Some notes on RSI

What I am about to discuss should be taken with caution. Never deviate from your protocols and standing orders. You should always follow protocol and medical direction. This is also by no means a complete discussion on RSI or the medications that can be used for it. Any questions, feel free to ask, any suggestions would be greatly appreciated. Experiences you’ve gone through first hand would also be great, I would like to post a follow up to this post with at least 5 real world uses of RSI explored in detail. While some aspects of patients have been changed to protect the identity, I have tried to stay as close as possible to the emergency so as to provide as clear a picture as possible into the use of these treatments. This is also by no means a complete guide, just a few thoughts I’ve put together based off of personal experience, recent education and the experiences of knowledgeable and dedicated providers around me.

RSI can stand for rapid sequence intubation or rapid sequence induction. Either way it is a very extreme treatment regiment and should be done with extreme caution. What we are doing is paralyzing someone and taking over their respirations. Completely taking over a patient’s body. If we don’t breath for them they can no longer breath for themselves once we have paralyzed them. In very few other situations is the term, the patient’s life is in your hands, more applicable.

Some notes on some of the more common medications used in RSI.

Fentanyl/Sublimaze should be used for analgesic properties. Fentanyl also has very little to no effect on blood pressures so you can use it and trust that pain management will be as safe as possible. One of the things I like in my drugs is for them to have as little side effects as possible, if a drug is an analgesic I don’t want it to also drop my patient’s blood pressure. 
Dosage is usually 1 to 2 mcg/kg for adults and 2 to 3 mcg/kg for pediatrics. 
Notes on Fentanyl: it can cause muscle rigidity which in extreme cases can cause respiratory complications. I have heard uneducated doctors (I know, a misnomer) state this is the reason we shouldn’t be using fentanyl in the field. If used properly, given at a correct rate and correct rate of infusion this is rarely seen. Respiratory depression can also be seen. It is an opiate so it can be reversed with Narcan. For our use it would not be a problem since we are paralyzing and controlling the airway.

Anectine/Succinylcholine: ultra short-acting depolarizing-type, skeletal muscle relaxantThis will be important later. Some precautions: do not use in patients with rhabdomyolysis. Do not use in patients with diagnosed or suspected hyperkalemia, in patients with personal or familial history of malignant hyperthermia, skeletal muscle myopathies. This is important because we have to remember that if a person is hyperthermic or has diagnosed hyperkalemia we should skip anectine and go to your longer acting paralytic such as Vecuronium or Rocuronium. Care should also be used with people suffering from ocular injury, since Anectine can cause increased ocular pressure.
Dose: 1mg/kg not to exceed 150mg. Onset will usually be seen in under a minute so long as the IV line is patent and running well.

Typically we would sedate and give pain management prior to paralyzing. The nature of EMS is one that we cannot always predict what situations we will run into. There are guidelines we can follow, best practices we can learn, but there can always be a new complication. Take this story for example:

EMS crew is responding to the scene of a patient experiencing a seizure. As per family prior to the seizure the patient was showing sings and symptoms of a CVA. The patient has a past medical history of CVA as well as Hypertension. No history of seizures. When the EMS unit arrives the patient is still seizing. Grand Mal seizure lasting over 25 minutes, as per family. Treatment is begun, IV established, oxygen, Ativan is administered @ 4mg via IV. The patient shows no signs of improvement. In fact the patient begins to have emesis seep from his clenched teeth, suctioning is started but the medics are unable to open the jaw. oxygen saturations are dropping. The decision is made to RSI the patient. The first drug administered for RSI is Anectine @ 1mg/kg. Within 20 seconds the patient has stopped seizing and jaw has relaxed. Airway is open and suctioned, patient is intubated. Initial inline CO2 is marked at 70, oxygen saturation is instantly better going to 100% within a couple of minutes. It can be said that no analgesic was administered prior to RSI. That would be true, but the patient’s condition, at least in the medic’s perspective, warranted immediate intervention. If you were to begin ventilations without opening and clearing the airway aspiration could be a major issue, if Versed or another benzodiazepine was used respiratory depression could occur and without a patent airway the patient could be in worse shape. As soon as the airway is cleared and controlled the patient is administered fentanyl, versed and then given Vecuronium. The patient was transported and received at the ER. Within 30 minutes they had done everything they needed and had the patient inside the operating room receiving treatment for a massive stroke.

