Monday, April 28, 2008

Can you find the common thread in these two articles?

Oglethorpe County, Georgia has been in the news twice this week. Here are the two articles:

Wait for ambulance cost man's life


Raffle to pay for new 'Jaws of Life'

While some may make this a paid vs. volunteer issue, it is deeper than that. It is called commitment at the the county level. The gold standard: What is in the best interest of the patient?

I am an old volunteer. Born and raised that way in Upstate, NY and hold that experience near and dear to my heart. I believe there are communities that can maintain volunteer systems. I believe in community-based providers/systems who provide quality, compassionate, patient-centered care. This is where EMS comes from.

Yet there are times when systems need help. James Matthews, Oglethorpe's EMS Director is quoted in saying

There simply isn't enough money to fix the problem, he said, and while the addition of a second 24-hour crew would help, Oglethorpe County's EMS service needs a major overhaul as the population continues to grow.

"We're still trying to work off the same budget we've had for the last two years," the EMS director said. "Problem is, there's still going to be more cases. There could be three trucks on and you'd still need a fourth one."

The Oglethorpe County Commission Chair, Robert Johnson said:

The county's land mass - the largest in Northeast Georgia - is working against EMS crews, said Robert Johnson, Oglethorpe County commission chairman.

"An ambulance could be anywhere in the county and it could still take it 20 minutes to get there," Johnson said.

Ambulance services, he said, are expensive, and with the rising costs of medical supplies and fuel, the situation in Oglethorpe County is not likely to get any better any time soon.

"We have an outstanding EMS service," Johnson said. "They do exceptionally well with what they have to work with."

I believe the individuals in the Oglethorpe Emergency Medical Services are outstanding. It appears there is no argument there. But for one woman who lost a husband "They do exceptionally well for what they have to work with." isn't enough--nor should it be.

The money the county pays her to settle the lawsuit should have been invested in EMS before this tragedy. And Oglethorpe County, while you are writing checks, buy your EMSers a new Jaws of Life.

Saturday, April 26, 2008

Revelations from Billings, Montana

This revelation may not be huge, but it is certainly important: people watch what we do and make opinions based on it.

While riding with Billings, Montana Fire I shot a call for a "man down." Sure enough he was down and had an altered mental status. I am proud to say that this patient received competent medical care and compassionate personal care. I am even happier to note the compassionate personal care because, as you will note in the photos, we were being watched. (Click on photos to enlarge.)

As I was photographing I saw three people walking toward us. Musicians, dressed for a concert, carrying instruments and music stands. They had to move into the street to get around the emergency scene.

As I changed position to continue my photography I saw the people watching from inside the window.

Each of these people were on the outside looking in. They will judge everyone in EMS by the way the Billings FD and AMR treated this patient. At that moment it doesn't matter if the patient is a homeless person or the mayor of Billings. Inappropriate jokes, laughing, sloppy or inattentive care, or the appearance of indifference erases all prior good done by EMS providers in the past. You are their lasting memory of EMS providers.

The interpersonal component of this is most important but I would be negligent in not noting that the people watching you provide care may one day in the future be in a voting booth in a position to deny your raise or new station.

The providers on this call passed the bystander opinion test. Do you?

Long Island disaster drill delayed by traffic jam

OK, I know that really isn't the point of this Newsday story, but it did strike me as more than a bit funny.

A large-scale emergency drill went smoothly Friday at the Suffolk County Fire Academy in Yaphank, officials said, despite a two-hour delay because of an accident on the Long Island Expressway.

The scenario: a dirty bomb is detonated at a federal courthouse. Using a $175,000 Homeland Security grant for the largest scale drill ever held on Long Island, it sounds like an amazing production:

More than 600 people from 60 agencies from both Nassau and Suffolk counties will participate in the event, which officials call the biggest in Long Island's history. The drill will conclude Saturday afternoon.

If you get a chance, watch the video on Newsday's site about the drill. It begins informative and finishes, well, funny. It seems that probationers who had to do community service were used as patients in the drill. Guess who was interviewed?

It also seems to highlight the provision of Murphy's Law that can affect even terrorist incidents: traffic jams on the Long Island Expressway. Let's just hope its the terrorist that gets stuck in traffic and not the public safety personnel.

Did you ever wonder what your obituary would say?

Now if that doesn't get your attention, nothing will.

In my EMS news today I found an article/obit from Whidbey Island in Washington State telling of a memorial service for Charles F. "Curly" Charleton.

I didn't know the man but had the honor to know many who I imagine were like him. Vietnam vet, pillar of the community, police officer, firefighter, EMT, lifelong learner. Someone who made a difference. It seems the world is a better place having Mr. Charleton here for almost 70 years.

