It’s midnight in San Fransisco and I am waiting here for Jesus on my knees.

In August and everything after, I want someone else to bleed for me.

- Counting Crows, August and Everything After

A busy month indeed at The EMT Spot. This month I experimented with quality over quantity and I hope you found enough good stuff to stimulate your noggin. We started with another installment of the ultimate guide to EMT vital signs. This month we looked at respiration. Then I took another run at the controversial phrase, “Patient’s define their emergencies.” After that we talked about doctors watching EMS care on cameras and we wrapped it all up with the question, “Is there such a thing as too much information?“

But enough about me, some other great happenings around the EMS blogsphere were also well worth your attention. We’ll start with the much heralded return of blogging great Mark Glencorse and his Medic999 blog. Welcome back Mark. The often overlooked but always fantastic EMS Haiku blog offered nasty burrito. Basics doc explained that getting there is only the beginning in dreams, rain and driving. Kelly Grayson asked for a little help spreading the word about a business that’s practicing some good ol’ southern style bigotry. Greg Friese told us about five things he personally checks at the beginning of each shift. Jeramedic asked, “What’s the blood pressure?” Chris Kaser explained an epiphany that allowed him to shine through the suffering. Tim Noonan discussed Lasix and Nitro. MsParamedic shared why she still believes in the tooth fairy and Justin Schorr stirred up a bit of controversy (OK maybe it wasn’t that controversial until I took issue with it.) with the request, “May I have the definition please?“

In EMS news, earlier this morning, the associated press sadly announced the deaths of an EMS helicopter flight crew. A Pennsylvania paramedic who obstructed a police officer trying to deploy a TASER will stand trial for interfering with police.  So you think you had a busy weekend? On the leading edge of hurricane Earl, Maryland lifeguards rescued over 400 people over the weekend and one swimmer is presumed drowned. One Connecticut ambulance crew chased down the man who stole their ambulance from the hospital bay and recovered their vehicle from him. A distraught New York City mother claimed an NYPD officer told her, “I don’t do CPR.” while her daughter died in the back seat of her car and the House of Representatives failed to pass a medical aid bill for sick 9/11 responders. (Shame on you guys.)

On the podcasting front, the boys from The EMS Garage talked about the overuse of oxygen. The EMS Educast shared the details on a very progressive EMS training program for youths. The Medicast dscussed the sometimes all to complex world of psychiatric and behavioral evaluations and The GenMed show hinted at a fun new series of podcasts that are currently in production. Can you guess where they’re going?

So that was August. Good lord, where did the summer go? And who ordered this fall weather? I’m not ready. See you back here in September, and I hope you’ll come say hi at the EMS Expo in Dallas. See you there.

So we do what we do every class. We practice and practice and practice. So there we were, gathered around in groups, practicing our National Registry skills sheets. That’s when Joey asked me the question that absolutely floored me. It floored me and annoyed me, but really didn’t surprise me. I’ve heard the question asked before in many different ways.

Joey finished up his medical scenario and I was giving him some feedback on his performance. He looked down at the fictional patient’s medication list that I had provided him and he shrugged his shoulders. “We don’t really have to know what all these mean right?”

I told him I didn’t understand. He mulled the thought over in his head and took another stab at it. “I mean…we need to write these down and report them to the doctor, but it isn’t important for us to know what they all do. (Pause.) As EMT’s. (Pause.) Right?”

I thought my answer over carefully and then I explained that knowing the actions of the patients home medications was not a part of the standard EMT curriculum but it was a great educational goal. I gave him a few examples of why I thought the information was important. I explained why a septic patient taking beta blockers would present differently than one who was not. I explained why a trauma patient taking Coumadin would be examined with a higher index of suspicion than one who was not.

And then I told him something that I hope he carries with him into his EMT career. I said, “Joey, the world is going to work hard to place limitations on you. Don’t waste your time placing limitations on yourself.”

The world is full of people like Joey. Working hard to place limits and boundaries around their knowledge and their abilities.  People struggling to define the outer limits of the worlds expectations.

I gave a 10 minute talk on evaluating nystagmus to a group of EMS educators and had an EMT instructor write on my evaluation form, “This is too advance for EMT’s.” I felt sorry for that instructor, but I felt more sorry for her students. Greg Friese recently thumbed through a stack of classroom evaluations to come across the remark, “This is too much information for a paramedic.” What the heck is too much information?

What makes us so willing to fence in our ability? Why are we so inclined to define the outer limits of what we should know and understand? I think there are three closely related reasons.

1) We like to keep the bar low.

As much as we might hate to admit it. We’re more comfortable with the bar set low. Life is easier when we know that we can clear the bar. When we’re confident that we can barely clear the bar, we naturally resist anyone who looks like they might want to set the thing higher.

“Wait a minute!” our comfortable self proclaims, “Nobody said we needed to jump that high.” Instead of warming our legs up and refining our technique we simply attack the bar raisers. Who needs them? Life is easier without them. Once the bar is firmly established we can switch over to cruse control and stop growing.

What we forget is that every living thing is either growing or dying. Not growing seems like the most comfortable choice, but the consequences of refusing to grow always catch up with us.

2) We fear the limitless and undefined.

Unlike many areas of knowledge, our current understanding of medicine is so vast that no single human being could possibly grasp it all. It stretches out in all directions and continues to grow each day. Swimming in the pool of medical knowledge is like swimming in the ocean. It has no boundaries that we can see and that leaves us with a lot of freedom. How far should we swim? How deep should we dive? How long should we tread?