Norcuron/vecuronium: a non-depolorizing neuromuscular blocker. Remember I stated earlier that Anectine is a depolarizing agent. If a patient has a condition that may be exacerbated by Anectine it could still be safe to use vecuronium if the patient requires RSI. Dose is usually 0.1mg/kg. Onset is a little longer than Anectine but if you have the opportunity to premedicate with a sedative and an analgesic you should be on track with RSI. Of most RSI’s that I have seen only a couple have required vecuronium as the initial agent. Usually where I have seen Anectine work in 30 to 45 seconds on average, vecuronium has taken about a minute and a half to two minutes. The big difference is how long they will keep a patient under. 
Here is an example I love: 

Medics are called out to an emergency room for an emergency transfer. The hospital has been dealing with a trauma patient who has been diagnosed with rhabdomyolosis. The patient’s condition is deteriorating and his airway is now being compromised. The medics are told to prepare to transport an intubated and ventilated patient. The ER doctor is about to RSI the patient. As the medics prepare their equipment for transport they see that the patient is still very much moving and fighting the intubation process which is making the doctor not establish an airway. The patient is being sedated only, fentanyl, versed and some morphine is being used in increasing doses with little to no effect. 
For anyone who has used analgesics it is known that they are great for certain things and completely ineffective for others. An isolated fracture, some chronic back pain, maybe even some open fractures from trauma and fentanyl can help, versed can sedate. Try realigning a  dislocation with only fentanyl and you will quickly learn it is not as effective.  The same goes for someone sticking a tube down your trachea. The medics step in and begin to ask why the doctor is attempting an RSI without a paralytic also telling them that if the patient is successfully intubated and transport is initiated they will not take the patient without paralyzing him, it would be too dangerous in the unit to do so. The doctor, in the way only doctors can, scolds the medic and says a paralytic can’t be used because a depolarizing agent can exacerbate rhabdomyalosis. The response, which was delivered in the way only a medic can, said, “if your scared of exacerbating rhabdomyalosis because of a depolarizing paralytic maybe you should use a non-depolorizing agent like vecuronium.”
Let me explain something here, this was not my call, this was not me answering the doctor, but I was so proud watching it unfold. Everyone is quiet, except for the squirming patient, and for a split second I think the medics might be thrown out of the ER. Then the doctor calmly turns to the nurse and asks if they could draw up some vecuronium. Did the paramedic know everything there was to know on rhabdomyalosis? No, I asked him, but he did know enough about his medications that he was able to work the problem and had enough experience to find a suitable solution. The rest is history.

In any emergency there is pressure, in a critical call where you are getting ready to paralyze someone the pressure can cause you to forget one name or the other of medications or conditions. Some names you just have to learn and it’s a good thing to learn more than one name for each drug. Someone might not learn the same one you do. For example:

Anectine is Succinylcholine and most people just call it Sux. I don’t, I call it Anectine just because it is easy to say for me. I have trouble saying succinylcholine. 

Ativan is lorazepam.
Midazolam is versed.
One way I remember this is A is closer to L so Ativan is lorazepam. M is closer to V so Midazolam is Versed.

A good versed dose is typically 0.1mg/kg. This is a large dose and while you should still use a paralytic you should be ready to assist ventilations as soon as you’re administering versed in the off chance that it knocks out the patient’s respirations.

We don’t carry Valium in my service so I don’t have to worry about it. Valium is Diazepam. 

Final note on RSI for now: I typically am very pro education and believe even new medics have to learn how their meds work. I tell all my precepts that the books can’t show you everything. Only after you use a medication on a patient, over and over, different age ranges and for different symptoms are you really going to know what that medication does. Epinephrine, albuterol, brethine, benadryl, and many more. With an RSI you don’t just have to be proficient in intubation, different medication administration, and probably most importantly, a level head for when you get questioned about your call at the ER, you have to be experienced. This is one procedure I do not advocate for new paramedics. It isn’t that they are not knowledgeable enough, it is that experience is very important. If a medication causes a reaction you weren’t expecting you have to be able to react and correct the situation. Pride should not be a reason you are continuing to try to intubate a patient you have attempted to RSI and found extremely difficult. When done correctly it can be an absolutely life saving procedure, if done incorrectly it can be disastrous. 

Improving EMS part 3 Regulation

ImageThis next portion of how to improve EMS may be controversial. Depending on your political leanings this could be anathema.

I will be very blunt to hopefully diminish any misunderstandings. I also want to start by saying this may be very restricted to what happens in the USA and maybe even just what is needed in my home state of Texas. This is after all where I work and see most of the first hand things that happen in the EMS systems around me.

We need more regulation in our industry and more power given to those tasked with regulating it. Currently if a semi-truck driver is working and he is pulled over by the state troopers that truck driver is responsible for everything going on with his vehicle. Broken lights, missing license plate, too many hours on the road without taking mandatory breaks for sleep and he can get cited and even stopped completely until he complies. A paramedic can work 48 hours or more and no one even thinks to question if he is still safe to operate an ambulance.