An obituary says a lot about how a person lived. Steven Covey in his book 7 Habits of Highly Effective People (wiki) uses this obituary concept as an exercise to encourage people to make big picture, principled decisions rather than chasing minutiae without direction.

In EMS our influence is both large and small. It is large in the commitment we make, the impact on our communities and the good we do for people. It is also seemingly small, but important in scale when we help an individual or comfort the family member of a sick or injured person.

Yet when the tables are turned and the relative of the sick or injured person looks at what we did for them; a kind word, action or simply providing comfort, it will be regarded as one of the largest and most important things we could possibly do. To be there for someone in a time of need.

When the obituary of an EMS provider is written it won't (and maybe shouldn't) contain things like "Stanley had the highest success rate for IVs and intubation of anyone in the county." or "Felicia worked more overtime than anyone in recorded history." That misses the point.

Those who stay and thrive in EMS realize that the words, "...proudly served his community helping others as an EMT." is just right. Because once the obituary is written our time here is through. The people who are left behind to read this will have the memories of the dedicated service you provided. The memories of the pride and passion you displayed. And the gratitude of the people you served.

When I look backward and forward to envision my obituary, I am proud that it will contain my years in EMS. I also realize that I have much more to do before that obituary is written.

And so do you.

Tuesday, April 22, 2008

South Carolina EMS Conference

I just returned from the South Carolina EMS Conference in Myrtle Beach. It was a great show. One of the things that impressed me most (in addition to the very motivated attendees) was their annual paramedic competition.

South Carolina Paramedic Championship

This was the second time I was a judge for the competition. I have to say that I find it refreshing when EMSers take pride in what they do.

Five teams competed. Four were regional contest winners plus the winner from last year's statewide competition. Each two-person team was faced with a school shooting scenario. The teams were on their own for 8+ minutes with 7 patients. And they did well.

Hats off to the competitors for being there and competing in the finest EMS tradition. It was a great conference. I hope to see y'all again soon.

Wednesday, April 16, 2008

Reality check for this week

I am in South Carolina preparing for a 4 hour instructor session this afternoon. The session is on active learning--techniques to make the class more interesting, active and to promote learning. I also present on teaching affective objectives. These are areas where instructors must reach outside of tradition and the ol' comfort zone to really reach their students.

One of the things I talk about is teaching safety and survival. New students don't really understand what the hazards are...what causes injury and kills EMTs. Violence is perceived as a leading cause, but is much lower than the big three: air medical crashes, heart attacks and motor vehicle crashes.

My daily check of EMS news found this article: EMT loses arm in RT. 59 crash

Our best wishes to Bonnie Ames and Scott Millar. And to all, be careful out there!

Wednesday, April 9, 2008

Ambulance or bus?

Don't mean to always use articles as blog fodder but this one made me pause to think:

An ambulance is not a bus

I don't totally agree with David Becker on this one. I think that professionalism comes from many different areas, most specifically our education, how we treat our patients, how we treat our colleagues and how we are perceived in public. To a small extent Becker may have a point on perception.

But in the grand scheme of things, whether we call it a bus or rig or flying shit heap, this is very, very small compared to the bigger issues facing EMS. We aren't doing enough of our own research, we whine instead of making meaningful change from within and we need strong national representation.

Like Mr. Becker, I am also an old-timer. But I believe we must merge the spirit and passion of old with the professionalism we desire now and in the future. We can't forget our past as we move forward.

"Dispatcher, we need another bus to the scene..."

Friday, April 4, 2008

Good reading for today

Bryan Bledsoe doesn't mince words. His articles and presentations on CISD and air medical issues certainly didn't gain him any friends. His column in this month's JEMS will strike a similar chord with some EMS programs and systems.

I posted on this last month in my report from the EMS Education Standards Stakeholder's Meeting. I was surprised more people didn't balk at the requirement for accreditation of paramedic programs. My belief was that stakeholders didn't bring it up at the meeting because they planned on fighting it by other means.

While painful for some systems and a serious reality check for others, it is good for EMS and we did get 5 years advance notice.

Read Bryan's column. As usual, whether you agree or not, it is well written and brings up interesting points.

There is one other thing that is good business and drives us closer to being a profession: intelligent, reasonable, public discussion. Make your "robust yet succinct" comments (as we learned at the stakeholder's meeting) constructively and in a proper forum.

This is another way we become a profession.

Be sure to check out Bryan's unique EMStock EMS conference.

Thursday, April 3, 2008

USA Today's article on home defibrillators

USA Today's Bob Davis published a story on the concept of defibrillators in the home. Home defibrillators: Worth the price?

I tried offering a CPR course a few years ago which included a defibrillator. I figured that there would be a certain population that could afford the $1,000 course which included a CPR card for anyone in an immediate family, the prescription, defibrillator, case and supplies. Many of our seniors leave Maine and head to warmer climates for the winter. I thought they may want to also have a defibrilator for the road.