This can induce a lot of fear. We long for someone to define the boundaries for us. We want a swimming zone sign and one of those neoprene ropes with the little floaty buoy’s on it. Nothing induces fear quite like our own freedom. And so we respond to our fear by creating the limits and blowing the whistle on anyone who tries to swim past the rope.

Nobody ever became a really great swimmer by staying inside the rope. As soon as you feel strong enough, swim past the rope.

3) We are inherently insecure.

On second thought, there might be one thing we fear more than unlimited freedom. We fear failure. Once someone raises the bar into unknown territory we invariably begin to imagine ourselves failing to clear the bar. We imagine ourselves crashing down in front of all of our peers and exposing ourselves as faliable and human.

What could be worse than the public humiliation of failure? The very idea of failure is so scary that some of us spend our whole lives only trying new things when the possibility of success is almost certain. And when someone challenges that feeling of certainty we lash out.

Fear is a powerful thing.

Now it’s your turn: What do you think? Is there such a thing as “Too much information?” Leave a comment and let us know.

And then go check out what Greg Friese of Everyday EMS Tips and Chris Kaiser over at Life Under The Lights have to say about this subject. Special thanks to Greg for inviting us to write on this topic.

For some reason this next story set my skeptic meter needle into the red. I’d like to know what you think.

Florida tax-payers are funding a $100,000 camera system for various key-west EMS providers that will allow doctors and trauma surgeons to view the prehospital environment remotely from the hospital. Apparently these cameras will be worn by various EMS personnel and be installed in the local transport vehicles to give the hospital a real time view of accident scenes and patient care.

The big selling point being pushed is that, when doctors are allowed to look at the patients on scene, they’ll be better prepared to receive them at the hospital. This visual benefit is supposed to be great enough to justify the tremendous financial, logistical and technological burden of installing, carrying and maintaining all these cameras. I’m not so sure.

Here are a few quotes from the article posted at KeyNews.com:

Before, we were doing this verbally through radio communications. With this, I can let the doctor view the patient, who might be trapped in a car, for instance, and that doctor can make a lot of determinations then and there, before that patient has been removed or is even in the air.

-Key West Rescue Supervisor, Steve Simonaitis

OK…what? What determinations can the doctor make right then and there that he couldn’t have made based on my reported description of the incident and the patient? I guess “a lot” would imply a whole list of medical determinations. I can’t think of a single one. I’d like to hear an example of a single determination that a physician feels they might make differently if they could see the patient on scene as opposed to hearing me describe the patient on scene.

I saw a guy in the field deliver babies using this system,” Erwin said. “I’m talking about guys not trained on how to deliver a baby getting direction from a doctor miles away.

Key West Rescue paramedic supervisor Dave Erwin

I can certainly see how that would be useful, if I was delivering a baby and I hadn’t been trained in how to deliver a baby. But since I have been trained fairly extensively on how to deliver a baby, I think it would just be an annoying distraction to have a doctor looking through a camera, asking me to adjust my camera angle and telling me where to clamp the cord.

I thought that was the reason I was trained to go out and deliver babies…so that a doctor didn’t have to be available to go deliver the baby. If someone calls 911 and says, “My baby is coming.” They don’t send a doctor, they send me. What’s the point of sending me with a camera on my head so that a doctor can stop what they’re doing, look through the camera and deliver the baby by talking in my ear? Why not just send the doctor?

Dave was also quoted saying that it’s nice to have a surgeon looking through the camera and telling him when he needs to control arterial bleeding. Really? You need a surgeon to tell you that you need to stop arterial bleeding? I don’t agree.

I don’t want to pick on Dave too much but he ends the article saying, “Trust me, a picture is worth a thousand words.” Let’s put that to the test.

Me: Littleton hospital this is medic 42 enroute emergent to your facility with a trauma alert let me know when you’re ready to copy.

Them: Go ahead medic 42.

Me: I’m enroute emergent with an ETA of 12 minutes, on board a 32 year old male, restrained driver of a mid-sized vehicle who hit a guard rail at approximately 40 miles per hour. Air bags deployed. 2 feet of driver’s side engine compartment intrusion. Negative passenger space intrusion. Steering wheel intact. Windshield removed. No loss of consciousness. Patient has a probable left clavicular fracture with deformity. Chest wall intact. Bruising across the epigastrium with pain on palpation to the upper right quadrant and an unstable mid-shaft tib-fib fracture on the left leg. Distal sensory motor and neuros intact. Skin is pale cool and diaphoretic. Respiration’s 26 and shallow with pain on inspiration, pulse 94 and regular. Blood pressure 104/60.

That’s 108 words dedicated to my description of the incident, mechanism and full patient assessment. That report would have taken 20 seconds and cost about $100,000 less to deliver. Explain to me how a picture is going to be 10 times better than that. What things will the doctor be able to do, what determinations will he be able to make by looking at that picture instead of listening to my description?

While you’re thinking it over, note that the picture still doesn’t replace my assessment and report. I still have to give this report. The doctor can’t feel cool skin or check distal pulses or listen to lung sounds or palpate a chest or abdomen by looking at a picture. For all these things, my report is much, much better than a picture.

That’s possibly the most overlooked fact with this system. Seeing is a small fraction of assessment.

This is a fun idea and I imagine the folks in Florida will have a good time playing with this new technology. I commend them for putting themselves out there and trying something new. I doubt this will do anything to improve patient outcomes. I suspect it might just complicate matters significantly.