 We can talk about how much this would cost, or who would implement it, or even if it would initially be more of a burden followed by the benefits it would bring across the field. What is plain to see is that it would help normalize what is expected from ems in the long run. Imagine if a police officer working for one city went and worked another full time job somewhere else. Adding up both full time jobs would only equal 80 hours. There are some medics that can work 96 hours per week and no one examines it, no one even is tasked with trying to look into it. Some companies are policing themselves, but even then it is sparse and hard to do if other companies are hurting for medics. We can talk about why it shouldn’t be necessary for a person to work so much to provide for their family and the role of increasing pay for medics across all levels would help cut this down, but no one wants to begin the conversation of setting concrete limits on amount of hours worked in one shift, let alone in one week or some sort of network to monitor if they are moonlighting somewhere else.

Some will come right out and say the agencies are already in place for dealing with these types of incidents and much more. The state regulating agencies and so forth. So let me tell you a story of an ambulance service in a nearby area. In the past few years this company has been investigated and fined for animal cruelty, lacking necessary medical equipment such as oxygen, dextrose sticks for their glucometers, functioning lights both in the patient compartment and emergency light bars. There were cases against that ambulance service for hiring a registered sex offender and then mandating he work on an ambulance that went out and made contact with children. There were cases of missing equipment on an ambulance that responded to a cardiac arrest, the missing equipment? A cardiac monitor.

With all this going on with the service, surely the powers that be, who sided against the ambulance service, must have taken some pretty drastic steps to prevent it from happening again. So what was the result of all of these incidents? A fine. The service was never even threatened with closure or suspension of their license. Accidents involving serious injury to medics, even deaths, have happened with this company. Two of them, at least, were a direct result of a medic being on duty for too long and lack of equipment. (One case involved a paramedic who was on duty for 36 hours with the last 9 or so hours spent driving, the other case involved a unit deficient in needed emergency supplies that made them transport a normally code one transport code 3 that resulted in a massive collision with a death and six other people transported to the hospital.) This has to be an isolated case? A fluke in the system. Unfortunately that is not what I have seen. Sure we occasionally hear about a suspension, a closure of an EMS service, usually these are due to extreme financial problems within a company and not a direct result of deficiencies or a state agency taking action. Suspensions of medics are usually drawn out affairs and I have heard of many more cases involving very bad care go unpunished, not because there was a lack of evidence or a clear lack of explanation by the medic, but because the agency tasked with investigating was overburdened. Can you imagine how fast companies would rush to comply with each and every rule if one day, just for one day even, they started shutting down ambulances on the spot if major deficiencies were found?

I did an informal survey in my area, two things came into shocking focus. One: most EMS personnel do not even know where to look for the rules and regulations that can cause the state agency to suspend, fine or decertify them. Two: most EMS personnel were more afraid of getting sued than being punished by a state agency. Even though no one they personally knew had ever been successfully sued. (This survey is still in progress and if anyone wants to participate just let me know, it is only a few questions and will be used in a future post.)

I’m going to take this argument one step further. Critical Care ambulance services. Currently there is a local hospital that requires critical care ambulance transports for cases they cannot handle internally. There are 4 services that rotate throughout the month. Each service takes a full week of transfers. Each of the ambulance services that provide the care say they are critical care certified and have the capabilities to do these transports. The differences between the services is staggering. One service carries LTV ventilators as well as Carevents on each and every critical care ambulance as back up, along with the usual assortment of BVM’s, ET tubes, LMAs, Cric kits, EZIO’s, Lucas devices, IV pumps, refrigerators for medications and hypothermia treatment equipment. Training on ventilators is done by respiratory therapists and an unusual amount of training, at least for this area, is provided yearly. AMLS, NRP, PHTLS, ATLS, ACLS, PALS, and more that I’m not thinking of right now. Each of the critical care trucks must be manned by at least one flight certified medic.

Now that is one service out of 4. The other services, even though they are called critical care by the hospital, do not do any of this. Let me repeat, they do not do any single thing that I mentioned as far as training. All training is done in-house and such gems as these have been heard:

  1. I was told we didn’t need to know what PEEP was, just plug in what the RT tells you.
  2. I didn’t know we could turn on the waveform of the CO2 on our monitors, I thought we could only see the numbers.
  3. We went through that class too, well we got the cards, we didn’t really take a test or anything.

Now let me be extremely clear here, I am not saying the other three services are bad, but shouldn’t there be clear cut policy for who can and can’t be classified as critical care? Shouldn’t an agency be able to monitor who is taking these extreme patient cases out of ICU’s and transporting patients with extremely sensitive medications? In just my current area there have been at least two cases of a ventilator failing and a patient dying. I was not at those scenes and I know that some of these patients are very sick and can be troublesome, but it also nags at me thinking about some of the comments I’ve heard from even the people that provide training in our areas on critical care.