We publicized it but didn't get any takers. A few calls for interest but no one putting their money where their heart was. It did raise awareness in the community and as a result we did get defibrillators placed in a church and one other business in Town.

This article spells it out pretty well from a science, statistical and personal angle. The researchers and statisticians say it isn't worth it. But then again, it isn't their heart.

Wednesday, April 2, 2008

More on CPR...This just in:

It is my strict policy not to republish private conversations or emails on my blog, I post this because the email from a listserv ended with a "feel free to forward" note.

I honestly don't know how to take this. Part of me feels that the bystander acting as taught by their AHA course/instructor according to national consensus provides some serious footing. The chances of survival for the patient are pretty slim to begin with. And Lord knows that AHA has published things before with less than solid science behind it.

I recall a session in Orlando some years back when the "between the nipples" hand position was rolled out. The presenters said this was based on "looking at the nipple levels of 'several' dead, recumbent people, some of which had pendulous breasts."

Hmmmm. Maybe I could do research after all...

In any case here is an email from an attorney with EMS experience who proposes a poor legal prognosis for the new CPR guidelines:

Hi all,

I've discussed this issue on this list before, but given the current situation feel the need to mention it again.

The overall standard of emergency care/first aid/CPR and so forth is "reasonable care under the circumstances."

In particular, complying with a standard of care does NOT insulate someone from a negligence lawsuit if the standard itself is found to be unreasonably low. They teach this in law school by pointing out that on the day the Titanic sailed it complied with (and even exceeded) all maritime standards in place at the time, but still had lifeboats for only about half of the people involved -- so therefore the standard itself was substandard and people who complied with it (here, the Titanic's owners) were vulnerable to a negligence lawsuit.

We may very well have a comparable situation with compression-only CPR. Pardon me for saying so, but I'm something of an expert in the law of emergency care (among other things, I'm a part-time law school professor), and as such an expert I am gravely concerned that a jury could find that giving compression-only CPR was substandard care and therefore negligence (with resultant liability) *even if* that's how the rescuer were taught to do it. This would particularly apply in situations were the Good Samaritan law likely did not apply, such as in the workplace.

(Actually, what would likely happen in the event of litigation was that not only would the rescuer be sued -- along with their employer, if any -- but also the instructor who taught them this technique and the organization that the instructor worked for.)

From a liability point of view, this new supposed "standard" scares the hell out of me. I am going to be in Absolutely No Rush to teach it, and will discourage it if it is mentioned by any of my students.

Please feel free to forward this.

Most sincerely,

Jay Wiseman, JD

I'll end this post as I did my last: Keep doing good things for people. It is never wrong.

Blowing is OK in Europe

...for CPR that is.

The European Resuscitation Council (ERC), the equivalent of the AHA in Europe, issued a statement advising their members that CPR conducted using the standard 30:2 ratio was recommended for all BLS trained personnel.

While they acknowledge that hands-only CPR is better than nothing, and that telephone CPR doesn't include ventilations, they still prefer ventilations. The following is from their document:

The European Resuscitation Council has reviewed the available published scientific evidence. The ERC considers this evidence insufficient to alter its guidelines for BLS at this moment. There are several important considerations for this recommendation:

1. The recently published studies are uncontrolled, observational studies of experience, dating from 1990 to 2003. Such studies are generally considered to be insufficient to enable definitive conclusions about the superiority or equivalence of any methods of CPR. The outcomes of these studies are still compatible with the hypothesis that the currently recommended combination of chest compressions combined with mouth-to-mouth ventilations is superior to chest compression-only CPR.

I'm not sure, but the AHA may have just been slapped.

I find it interesting that the ERC notes that the percentage of bystanders who perform CPR is higher in Europe than in the United States. This was a factor in the decision. Another factor noted is that the 2005 guidelines have just recently been reviewed, translated and distributed.

While the constant flow of information from the AHA in regard to resuscitation science and opinion is generally positive, I am not sure they always anticipate the full scope of these statements as they translate through the media, to instructors and most importantly to bystanders who must make a decision to help in an emergency.

The listservs have lit up with CPR comments and opinions. My advice going forward: Keep doing good things for people and students. This will be far from the last change we will experience--maybe even this year.

Tuesday, April 1, 2008

Hands-only CPR

The AHA recently issued information on hands-only CPR. It has caused quite a stir in the media...and quite a bit of confusion for instructors.

In short, the changes only affect bystanders and then only in a witnessed adult arrest situation. It doesn't apply to unwitnessed adult arrest, infants or children. Health care providers will still perform CPR as originally taught while on duty, but could arguably fall under the bystander category when off duty.

This link from the American Heart Association explains their intent and contains a downloadable video explaining how these changes affect current courses. It is worth watching.