Now it’s your turn: What do you think? Would you like to use this kind of system? Do you think it will be useful? Leave a comment and let us know.

Read More EMS News:

207 Reasons to Stay Current on Your Continuing Education

Regarding the Duty to Act

The C-spine Immobilization Controversy

The Oklahoma State Trooper vs. EMS Mess

Chest Pain: Is EMS Really Best?

The dispatch information was updated before we had even rolled our rig out onto the pad. Eye injury, no serious symptoms. Jodie shut down the lights and I informed dispatch that we’d be responding non-emergent.

Up stairs and inside the small two bedroom apartment, Samantha, our patient, was waiting on the couch, holding a hot compress to her swollen right eyelid. Mom worked calmly in the kitchen finishing diner for her other two children. Alan, Samantha’s father sat on the edge of his seat next to his daughter in a state of barely containable anxiety.

He had recently arrived home from work and his wife had informed him of the apparent infection in Samantha’s right eye. One look and he was on the phone to us. Now he breathed rapidly as he fumbled through a list of questions. What caused it? Could it damage her vision? Could she lose her eye? Could she go blind?

I cleared the engine to go back in service and sat down next to him. Over the next ten minutes we both explained what pink-eye was and how to take care of it. We talked about hot-compresses and how contagious the bacteria was going to be. We reviewed the typical course for such and infection. How to prevent it in the other kids. How likely it was that one of them already had it. And we discussed his plan for morning. (It involved asking a neighbor to drive them to a near-by clinic.)

Alan called 911 for pink-eye. And…(This part is bound to be controversial, depending on what kind of system you work in.) I never offered to take him to the emergency room. And he never asked.

If he had asked, I would have most-likely obliged. I’d have put Samantha on the pram and given her a fun ride to the E.R. I do stuff like that frequently. I imagine most of us do.

So why am I telling you about Alan and Samantha now? What’s the point? The point is that Alan called 911 for pink-eye. He called because, in his book, a child with pink-eye was a medical emergency significant enough to warrant a response from the local emergency services. Alan defines pink-eye as a medical emergency. He’s wrong, but that’s beside the point. I don’t get to decide when Alan calls 911. Only Alan gets to decide that. I do get to decide how to respond. I decide how to respond with my apparatus. I decide what service to offer and I decide how I feel about it. That last part is important. I decide how I feel about Alan calling 911 for pink-eye.

The Happy Medic and Me

I bringing this up now because I got called out. (Well…sort of got called out.) I felt like I got called out anyway. The Happy Medic, Justin Schorr went off on a rant about blonds and library’s and patient’s and stubbed toes. And then he said this:

I hear from many corners of the EMS industry that we need to lose our “above them all” attitude and just take people in that want to go in.  “It’s their definition of emergency, not yours” is something I am tired of hearing.

For the record, I never said “It’s their definition of emergency, not yours.” and Justin never mentioned my name in his post. But I did say that patient’s define their emergencies. Which is the closest thing I’ve ever seen to Justin’s quote in the blogsphere.

This isn’t the first time my words haven’t set well with Justin.  He recently mentioned that he thought he resembled my 7th tragic EMS flaw. We’ve had a few lively discussions and we certainly don’t always agree on what’s best for EMS as we move in to the future. I’m glad I have Justin around. Sometimes I think that if it weren’t for him and Tim Noonan, nobody would ever disagree with anything I say. How boring would that be?

I also consider Justin a friend. He’s got a great blog, he’s a linchpin at the center of some of the coolest video projects in the history of EMS, and he once talked me out of punching an obnoxious dude in a bar who desperately needed it. We also agree on a lot of stuff. On the topic of non-emergent EMS System use, here are some of the things I think Justin and I agree on:

• People who call 911 deserve to be treated with respect.
• Our current EMS systems are an inadequate and flawed model for dealing with the complexity of prehospital medicine.
• Care providers should have more options in addressing the needs of our patients.
• Transporting everyone to the E.R. is a bad solution for non-emergent 911 use.

I could go on. The list of things we agree on is much longer than the list of things about which we disagree. We disagree on the usefulness of paramedic initiated refusal. We disagree on whether or not Alan should even get the opportunity to talk with a paramedic in his living room. And we disagree about how we feel when Alan calls for an ambulance when his daughter has pink-eye. So I’d like to put in my two cents as well.

Why do people call 911 for non-emergent reasons?

With all the information about dialing 911 in an emergency, why would anyone access the system for a stubbed toe, a cut lip or pink -eye? Are they, as Justin theorizes, just drastically misinformed? Do they think they’re standing in a fast-food restaurant instead of a library? Should we simply cater to their remarkable ignorance?

I think the idea that people call 911 out of ignorance is a flawed analysis. People call 911 inappropriately for two reasons.

1.) They have reached the end of their problem solving capability and need help. They don’t care if they are misusing the system. They care about getting help because they don’t know what to do. In their mind, that is an emergency.

2.) They are purposefully abusing the system for personal gain. Whether it is for controlled medications, in-home health care, a ride to somewhere closer to the hospital, attention, a warm bed or food, they want something that we provide and they don’t care if they have to game the system to get it.

Notice something about both of these types of people. They both have a basic understanding of the 911 system. Educating them further on the appropriate use of 911 will not prevent their next call. Even if you could stop them from calling, their problems are so common that their will almost certainly be a new person to call tomorrow instead of them. And the process begins again.