Can there be problems with more regulation and more power given to those that are entrusted with policing it? Yes, of course, but the problems we are facing right now in many areas are too dangerous to just be let up to the capitalist survival of the fittest. A coworker I talked to about this told me why I worry so much about this if our immediate area and service is not a problem and would pass any regulatory visit. I answered because I have family in other areas that may one day need an ambulance and may have to be treated by a service that has not been compliant with state regulations in a long time. It is because there should be very clear cut minimums when it comes to anyone providing ambulance transport. It is because a service that is cutting every possible corner and hurting people ends up hurting our reputation as a whole.

Any questions or comments are always welcome.


About Apathy

About Apathy

A little read that got me thinking into all those medics that do the bare minimum for their patients. Have a read:


Just for those of you who asked, I will post my thoughts on the state of apathy. I might even use a big word. Just bear with me.

Everybody just wants to complain. Whine, moan, bitch, and complain. But they don’t want to do a thing about it.

We want more drugs, more procedures, more leeway to determine who does and does not need to go to a hospital. But we don’t accept the responsibility that comes with it. We don’t go to lectures at the teaching hospitals offered to the medical staff. We don’t read. We don’t write. We don’t further our profession.

No. We come to work for our checks and we bitch all the way to the bank.

And I’m tired of it.

I know other paramedics don’t go to medical staff lectures. I know this because I do, and invariably, I am the only paramedic in the room. Hell, I’m the only guy in the room that doesn’t have MD or DO behind his name.

I know this because I have been going regularly. Some of the doctors at Big Teaching Hospital know me by name. Because I am involved. I take notes. I ask questions. Good questions, too. Questions that other medics should be asking, but they can’t because they are too busy planning their next vacation or playing the newest video game or planning their next drinking binge with their buddies.

Call me self-righteous all you want. But don’t call me lazy. And you sure as hell better not call me apathetic.

Why wouldn’t we go to the same continuing education programs that physicians do? For crying out loud, the word Paramedic means a person who is trained to work in an auxiliary capacity to a physician.  

I know other medics don’t read. I know this because of the looks I get when I reference medical research. “There was an article in the BMJ a few months ago that…” “What the hell is the BMJ?” is the response I get. “Why would I read a medical journal?”

We don’t further our profession because we don’t care about our profession. Perform your own experiment at your service: ask your coworkers what their plans are for EMS 2.0. Let’s see what the response is.

But nobody cares. NOBODY CARES.

Sure, there are those of you who are regular readers of EMS bloggers. You care. Those with the blogs care. But the rest of EMS doesn’t. I can wade through my almost 1,000 comments posted to my blog since I started roughly 14 months ago and bet that there are fewer than 50 contributors The same people are commenting over and over again.

I’m no prolific blogger by any stretch of the imagination. But when I review my stats, the two posts that have the most views are posts entitledI don’t like people and A letter to a stethoscope thief. That’s what interests the vast majority of blog readers: sophomoric musings on why people generally suck and an asshole that stole my stethoscope. (Well, mine at least.)

But when I try to get people involved, to actually take ownership of EMS, and to play a more proactive role, I am met with a lugubrious apathy that irritates me to my very core.

I was met with this during our protocol-writing meetings. “It’s not fair that some paramedics would be able to use drugs that other paramedics can’t” was the paraphrased response I heard when we were discussing carrying some antihypertensives. “Life ain’t fair, buddy. You want to use the fancy stuff, go to the fancy classes.” was my response.

Andrew Grove, who rose to be CEO of Intel, wrote a book called Only the Paranoid Survive in which he gives leadership advice to people that work in any industry. Andrew Grove knows how to be successful. He says that there are:

“…moments in any business in which massive change occurs, when all the rules of business shift fast, furiously and forever. He calls these moments “strategic inflection points (SIP)” and he has lived through several. They are not always easy to spot – but you can’t hide from them.”

These strategic inflection points can make or break a business. I believe we are in the midst of what Mr. Grove would refer to as an SIP. Community Paramedicine, Critical Care Transport, expanded scope, changing educational requirements. Those that aren’t prepared to change and adapt are doomed to suffer terrible losses, the same that Intel suffered for three years before realizing they had to change their business model to compete with the Japanese.

Those in our profession who are not willing to change, who are okay with the prevailing apathy, are about to get, run over by a train. And when they get knocked out and wake up to a bright light, it’s not a paramedic checking their pupils; it’s that train coming right back for them.

So, if you aren’t ready to change, if you aren’t ready to make this the true profession that it should be, if you aren’t ready to learn, to take responsibility, to take ownership, to be proactive, then leave.

Go get a job doing something else. Do everyone a favor.

And if you are a manager, and you are the resistant force to this change, step aside and let a true leader take over. Managers manage, and anyone can do that. It’s not hard to babysit employees and to slap their wrists when they do something wrong. It is a whole different story when it comes to being a leader. Leaders have vision, and they know how to accomplish their vision.

