Archive for March, 2013

Pay

When people say pay is not an important aspect to improve for our medics I turn and give them the great medics that have to leave the field for a better life for them and their families.

There are many competent medics, but great medics, that study the art of emergency medicine, that push the boundaries in a calm and professional manner, that don’t settle for average are few to come by.

I have met a few during my career. Unfortunately almost all have now moved on to different careers outside of Ems. Today I was approached by a newer medic, he’s been in the field only a few years but I really think he has the potential to become great, and have been told he will most likely be leaving the field. It isn’t that he doesn’t love it, it isn’t that he isn’t progressing in it, it’s just that he is not making enough to justify staying in Ems when there is more money he could be making for doing a lot less.

I have heard it said, “in emergency medicine you can have fast service, cheap service or excellent service. But you can only choose two!”

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Just an idea

In certain services in EMS:

We have the ability to paralyze patients and establish advanced airways directly (we hope) into the trachea.

We have the ability to drill a needle into bone and administer medications into the intraoseous space.

We have the ability to give patients narcotics, give the patients medications that speed up the patient’s heart, slow down the patient’s heart, any of which can have the side effect of stopping the patient’s heart.

We can administer electrical “shocks” to patient’s hearts, decide if a person is past the point of being saved and terminate efforts in obvious deaths, we interpret electrocardiographs and determine patient care, we determine if patients should be flown out of rural areas or areas that are too far for ground transport. We can do chest decompressions, nasal gastric tubes and regulate ventilators.

We can do this and so much more and yet we cannot tell a patient that they should not go to the ER for that splinter in her finger (really, I’ve had this patient); we cannot tell the patient that has told us he have no chief complaint except they want to go to the behavioral unit and going by ambulance is faster in the ER for medical clearance (this one goes 3 times a year). We cannot, with all of our experience and training, tell a person that a glucose of 255 mg/dl is not an ER problem but a problem that should be examined with their personal doctor (this one also goes 3 times a year at least).

I’m not saying everyone should have this ability, by no means. I know what kind of medics are out there. Being able to tell a patient they are not in need of emergency medical services is a big responsibility, filled with possible complications. Just like half of the interventions we perform on patients. I am saying that there are some medics that should be able to do this. I’m also saying there are a lot of medics who are doing this and worse because there is a failure in policing refusals at the moment.

Will this solve all EMS problems? Of course not, in fact it might create some very new ones. Think about this before you dismiss the idea just on principle:

Can police officers tell people calling that the situation they are talking about does not need police intervention? (Have you heard of the people that call because a burger was not prepared as they wanted? That person got a ticket and then was arrested.)

Would the fire department be forced to respond to the same house time and time again if it was just to help the residence get seen faster?

Yet us, and again I’m not saying everyone in EMS but certainly a few of us, are forced to transport everyone for anything.

This has just been a thought, I have an idea that there has to be some significant changes to EMS before it becomes a reality.

Thank you for listening.

How to improve EMS quality assurance internally.

I’ve gone over why I initially didn’t like receiving updates on my patient outcomes in a past blog. Short story of it is I didn’t like receiving bad news about my patients after I had delivered them to the ER. I wrote more about it here: Why I avoided patient outcomes.

I learned during my career that there can be some very significant benefits to knowing patient outcomes. I have seen many different types of QA/QI and CQI being implemented and think all of them could benefit from something very simple being added to every emergency run: tell the ambulance crew the patient outcome post ER stay. After every call. After every patient. Don’t make it about reprimands or link it to pay raises, just do it to attempt to improve patient treatment and interactions.

You take in a patient that suffered a fall, follow up the run by telling the medics if there was a fracture or not. Tell them what pain medications were used on the patient during the hospital stay. Was anything else discovered the medics didn’t catch?

Shortness of breath? Tell the medics if it was pneumonia or the flu, what interventions were ordered.

Chest pain, did it end up being a cardiac problem even though its our frequent flyer? Speaking of frequent flyers, so much time is dedicated to ranting and raving about how much of a tax they are to EMS systems, well this method would teach us if that is true in our individual area. I have heard of some systems complain that a frequent flyer is anyone that uses 911 more than 3 times a year and that as little as 100 frequent flyers can cost an EMS system more than 800,000 dollars.

I have also heard of frequent flyers being dismissed as a nuisance and die because of medics telling them to ignore that chest pain and drink some Maalox. How much is the payout on a malpractice suit if it results in the loss of life running these days?

Ahh refusals. That’s a few blog posts on their own.