Neither of these types of people are standing in a library asking for a cheeseburger. They understand how the system is supposed to work. Most of the folks in category two understand the system far too well.

Here is my point:

System abuse isn’t about a lack of education or a lack of understanding. You could put billions of dollars into PSA announcements and it wouldn’t change things a bit because system abuse is about needs.

When Alan isn’t sure if his daughter is going to go blind he has a need. When Martha runs out of the pain pills that she’s addicted too, and she needs a fix, she has a need. When Reggie lives on the street and he wants a warm bed and some food, he has a need. All of them may turn to the 911 system. We get to filter it all. And we work in a system that gives us far too few tools to work with. Some systems only give their EMT’s one tool…transport them all to an emergency room…period. And that’s frustrating.

But we shouldn’t respond to that frustration with barriers that leave the need unmet. I just don’t believe that, “Sign here, it’s not my problem.” is the solution to the problem. I could have simply refused Alan my services and left him at home, scared and pissed off because the best we could do for him was reject his needs as unfit for our service. But the need persists.

If Alan asks for a hamburger, I’m not going to fire up the grill, but I can at least tell him where to find the local Burger King. I can even take the time to draw him a map.

So Why Is All This My Problem?

Because we gave everyone in the world our phone number. We created the system. We designed a system with virtually no barrier to entry. If you can remember three numbers and find a working phone, you can calls us and we’ll help you resolve your emergency. We taught this to EVERYONE.

And now we’re shocked when people call us for pink-eye.

The Way Things Are

I know what you’re saying. “OK smart guy. Then what’s the solution?” Good question. First, we need to drop the pissed off, “I can’t believe you called for this.” attitude. Of course they called for this. Reread the part about giving everyone our phone number. Drop the surprised look and let’s get real about the way things are. Then we can make peace with it and get on with the productive work. To start, allow me to draw you a quick diagram.

Line-A represents reality. The way things really are right now. Line-B represents the way we want things to be. The distance between line-A and line-B represents stress. The farther line-A gets from line-B, the more stress we experience. This applies to anything in life.

Sometimes that stress is good. If this chart is used to address your personal fitness, perhaps a good distance between line-A and line-B could lead to some very positive behavior changes. But when we apply this equation to something big and primarily out of our control, something like our 911 system designs, we’re better off keeping that distance in check.

One of the best things I ever did for the long term survival of my sanity in EMS was to recognize that patient’s will always be the ones who define their own emergencies. I can’t be there when they call 911 to guide them. They do it on their own. That’s the way it works. This is why patient’s define their own emergencies. They just do. It’s the way things are.

That doesn’t mean I don’t get to have my say. Once they call for my help, they’ve invited me to interject my experience and training and bring it to bear on their problem. This is where Justin’s analogy goes astray. The “..not you.” part of the equation. I would get pretty frustrated if I felt like I didn’t have any say in the process and had to blindly follow my patient’s whims. But who does that?

Just because you don’t get to tell your patient to pound sand doesn’t mean you don’t get to interject your experience and judgment. And that’s where the tool box comes in. I’d like to see the tool box filled with more useful tools. Pound sand is not one of those tools. Neither is, “It’s not my problem.” We invited them. They called. It’s our problem.

They Call We…Don’t Haul?

I consult with my base physician more than most paramedics in my system. Part of finding more useful solutions for our patients is having a rapport with the base hospital and feeling comfortable talking on the phone with your physicians and building their trust. A big part of that trust equation is doing a good job when you do transport patients to their facilities, practicing good, thorough physical assessments and performing good medicine.

The more the folks on the other end of the phone trust you, the more likely they are to believe you when you consult with them on the phone. When I call the local E.R. doctors on the phone, they tend to trust me. That helps a lot when I want to advise someone that they can go seek help from the urgent care down the street.

Fill the Need

Systems that aggressively pursue alternatives to emergency room transport have developed connections to the alternate resources that our patients need. Without these connections we leave a vacuum of need that will invariably lead to more use of the 911 system.

The systems that actually reduce the volume of non-emergent 911 use are the systems that connect people with detox facilities, substance abuse programs, urgent care clinics, food assistance programs, home health care providers and all the other appropriate resources that can fill the needs of the system mis-user / abuser much better than an emergency room can. In most large communities these resources already exist, we just haven’t partnered with them yet.

The system doesn’t need more barriers and gatekeepers, the system needs more resources and tools.

It also doesn’t need our anger, frustration or righteous indignation. That’s not to say that it isn’t OK to occasionally be upset, frustrated or even righteously indignant. But we need to recognize that those aren’t the things we need to change the system. To change the system we need courage.

We also need to fundamentally change the way we see our role in the big picture. We’ll talk about that next time. Until then, I’d like to know what you think about this. Leave a comment below and add your voice to the debate. What you think is important too.

The respiratory vital sign rounds out our “big three” vital signs. (Pulse and blood pressure being the other two.) It is, quite possibly, the most misunderstood and overlooked of the big three vitals.

Two big problems we encounter when factoring in the respiratory component of the vital signs are:

1) We’re comfortable fibbing about the true respiratory rate. More so than pulse or blood pressure, respirations encourage us to violate the first rule of vital signs. Especially when the patient is in no apparent distress. We look at the patient, we make up their respiratory rate and, quite often, we’re wrong.

