012-11-11T09:02:00.003-08:00

My thoughts on Veterans Day and EMS

The US Army's Combat Medical Badge

Today, as the 11th hour, on the 11th day, of the 11th month draws close, I feel the need to reflect on my service, and the path it has lead me on. I obtained my first EMT cert (NREMT) at Fort Sam Houston in 1990. Several years later, while on active duty, I was assigned to the post EMS, and obtained my Paramedic Certificate as well. So certainly my military service has had a lasting positive impact on my life in many levels. But, this is not my point.

After serving in a "Division" unit with the 101st ABN, I served with he post EMS, and was lucky enough to attend paramedic school.

It was while reflecting on my personal history in service…. I thought on all the ways the military has impacted all of our jobs today.

Just some random Thoughts off the top of my head. I am sure others can/will/should add more.

· The concept of the ambulance started in the Napoleonic wars, for the evacuation of wounded.

· R Adams Cowley, the father of modern trauma medicine and the concept of the Golden Hour, first noticed the relationship of time to mortality in trauma during his tour as Lieutenant Cowley in the European theater, at the end of WWII.

· The US Army had a formal training program for enlisted combat medical corpsman as far back as 1921, almost 50 years before the concept of EMT was realized.

· MAST/PSAG were developed in the early 1970's for combat medicine by Lt. Col. Burton Kaplan during Vietnam, based on G-Suits

Good article on the history of MAST/PSAG here http://www.oiresource.com/mhistory.htm

· Evacuation by helicopter was first used during the Korean conflict, and widespread by the Vietnam Conflict, evolving for its use in civilian operations. (Evacuation of military wounded by airship was significantly earlier than that)

· The concept of highly trained advanced care outside of a hospital was born on the battlefield as well.

· Many of the early pioneers in surgery, and medicine, served in the military of their respective countries.

· Seriously, we have seen more advances in medicine in the past 7 years than my entire 22 year career so far. Today, the resurgence of the Adult IO, the tourniquet, the king LTD, and new (and old) concepts in trauma resuscitation is easily traceable to the conflicts in Iraq, Afghanistan, and abroad.

· And I am sure, just as we saw in the 70's. at the end of the Vietnam conflict, young vets with real world experience are returning to the civilian world, bringing new perspectives and old school EMS experience, and they will jumpstart EMS again.

So when you go out to your rig, remember that in a very real-world-street-level sense, you not only owe your freedom to the military, but your very profession. So, thank a vet.

Oh yes, one final thought while most of the medics of my generation grew up watching EMERGENCY!, I grew up watching…M*A*S*H! Think about it, M*A*S*H.. While funny, was always more about what you did for the patient (and each other) than what you did to the patient! Now that’s a lesson for the ages! (also says a lot about me I guess!). So I guess this is another thing we can learn from Military Medicine.

Have a good veterans/armistice day. .....

EMS Thoughts: Be Nice

2012-10-10T20:23:00.003-07:00

Be Nice

One of the earliest lessons I learned on this job was this:

"Dalton's Third Rule: Be nice. "

The great prophet Dalton elaborates for us mere mortals:

"If somebody gets in your face and calls you a cocksucker, I want you to be nice. Ask him to walk. Be nice. If he won't walk, walk him. But be nice. If you can't walk him, one of the others will help you, and you'll both be nice. I want you to remember that it's a job. It's nothing personal. "

And its good advice. People are less likely to sue/complain about people who are nice. People cooperate more when your nice. People watch your back when your nice, (and my favorite) People are less likely to try to kill you ...when your nice.

You could be a total nincompoop of a paramedic, but if you are nice, you will have a long career ahead of you. (Trust me, I have seen it).

Conversely, you can be the bastard cloned offspring of Peter Safar and R Adams Cowley, with a sprinkle of Micheal Copass and Nancy Caroline thrown in...but if you are a D-bag.... you wont last two years in this job (unless you are a part of a few well known agencies)

Its because this job is about people. and interacting with people is 90%of what we do. To get people to work with you (even when its in their own interest), you have to get them to want to. Being a badge-heavy-paramedic-know-it-all will make every call a pain in your ass. Conversely, Getting Mrs. Rosengirtle Bahmgartner to think you are her long lost favorite grandchild is both an art form...and a necessity.

That's why good EMS agencies don't hire talented people (you can train talent), they hire nice people. People who are honest, kind, and diligent. People who will make sure grandma is safe and well looked after on that so called routine transport. People who you can trust alone in the back of the rig with an intoxicated 18 year old cheerleader. In short, nice people are good for a service, good for the patients, and good for the profession.