Rudy Giuliani was by most accounts, a great mayor. Mayor Giuliani recognized that he did not know how to solve problems, but he had a vision for the way things should be. He used his vision to select people who shared his vision to fill his positions of leadership. And he accomplished his goals as a Republican in an overwhelming Democratic city. I am not from New York, and if you want to disagree with me on Mayor Giuliani’s politics, do it somewhere else, not here.

This is my career. This is what I want to do. It is not a ‘stepping stone’ nor am I in a ‘holding pattern until something better comes along.’ This is what I do.

And frankly, I am tired of the same old lazy, apathetic losers standing in the way of our progress.

Change, get out of the way, or get out. Period.

A grand quote from the aforementioned Mr. Grove:

“Your career is your business, and you are its CEO”

Would you fire yourself? A lot of EMTs and Paramedics should.

A question every new paramedic should answer

A question every new paramedic should answer


A very good call to arms for new paramedics. I firmly believe that many medics are a certain way from school. Some change, but it is hard. Starting from the beginning with a good foundation can go a long way. Read it, imagine it’s coming from a preceptor as you are graduating from your EMS education, imagine it’s coming to you from someone seeing what kind of medic you can be. Here’s the post


The last time I addressed a paramedic school graduating class was my own…twenty-one years ago, almost to the day. On that day, I read a poem. I don’t remember the poem…I don’t know what it was about or who wrote it, it was just what the staff told me to read. I would have given the valedictorian speech, but I missed it by a tenth of a percent. I’m not bitter…I’m just saying that by a tenth of a percent, Josh Binder gave the valedictorian speech and I read some crappy poem.

What kind of a provider are you?

Graduation day advice for you old dogs

As the new generation of paramedics hits the streets, you old dogs and veterans will face another onslaught of young, energetic, and impressionable providers who will follow the examples you set.

Just as this new legion must consider how they will change the world, you seasoned veterans must consider what impact you will have on these young minds. And how the world will change as a result.

As EMS welcomes the new grads, perhaps this is a good time to consider (or reconsider) who you are as a provider. Perhaps it is a good time to reevaluate the reason you do what you do, and the way you do it. Perhaps this is a good time to look back on your own career and remember the moments that have most touched you…and those you wish you could forget.

Most of all, perhaps this is a good time to truly ask yourself what kind of provider you are. If, after serious reflection, you find that EMS is in your soul and that being the best is the only way to do it, then reach out and show the newcomers what it means to be a Paramedic. If, on the other hand, you come to realize that your heart is just not in it anymore, then it is time to hang it up before somebody gets killed.

No matter how you answer, I urge you to remember the words of Polonius in Shakespeare’s Hamlet, “This above all: to thine own self be true.”

Today, though, is a much different day, for both of us. Instead of reading a poem that somebody else wrote, I get to tell you how it really is; from real experience with real people and real blood. I get to tell you what I know to be true about being a paramedic.

When I say that I believe “paramedic” is the single most significant job there is, I’m not just blowing sunshine up your collective rectums because this is a paramedic school graduation; and I’m not saying it because I spent most of my adult life working as a paramedic; and I’m not saying it because defending paramedics and EMS providers is the cornerstone of my legal defense practice and some of you look like potential clients.

I say that “paramedic” is the most significant job there is because I know it’s true. Think about this: Unlike even other EMS providers, it is the paramedic who willingly puts himself or herself smack in the middle of tragedy. It is the paramedic who willingly seeks out life’s worst moments and brings hope and comfort. It is the paramedic who willingly faces the absolute worst that human kind has to offer and takes control with a level head, a firm voice, and gentle hands.

But, more than all that, it is the paramedic — and nobody else — who goes to work every morning, takes out their license to practice, slams it on the table and says: “I dare you, world; I dare you to take this away from me today. I dare you to take my livelihood, my possessions, and even my life. I dare you.”

Because, unlike any other profession, in EMS a simple twist of fate, a simple mistake or simple misjudgment can cost you everything. I’ve tried, but I cannot think of any other profession where that is true. There are jobs that are singularly more difficult. There are jobs that are singularly more dangerous. But there is no other profession that is more significant for those reasons and many more.

We are it
To add a little perspective, I remember lying awake some nights in quarters thinking to myself: “Wow, if I called 911 right now, I would get…me. That’s it. I’m it.” For all intents and purposes, that was true. There is no 911 for 911 to call: You are it. For that reason alone, most people cannot do this job. Most people are not willing to take the kind of risks that you will take every minute that you hold a paramedic license.

Notice, I did not say “every minute that you are working,” I said every minute that you hold a paramedic license. Because your status as a licensed paramedic, what is expected of you, is not limited to who you are and what you do on duty. As an attorney who defends paramedics against actions taken by the California State EMS Authority, I am here to tell you, the State cares very much who you are and what you do all the time. As far as the State is concerned, who you are and what you do away from the job can have just as detrimental an impact on your license — and you career — as when you are working.