2) We fail to recognize the relationship between rate and volume. In EMT school we are rarely asked about the respiratory volume. We perform our scenarios. We count a rate of respiration. We report it. The scenario moves on. In the process we forget that respiratory rate is only half of the breathing equation. Without volume, the rate means very little to us.

With those two common errors in mind, let’s talk about obtaining an accurate respiratory rate and then let’s talk about truly assessing the quality of the patients respirations. Consider this your quick guide to respiration assessment mastery.

1) Assessing the True Respiratory Rate

Maybe we’d see less fibbing on the patients documented rate of respiration if we just admitted that the true respiratory rate isn’t as important as you may have been lead to believe. I confess; I rarely count a respiratory rate while I’m on scene with the patient.

What’s more important than finding the exact respiratory rate is your ability to recognize if the patient is breathing normally, or abnormally fast, or abnormally slow. With that in mind, try this. Look. Yes…just look. Instead of waiting until you have a moment to hold up your watch and count a respiratory rate, simple get in the habit of looking at your patient and asking yourself, “Are they breathing to fast, or to slow or just right?” Then act.

Consider the patients age, their fitness level and other factors like recent exertion, ambient temperature and emotions like anxiety and anger. The respiratory center is sensitive to all these factors.

When it’s time to take a real-deal, documentable respiratory rate, find a moment when you can delegate a task to another provider, then step back and watch. I know that it’s common to teach people to pretend that they’re taking a pulse while they watch the respirations. This patient care head-fake always seemed a bit awkward to me. I just feel like I’m giving the appearance of taking a ridiculously long time to take a pulse. (Remember that I’m the guy that advocates for the three second pulse check.)

You might find that taking a moment to step back and just watch the scene progress while you partner and crew perform some task really improves your scene awareness. While you’re taking that 30 seconds to count the respirations, glance around and see what you might have missed while you were engaged in direct patient assessment.

If your patients respiratory rate is abnormally fast (tachypnea) you can get a pretty accurate idea of the true rate by counting for 15 seconds. Patients with respirations below 20 breaths per minute will fool you if you don’t take a full 30 second sample.

2) Assessing the Quality of Respiration

Minute volume is the volume of air the patient inhales and exhales over a one minute time frame. Do you remember the minute volume equation you learned back in EMT class? Here, don’t hurt yourself:

Respiratory Rate  X  Tidal Volume = Minute Volume

We didn’t teach you that equation with the idea that you were going to go out and get a spirometer and start documenting minute volumes on your patient care report.

The reason we made a big deal out of minute volume was to drive home the point that respiratory rate was only half of the respiratory equation. You can’t expect to count the respiratory rate and be done with your clinical decision making process. This misconception is often demonstrated by the very common EMT class question, “At what respiratory rate should I start bagging the patient?” My answer is always a resounding, “It depends!”

Imagine I asked you to tell me the value of Y in this equation:

5 + X = Y

You’d probably say, “Steve, I don’t have enough information.” (OK the wise-guy Algebra dude in the room might reply X+5, but nobody likes that guy.) You can’t tell me the real value of Y because you only have half of the equation. In the same way, I can’t tell you when to start bagging a patient based on respiratory rate alone (usually) because it’s only half of the equation. I also need to know about the volume of air being moved with each breath. I need to know about the quality of respiration.

So how do we figure that out? I’m glad you asked.

1.) Look at the patient’s posture.

I put this one first because it should be the first thing you instinctively evaluate as you’re approaching a patient with respiratory difficulty. How are they sitting? (Or standing or laying.) People with advanced shortness of breath don’t sit in a relaxed repose. They sit forward, often leaning on their knees. (Tripoding.) They prefer their legs down. And they don’t lay flat on their back unless they are doing pretty good or they are nearing the point of intubation. It won’t take you long to decide which side of the spectrum they’re on.

2.) Look at their chest.

If the patient has relaxed, normal respirations, you won’t see very much chest wall movement. But if they’re working to breathe, you can tell if they are getting a good, equal expansion with each breath. Does the chest wall move with each breath or is much of the effort wasted?

Also not how they use their muscles. When they breathe in does the area above their clavicles retract? How about between the lower ribs out near their sides? How much effort does each breath take? How long do you estimate they can sustain that effort?

Also remember that our obstructive patients aren’t fighting to breathe in as much as they are fighting to breathe out. Pay attention to the effort of exhalation. Beware the patient who is getting tired of breathing.

3) Listen to their lungs.

I know, I know. Some people still like to argue that lung sounds aren’t an EMT skill. Forget those people. You’re not going to get in trouble for using your stethoscope like a stethoscope. Listen to the anterior chest, just below the armpits and on the back, both between and under the scapula.

• Listen for sounds of obstruction like wheezes and stridor.
• Listen for sounds of fluid like ronchi, rales and crackles.
• Listen for no sound at all. (Absent breath sounds should make you nervous.)

If you’re new to the lung sound scene, listen to a lot of lung sounds. The best way to differentiate poor air movement and abnormal lung sounds is to hear lots of normal lung sounds first. Don’t make the error of ignoring lung sounds on patients who are breathing normally. Learn what normal lungs sound like. Then the abnormal sounds will make more sense.

Now you’ve got the whole equation. The whole kit and caboodle. The whole story. Go forth and assess some respirations. Hopefully, the next time you evaluate and report the patient’s respiratory status, you’ll be talking about more than just a number.

Now it’s your turn: Do you have any tips or tricks for becoming a respiratory master? Leave a comment and pass your knowledge on to the next guy (or gall) Thanks for coming.