When you have them, you nurture them, hold on to them, and hopefully their magic will rub off on the other employees who are not as nice. This is leadership 101 stuff. Even Steven Covey talks about it. This is why I am continually shocked (but not really surprised) when agencies tend to suppress and discourage niceness. For example, lets look at the the latest fiasco out of Detroit Fire and EMS.

A little background is in order...

OK, many of my fellow EMTs and Paramedics may not be aware, but Detroit Fire and EMS is a system (and a City) in dire , dire crisis. Up until 5 years ago, I would have given the title of the most dysfunctional EMS system in the US to DCFEMS (Thats Washington D.C. Fire and EMS for those of you not hip to the lingo). However , in the past five years, Detroit has taken the cake, There are numerous stories over broke down vehicles, medics left stranded in the middle of gun fights, ambulance response times exceeding 30 minutes routinely, and even worse. It seems the not nice guys are running the show, and the nice guys who have stayed there are in deep doo doo.

This latest story doesn't involve million dollars of missing money, and it doesn't involve people dying from improper care. It doesn't involve racism or class-ism It involves one man being nice, and getting in trouble for it.

The story goes that Detroit Paramedic was at a house fire and noticed the now displaced resident (a disabled elderly gentleman) shivering in the cold, in his underwear. In an inexplicable breach of Detroit EMS protocol, the Paramedic was....nice.

He gave the man a blanket.
(Full story here: http://www.myfoxdetroit.com/story/19788029/detroit-paramedic-im-being-punished-for-giving-cold-man-a-blanket )

Well, he didn't run it up the chain of command, fill our a form 13, and get the division chiefs approval to give away the blanket, so now he is in trouble. I don't even know how he got narced out, probably a well meaning member of the Order of the Blue Falcon (http://www.urbandictionary.com/define.php?term=blue%20falcon) . But the bottom line is he is now in deep trouble.

I am reminded of another wise man, Phill of Norris (EMT-P) who had two rules.

Don't make the rest of us look bad
Don't be a douche

One of the first rules of leadership is "Lead by Example". Whether he realizes it or not, this young paramedic is leading, and showing other paramedics how to behave. He is showing other responders in that crappy system, even when your ambulances break down, even when you are shot at, even when you are working in the worst ghettos of the country, you can still ...be nice. Think about it for a minute, and just how rare that commodity really is.

And when the so-called leadership of the Detroit Fire Department comes down on the paramedic, perhaps the message they are sending to the rest of the organization is the opposite of the Norris rules.... "Don't be nice. Be a douche".

I hope this Paramedic's career survives this ordeal. And when faced with the exact situation again, surely giving another blanket away wouldn't be smart. But hopefully he doesn't care. Because I am reminded of one more wise man. The Late Great Shepherd Derrial Book, who said:

"If you cant do something smart, do something right"

I guess that's the really message of my rant tonight When in doubt, do something right. And being nice is always right.

EMS FTO: Change is good

2012-10-04T22:52:00.000-07:00

EMS FTO TIPS: CHANGE IS GOOD

Hello all! Well, hello at least to all 2 of those who read my blog so far (including family).

This week I was involved in a conversation online at www.emtcity.com on FTO/preceptor programs. Part of this conversation, well much of this conversation, revolved around FTO development. What training they have, how they are held accountable for the success of their preceptee/students/probies, etc.

I thought I would one share part of that discussion. I will probably discuss other parts later. After all, I am getting old so I have to pace myself.

(Remember the joke about the old bull and young bull and the herd of cows...?)

In many Field Training and Evaluation Programs (FTEP's..the names differ between agencies, but this is what we will use today) the trainee/preceptee is paired with a single FTO for training, and then either on to a credentialing test or simply "cleared for duty". Now this is a vast improvement over the days of simply handing the keys to the rookie and praying they don't kill somebody, but I would like to offer one of the lessons learned in my own organizations FTEP many years ago. In fact, I owe my continued employment to this lesson.

Many years ago when I was a newly hired probationary officer, my first FTO was also new to the FTO position. while he and I have become friends today it is safe to say that we truly did not get along. Don't get me wrong, I was (at least in my mind) not a trouble maker. And he was not (at least in his mind) not an overbearing, rule-nazi, my-way-or-the-highway type of FTO. But one thing was sure, we were indeed oil and water.

It started with the little things. He didn't like the order I would set up a procedure. I thought he wasn't giving me a fair shake on my evaluations. he didn't like my charting style. I thought he was not providing enough direction. Slowly over the next 12 weeks it began to escalate. Combined with the stress of potential failure and unemployment (not to mention I had moved across the country for this particular job...) our "relationship" had reached a breaking point. I think at some point, just like a married couple just prior to a divorce, we were subconsciously pushing each others buttons out of frustration.