Again, most normal people are simply not willing to be held to those kind of standards… but you are — and you’d better be.

Experience has shown me that there are only three kinds of paramedics. There are the naturals; the ones for whom it is effortless… guys like Victor Oseguera, Paul Cooper, Kevin Murphy, or Mr. “tenth-of-a-percent” Josh Binder…these guys have it flowing through their veins. Then there are the ones who work very hard to be the best they can be; they read everything they can, they do twice the amount of CE they need to; the ones who bust their butts to make it look easy because being good is that important. That was me. (Probably why I only got to read a poem).

And then there are the rest. The ones who slipped through the cracks. The ones who view being a paramedic as just another part of the job. The ones who reach limply for the bare minimum. The ones who, when you know they are working, you stay out of their first-in.

The choice is yours
Which one are you? Each of you knows the answer already and I hope my words here today will solidify what you need to do with that answer.

Standing here now…as a lawyer…it seems surreal that it has been twenty-one years since the Spring of 1989 when I did my internship at the old LA City 66’s at Florence and Western.

I clearly remember that my preceptors, Kelly McKee and Mike Samudio, spent a lot of time making sure I knew my policies and procedures…and my drug dosages. In fact, Kelly carried with him a toy squeaky hammer and gummy-bears. When we would meet up with other crews he would show off what I knew by asking me difficult questions; if I answered correctly, I got a gummy-bear. If I was wrong, he would hit me in the head with the squeaky hammer.

Kelly and Mike showed me that as serious as this job is, it can also be fun; that, more than anything, the job is about people…people who depend on and deserve the best we have to offer…every time, no matter what.

Of course, I also learned that the right amount of armor-all makes it impossible to stay in one place on the bench seat.

The past two decades
That was two decades ago. I was twenty-years-old and ready to save the world. And back then, I believed I could. And I believed I would.

Looking back on those two decades, I believe I did. If only for one family, though I know it was many, many more, I did change the world. And now it’s your turn.

The question now is…how will you change the world? Who will you be??

Will your commitment and your effort allow an elderly couple to enjoy just one more anniversary? Or will your complacency and disinterest cause a grieving widow to wake up alone for the first time in 50 years?

Will your knowledge and skill remind you that a stomach ache is not always a stomach ace? Or will a culture of burn-out and malaise allow you to believe that a drunk is always a drunk.

Will your passion lead you to find or create innovative solutions to problems old and new? Or will just enough, be enough?

Today is the day, now is the moment to ask yourself, not only what kind of Paramedic you want to be or will be…but how will you change the world. Because, for paramedics, changing the world is not some ethereal or esoteric notion, it is what you will do every single day.

In fact, right now, someone somewhere is going about their regular daily life. They are not thinking of you any more than you are thinking about them. But they are out there; sitting in traffic, buying groceries, having a late lunch with an old friend, planning a wedding, making a baby, walking between classes, or just lounging by a pool somewhere having a drink. Wherever they are, they are just doing their thing.

They are happy and relaxed because they don’t know that one day next week, next month, or maybe next year their entire existence is going to be hanging by a thread; their breath may be short, their heart may be fibrillating, their limbs may be convulsing… or they may be staring helpless at the bloody, lifeless body of their child and the twisted metal that moments before was a bicycle…and there will be you. Your senses, your hands, and your decisions in that moment will be the difference between hope and hurt, life and longing, another birthday party or a child’s funeral. What you do in that moment will change the world for them and for you and that change cannot and will not be undone.

So, I ask you: Who will you be in that moment? Will you be prepared or preoccupied? Will your passion for perfection carry the day? Or will the pursuit of mediocrity be too little, too late?

As you sit there, the slate is clean; the choice is yours and I offer you this: Being a paramedic is the single most significant job there is; it is rich with reward and possibly the most fun you can have with shoes on… but there are no second chances; not for you and not for those who depend on you.


I am trying to set up a schedule for posting my posts. On Tumblr I like to reblog everything I like that is EMS related on a regular basis but think some of the posts I work on myself need to have more structure. Right now I am planning on posting like this:

Saturdays will be for links to news stories and articles throughout the internet. There are many people that are doing some great writing on EMS both from major organizations as well as from smaller blogs. I am going to try to set up a page just for these links on my blog so if you feel like reading different articles on various EMS subjects you can go directly to that link.

Thursdays will be my longer work, I am currently working on the 5 part Improving EMS series but have a few more ideas for the future. These will be the longer posts of generally my original content.

Tuesdays will be for general stuff I just thought of during the week. Memes and pictures that caught my eye. 

What do you guys think? Any suggestions for regular posts I should schedule in or changes I should make? Let me know. 

Thanks again to all my followers and hope you guys are doing great and staying safe out there. 