Read More of the Vital Sign Series:

Part One: The Pulse

Part Two: The Blood Pressure

Part Three: The First Rule of Vital Signs

]]> http://theemtspot.com/2010/08/10/the-ultimate-guide-to-emt-vital-signs-2/feed/ 2 http://theemtspot.com/2010/08/02/the-july-ems-roundup-2/ http://theemtspot.com/2010/08/02/the-july-ems-roundup-2/#comments Mon, 02 Aug 2010 20:41:12 +0000 administrator http://theemtspot.com/?p=3497

“That beautiful season the summer!

Filled was the air with a dreamy and magical light;

and the landscape

Lay as if new created in all the freshness of childhood.”

- Henry Wadsworth Longfellow

Here in Colorado, July came with all the freshness of weddings, heat and afternoon thunderstorms. I took a short break to go to California and play best man at the wedding of a great friend. And then it was back in the EMS blogging saddle. We started with a discussion about eight tragic EMS behavior flaws to avoid and then I gave you 207 reasons to stay current on you continuing education. I explained why litter begets litter and then asked you to finish the sentence, “Behind every great EMT…” We ended off with a lively discussion about fire based EMS vs. private EMS which is still raging on. Bring the storm!

Lot of great stuff on other peoples blogs as well. Basics Doc touched on the unspeakable moment when words just won’t come. (He also hasn’t posted since. Come back BD, we miss you.) Greg Friese asked, “What would you do?” (And I answered.) RevMedic asked about a patients medical history and got the best answer evar (sic). Firegeezer, Bill Schumm highlighted more hits to the public service world with a slew of layoffs on the dusty roster roundup. Jaramedic and MsParamedic joined forces for a very cool video project called Mutual Aid. MedicTHREE related the story of an elderly couple’s death that he found tragic yet sweet. EpiJunky rocked her National registry practical. The Happy Medic spoke of cookies and marriage and what he overheard in the firehouse. Just My Blog gave a humble thank you in two parts. Rogue Medic, Tim Noonan pointed out an error and mused on drug calculations and Michael Morse demonstrated why it’s OK to sometimes bend the rules in the beautiful piece Sunrise. He also showed why his writing is such a gift to EMS.

On the news front, AMR created a new position of Chief Medical officer and appointed Dr. Edward Racht, M.D. to the position. The inside track at The Spot is that Dr. Racht is the real deal. Good news for AMR employees. EMTs in New Jersey staged a protest to highlight what they felt were unsafe working conditions. Two ambulance companies in South Carolina have taken to racing each other to the scene for transport dollars. A volunteer ambulances squad in Woodbridge, New Jersey was accused of having parties at the station with prostitutes. The Indiana EMT accused of molesting a patient in the back of his ambulance has apparently fled the state.

And finally, in the EMS podcast world, The GenMed Show addressed EMS longevity. The EMS Garage went for the jugular with the subject of  response time myths in EMS and talked at length about a very sad event in the EMS blog world, the departure of Mark Glencorse from The Medic999 Blog. Jamie Davis and the Medicast looked at understanding allergies and The EMS Educast examined high school EMS programs.

“In Germany they first came for the communists, and I didn’t speak up because I wasn’t a communist. Then they came for the Jews, and I didn’t speak up because I wasn’t a Jew. Then they came for the trade unionists, and I didn’t speak up because I wasn’t a trade unionist. Then they came for the Catholics, and I didn’t speak up because I was a Protestant. Then they came for me – and by that time no one was left to speak up.”

- Rev. Martin Niemoller

Yesterday an Action Care ambulance covered my station while I was at a training. Action Care is the local private ambulance service. I know, the name always seemed a little silly to me. If a super hero ever created an ambulance service, he would most certainly call it Action Care. I joke about the name, but they’re the real deal. If you’re going to work as a private service EMT, you could do worse than Action Care. And if that doesn’t work out, there’s always the medical billing and coding field.

I’m glad we have Action Care. They help cover our district when we are low on resources. They are always professional and polite on scene. They give good care.

Sometimes, working with a private ambulance service on scene can be challenging. There are conflicts. There always are. Occasionally a private ambulance service medic will assume that I’m an idiot because I’m wearing fire gear. Sometimes, that can be amusing and sometimes it can be frustrating. Sometimes a fire medic will assume that the private ambulance medic needs her hand held because, well, she works for a private company after all. I’m sure that’s frustrating for them as well.

I know that most of these biases are made up. When I was in the private ambulance service, I advocated for the advantages of private ambulance service and denounced the fire service as bad for EMS. When I became a fire fighter I suddenly saw things differently and the flaws of private, for profit medicine became more evident.

I’ve certainly seen both sides of the equation. Which, recently made me consider an interesting question. While driving back to my station, thinking about how much I appreciated having our local private service available for our district, an interesting thought occurred to me.

What would happen if we advocated for each other?

I know, it’s a crazy thought. The very idea of a fire fighter / paramedic extolling the virtues of private ambulance service medicine and a private service medic understanding and advocating for the benefits of fire based EMS seems insane. But consider it. Go crazy with me and ask yourself, “What if..?”

What if firefighters saw private EMS as good for our industry and supported the efforts of their private ambulance brothers and sisters?

What if private services recognized the important contributions of fire based EMS systems?

What if, instead of being threatened by each other, our service were public advocates for the others needs?

What if I told members of the community that our local private service was an essential part of our response plan and an excellent example of everything private services can be?