It ended with what was supposed to be a "come to jesus" talk with the FTO coordinator/supervisor. What it became was a very verbal, very heated, in your face discussion between both of us. What had happened was a simple personality conflict that was unresolvable. The FTO program as a formal entity in this organization was new and this was something that had not been previously encountered. In many organizations, I would have been kicking rocks down the road after that meeting, but the FTO coordinator apparently saw the problem. I am grateful he did.

I needed a new FTO.

Let me be clear. I am not excusing my comments that day. But every one of us in the wrong situation will find ourselves unable to get along with someone else. This is interpersonal relations 101. As an FTO/FTEP coordinator we must recognize that fact if we want to truly serve the organization. We must always consider that we are part of the problem.

So , instead of "kicking rocks", or "freeing up my future", or any number of other euphemisms, I was assigned another FTO. All in all I had 4 more FTO's , including my "Phase III" FTO (i.e. final evaluation FTO) which I successfully impressed enough that I am continued to be employed in the same organization. That original FTO and I actually work together just fine now without any problems at all. But at that moment at that time, I was dangerously close to FTO-icide.

Rotating to a different FTO saved my job. I firmly believe that every FTEP program should have built in to its framework a mandatory rotation through a minimum number of FTO's. Some of the reasons are below:

Different methods of training. Lets face it, the way I teach patient assessment will be different than the way the next FTO does. This is not inconsistency, this is diversity in education methods. When one FTO cant seem to teach a probie how to talk to a patient, sometimes another finds away to do so. None of us can teach 100% of topics to 100% of students with 100% success 100% of the time. Adding multiple educators to the process increases chances of success.
Reducing Personality Conflicts. As I discussed above, my first FTO contact almost ended my career. It is neither fair, nor intelligent, to spend the resources to recruit, test, and train an employee only to fire in short order based on a single perspective (with a few exceptions, such as integrity issues).
We can become too comfortable. Over time, we can begin to treat each other like partners, instead of like FTO-Preceptee's. This will taint the evaluation, and get in the way of good critical review and training. Rotating the preceptee keeps the relationship "new" and everyone on top of their game.
Better evaluations. Every FTO has "hot buttons" they focus on. One of mine is patient assessment. I expect a probie to do a thorough patient assessment and ask detailed questions, good data acquisition as I call it, prior to performing treatments that may have adverse outcomes. Other FTO's really hammer pharmacology, or appearance, or communications. None of us deliberately neglect the other parts of our evaluating of the probie, but if a probie shares a common interest, or plays to our hot buttons, then we may overlook their failings. By rotating the probie through multiple different FTO's, then you get a more unbiased evaluation.
Legally defensible. If your organization ever terminates an employ in the FTEP program, and a civil suit is brought, then having multiple credible FTO's who have all followed policy and all provided detailed evaluations looks far better in a court of law than a single FTO, especially if discrimination (i.e. age, race, or sex) is an issue.

So, if you are developing a new FTEP program or are evaluating one you have now, consider this. CHANGE IS GOOD. Change up your FTO's frequently. Both your FTO's and your preceptees will thank you.

Ask the EMS FTO

2012-10-02T10:42:00.001-07:00

Do you have a question, problem, or just weird topic you want me to discuss? Do you have a tip of trick you want me to share? Write to me on here, or to croaker260@gmail.com, and I will do my best to answer it in my next blog.

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EMS FTO: Types of mentoring roles

2012-10-02T10:30:00.000-07:00

Types of mentoring roles: The clinical Internship

In my last post on EMS FTO's, I briefly mentioned the four basic types of roles/functions the FTO may be called on to fill within an organization. Today I think we will elaborate on them.

As point of review , the four basic roles are:

New Employee Orientation
Clinical Internship
Field Internship
Remediation

Over the next few posts we will discuss different evaluation settings, their commonalities and their differences. The first we will discuss is the most common, the clinical internship.

What is the Clinical Internship?

The first exposure many EMTs and Paramedics have to the “medicine” is the Clinical Internship. Whether this is a single ER rotation in EMT school, or a prolonged and repeated rotations through the ICU, the clinical internship is the most important, and often the most neglected, form of internship.

Students in clincial internships are still learning how to swim.
Dont set them up to drown.

The clinical internship is a controlled learning experience, proctored by the FTO/Mentor, or other functionary, during the course of the training program. The clinical internship may take place in many settings, from the ER, the ICU or the ambulance. Even though a clinical internship may take place in “the field”, it is not a “field internship”. In the clinical internship setting the role of the PO/intern is not to direct patient care, but to learn about aspects of their job through exposure to real clinical situations, patients, and problems. Skills, assessments, and learning through doing and observation both are the order of the day.

In some programs, the PO/intern may be paired with an actual FTO,, but in many systems it is simply a medic, EMT, nurse, or other mentor chosen for the day. The emphasis is on the clinical care, not clinical leadership, though where clinical and operational issues overlap, so does the learning.

One of the more challenging aspects for the coordinator of a clinical internship is the mentor selection and proctoring. Unless all clinical internships are done internally, the ability of the coordinator to select, brief, or otherwise monitor mentor performance is extremely limited. In most situations, the coordinator cannot discipline, counsel, or otherwise coerce performance without stepping on many toes in the process (to say the least), possibly resulting in the site being closed to future rotations. This is especially true in OR and other physician led clinical settings. Almost every paramedic program coordinator has a “OR” horror story where a student or a mentor had a misunderstanding that had lasting effects.

Challenges and Hurdles

The clinical period is the setting with the most variability in quality and styles of FTO's and mentors.

Evaluations during the Clinical Internship

Evaluations during the clinical internship should focus mainly on affective performance, and cognitive knowledge, rather than clinical performance. In this phase the student is not only learning, but often learning in leaps and bounds one week, and very slowly the next. A student at this phase is not yet a Paramedic, or EMT, and has not even completed all their training to become one. evaluating them as a leader is often unrealistic. In addition, as an evaluator in at a clinical site it would be very difficult to evaluate a student on his clinical/academic knowledge in this situation without being intimately involved in the day to day classroom education as well.

While there is benefit of a detailed evaluation form, in the clinical internship the KISS principle is better. Many FTEP programs use a numbering scale, for example the San Jose model (Kaminski FTO) uses a 1-7 scale in their field internship. For other situations where there is formal FTO training, this is appropriate. In the clinical settings, however, the simpler the evaluating the better.

Improper evaluations are as counter-productive as not having any evaluations at all. In the clinical setting, controls are looser, and simply needs improvement/ acceptable/exceeds are sufficient. This is discussed in more detail later.

Some things to keep in mind:

Often mentors in organizations that receive interns from multiple institutions cannot remember who the sponsoring agency is. Therefore a distinctive school uniform is beneficial. One local program uses bright orange shirts (incidentally school colors) for its interns. While this bothers some of the more fashion conscious students, that program never has a case of mistaken identity. In the OR this is much more difficult as student must often wear scrubs. Some schools are currently exploring issuing special colored scrub hats to identify our students from others in this setting.

A Case of Mistaken Identity

A local hospital closed its OR to a paramedic program after a “student” displayed an improper attitude during a failed intubation attempt. Subsequent investigation revealed that the offender was actually a firefighter paramedic doing remedial training in the OR and was not a student at all.

Despite the best efforts of the educational institutions however, the OR was closed to all students, including our program. This one event set back their paramedic program at least two years.

Uninformed and untrained mentors

Another challenge for the clinical coordinator is the uninformed mentor. In many cases the mentor is simply the on duty Nurse or other provider , and not someone specifically selected for their educational expertise. They probably only have a cursory idea of the scope of practice of the student. Students come to clinical sites at different stages in their training, from services with different protocols, and even from different levels of class. To the uninformed they are all simply “EMT students”.

Because of this the Mentor may not be familiar with what the student can and cannot do. If possible a briefing before every rotation period is optimal. What is essential is continued and repeated contact with the charge nurse or lead faculty of every clinical site. If you can make this person your on site champion, many of your problems with site staff will disappear. Like any relationship this will take constant maintenance. Consider thank you cards to the staff, and perhaps T-shirts or thank you certificates to the lead faculty. Be creative, the more personalized the better.

The "Rookie Book"

A good idea I have used for some time is a “rookie book” with a briefing page listing EXACTLY what the goals of the clinical rotation are, what skills are permitted, and who to contact for questions or concerns (day or night). The expectation is that the student will have the book with them at all times on a clinical rotation.

The "rookie books I currently use at my service also have a column for each policy, protocol, medication, and skill at my particular service. It also has a check off box for three separate discussion on each topic. I have found that this breaks down the barriers of communication and often results in mentor led one on one discussion and education that might not otherwise occur. A large problem is the willingness of the student to step up and present the rookie book to the mentor. It must be stressed that the rookie book is mandatory and part of their grade/evaluation as well.

Closing thoughts

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At the end of the day, clinical internships are momentary, transient events in of themselves, but poor management of clinical internships and disagreements can have lasting effects on intra-organizational relationships, as well as on the students. Chose wisely the battles you fight and decisions you make over clinical internships.