Reply from Gorrillamedic on Improving EMS part 2

EMS systems are still primarily paid for transport. So long as this is the case, we will continue to be the bastard step-children of healthcare. We need to be clinicians, treating patients, but to do this (on an industry-wide scale) we need to be paid as clinicians primarily. Now, this is not as simple as going to the powers-that-be and saying, “Hey, I diagnosed an anaphylactic reaction and treated it with epinephrine, albuterol, Benadryl, famotidine, and Solu-Medrol. I did everything the ER would do, so pay me what you’d pay the ER.” We need to prove our worth to the healthcare system first, and this means that we, as an industry, need to be able to point to how EMS clinical care in the field saves money overall. Mobile integrated healthcare and community paramedicine programs are popping up in progressive services across the country and are a good step in that direction.

We also need to stop being technicians and start being clinicians. If you don’t read medical journals—why not? If you’re not seeking out advanced knowledge—why not? What we learned in paramedic school is a starting point but I’m convinced it’s not enough. Hell, in my school we really didn’t even talk about 12-leads, only learned how to place them and transmit them (admittedly this was a WHILE ago and a lot has changed). Now, We should be able to identify which vessel has a lesion from a STEMI 12-lead. We need to know how to differentiate sepsis from pneumonia and pneumonia from CHF. We should know why CPAP works for asthma and how it works for CHF (and how the two are different). We need to be comfortable with using PEEP on your patients. We should know what Early Goal Directed Therapy is and how it is relevant for our patients and their transport destination. We should know what dobutamine and Levophed and dopamine are and how they work (and what they work for). 

And this goes for EMS systems too—they need to be developing and encouraging clinicians. If the clinical director doesn’t know the above things, they shouldn’t be leading. EMS systems need to be doing research. Continuing education ought to be a focus. QI/QA shouldn’t focus on how closely protocol was followed but on whether or not care provided was clinically sound and beneficial to the patient.

Part of becoming a profession of clinicians means we need to focus in on how our delivery of service affects our quality of care provider. The biggest 911 EMS provider in my regional trauma council happens to be the worst. They routinely will transport patients to the hospital without getting a set of vital signs or doing even a rudimentary assessment. They (with a few exceptions) simply do not provide patient care, only transport. Why? Because they are a large city fire service, one of the top five in the nation. Most of their ambulance crews are firefighters first, and EMTs a distant second. Most (that I’ve talked to) don’t have a passion for EMS and don’t particularly care for. It would be like having an ER physician whose passion is law, and who got his MD just so he could get a job in a hospital to practice law. That environment—which is common to most of the combined Fire/EMS services I’ve seen—won’t lead to a system of clinical excellence and won’t encourage those who do care about EMS to develop into the clinicians we need to become.

A similar thing can be said about non-critical-care transfer work: the dialysis runs, discharging patients from hospital, and the like. I’ve done it, and I know how boring and inane it can be. It doesn’t encourage growth or even good morale most the time. And around here, private services are more than likely small, pretty unorganized companies that invest nothing in their employees and discourage them from finding a career in EMS.

We have to create environments that encourage that growth in EMTs and that expect clinical excellence. Only then will the public begin to see real value in the care we provide.

I remain optimistic that we will see, in our lifetimes, EMS take a more prominent role in healthcare. I think we will see pay increase some; probably not as some would hope.


(I found these points very well said and an important aspect of improving EMS. I will touch on some of these in the upcoming parts of Improving EMS. This response can be found on his blog at )

Improving EMS part 2: Pay

How do we improve EMS in one word?

Now before you all begin chanting praise, hear me out, this isn’t a simple catch all.

I am in no way saying pay should be increased for all in EMS. I think one of the things may people make the mistake of doing is they lump up all EMS as one, and it just isn’t the case. Different areas even within the same state can often be completely different from each other and require much different systems. Some EMT’s and Paramedics out there are medics who are very competent, very proficient at their service and deserve so much more pay than they are currently getting. We all know the horrible retention rates that plague EMS, better pay for these medics would go a long way in securing their positions. There are EMT’s and Paramedics who can surprise even the most jaded doctors and nurses, I have seen EMT’s school people on patient care regardless of certification level. There are paramedics who not only have the courage but also the knowledge to outperform respiratory techs with ventilation and advanced airway placement. These medics should not have to work 60 or more hours of OVERTIME a pay period to make a living!

There are other medics, however, who do the very minimum with their patients. We have all seen them and heard of their stories. Sometimes it is that they are older and set in their ways, sometimes it is just that they are lazy and complacent. IV, oxygen and ECG monitor if their patient is lucky. If there are no obvious fractures they won’t even think of using analgesics. These are the types of medics that get upset at training, would never dream of going to a symposium of any kind, resent change and even nominal improvements in their service. They have never picked up an EMS magazine and laugh if anyone says they just read a medical journal. Pushing refusals is common place for them. Doing a 12 lead is rare and only for severe chest pain. Reading a 12 lead is left up to the ECG machine entirely, they don’t have the time to learn it, and their number one excuse? They don’t get paid enough for that.