What if my private ambulance counterparts explained why my fire based service was the right design for the community and a good model of what fire based EMS can be?

What if we spoke up for each other?

What would happen next?

You tell me.

I asked on twitter. I asked on Facebook. I even asked right here at the blog. And the answers poured in. Your responses represented the full spectrum of personalities that inhabit our workplace. There were poignant responses, cynical responses and a bunch of funny ones. The responses made me smile and frown and think.

Within this list of answers you’ll find feedback from 30+ year EMS veterans and newbies just getting their EMS feet wet. Everyone is represented. And the responses are telling.

I’m rather proud of how this little experiment turned out. I hope you find these responses as enjoyable and thought provoking as I did. Thanks for all your contributions. Aside from categorizing these contributions, I’ve made no further editorial additions. This post will become part of the guest posts category, because it was written by you.

Complete the sentence, “Behind every great EMT…”

The Humorous:

Behind every great EMT are 5 firefighters. – @isuhawkeye via Twitter

Behind every great EMT is a stack of empty pint glasses. – @MedicSBK via Twitter

Behind every great EMT is an Englishman in a green jumpsuit watching over them from a distance. – @MedicSBK via Twitter

Behind every great EMT is an ambulance. – Mark Daube via Facebook

Behind every great EMT is an adrenaline junkie. – Anonymous via the blog

The Cynical / Funny:

Behind every great EMT there’s a pissed off lawyer that can’t sue you. – @texaschef via Twitter

Behind every great EMT there’s a chief with a boot headed for your ass. – @texaschef via Twitter

Behind every great EMT is a partner who can’t drive. – @seanhfitz via Twitter

Behind every great EMT is a supervisor with a write-up for him. – @seanhfitz via Twitter

Behind every great EMT is an ambulance with a flat tire. – @seanhfitz via Twitter

Behind every great EMT is a line of bill collectors. – @Ckemtp via Twitter

The Egotistical / Funny:

Behind every EMT is chaos, brought under control, left in their wake. – @MedicSBK via Twitter

Behind every great EMT there’s a paramedic telling him to move so he can treat the patient. – @paramedicintern via Twitter

The Thoughtful:

Behind every great EMT is a role model, an excellent instructor, and sound judgement. – @hoplessromantic via Twitter

Behind every great EMT is a solid foundation of the basics. – @un_ojo via Twitter

Behind every great EMT is a conscience that whispers, “Is this in my best interests, or the patient’s? – @AmboDriver via Twitter

Behind every great EMT is a never-ending willingness to always learn more & strive to always put the patient first. @JustMyBlog via Twitter

Behind every great EMT is a very understanding & supportive family. – @EMTwicks via Twitter

Behind every great EMT there’s professionalism, patience, empathy, gentleness, and faith. – @dont39350 via Twitter

Behind every great EMT there’s an excellent instructor (or instructors). – @Bitzes via Twitter

Behind every great EMT there’s an ongoing thirst for knowledge. – @NJDiveMEdic via Twitter

Behind every great Paramedic is a damn good EMT. – @EMTDani via Twitter

Behind every great EMT is education. – @EMTDani via Twitter

Behind every great EMT is a mentor, supporter, and educator. – @Gfriese via Twitter

Behind every great EMT is a solid education and an extra dose of common sense. – @UKMedic999 via Twitter

Behind every great EMT there is a spectacular instructor. . .and a good team. – April DeGesualdo via Facebook

Behind every great EMT is a great mentor. – Anonymous via the blog

Behind every great EMT is a great mentor, a great education, and a great passion to keep learning. – Anonymous via the blog

Behind every great EMT are compassion and humility. - Captain Tom via the blog

Behind every great EMT are friends, family, a good head, the drive to keep going, and keep learning, and a love of what we do. – Jen D. via the blog

Behind every great EMT is the passion to always be improving through education, run reviews, and being a sponge with mentors and other EMTs. To learn to be humble, compassionate and remembering that every, I mean every call is important to the patient and we treat every call as such. If you don’t really enjoy what you do, it may be time to seek another career. – Randy via the blog

Behind every great EMT is the knowledge that it is all about the patients, not us. – Sean Fontaine via the blog

The Personal:

Behind every great EMT there’s a heart that cares and an inner drive that pushes you to always go above and beyond for your patients. – @PrRescue via Twitter

Behind every great EMT is a family that misses him. – seanhfitz via Twitter

Behind every great EMT is a great support network. – @NavyStingerDoc via Twitter

Behind every great EMT there’s a family and some friends that understand. – @Ckemtp via Twitter (With a bunch of accompanying retweets and affirmations.)

Behind every great EMT is a caring, and determined individual. The status of “E.M.T” is a means of developing skills and knowledge, paired with the legal ability to use those skills and knowledge, in a way that is true to the intrinsic nature of that individual. – Jeremiah Bush via Facebook

Behind every great EMT are their brothers and sisters in service. – Pamela Moore-Eaton via Facebook

Behind every great EMT are equal parts passion and compassion. – Steve via the blog

Behind every great married EMT is a great wife. – Anonymous via the blog

The Optimistic:

Behind every great EMT, there’s a long row of mediocre EMTs who need a little enthusiasm shared with them. – @FloBach via Twitter

The Hard to Classify:

Behind every great EMT is a confused but very lucky citizen to have encountered them. – @MedicSBK via Twitter

Behind every great EMT is an open door to escape through. – @CrazyMedic via Twitter

Behind every great EMT is a sandwich with one bite taken out of it. – Mike Taigman via Facebook

Behind every great EMT is someone just one hour of sleep short of being incapable of screwing up. – Joseph Schmoe via the blog

Behind every great EMT is The EMT Spot. – Anonymous via the blog (Thanks anonymous.)

And thank you to everyone who contributed. Don’t worry if you missed your chance to add your two cents. that’s what the comments section is for. See you next time.

You may be able to guess the results. If there were no pieces of litter on the ground, or only one piece, the subjects were unlikely to throw the unwanted piece of paper on the ground. After that, the likelihood of the person discarding the paper on the ground was exactly proportional to the number of pieces of paper already on the ground. The more litter already present on the ground, the more likely that the next person would also throw their piece of paper on the ground. It’s the law of social conformity.

Litter begets litter.

This isn’t new news. The 1990 research (Cialdini, Reno and Kalgren) was a repeat of similar research done in 1973 (Finnie), 1977 (Geller, Witmer and Tuso) and 1978 (Krause, Freedmen and Whitcup.)

How does this apply to you?

The law of social conformity affects everything. If you leave trash in the bottom of the trash can in the back of your rig, the next guy is likely to leave trash in it at the end of his shift too. If the floor is dirty it’s likely to get dirtier. If there’s blood splatter on the ceiling, the next medic is more likely to not wipe the compartment down either.

It’s not just a cleanliness issue. If you attend a C.E. class and twelve of your coworkers are there, you’re more likely to attend the next one than if there are only four. If two-hundred of your coworkers forge their C.E. documentation, you’re more likely to do it than you would be if only five committed the offense. If you don’t call the patient by their name it’s more likely that the next caregiver won’t either.

Of course, the inverse is also true. Your personal patient greeting, clean ambulance and impeccable C.E. record are just as likely to influence the culture for the better as your negative behavior is to influence it for the worst. Sometimes we talk about the culture as if we are only visiting. We are the culture. What did you beget today?

Now it’s your turn: What else have you noticed that begets more of itself? The possibilities are endless.

Read More Posts:

Ten Reasons I Work In EMS

Passion Counts

6 Reasons Why You Should Be A Better EMT

4 Sloppy IV mistakes You Should Avoid

EMT Burn Management

Perhaps you’ve already heard, starting July 1st, 207 EMT’s in the city of Boston will begin serving suspensions ranging from 45 days to 9 months for falsifying their training records and claiming that they had attended continuing education classes that they had not.

Now, to add a little bitterness to the whole thing, a few Massachusetts EMT’s have come forward to say that the suspensions are unfair. Instead of taking the suspensions with grace, serving the punishment and feeling fortunate to still have a certification, they are coming forward with some comments about the usefulness of continuing education.

Terry Urekew, an uninvolved bystander in the whole debacle, chimed in with this quote, “Give everyone a $100 fine and community service. Don’t take someone’s livelihood away from something that has no impact on whether or not we are better EMTs,” You can probably guess that a guy who writes a website with the subtitle, “Medicine moves fast…keep up.” is going to probably take issue with Terry’s assessment of the usefulness of keeping up on medical education. You’d be right.

Then there’s Kim, the state EMT suspended for nine months who protested, “The refresher course just repeats everything. We didn’t put you at harm.”  Uh, well, yes Kim, good point. But you didn’t not…not, put us at…safe? Bad grammar aside, Terry and Kim are glossing over a few important points about what they did.

If any of the Massachusetts EMT’s are still reeling in confusion over the unfairness of all this, let me offer up a few points of clarification for you.

1) You lied and cheated

There were two significant wrong-doings here folks. First there was the continuing education that you didn’t receive; The updates on protocols and changes to procedures like tourniquet use and CPR that you decided weren’t really critical to your understanding of your job. But then, there’s also the fact that you lied.

You work in a job where the community places great trust in you. They invite you into their homes when they are weak and helpless and they need to trust that you are morally sound. That means, when you say something, it’s true and when you do something, it’s proper. This was your greatest failure. Not your lack of knowledge but your lack of an appropriate moral compass.

2) You disrespected the EMT’s who work hard and follow the rules.

24,000 EMTs in your state managed to complete the requirements of continued certification without fabricating their training records. They followed the rues and respected the process. When you unilaterally decided to forgo your troublesome C.E. requirements you disrespected all of them.

This idea that, since you got caught cheating the system, you should be slapped with a small fine and allowed to continue is insulting to the EMT’s who could have also payed a little money to not go to classes but opted to follow the rules instead. Your punishment needs to be stiff enough that the EMT’s who worked hard can feel rightfully vindicated for following the rules.

3) You disrespected our profession.

This one burns me the most. I’m just astounded at the hubris in your statements. It’s as if you feel like everything you needed to know about medicine was covered in the 140 some-odd hours of your EMT class and now you shouldn’t be troubled with additional knowledge and skills.

What harm could possibly come from allowing you to continue in your work unhindered by advancing knowledge and skills? Well, quite a bit actually. The knowledge you were given barely scratched the surface of emergency medicine. You’re an EMT. You should be hungry for more knowledge. You should be eager to learn more about the medical challenges you’re bound to face in the future.

Perhaps you think your punishment was unfairly harsh. I disagree. I think the system that you continue to openly disrespect was unusually kind to you. The next time a news reporter calls asking for your your opinion, you may want to try, “No comment.” as a response.

What do you think?: Were the Massachusetts punishments unfair?