I think in a short amount of time getting feedback on all our emergency room patient deliveries could greatly improve understanding and aid in patient treatment. I know of many medics that go back and check on their patients, this would just be an expanding of it. I also am not talking about a very costly service. In all likely hood the most important link would be a good relationship with local emergency room staff and whoever is in charge of QA. Trend outcomes, help with things like 12 lead times, stroke, STEMI and trauma alerts could all gain from this. The benefits are truly endless as well as modifiable to individual service needs. Research into medication administration, equipment use such as the AutoPulse or Lucas devices for CPR, and specific interventions can be studied.

I am hoping to introduce this to my department soon and hope they at least consider it. Too many times I see an emphasis on certain types of emergencies and just think a massive blanket review on all transports, at least to start with, could greatly benefit us all.

Why I avoided patient outcome information at the beginning of my career.

Very early on in my EMS career I decided that I would deny myself the joy of knowing I made a positive influence in somebody’s life in exchange for not having to face the fact that sometimes no matter what I do people die. It was a very conscious decision and for years I lived by it.

Let me explain:

There was a very bad shift when I had two emergency calls. The first was a small child, about 6, that was run over by an unknown vehicle. We knew it was a vehicle of some sort because he still had the tire marks on his back. Multiple fractures, tension pneumothorax, mass felt to his abdomen. Patient required RSI and in my opinion he was holding on by a thread. My partner was a big, tall and very tough white boy. Believe me, he was about 6 foot 5, 280 solid pounds and I had seen him brave some of our very toughest emergency calls. On the elevator up with the patient and the ER team I think the amount of stress we had gone through got the better of him. I didn’t hear it, but when I turned to him there were tears streaming down his face as he looked at the poor child on our stretcher. He apologized, something I quickly dismissed. I told him it was ok but we still needed to finish the call. No matter what the emotions. We did finish the call and delivered him right to the waiting trauma surgeons who quickly determined there was a liver laceration that would have to take priority.

Shortly after we had another emergency. A 15 year old babysitting his brother while their mother was next door suddenly has an extreme headache. He literally tells his brother to run and get their mom because he feels his brain bleeding. Unresponsive upon our arrival, code 3 transport to the ER with supportive measures being done. He was alive as we delivered him to the ER. No past medical history, all vital signs were normal. CT shortly after showed a massive hemorrhage.

Here’s the crux of the story: A few days later my partner, who had been following the outcome of the two patients, comes into the office and informs me that the 6 year old had survived the surgeries and was progressively improving. The doctors were now being cautiously optimistic and even went so far as to say no neurological deficit had been noted and wasn’t expected.

Can you imagine the elation? We saved the child, we stopped something I felt was inevitable! A complete recovery.

Then my partner told me the 15 year old had died within the hour after we had left the ER. A 15 year old stroke patient. Dead.

It didn’t seem worth it to me, the save was great but I felt the loss extremely.

So for a few years I didn’t go back to get the outcomes of my patients. I did what I could, I followed my protocols, the latest ACLS, PALS, PHTLS, AMLS and any other teachings I could get my hands on. I prided myself on pushing myself for my patients and then as soon as they were completely under the care of the nursing staff at the ER I would forget them.

It took me a long time, but I learned something.

I learned the dead sometimes can still teach us a few things. I learned sometimes being punished, even if it’s by your own self, can be the best mentor. I learned that pain is necessary.

I will continue on why this is important in my next blog.

Thank you for listening.

Final Destination?

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170 years punishment for man that shot into ambulance.

A man just convicted of shooting into an ambulance as the ambulance was attempting to transport a stabbing victim to the hospital has been sentenced to a 170 year sentence. The man also shot at the vehicle following the ambulance. The vehicle following the ambulance were family members of the stabbing victim.

I hope that this sentence, while certain to be appealed, sends a clear message about attempting to injure EMS personnel. I have heard too often of lenient judges handing out light sentences when EMS and other first responders are assaulted and harmed. We are out in the streets everyday treating all that require our assistance equally and should be protected by the law accordingly.

Here is the link to the story: 170 years for ambulance shooting

No CPR allowed!

I have gone to many scenes where I am dispatched for a full arrest where I find a dead patient with no CPR or very inadequate CPR being done. I have heard of many reasons why no CPR was started. I distinctly remember a patient I encountered while off duty who was surrounded by family when he went into cardiac arrest and no one started CPR. After I began chest compressions I asked the patient’s brother to give mouth to mouth ventilations and one by one the family refused. (I don’t know if they knew something I didn’t so I continued with compressions only, I didn’t have a shield.)
Even with all of that I was very surprised to learn that there are nursing facilities that as per policy are not allowed to administer CPR. I came upon this article via medicmadness and don’t know what to think.
Part of me understands the whole follow policy so you don’t get blamed aspect. Another part of me doesn’t understand how a policy like this could ever make it onto the books. Have any of you heard of anything like it?
Here is the link to the story: Medicmadness No CPR for you