You know them, they are around you, I hate to say this, but many of you reading this post could be these types of medics. I am saying, in no uncertain terms, whatever these medics are getting paid is well above what they deserve and if the world was just, they would be put out of a job.

I am not saying critical care, I am not saying that every medic should be flight medic certified, I am saying you should be competent in the equipment you are using. You should be treating your patients not to the basic necessities but to your greatest level. You should be very up to date in the latest practices and procedures. You should not hide behind your protocol. These medics are borderline incompetent and should be removed, but we can’t can we? We don’t have enough medics to man all the emergency vehicles as well as the transfer services.

Which brings me to the second part of my post: pay for the EMS companies.

Without the EMS companies getting paid, reimbursements or through city contracts, the medics can’t get better pay and benefits. With the way reimbursements are coming from insurance companies and the government it is now more imperative than ever to push for change.

There are three components to just about any service. These are called the Project Management Triangle (also known as the Triple Constraint or the Iron Triangle) basically it goes like this: there are three components that always affect each other. How expensive a service is, how good the service is and how fast that service is delivered. You can excel at two of them if you are lucky, but the third will suffer for it. Any serious deviation in one area will impact the other. If you are operating an ambulance service and are very fast and very cheap, chances are you will be suffering in quality. Why? Simply because good quality costs money, good equipment is not free, training has to be maintained or there will be degradations in knowledge as well as current trends in medicine. Ok, so the service is exceptional with all the latest and greatest technology and is very fast, response times well below the national averages. Without looking into the crystal ball I can tell you that that service will not be cheap.


For this reason pay should be increased, not only to the individual medic but also to the company for providing the service. If half of the emergencies are not being paid for obviously there will be a degradation in the triangle at some point. If reimbursements are not being received for their service, while the ambulance service might not want to, they will begin to go into the cheap area and their effectiveness and quality will suffer.

Ok, so I’m preaching to the choir right? The big question, how do we start to improve pay for those that are deserving and to the companies that are employing them? While the answer is not simple, I believe one of the ways is by educating the public and pressing the issue of emergency services. The vast majority of the public views EMS as a business, the cheapest provider is picked in many areas and no one bats an eye. I have sat in city commissioner meetings as three ambulance services come up and argue against each other, each saying they can outdo the other for less and less money. A simple diagram showing how most MICU ambulances cost approximately 250,000 dollars a year to operate will show how ridiculous it is to demand 4 or 5 in a city for emergencies and want to pay nothing for them. Can you imagine if the police department was put up for bids and the company with the lowest bid won the contract for a few years? Do you really think the citizens would back up that plan? What if the fire department of a major city, such as New York or Los Angeles was to go out for bids? But when it comes to ambulance services that is all taken in stride.

Take this example for instance, there is a city near where I work that runs a dual system, firefighting and EMS. The EMS portion is ALS but is very basic in its functionality. There are many things that the EMS personnel for the city cannot do, both due to a lack of training as well as a lack of equipment. If a vent patient, a patient that requires advanced medication administration, a patient that requires IV pumps or CPAP is encountered they call us and we go into their city and transport the patient out. While this is great for my company, since we gain the transfer and the pay for that patient, sometimes the patient suffers because they have to wait for us to send a unit from far away for them. In critical cases we have even had to respond code 3 to the hospitals in their city because the patient is in need of critical care and immediate transport out of that facility. This is a fire/ems department that has a multimillion dollar a year budget, a massive training facility and multiple university affiliates. They are the highest paid service in our area, but cannot handle these types of calls. It is not that they do not have the personnel, they are currently upping the requirements for everyone that is hired to become paramedics, at their expense. Can you for a second imagine if that same service said they couldn’t handle a specific type of fire? What uproar would be heard throughout their city? Imagine if they had to ask for another fire department to come into their city to handle something like difficult car extrication? Is it that they don’t have the staff? No. Is it that their staff is not competent? No. It is that the general public can accept something like that, because they don’t know any better.

“Oh the fire department can’t take my mom out of a car?! Where are the petitions to change this I’m signing them all!”

“Oh the same EMS service can’t handle taking my mom out of the hospital to a better hospital? No problem, just go over a few cities to the lowest bidder who has taken the time to learn how to and use them. No worries.”

EMS has to be a bigger part of public safety and should be viewed as a necessity at least on par with Police and Fire. Understanding that a service can only operate within the constraints of the Iron Triangle and explaining that to the citizens is imperative now.

Any thoughts would be greatly appreciated. Thanks for your time.

Credit for image: