Emergency Care

New Blog

2010-10-27T09:33:00.002-05:00

I have moved my blog to:

The EMS Classroom

Please follow me there!

Thanks.
Dan Limmer

Dave Page strikes again

2009-07-15T14:10:00.002-05:00

Dave Page is one of the brightest stars in EMS today. He is smart, talented, focused, visionary and an amazing educator. My EMS news feeds picked up this story today:

Students get paid to learn to be lifesavers

It is win/win/win when we train people for careers, offer a hand to those who might not be able to afford it and expand diversity in EMS. I applaud Dave and his colleagues for his efforts in the Emergency Medical Services Academy.

I post this coinciding with the confirmation hearings of Sonia Sotomayor for a reason. There is no place for discrimination of any kind--reverse, forward or otherwise in EMS. I would hate to see the issues surrounding the New Haven firefighters having a negative impact on any qualified individual in choosing to follow their passion into the emergency services.

Memories of Love and War

2009-02-12T09:44:00.007-05:00

You'll see in my profile that I also wear the hat of a journalist. No one in EMS has only one job, right?

I had an idea which began percolating years ago as I was in the back of an ambulance with an 80-year-old woman during a 30 minute ride to the hospital. I had a precautionary line started and 12-lead done with 25 minutes to go.

This is where many of the excitement-driven medics would languish, longing for the next glimpse of major trauma or cool invasive procedures. Me, I figured we had time to chat.

It turns out this woman was a nurse in World War II. She didn't say specifically, but alluded to coming from a wealthy family in Manhattan. In the 1940s women had certain programmed career choices. She became a nurse. A poster in the hospital said the Army needed nurses stateside for 1 year. What the poster didn't say was after a year and one day she would be headed overseas.

She enlisted and ended up in North Africa seeing battlefield casualties. She spoke little of that; her generation guards their military experience with an iron clad stoicism that has spanned 60 years. I could see between her words, in the pauses where memories remain cloistered, that there was more. I regret never going back to see her. To talk more about that time, listening to more of the memories, even if for my own selfish desire.

While I may have saved a patient or two in my days in EMS, I look back at my time with her as one of the best and most profound experiences in 30 years riding in the back of an ambulance. I think about it often.

I recently returned to the assisted living facility where I met the World War II nurse several years ago. My chance to talk again with her had passed. Knowing this, my goal was to gather more of these memories before they were lost forever. It wasn't an original idea. Many have written and photographed projects before me. It was a personal quest.

I pitched the series to our local weekly newspaper and they went for it. Today's installment brings this blog post full circle. The link below is to an article I did for the Valentine's day edition of the paper. I interviewed three fascinating people about their half-century relationships and how they were affected by war. It is called:

The Generations Project: Memories of love and war

More for the educators...

2009-02-05T09:58:00.003-05:00

I'm in awe. After looking at the video in the previous post I wanted to know more about this classroom and professor. I found a video which gives a better idea about the man and his methods.

It is something to aspire to. Imagine your EMS students considering their education a journey rather than a hurdle to get "the card." Imagine probing questions, discovery and insight being part of that journey...and your classroom.

Imagine your students feeling like this:

One for the educators...

2009-02-05T09:18:00.004-05:00

I taught an instructor CE class on online learning last Friday (to a great group in Bangor, Maine). One of the statements I made was that our educational system in EMS uses the worst possible methods for the students--and the best for us--or at least the one that makes us feel best and most secure. If you haven't guessed, I am talking about lecture.

Everyone is angry at the AHA for going to the video-driven classes but the AHA is right. We talk too much. Students don't practice and apply enough. Listening to the instructor is one of the worst ways to learn. I'm sorry but war stories have a limited value and only when short and in context. Students need to think, apply and problem solve.

In Maine there are many who oppose online classes (better termed asynchronous learning). When I suggested a hybrid online/classroom-based EMT-I class two years ago you'd think I kicked Johnny and Roy right in the nuts.

My opinion: asynchronous learning can provide better learning than we offer in the traditional classroom when done right...and make it easier for us to reach more people. Doing it right involves well constructed classes, choosing appropriate topics and providing active student/instructor participation.

I believe students text and Facebook in class because they are bored. Students are tech savvy and have outgrown our fascination with PowerPoint long ago (which seems to drain interactivity right out of the classroom unless it is done properly).

My sister-in-law (a teacher and school board member) recently posted a youtube video on her facebook page. It gives an interesting glimpse into the lives of students and some shocking realities for the classroom. Please take a look.

Emergency Care in Japan

2009-01-19T10:29:00.003-05:00

I picked up this article from The Japan Times on my daily EMS news feeds.

It seems like Japan is having hospital diversion issues similar to the US--and the rest of the world. From the article:

The deterioration of emergency medical services has become a nationwide worry. In October, a pregnant woman transported by ambulance was refused admission to eight hospitals in Tokyo and died after giving birth. In December, an elderly woman seriously injured in a traffic accident died after she was refused admission to six hospitals in Fukushima and Ibaraki prefectures.

The Fire and Disaster Management Agency's 2008 white paper says that, in 2007, an ambulance took an average of seven minutes to pick up a patient — 0.4 minute more than in 2006 — and 26.4 minutes to take the patient to a medical institution that accepted him or her — one minute more than in 2006. Both times were the worst ever. The 26.4 minutes to transport a patient was 6.5 minutes longer than 10 years ago.

Medics, muscle cars and Margolis

2009-01-09T17:20:00.004-05:00

Scott Snyder out at the San Francisco Paramedic Association sent me a link thinking it would be good "blog fodder." He was right:

Paramedics get muscle cars

There are two things I find interesting. First is the "muscle car" reference. It doesn't seem to fit with my thinking on EMS. And lets be real, we could all drive 4 or 6 cylinder vehicles but we'd beat the crap out them and they wouldn't last 18 months. Couldn't take the beating.

I just hope nobody crashes one. The lawsuit will certainly bring out that headline in a negative light.

OK, stereotypes dealt with, I then noticed the reference to advanced practice paramedics. You may recall how that was initially one of the levels proposed in the early EMS Scope of Practice drafts. It was considered impractical, before it's time and taken out relatively quickly.

I remember presentations given by Gregg Margolis about the process and the advanced practice paramedic. We also had personal conversations. I had the good fortune to work for Gregg at The George Washington University. Gregg was an advocate for the APP. I think that it is important to note that the advanced practice paramedic concept has resurfaced.

I think most changes in EMS will be evolutionary, not revolutionary. Gregg was looking for a revolutionary change. One that would have given EMS increasing professionalism, more training and responsibility and perhaps most importantly, a career path.

Gregg worked on a revolution and didn't get it the first try. But when someone tries for something lofty but worthy, people notice. It is like planting a seed. The APP concept in Raleigh likely isn't the full scope of the original concept, but it is a sprout from the seed Margolis (and others) planted.

I just thought it was important to mention this evolutionary step toward a revolutionary vision. Good happens slowly. Sometimes imperceptibly. But it seems to be happening here.

Thanks, Gregg. You are good for EMS. Revolution or not.

EMS in top 5 worst jobs

2009-01-07T11:01:00.002-05:00

I was watching CNN on the plane this morning (Go JetBlue!) and saw a report on the best and worst jobs. You'll be happy to know that EMS landed at number 5 in the top 10...WORST JOBS.

10 worst jobs

Well, at least we aren't lumberjacks...

EMS lost a friend

2009-01-06T09:58:00.005-05:00

John Pryor, MD, a Major in the Army Reserve was killed in Iraq on Christmas day. His funeral service was yesterday in Philadelphia.

I don't call this out because we lost a soldier or because a family lost their father--although this is certainly and painfully the case. I call this out because EMS lost a true friend and advocate.

I first heard of this through the National Collegiate EMS Foundation. I lurk on their Facebook page because I feel it is an important organization. They sent out an email immediately after Dr. Pryor's death. It seems Dr. Pryor heard of the NCEMSF and "adopted" them.

I really can't begin to post a eulogy here but I'll provide a few links that do. Please take a moment to look these over and pay respect to a man who gave so much--even before he gave his life.

Philadelphia Inquirer
National Collegiate EMS Foundation
Dr. Pryor's faculty profile at Penn

And finally, An editorial in Dr. Pryor's own words.

Theodore Roosevelt, our 26th President, delivered a speech which became known as "The Man In The Arena"
at the Sorbonne in Paris, France on April 23, 1910. It is my favorite of all time. The part of this speech that many of us in the emergency services relate with is most appropriate at times such as this.

It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.

In Memoriam and Honor of
John P. Pryor, M.D. 1966-2008

Happy New Year!

2009-01-05T10:51:00.005-05:00

I hope your holidays were happy and your New Year is filled with hope and opportunity.

No resolutions here--I'm going to continue my efforts to be more active in blogging.

A few bits and pieces for the New Year:

The New York Times agrees with my thought on California's recent interpretation of the Good Samaritan Laws:

I'll have to call my lawyer

There have been some changes to the NIMS. Nothing I would call sweeping but it might be helpful to take a look:

NIMS Changes 2008 (PDF download)

2008 was the big EMS social networking year with several sites popping up including two by the EMS magazines:

JEMS Connect
EMS United

And you can now find almost everyone (including me) on Facebook

Bryan Bledsoe posted his Top 10 EMS research papers on jems.com recently. These are definitely worth a look:
Bledsoe's Top Ten

Now, for those of you that know me, I have not only been in EMS for 31 years, I also spent quite a bit of time in police work. I am including this photo of yours truly as a rookie police officer in 1984 for the obvious laugh factor, to point out the benefit of Explorer Posts (I was a member of a police and fire post prior to getting on both jobs) and to remember the close friends and wonderful experiences I had as a police officer in Colonie, NY. Here I am with Neil Leach, a great friend for over 30 years.

I sincerely hope that your experiences in the emergency services are as rich and wonderful as mine have been over the past 31 years.

Happy New Year!

Emergency personnel should get drugs during pandemics

2008-12-23T11:19:00.002-05:00

Reuters reported on a DHHS guidance memorandum advising hospitals and emergency services employers stock up on antiviral drugs for their workers.

Health, emergency staff get drugs 1st in pandemic

It seems Avian flu is the big concern. While according to the article there have only been 390 people infected worldwide--246 of those have died. The big question, and one not to figure out after it is too late: Are we a mutation or two away from trouble?

I am guessing that most employers will take some time to get this plan up and running--and that the antiviral drugs will have a significant cost attached. A quick check at drugstore.com shows a price of about $100 for a ten day supply (prophylactic dose) of the medication.

Has anyone seem preparedness efforts such as this in their agency or area?

So much for the Good Samaritan Law

2008-12-19T08:56:00.002-05:00

California's Supreme Court just gave the concept of helping one another a slap in the face with their recent ruling (link from the LA Times):

California Supreme Court allows good Samaritans to be sued for nonmedical care

The article summarizes:

The California Supreme Court ruled Thursday that a young woman who pulled a co-worker from a crashed vehicle isn't immune from civil liability because the care she rendered wasn't medical.

The divided high court appeared to signal that rescue efforts are the responsibility of trained professionals. It was also thought to be the first ruling by the court that someone who intervened in an accident in good faith could be sued.

Of course the ruling has some significant legal and factual issues, mostly whether the action (allegedly pulling the woman from the wreck "like a rag doll") was negligent and the cause of the injuries. The fact that alcohol was involved certainly muddies the waters.

The dissenting opinion from the court seems reasonable to me:

Justice Marvin R. Baxter said the ruling was "illogical" because it recognizes legal immunity for nonprofessionals administering medical care while denying it for potentially life-saving actions like saving a person from drowning or carrying an injured hiker to safety.

"One who dives into swirling waters to retrieve a drowning swimmer can be sued for incidental injury he or she causes while bringing the victim to shore, but is immune for harm he or she produces while thereafter trying to revive the victim," Baxter wrote for the dissenters. "Here, the result is that defendant Torti has no immunity for her bravery in pulling her injured friend from a crashed vehicle, even if she reasonably believed it might be about to explode."

Yet the constitutional scholars believe the court ruling has merit:

Both opinions have merit, "but I think the majority has better arguments," said Michael Shapiro, professor of constitutional and bioethics law at USC.

Shapiro said the majority was correct in interpreting that the Legislature meant to shield doctors and other health care professionals from being sued for injuries they cause despite acting with "reasonable care," as the law requires.

Noting that he would be reluctant himself to step in to aid a crash victim with potential spinal injuries, Shapiro said the court's message was that emergency care "should be left to medical professionals."

While I agree that yanking someone from a car when there is no real hazard may cause injury, does this ruling keep people from stopping and helping those who really need it? In the bigger picture, does this ruling take us back a step in civilization by making well-meaning citizens reluctant to help another human being in a time of need and ignore the greater good? I think so on both counts.

I also think that the next time I need help on the side of the road I hope a constitutional scholar isn't the one driving by. I could be there for a while.

Florida sun charges ambulance batteries

2008-12-18T13:42:00.003-05:00

Sunstar ambulance in Florida mounted solar panels on the roof of two ambulances to charge batteries in monitors, stretchers and other devices.

From an article on Tampabay.com

People looked at Terence Ramotar like he was crazy last spring, he said, when he suggested putting a solar panel on the roof of an ambulance.

The idea is now a reality. On Monday, Sunstar Emergency Medical Services will roll the first of its two solar-powered ambulances into service in what appears to be the first such project in the nation.

The solar panels do not power the vehicle, but rather supply power to recharge the batteries for various life-saving devices.

Whether this will work has yet to be determined. I have certainly seen crazier ideas. But when Sunstar has a full-time person assigned to shuttle batteries out to crews in the field, the $4,000 price tag doesn't seem so crazy--plus a hint of environmental responsibility is always a good thing.

Definitely worth keeping an eye on.

How can you tell if your patient is stable?

2008-12-18T13:07:00.002-05:00

According to an article in the Canadian Press the ability to send a text message is a sign of stability. Apparently this is used at "packed to the max music concerts" in the UK as a method of determining whether a patient is ready to get back to the concert. From the article:

"The main point is when you've got, mainly at music festivals, a band playing that is very popular amongst teenagers, you have to expect a lot of them to faint, get panic attacks in the crowd, get stressed and want medical attention, when they're otherwise uninjured," Sinclair said Wednesday from a ski holiday in Chamonix, France.

"And when you get inundated with hundreds coming in in an hour, you need some means of getting them out and back to enjoying themselves quickly. And we found the texting sign is very useful for that."

Looking at it, texting shows fine motor function and mentation. Judging by the way younger people text it could also be said they have their sense of purpose back.

I wonder what would happen if we noted a "positive texting sign" on our run report here?

I love quotes...

2008-12-18T09:50:00.001-05:00

These came up today on my Google homepage.

Everyone's a hero in their own way, in their own not that heroic way.
- Joss Whedon, Zack Whedon, Maurissa Tancharoen, and Jed Whedon

I have not failed. I've just found 10,000 ways that won't work.
- Thomas A. Edison

The stupid neither forgive nor forget; the naive forgive and forget; the wise forgive but do not forget.
- Thomas Szasz

More on volunteers: Delaware

2008-12-08T10:44:00.002-05:00

The News Journal of Delaware published an article on the volunteer EMS and fire services in the state: When Every Second Counts.

The article looks at response times noting several larger scale incidents and comparing Delaware's response times to NFPA and other standards. As with many article like this it didn't take long for the comments to pour in using the newspaper's comment feature attached to the article.

It is clear that there is both a strong voice from the volunteers in Delaware (many of whom I met while at their conference last year) and support from the public as well.

If you read the EMS magazines (one I read recently had several editorials on how volunteers fit into the emerging professionalism of EMS) the paid vs volunteer service certainly is a hot topic.

The topic extends into more than professionalism. Volunteerism was at the core of society but has taken hits from shrinking available time and the shrinking economy. Yet could a municipality today say, "Next year we are doing away with volunteers." and find the budget to hire the staff that would be required to cover that jurisdiction? I think not.

I've been posting quite a few news pieces without commentary recently. Here are my thoughts on this issue of volunteer vs paid in the United States:

I believe the answer relies in setting a standard, then using resourcefulness and collaboration to meet the standard. And not a reduced or varied standard.

I believe that a family traveling down the East Coast (or anywhere) shouldn't receive varied levels of care. Not just whether it is BLS or ALS, but the actual quality of the system and providers should not vary based on the type of system.

I believe we focus too much on paramedic services when an EMT or EMT-I service with a shared paramedic response will meet that standard in many (but not all) communities.

I believe that a territorial attitude and competition sometimes seen in the volunteer services must cease in order to meet these standards and assure fiscal responsibility. I came from a system in which there were 3 truck companies (each with 100+ ladders) in a 6 mile stretch of highway. (This has since changed.) There are times crews and apparatus decisions must be done cooperatively between adjoining districts for the good of those we protect.

We need to get out of the box and put service first--first over paid or volunteer. We need to create quality, cooperative training and emergency response. Those who are hired to supplement volunteer organizations should be carefully chosen to "fit" well with the call force. Paid personnel should receive training in mentoring and teamwork.

Volunteer services aren't going anywhere. No municipal budget has the ability to just "go paid." Rather than get into arguments about what is best when we have no ability--and in many cases no desire--to change is senseless.

Why do senseless things? Lets make what we do and who we are better. Every person. Every agency. Better.

Start today.

Another bad week for EMS news

2008-12-04T13:11:00.002-05:00

A quick round-up of stories that show the challenges of EMS on the street.

According to the Washington Post, more trouble in a troubled city:

Man Dies at Home After Paramedics Diagnose Acid Reflux

In Albuquerque:

Ambulance worker arrested on scene

And in a bit of good news, Maryland is working to get its flight program on the right track. Most agree that the business-driven model of air medical transport seen in many areas results in unnecessary flights. (Maryland is run by the State Police) In an interesting quote from a Baltimore Sun editorial:

Data from the Maryland Institute for Emergency Medical Services Systems also has shown that 43.7 percent of patients flown to trauma centers are released within 24 hours, a statistic that critics said suggested the choppers were used too often.

Here is the editorial: Support for medevacs. I look at this as a well balanced editorial. It is refreshing to see that a newspaper (The Sun) looked at the issues and was constructive rather than taking a sensationalist approach--especially in the wake of a tragic crash. Their point is correct. Give an amazing system a tune-up and keep it going.

For all of these reports remember that there are two sides to the story. This combination of stories highlights a common theme I teach: EMS is about decision making and people.

More on EMS in crisis

2008-11-20T10:36:00.002-05:00

Bryan Bledsoe forwarded an article from Men's Health about EMS in crisis. The article takes a look at Philadelphia and New Jersey EMS systems as an example of problems such as system abuse, fatigue among providers and provider shortage.

Melissa Alexander called out a similar EMS piece from the Albuquerque, New Mexico area.

I believe we'll be seeing more and more of these stories. Unfortunately EMS has many crises these days. Perhaps the most important ones are those involving identity and value of the EMS system and the providers that serve in it. Many of the problems we face seem to have roots in these basic issues.

I should note that Bryan Bledsoe was named one of Men's Health magazine's Heroes of Health and Fitness as well as one of ACEP's Heroes of Emergency Medicine. Bryan was an early voice in the air medical transport issue. emsresponder.com reports on this story. Congratulations, Bryan.

Stay tuned...

Editorial calls for EMS reform in NJ

2008-11-17T11:52:00.002-05:00

I have mentioned the EMS system in NJ several times in my blog. It seems to be at the critical intersection of funding crisis, identity issues, big population numbers and the decline of volunteers seen throughout the country.

This editorial in the Star Ledger provides an overview of the issues in NJ.

What most outsiders don't realize is the impact of transition from older models steeped in tradition to newer models. I believe there is a benefit, both fiscally and for the age old concept of neighbors helping neighbors, in keeping a volunteer presence in communities when it can be maintained with quality and consistency.

Unfortunately the psychology of maintaining that balance can be more elusive than finding 14 million dollars to implement reform.

Google predicts flu outbreaks faster than CDC

2008-11-16T09:48:00.003-05:00

Could it be true? It makes sense. Based on search terms, Google Flu Trends can predict flu outbeaks, and do it well. According to a CNN article:

In the 2007-08 flu season, Google accurately estimated current flu levels one to two weeks faster than published CDC reports in each of the nine U.S. surveillance regions, Google said in a statement.

This shouldn't be a big surprise when in the past, according to the same article, trends were determined by:

...physicians' reports of patients with flu-like symptoms, lab reports of influenza from nasal and throat swabs, and death certificates.

I suspect this will also send up early flags in the event of chemical or biological terrorist attacks as well.

Go Google! And kudos to the CDC for collaborating and seeing the potential in non-traditional epidemiology.

Coming soon: Tele-EMS

2008-11-13T09:41:00.003-05:00

A company called SwiftMD has been contracted by a Montana "Preserve" to deliver "emergency medical services, via the phone, Internet or bi-directional video, to all residents and Ameya Preserve employees and their families."

I found this article (essentially a press release) on Marketwatch.com as part of my daily searches of EMS news. From the article:

SwiftMD, the revolutionary telemedicine firm, today announced that it has been selected by Ameya Preserve in Bozeman, Montana, to be the sole telemedicine supplier for each of the 300 new homes built in its development. Under the terms of the agreement, the first of its kind in the United States, the company will provide emergency medical services, via the phone, Internet or bi-directional video, to all residents and Ameya Preserve employees and their families. Each home will be equipped with all necessary technological components for the service - an important feature as the nearest healthcare facility is 45 minutes away. The homes are expected to be completed in 2011.

Does anyone else think this is as huge as I do?

From the "Conditions we treat" section of the SwiftMD site:

For most members, SwiftMD is they first call they make at the onset of illness or injury. If it could be treated by a routine office visit or a trip to an urgent care center, SwiftMD is an excellent choice. In fact, the majority of routine and urgent care cases can be safely treated by a SwiftMD physician over the phone.

Our services are appropriate for most people from 3 to 69. To ensure patient safety we do not treat other age groups or people with some conditions, including pregnancy-related problems and psychiatric disorders.

When you call our toll free number you will answer a few questions to determine whether or not a telemedicine consultation is appropriate for your condition. If not, you will be advised to visit a doctor for a physical exam, or call 911 if it’s a life-threatening problem. Otherwise we’ll schedule an appointment and you’ll be talking to a SwiftMD doctor within an hour.

It is rare to find me relatively speechless. Quite frankly I am not sure whether to sign up and see if I can buy stock in this company--or wonder about the quality and direction this takes medicine in...

What do you think?

If you like lights and sirens you'll love this

2008-11-12T20:28:00.002-05:00

Make way for the Howler.

EMSA, an EMS service in Oklahoma, held a press conference today to announce they were installing Howler sirens in their ambulances.

According to an Associated Press article:

"The most frequent thing motorists say to us is they didn't see the ambulance coming," Wells said at a Tuesday news conference, where the new technology was demonstrated.

During the demonstration, two ambulances were parked near each other. A plastic stepladder with three glasses of liquid on top was placed in between the vehicles.

The ambulance without the Howler sounded its siren and produced its familiar wail. Then, the Howler, which produced booms that sounded like a 1980s video game played at an earsplitting level. The liquids in the three glasses rippled. Wells jokingly said the new sirens sounded like "a vacuum cleaner on steroids."

The Howler is sold by Whelen whose literature on the product recommend hearing protection.

"a vacuum cleaner on steroids..." I'm guessing that hearing protection is more than just a good idea.

It is National Collegiate EMS Week

2008-11-10T07:48:00.002-05:00

Congratulations to all those providing EMS on college campuses around the country. The event, sponsored by the National Collegiate EMS Foundation, recognizes the hard work and dedication of campus EMS providers.

The purpose of the foundation (from their Facebook page):

Founded in 1993, NCEMSF is a 501(c)(3) non-profit professional organization committed to scholarship, research and consultancy activities and to creating a safer, healthier environment on college and university campuses. Comprised of approximately 200 college campus based emergency medical service (EMS) agencies trained to respond within minutes and provide care tailored specifically to campus emergencies, NCEMSF's purpose is to support, promote, and advocate EMS on college and university campuses nationwide. In addition to providing for the acquisition of medical knowledge, campus based EMS allows student participants to develop certain life skills including leadership, communication, and decision making. NCEMSF provides a forum for communication and creates an environment where ideas can be exchanged and problems can be solved.

I have a special place in my heart for the college services. When I couldn't take an EMT course because I was too young (many, many years ago) I enrolled in a Red Cross Advanced First Aid course taught by members of the Five Quad Volunteer Ambulance at SUNY Albany. What a dynamic and talented group of college students.

I have no doubt that the passion those students showed toward EMS is one of the reasons I am still here today doing EMS.

Happy National Collegiate EMS Week. Remember all you can do. Know the difference you make. We need a new generation...a future...for EMS. You are that future.

An unexpected cause of hypoglycemia

2008-11-09T09:56:00.003-05:00

The FDA recently announced a recall of syringes:

The U.S. Food and Drug Administration is notifying health care
professionals and patients that Tyco Healthcare Group LP (Covidien) is
recalling one lot of ReliOn sterile, single-use, disposable, hypodermic
syringes with permanently affixed hypodermic needles due to possible
mislabeling. The use of these syringes may lead to patients receiving an
overdose of as much as 2.5 times the intended dose, which may lead to
hypoglycemia, serious health consequences, and even death.

The recall applies to the following lot number and product information:

-- Lot Number 813900
-- ReliOn 1cc, 31-gauge, 100 units for use with U-100 insulin

We think of many reasons for hypoglycemia when working a diabetic call...but this one wouldn't even be on the radar screen.

The full article:

FDA Reports Nationwide Recall of Mislabeled ReliOn Insulin Syringes

Differing opinions are healthy

2008-10-31T05:03:00.002-05:00

A Colorado state senator from Denver wrote a very interesting letter to the Denver Post recently.

This ex-medic and politician makes some points which seem to be supported by recent literature--that more medics on the street may not be the answer. Denver is struggling with response times. The letter is a bit long to post here in its entirety. Here is a highlight:

But I have to tell you, I would rather wait ten minutes for a skilled
paramedic who can start the process of saving my life than have one by my
side in three minutes who does not have the necessary skill or experience.

I know there is controversy. I know there is currently an audit in process.
I spent nine years as a CPA, so I understand the auditing and accounting
procedures well. Unfortunately, you are on a path to lower the quality of
your emergency medical service because, I submit, you are counting the wrong
beans.

Response time is important, but it is only one component. Making decisions
based on response times alone is irresponsible. Look at the whole system.
Look at the amount of time spent on the scene. Look at the save rates for
viable patients.

I think this is a very positive letter. I don't know enough about the issues in Denver to form an opinion, but I do like the fact that someone will look at things differently. This is how we grow. It is essential to stop reactive, emotional, non-research based opinions to move EMS forward in both practice and professionalism.

It is important to read the whole article. It seems that there are other intertwined issues--such as the fire department taking over EMS--so it is equally important to get get all the facts. Senator Morse concludes:

You have one of best trauma systems in the country. Rely on the experts who
work there, not the auditors and the politicians who know nothing of trauma
care.

One more thing,, be wary of those who would move the paramedic response to
the fire department.

That solution would nearly double the cost and significantly reduce the
quality because each fire paramedic would see hundreds fewer patients every
year and their skills would atrophy-paramedic skills are perishable.

Keep them fresh even if you have to wait an extra minute or two for them to
arrive.

Several years ago in Kennebunk I unpopularly argued that clinically competent, community-based EMT-Intermediates may be better for the system overall than bringing in out-of-town per diem medics.

I had a bit of a flashback here...

What would you do?

2008-10-30T10:23:00.004-05:00

You are in a hotel room at 5:30 in the morning. (Get your mind out of the gutter--I am speaking at a conference.) The hotel's fire alarm sounds. If you ever wondered what that strobe light and speaker did...WOW...loud and bright.

Do you get up, get dressed and exit the building according to the evacuation map on the door...or do you stay in bed and wait it out? Probably a false alarm. Don't smell smoke.

This blog is read by EMS and Fire personnel as well as students. What would you do? What do you think I did?

Comments anyone?

We're not in Kansas anymore, Toto...

2008-10-29T12:50:00.003-05:00

Picked this one up from Paul Maniscalco's EMS news listserv:

The federal Advisory Committee on Immunization Practices (ACIP) has opened the door to voluntary anthrax vaccination for first responders, revising an 8-year-old recommendation against that step.

The committee, meeting yesterday, said the risk of anthrax exposure for emergency responders is low but "may not be zero," and therefore first-responder agencies may want to offer the vaccine on a voluntary basis, according to information supplied by the Centers for Disease Control and Prevention (CDC) today.

It is worth reading the entire article.

What does this mean to us? Hmmmmm. Is there something we don't know or is someone simply confirming the world may not be the place it once was?

How long do you think it took to craft the statement "may not be zero?"

Sorry. Don't mean to be cynical. As a matter of fact I (along with many others) cringe every time I see the headline "breaking news" come across my Blackberry. In a post-9/11 world we know there are risks. Perhaps this just makes it a bit more real.

Achieving protection would require 6 vaccinations over 18 months that have some side effects. It would also require yearly boosters. It is vital to make an informed decision about this one.

How about a program for EMS, Fire and Police similar to mail carriers being issued antibiotics:

Oct 2, 2008 (CIDRAP News) – Federal health officials yesterday announced a plan to supply mail carriers with antibiotics so they will be protected and prepared to deliver the drugs to others in case of an anthrax attack.

The program will start with a $500,000 pilot project involving carriers in Minneapolis and St. Paul, which were chosen because of their extensive bioterrorism preparations, according to an Associated Press (AP) report yesterday.

"In an anthrax attack, time is of the essence," Health and Human Services (HHS) Secretary Mike Leavitt said in a news release. "By providing advance protection to letter carriers who volunteer to deliver antibiotics in an affected community, we can gain the benefits of the unique capabilities of the Postal Service to get much needed medicine to those who need it quickly."

Inhalational anthrax is usually fatal unless the patient is treated with antibiotics early. In 2001, five people died and 17 others got sick after envelopes containing anthrax spores were sent to several media offices and two US senators.

In recent years, HHS and the Postal Service ran exercises in which mail carriers in Seattle, Philadelphia, and Boston delivered empty pill bottles and explanatory fliers to residents. Carriers paired up with police officers to distribute the items, the AP reported. William Raub, Leavitt's senior science adviser, said that 50 carriers reached about 53,000 Philadelphia households in 8 hours, according to the story.

The tests were part of the Cities Readiness Initiative (CRI), a federally funded effort to equip 72 major cities with the ability to deliver antibiotics to their entire populations within 48 hours, in the name of bioterrorism preparedness.

According to the AP, the Postal Service and its unions told the government that carriers who volunteered to deliver antibiotics in an anthrax emergency would need assurances that they and their families would be protected. That led to the idea of giving carriers a supply of doxycycline to keep at home for themselves and their families. In an emergency, they could start taking the drug while the government brought in supplies that the carriers would deliver to residents.

No, we're definitely not in Kansas anymore.

The healthcare system...in France

2008-10-27T08:39:00.002-05:00

I am determined to post at least 3 times per week on my blog. Stimulating, thought provoking items everyone will want to read and comment on. And when I can't do that I'll post a link to an article where someone else has done this for me. :-)

The article from CBS News (below) should make you think. While the pros and cons of "socialized medicine" usually cause some passionate discussions--including quality of care and access times--can you read this article and truly say to yourself that we are doing the best we can do?

The system in France is about $14 billion in debt. But I'd certainly feel better bailing out a health care system like that than I would spending a trillion to bail out the greedy, visionless bozos on Wall Street.

Enjoy...and post a comment or two.

CBS News story on the health care system in France

Where have I been?

2008-10-25T20:14:00.002-05:00

Summer flew by and fall began with a hectic travel schedule. I had the good fortune to ride and photograph in Buffalo, NY and North Las Vegas, NV. I also taught in a workshop on the new education standards in Oklahoma City.

While I was in Las Vegas I had the opportunity to teach in the Rancho High School EMT class in North Las Vegas. While this blog often pulls in news about EMS which is less than positive, I have to say that teaching this class gave me hope for the future of EMS.

This class was full of bright and responsive students who had a clear vision on what they wanted from the future--and I'm happy to say that several are looking toward a career in EMS. They asked questions, participated and showed a genuine interest in EMS. Definitely a highlight of my trip to EMS Expo.

I would be remiss if I didn't note the kindness, hospitality and professionalism I saw in Buffalo (Thanks to Deputy Whitfield and stations 21, 22, 26 and 33) and North Las Vegas (Thanks to EMS Chief Bruce Evans and Station 51) while riding and photographing. And also to JTM Training Group for allowing me to observe some amazing tactical medical scenarios at Nellis AFB.

A few more trips are on the horizon including Topeka, Kansas and Salt Lake City, Utah before the holiday break.

Stay tuned. I'm back and will post regularly. Please drop me a note or comment to say hello.

Learning from tragedy

2008-07-30T07:28:00.002-05:00

In June a volunteer firefighter and a sheriff's deputy were struck by a truck and killed on Rt. 17 in North Carolina near Camp Lejeune. The Marine Corps base was training with smoke which created an extremely low visibility area on the highway.

This article from ENCToday.com tells the story.

"Nobody thought how dangerous it was to enter the low visibility area," said Butch Thompson, Onslow County EMS director.

Deputies and firefighters were directing traffic in the area due to decreased visibility on the highway because of fog and smoke from a gun range fire aboard Camp Lejeune when Gene Thomas, a volunteer fireman with the Verona Volunteer Fire Department, and Steve Boehm, a deputy with the Onslow County Sheriff's Department, were struck and killed by a truck traveling northbound on U.S. 17.

Out of a tragedy comes good. Efforts are being made to help fire, EMS and police personnel who are likely to be called into the area again soon.

Does anyone out there remember the days before the scene size-up was added to the assessment process? When I became an EMT in 1980 (yes, I'm old) the mantra was "Airway is always the first priority." The article refers to this:

"We're trained to go into an emergency and we think of the victim's safety many times before our own safety - now we have to think of our own safety," said Steven Conrad, deputy division head of Onslow County Emergency Medical Services. "It's going to cause a delay in getting to patients but it's much needed to protect responders."

From a tragedy comes progress. As we remember those lost, we learn. More EMS providers are killed each year from highway crashes than from violence.

Please take a moment to visit the National EMS Memorial service site for a quick reality check.

Stay safe.

Bad news round-up

2008-07-22T08:07:00.003-05:00

Sorry, but a lot of the news I have been seeing recently hasn't been cheery. It is important to share the bad as well as the good. Here goes:

A Maplewood, Missouri firefighter/paramedic student who had only been on the job 10 months was killed in an ambush after responding to a vehicle fire. Two cops were also shot. Here is the story from Fox News in St. Louis.

The ambush was a tactic which was originally used against cops in the 60's and 70's. An ambush can also be seen in some domestic violence and violent psych cases. News reports thus far don't give a motivation. It seems the fire was started to draw emergency personnel to the scene. The suspect later burned his house to the ground and didn't negotiate with police.

New Jersey EMTs try to save their jobs. This report from the Star Ledger's nj.com.

I understand the budget crises that affect municipalities and taxpayers today. I also believe that there is a place for community-based EMS. One of the EMTs that would lose his job is from a family with a long history of public service.

The article makes an interesting point that the financial savings the municipalities see will ultimately be shifted to the taxpayer in the form of co-pays and denied claims when health insurance (if you are lucky enough to have it) won't cover the ambulance bills.

We need a solution that combines community-based EMS and helps the budget woes of municipalities. If I had an immediate answer this blog readership would soar!

Finally, in the category of bad news, Bryan Bledsoe addressed the helicopter issue (again) even before two medical helicopters collided in Arizona. As always, Bryan's columns are good reading.

Now more than ever, stay safe.

Lessons learned from Tim Russert

2008-07-08T19:51:00.002-05:00

Frank Poliafico, Director of the Initial Life Support Foundation posted this link to a New York Times letter on a listserv I subscribe to. It is a 50-year-old journalist's account of a silent heart attack he recently experienced.

Many on the listserv thought that this would be good to distribute to students. Perhaps you would like to pass it along or place a copy on your squad's bulletin board. The life you save may be someone close to you.

It is also a good reminder that before dismissing a complaint of weakness as dehydration, flu or general whining, always do a thorough exam. A nonchalant or disgruntled EMSer could easily have RMAed this one and found themselves in court--no matter how much the patient said he didn't want to go.

By the way, if you don't know Frank Poliafico, you should. He is an interesting, passionate man who usually has a booth at the major conferences. He is also an accomplished magician.

And if you don't know who Tim Russert is, Google him. He was a talented and highly respected journalist who didn't take shit from anyone. EMSers like people like that.

Fancy Home Defibrillator Used Only Once

2008-07-07T12:37:00.002-05:00

The Onion has a funny home defibrillator story in its online radio offerings today.

Enjoy it!

My surgeon called me "dude"

2008-07-07T08:03:00.003-05:00

Perhaps it is my age. OK, definitely it is my age. But this story is also an excellent example of how to navigate tricky medical-legal waters: Honesty.

I recently had surgery. An umbilical hernia repair. No biggie. At a check up two weeks post-surgery I told my surgeon about a hard lump under one of the incisions. He palpated and said:

"Oh, Dude. I didn't do right by you on this one. I stitched your abdominal muscle too tight. (pause, shaking his head in disappointment) Well, I'll make it right for you."

I'm not sure what struck me more, being called "dude" or his sincere honesty.

He explained it couldn't be fixed right away...not without giving me a new hernia. I'll get it checked at 12 weeks and see what happens. For those of you who know me, there is no risk that it will affect a swimsuit modeling gig or anything.

Have you ever had a situation like this with a doc? Have you had a situation in the field where you made an error?

I'm not saying this is the way to handle everything but it sure made me think about how I personally handle and teach medical-legal issues.

There is something about sincerity and honesty that go a long way...Dude.

Why do we help?

2008-06-06T08:49:00.002-05:00

A story that could be called interesting--or shocking--depending on one's perspective hit CNN this morning:

Hit-and-run victim left in street without help

A 78-year-old man was struck by a car and left to lie injured in the street as cars and pedestrians went by without rendering aid. The police chief told the Hartford Courant, "We no longer have a moral compass."

Why don't people help?

One witness, Bryant Hayre, told The Hartford Courant he didn't feel comfortable helping Torres, who he said was bleeding and conscious.

Why did I say this phenomenon is interesting? In a CPR listserv I monitor there recently was an in depth discussion on why people don't help. There is also an upcoming session at the Heart Association's ECCU Conference in Las Vegas in July. This session seeks to explore these non-system behavioral issues:

Reshaping the System of Survival for SCA

The Questions

Why after 40 years of enormous energy and resources is the Sudden Cardiac Arrest (SCA) survival rate low, very low—too low? Are we doing the “right” things?

The Pathway

Perhaps we could benefit from a new mindset in which we re-think and re-design how we prepare for and respond to SCA. Perhaps applying system and design thinking strategies from disciplines including management and behavioral science can be a creative and worthwhile pathway to address SCA challenges.

It is an interesting concept. Maybe we could save more people by greater involvement and commitment from the entire EMS system (including the public) than we could from a change in science.

My friends Allan Braslow and Frank Poliafico will be involved in this discussion. I believe it is an important direction and a worthy effort.

I'll end with a question or two. Why do YOU do it? Why do you stop when others won't? Why do you go in when others run away?

Catching up on the news...

2008-06-05T07:48:00.003-05:00

Every so often I post on a series of events that appear to be formative or important for EMSers. Here goes:

After a tragic helicopter crash (is there any other kind?) it is common for the media to examine how air medical services are used (or abused). The recent Wisconsin crash is no different. The Capital Times from Madison, WI tackles the issue.

The Houston Fire Department has been authorized to begin a tele-nurses program to help reduce non-emergent use of ambulances. The Houston Chronicle tells this story.

The Pittsburgh Tribune Review has an article on increasing EMS response times. This pretty lame article is probably predictive of what others around the country will say--and won't say. The article compares response times to three somewhat non-comparable cities but fails to trend calls in Pittsburgh over time to see if volume is responsible for the mounting delays. (The Chief does say he is handling the "same number of calls" but it still leaves me wondering not only about the volume of calls but if there are changes in priorities of calls.) The EMS Chief says budget cuts in 2003 are responsible for the increase. It is important to note that the response time to highest priority calls has stayed the same. It sounds like an EMS audit is about to be released. This piece certainly doesn't take a critical look at the issues.

That's it for the news. Stay safe.

Lack of contract is driving Boston firefighters to prostitutes

2008-05-30T18:13:00.003-05:00

I love these catchy blog headers. What surprises me is that the Boston Globe didn't use it when publishing this article.

A Boston firefighter was arrested in a prostitution sting in Dorchester, MA. As far as I'm concerned he's no different than any of the other five men arrested in the sting. Unfortunately, the Boston firefighters have been getting hit pretty hard in the press.

In this case, I think the Boston Globe actually used restraint. Check out this quote from the Boston Firefighter's Union President:

Edward Kelly, president of the firefighters union, said he didn't know Herelle but thought the incident could be a sign of stress from the contentious contract dispute between the city and the firefighters.
"I think that the pressures of working without a contract are beginning to manifest in the darndest ways," said Kelly, president of Local 718.

I want to make a few things clear: I am a fan of firefighters. This firefighter certainly deserves his day in court. But what was Edward Kelly thinking when he said this? Will anyone is Boston feel sorry for the firefighter without a contract, standing on the edge--only a prostitute between him and psychosis--when he made almost $100,000 last year?

The days of the indisputable firefighter/hero post-9/11 are over. People are fighting to keep their heads above water and pay the bills. We will all need to work harder to justify our existence.

Especially the Boston firefighters when they make statements like this.

EMS under fire

2008-05-19T17:40:00.002-05:00

Have you ever sat and watched a news-style lambasting of a hospital for suspected clinical errors and wondered how long it will take for suspected EMS errors to get the same big billing?

Wait no longer.

This video piece from the Fox station in the Cleveland area put local EMS squarely in the sights--and will put a chill in your spine.

The sad part is the only defense that could be offered by the EMS agency is: our care was acceptable...and our documentation was wrong. I felt badly for the department spokesman. It is a good thing the news stations don't know what a code summary is. Be sure the plaintiff's attorney will.

As bad as the piece is, it could've been worse. Those interviewed gave stock answers and tried to give EMS providers the benefit of the doubt. Yet the investigation by the TV station was unusually thorough and appeared to include access to hospital records.

This is sad all around. For the patient, family and EMS providers.

Is this where I should say Happy EMS Week?

Is CPR modern day bloodletting?

2008-05-19T09:59:00.002-05:00

Dr. C. D. Hardison, an Emergency Medicine physician from Tennessee, seems to think so. In a letter to the editor of Emergency Medicine News Hardison relates CPR as the modern day equivalent to bloodletting.

In this letter he states:

Death is inevitable. None of us escapes it. Our obsession of saving every life at all costs has become something beyond absurd.

While this letter brought some nasty comments from a CPR/BLS listserv recently can we totally disagree with Dr. Hardison? Would any other procedure that was so profoundly unsuccessful--even though there is nothing to technically lose in resuscitating a dead person--be supported in medicine? His point about the amount of time and money spent obtaining and maintaining alphabet certifications for these profoundly poor outcomes is eye-opening.

The truth is we're still too Johnny and Roy to give up CPR and AED. Don't worry. And I don't believe we should in many circumstances. Comments and points-of-view like Dr. Hardison's are necessary as we work toward evolutionary changes in the expectations of society and realities of medicine.

I personally applaud Dr. Hardison's letter as a necessary step in this process.

Another medical helicopter went down this weekend

2008-05-13T08:17:00.004-05:00

The Capital Times of Madison, WI posted breaking news about the crash of a University of Wisconsin Med Flight helicopter and the sadness that has enveloped the medical community there.

The Winona (Minnesota) Daily news posted video footage of a press conference and of the crash site

One interesting comment found in the Madison paper is from the owner of the ship that went down:

Craig Yale, vice president of corporate development for Air Methods, said using night vision goggles would be an asset for helicopter pilots, and the company has a commitment to outfit all 350 aircraft it owns with goggles, and make the necessary modifications to the aircraft, over a five-year period.

"We want to get them into all of our aircraft but the logistics of taking aircraft out of service to outfit them with the equipment takes time," he said.

Yale said the company is two years into the five year night vision goggle plan.

Another problem is availability of night vision goggles.

"The availability is real low, because most of the goggles are going to Afghanistan and Iraq," Yale said. "Everybody is trying to get them as quickly as they can."

The issue of helicopter safety is a hot one. We'll be hearing more about this. For now though we should grieve. This article about Mark Coyne paints a portrait of a fellow provider, a passionate educator--and even a Jimmy Buffett fan.

I'll raise a Margarita glass for Mark Coyne, and for Dr. Darren Bean and pilot Steve Lipperer. All made the ultimate sacrifice.

National EMS Memorial finds a home

2008-05-11T18:12:00.002-05:00

The Gazette of Colorado Springs reports that the National EMS Memorial's Tree of Life has found a home in Colorado Springs, Colorado.

The Tree of Life was housed at the To the Rescue Museum in Roanoke, Virginia until closing recently. A committee was formed to determine the new location. For those unfamiliar, each EMS provider who has died in the line of duty is memorialized in a leaf on the Tree of Life. A memorial service is held each May when provider's names are added to the memorial.

I have posted previously about the Muddy Angels who hold a fundraising bike ride to the service each year. A wonderfully noble effort to bring attention (and funds) to this important project.

Can anyone offer help to a fellow EMSer?

2008-05-11T15:57:00.002-05:00

I received this email from someone I met at an EMS conference in Salt Lake City, Utah.

Mr. Limmer,

I enjoy hearing you every November in Salt Lake. My wife and I had a child four months ago and he has been hospitalized since. He was diagnosed with a motor neuron disorder. We are trying to get him home but live in a "no service area" for home health care companies. We trached him after many unsuccessful attempts coming off the vent. To make us a family again it is going to require us finding a vent. Kemmerer's hospital is willing to take on our child they can't afford a vent. We are even looking for a refurbished one. Do you know of anyone that could help us? Our boy is currently on a LTV 1150 and doing great. If you could help I would greatly appreciate it and look forward to seeing you this November.

Thanks,

Lenn Johnson
Cokeville, WY

It is a great conference out there with some wonderful people. This family needs some help. I've seen the readership for my blog grow around the country. Can anyone help Lenn and his family?

Are we ready for 'the new normal?'

2008-05-10T06:55:00.002-05:00

You may have seen news stories on the train that was quarantined in Canada because of a potential infectious disease outbreak. This article looks at the incident from the pubic health side and should be a wake-up call for the future of EMS challenges to come. The article states:

But public health officials say it was the type of rapid reaction needed to detect and contain future SARS-like outbreaks. Further, they said this kind of lightning-fast response to clusters of unusual illnesses is actually a sign the system is working.

"Had we had that high level of suspicion in Toronto, for example, at the beginning of SARS, they may not have had the number of cases they subsequently had," said Dr. Perry Kendall, British Columbia's chief medical officer of health.

"So I think it's important that this is the new normal. And I think we will have events that turn out not to be events as we try and screen for events that might be events."

Are we prepared for this type of event? We spend quite a bit of time on hazmat and terrorist situations (which may surface as cases like this) but we don't associate with our public health responsibilities as much as we do our public safety responsibilities.

It is a classic resurfacing of the "Is EMS healthcare or public safety?" question. The answer to this question won't be offered in this blog (at least today), but one thing is certain, we will be forced into our public health role whether we are ready or not.

A different approach to assessment: poetry

2008-05-06T09:42:00.000-05:00

I had the good fortune to meet Paul Liebow, MD last May at an EMS week dinner. He is a passionate and committed physician and a very interesting man. He gives much to EMS.

In one of our subsequent conversations on books, photos and writing he offered to send me some poetry he has written. I'd like to share some of his work with you.

Just Listen to the Patient

In five minutes you will either know
What’s probably wrong or you may
Later that day, or you won’t.

Listen to Death whispering as it
Tiptoes in behind the woman
Who pushes the huge, protesting
[Too much!] man through
The hissing ED doors.

“I’ve got chest pain but its not my heart!”
So we coded him for two hours-
Every drug by every route
Know to medical science-,
Shocked him over and over.
He walked out of the hospital
Two weeks later.

“I’ve go the same thing my brother had”-
And eight other brothers-
All pipefitters in The Great War
Who chain-smoked Camels
The Army gave out as “rations”.

“You can do anything you want to me-
Treat me with anything you like-
Just don’t tell me I have cancer!”
She did and we did just as she said-
She died at Peace- her family beside her.
Of course they all knew.

“He was fine last week”
The whole re-united family agreed-
Though the poor shriveled up man
Had laid mumbling and contracted
For years in the fetal position.

“I know she just has a headache,
A little fever, and a beautiful smile-
But her sister had meningitis
When she was little”

If you see a mile long list of symptoms,
Tests, and specialists, and they’re now
“Here to find out what’s really wrong”-
You won’t ever know
Unless you immediately do.
And if you let them know they’re O.K.
Be ready for the complaint-
“The Dr. didn’t care about me-
The Dr. wouldn’t listen to me”

But if they are “never sick”-
With even the strangest complaint-
You had better be
Very, very sure it’s nothing-
Before you just write a prescription.
“I feel like my head is going to fall off!!”-
Because the rheumatoid arthritis has
Eaten away their odontoid process-
The last little bone between the
Cervical spine and the base of the skull”

“I’ve been on the Internet-
And I know I have “---”
Take them very seriously-
Get the best scientific article you can.
Give it to them, and they’ll be happy
Whether they do or don’t have it-
With a good referral
And a few simple tests.

In five minutes you should know:
“Live or die”
“Sick or well??”
“Admit or send home??”
“STAT tests or refer now??”
“Will I know before they leave the ED?”

It will still take an hour
To ask all the other questions,
Look and listen, feel and smell-
Answer all the phone calls,
Do all the paperwork,
See all the results.
But you won’t be disappointed-
And neither will they.

Thank you, Dr. Liebow

Childbirth is a natural process

2008-05-05T11:47:00.002-05:00

We tend to get worked up when delivering babies in the field. We just don't do it a lot. If we ever need a reminder of just how naturally a birth will go without us present, read this story:

Girl carries secret baby to hospital, still attached

It certainly reinforces the fact that we really don't deliver the baby. We're only along to help out a bit.

More on public opinion

2008-05-05T10:59:00.002-05:00

I posted some photos last week demonstrating how what we do is in the public eye. People form opinions on us based on our actions both on and off calls--even on and off the job.

An editorial in the Boston Globe demonstrates what happens when public opinion starts to swing in the wrong direction.

While I have great respect for firefighters--and love the City of Boston--it seems a perfect storm is brewing against the Beantown Jakes.

The post-9/11 high opinion of firefighters seems to officially be over. People who make half the salary of these firefighters can't pay for gas, food and home heat. They aren't going to be sympathetic, especially with the volumes of bad press the fire department has received.

It is time for a change. An image makeover. And, yes, some concessions. I am truly sorry to have to say that. Without public support the political clout once possessed by the firefighters is gone.

The tide has turned against Boston's bravest. Its is up to them to do the right things to get it back.

Can you find the common thread in these two articles?

2008-04-28T11:22:00.004-05:00

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

Wait for ambulance cost man's life

and

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 Onlineathens.com 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.

Revelations from Billings, Montana

2008-04-26T12:31:00.005-05:00

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

2008-04-26T12:04:00.003-05:00

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?

2008-04-26T10:48:00.006-05:00

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.

South Carolina EMS Conference

2008-04-22T20:07:00.002-05:00

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.

Reality check for this week

2008-04-16T07:36:00.002-05:00

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!

Ambulance or bus?

2008-04-09T09:26:00.002-05:00

Don't mean to always use jems.com 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..."

Good reading for today

2008-04-04T07:58:00.003-05:00

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.

USA Today's article on home defibrillators

2008-04-03T14:21:00.003-05:00

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.

More on CPR...This just in:

2008-04-02T14:20:00.002-05:00

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

2008-04-02T13:36:00.002-05:00

...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.

Hands-only CPR

2008-04-01T12:17:00.003-05:00

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.

My email to Senator Exum

2008-03-31T11:37:00.001-05:00

Senator Exum,

I am a paramedic and former Maryland resident. I am writing to tell you that the comments you made in reference to paramedics and firefighters in The Capital are insulting and inappropriate. In the event you don't recall the comments, I'll copy them here:

"But we aren't even able to talk about it," Mr. Exum said of the intense lobbying pressure. "They (state police and the Maryland Institute for Emergency Medical Services) call all the little people back home, the firefighters and the paramedics, and tell them we are trying to dismantle the system, and they come running." Mr. Exum said.

Maryland has a long tradition of proud service in both firefighting and EMS. The firefighters and emergency medical services personnel, both paid and volunteer, deserve better than to be referred to as "little people back home."

Perhaps these comments come from an over-inflated sense of self worth on your part. In my opinion, most people appreciate their local heroes much more than their politicians. Your behavior simply reinforces that belief.

I recommend an immediate public retraction and apology for your offensive comments.

Sincerely,
Daniel Limmer, EMT-P
Kennebunk, Maine

Senator Exum, please remove the foot from your mouth

2008-03-31T11:09:00.005-05:00

I search the web every day for interesting articles to post. I find so many heroic and exceptional providers I can't list them all. I find systems losing volunteers, systems needing funding and systems with call volumes skyrocketing.

I also find politicians who don't give us the respect we deserve. Enter Maryland Senator Nathaniel Exum, D-Prince George's. While discussing whether the Maryland State Police helicopter program should be privatized he told The Capital:

"We have some concerns about the system, and the public needs to know," said Sen. Nathaniel Exum, D-Prince George's, who sponsored a bill four years ago to establish a medevac privatization pilot program.

"But we aren't even able to talk about it," Mr. Exum said of the intense lobbying pressure. "They (state police and the Maryland Institute for Emergency Medical Services) call all the little people back home, the firefighters and the paramedics, and tell them we are trying to dismantle the system, and they come running."

Little people? Regardless of your opinion on the helicopter system please let Senator Exum know what you think of this comment. Maryland has a quality EMS system with proud, talented people. They deserve better.

As a service to those reading this blog, here is the contact information for Senator Exum:

James Senate Office Building, Room 303
11 Bladen St., Annapolis, MD 21401
(410) 841-3148, (301) 858-3148
1-800-492-7122, ext. 3148 (toll free)
email Senator Exum

Even if you aren't from Maryland, Sen. Exum should know EMS won't stand for being treated like this.

Everyone loses on a call like this

2008-03-22T07:43:00.003-05:00

Calls like this cause hearts to sink--for both the family and the EMS providers.

Family: Rescuers Questioned Need To Transport Baby Who Later Died

It is important to note that no details have been disclosed and it is not the intent of this blog post to second guess or make any opinions for or against anyone in the call.

One thing is certain, a family is grieving and an EMS crew is under investigation and will likely have some deep emotions about the call as well. The call does reinforce some other commonly taught themes:

1. Patient refusals are a leading cause of liability in EMS
2. Sometimes patient perceptions are their realities--especially in times of deep stress and emotion
3. Incidents that cause EMS providers stress aren't just bad trauma calls--or even kid calls. Stress comes from bad outcomes regardless of perception of fault. The perceptions and whisperings of colleagues can be very painful in the social microcosm of EMS or fire stations.

I will keep an eye out for updates. My thoughts go out to both the family and the providers in this tragic situation.

New drug hitting the streets

2008-03-20T12:44:00.002-05:00

Just off the wire:

Dexaflox5 gets users high

Cutting edge information such as this is why EMSers in the know read my blog...

EMS Education Standards update

2008-03-18T21:20:00.002-05:00

Last month I attended the National EMS Education Standards Stakeholder's Meeting in Washington, DC. Representatives from national EMS, fire, medical and government organizations were present to provide input to the project team.

The meeting was run by a professional facilitator. This resulted in meeting speak such as placing agenda items in the "parking lot" and requesting comments be "robust and succinct." While the inner child in me giggled when these phrases were used, the end result was a worthwhile meeting which I am happy to have attended.

I do have concerns from the meeting. The first is that controversial items such as accreditation of paramedic programs weren't the hot button I expected. I am afraid this means some stakeholders avoided the topic at the meeting but plan to oppose this in other arenas (e.g through political or other pressures on NHTSA).

The second area of concern is the instructional guidelines (IGs). The educational standards are broad stroke and conceptual. Instructional guidelines were initially proposed to help clarify the standards without being prescriptive as to content.

The instructional guidelines haven't been updated since the first draft of the standards. As we prepare to move to the third and final draft of the standards it looks like the IGs need to be trashed and begun again.

The primary issue noted by the project team is that the IGs are unfunded. They have been a bit of an albatross for the team--but a necessary one.

As an educator and textbook author I an deeply concerned about the process if the educational standards aren't accompanied by IGs. Interpretation of the standards without some clarification could be tragic for EMS education.

An example is patient assessment. The standards describe a primary and secondary assessment process but no further details are included. Now imagine authors such as myself and Mike O'Keefe, Joe Mistovich, and Walt Stoy and Tom Platt working separately writing a book and defining the steps of the assessment process. Everyone's would be different. Perhaps dramatically different. Every textbook/publisher could have a different assessment process. How would this be tested nationally?

IGs level the playing field. Without them there isn't a playing field at all.

I believe the education standards project is a step forward for EMS education. The less prescriptive process should make this more of a living document. IGs are a necessary item to assure some level of uniformity--at least until EMS practice and education matures and becomes less region- and state-centric similar to other medical disciplines.

Nebraska EMS Association

2008-03-17T09:52:00.003-05:00

I just returned from the Nebraska EMS Association conference in Columbus, Nebraska. There I met about 400 of the most enthused EMSers one can find. I would recommend the conference to anyone. I would caution anyone venturing to the conference to be wary, however, of evenings at the bar and annual dinner. They know how to have a good time in Nebraska.

The attendees also know how to learn--even after nights in the bar. It is refreshing to speak to attendees who are eager to learn and stretch their knowledge and practice. I had the good fortune to speak there with Heather Davis and Chris Nolette. It was the first time I met the knowledgeable Dr. Nolette, a Texan who now lives in California. This combination leads to some very funny stories.

I also had the opportunity to ride with Omaha Fire Rescue Medic 21 and Columbus Fire Rescue and was able to observe and photograph quality EMS in action in America's heartland.

A friendly tip 'o the hat to my new friends in Nebraska. I hope to see you again soon.

Real Life EMS 2008

2008-03-04T21:24:00.003-05:00

Here is the first issue of Real Life EMS for 2008. Click on the cover to enlarge it.

In case you don't get my not-so-subtle point, the professionalism we want must be earned. The respect we crave is earned. The aggressive protocols we want--you guessed it--earned.

Be a clinician. Dig into some research and make an educated stand to your medical director or regional authority. Don't whine about your protocols not being as good as the next region or state.

Change begins within. You'll be surprised what can happen.

DC medics to be retested

2008-02-27T08:02:00.003-05:00

In an unusual and sweeping move, Washington, DC Fire Department will retest all of its 250 paramedics for "competency." The testing has been contracted out to the Maryland Fire Rescue Institute (MFRI).

This is a bold move in a troubled department. You may recall the lawsuit filed by the family of David Rosenbaum, the journalist who died in DC after a series of errors.

Looking between the lines it seems quite a bit of power is held by Dr. Michael D. Williams, the DC medical director. After all, the medical director is ultimately responsible for the clinical aspects of an EMS system. But other angles (Rosenbaum lawsuit, legal maneuvering around union issues, politics, etc.) make the medical director the ideal person--and the most bulletproof--to make decisions stick. He says:

"I expect there will be people that fail this process," Dr. Williams said yesterday. "And I think I will be saying, 'You're really not functioning as a paramedic, so we're going to pull you out.' "

Dr. Williams said the policy could create difficulties for the department official who assigns crews to ambulances, but "my obligation sort of trumps his on this one."

Using an outside agency was also wise. MFRI is respected in the area. Offering remediation to those on the edge prevents this being an outright slaughter. I am not sure whether ousted medics will be any better as EMTs. Time will tell.

There will be more chapters to this story. You can read the entire article:
DC medics to be retested.

Living in Maine

2008-02-09T22:09:00.000-05:00

I was living in the Maryland - Washington DC area before moving to Maine. People would literally ask, "Can you get the internet up there?" and "Do you have a summer?"

(Yes and yes.)

Stories like this don't help:

Toboggan crash injures 6

Not the multiple casualty incident you'd expect in Florida for sure.

On another note, I'm off to the DC area in the morning for the National EMS Education Standards stakeholder's meeting to see what is up with the new education standards.

If you haven't already seen them you should take a look: National EMS Education Standards.

I experienced the 1994 EMT-B curriculum change. It was quite dramatic. This one, while highly anticipated, is much less controversial than the 1994 changes. Possibly because the drafts have been available right along and also because many instructors have been through the 1994 changes. The trauma and the drama of curriculum change is old hat. The big issue isn't how they will change as much as when they will change.

A question we'd all like to know. Stay tuned...

Moo-chanism of injury

2008-02-02T12:11:00.000-05:00

Sorry. I couldn't help it. From the Boston Globe:

Woman finds a cow in the back seat
February 2, 2008 01:01 AM

By Caitlin Castello, Globe Correspondent

A woman who was driving down a Rehoboth road found an unfamiliar passenger in her back seat after an accident Tuesday night -- a cow.

Tanya Coccia, 46, of Seekonk was driving on Providence Street when she hit two cows. After rolling over the hood and roof of the car, one of the cows fell through the back windshield into her back seat.

"It is shocking and really weird," said Coccia, who was returning home with her daughter, Haley, 14, after running errands at about 10 p.m.. "Who would have ever thought I'd end up with a cow in the back seat of my car?"

The cow that fell into the back seat survived; the other cow had to be euthanized, she said.

It is a good thing her daughter was 14 years old. If she was less than 12 she would've been in the back seat...and killed.

There's no check box on the run report for stuff like this...

EMS at Mardi Gras

2008-02-02T09:58:00.000-05:00

I was at Mardi Gras in New Orleans last year. I rode with Ken Bouvier and his crew (or would that be krewe?) and saw some great EMS being performed. Hospital diversions and crowding were a constant issue.

This year the MGTUCC will help. (From bayoubuzz.com)

Mardi Gras Protection

The New Orleans Office of Homeland Security and the Office of Emergency Preparedness, along with New Orleans Emergency Medical Services announce the establishment of the Mardi Gras Temporary Urgent Care Clinic (MGTUCC), erected at 1927 Tulane Avenue, just off of S. Prieur Street, near University Hospital.

Following the announcement, the clinic will be open from noon Friday until noon Wednesday, February 6, and will be fully operational around the clock to help facilitate medical services in the City during the biggest weekend and the remainder of Mardi Gras 2008. All services will be free of charge.

New York based DHS Systems, LLC donated items, services, and support - worth approximately $500,000, to assist Homeland Security and Public Safety agencies. The temporary quarters are part of the Deployable Rapid Assembly Shelter, or DRASH - mobile quick erect/strike tactical soft walled shelters that integrate shelter, mobility, lighting, heating, cooling and power distribution in one flexible package. It is a modular shelter system that is man portable, rugged, reliable and user friendly. The DRASH product line, is the primary product of the company.

"This is a real boost for our Mardi Gras operations," said Col. Jerry Sneed, director of the city's Office of Homeland Security and Emergency Preparedness. "One can never anticipate the unknown, but having the necessary resources in place makes the difference in the outcome. We are eternally gratefully for their support. This will provide an important supplement to the city's efforts to ensure that every resident and visitor has a safe Mardi Gras."

The Mardi Gras Temporary Urgent Care Clinic will be staffed by Board Certified Emergency Medicine Physicians, registered nurses, licensed paramedics and Emergency Medical Technicians, and will be able to handle minor traumatic injuries and illnesses during the carnival weekend. It has an intake/triage area, a treatment area and a 23 hour observation ward. There will be a total of 16 patient treatment beds at the site.

The clinic will operate out of a series of several military grade climate-controlled tents. Homeland Security will be utilizing the J shelter (1150 square feet) and M Shelter (653 square feet) at the urgent care clinic. Additionally, a MX shelter (442 square feet) will be used for medical care on the Endymion route (Orleans and Hennessey), as well as a 4XB shelter that will function as a command post at Lee's Circle.

DRASH features six different series of shelters with 45 models of multiple widths and lengths. Although single models range in size from 112 - 1,250 square feet, all shelters can be interconnected, allowing for effective joint operations. DRASH has been used extensively by all branches of the US military as tactical operations centers (TOCs), medical facilities and forward operating bases.

Several state and city agencies and offices are providing services and resources for the MGTUCC, including the State Department of Health and Hospitals - which was responsible for the overall coordination and funding, LSU Health Sciences Center, the State Office of Public Health, the Governor's Office of Homeland Security and Public Safety - which provided communication capability for the site, Sewerage and Water Board, the Department of Property Management, New Orleans EMS, New Orleans Fire Department, New Orleans Office of Emergency Preparedness, the city's Chief Administrative Office and Reeves EMS - which is a subsidiary of DHS Systems, LLC.

DHS Systems, LLC is a leader of high-tech, soft-walled shelter systems serving medical, military, government and civilian needs. In business for more than 20 years, the company enjoys the experience and professionalism of a seasoned team of more than 400 engineers, designers, manufacturing professionals, project managers, business development and customer support staff.

My sincere wishes for a safe and fun Mardi Gras to all at New Orleans EMS.

Now that you have learned something new about EMS go to nola.com to experience a bit of Mardi Gras for yourself.

(PS. Did anyone notice the sales pitch/PR angle of this piece? DHS Systems, LLC gets a lot of mileage from this.)

Must read clinical information

2008-01-19T17:29:00.000-05:00

I just saw the first EMS1 column from my friend Joe Mistovich.

I believe he is one of the best EMS minds today, both clinically and as an educator. What separates Joe from many of the other leaders in EMS is that Joe is relatively quiet and not at all flashy. Don't let this fool you. When he speaks--especially when he teaches--you should listen.

His passion (and an amazing talent of Joe's) is taking complex clinical issues and explaining them in a natural, easily understandable way.

In fact the name of his new EMS1.com column, a common Mistovich mantra, is It all makes sense.

With Joe, it does all make sense. Enjoy.

Bledsoe killing vampires...again

2008-01-16T12:18:00.000-05:00

Bryan Bledsoe's column in this month's jems.com is one of Bryan's most controversial topics but a message worthy of repeating: CISM doesn't work and may be dangerous. Bledsoe states:

CISM has been debunked repeatedly through scientific scrutiny by some of the world's foremost authorities on psychological trauma. In fact, it has almost become a punch line or poster child for pseudoscientific practice. In a recent academic debate by the British Psychological Society (BPS) on "the worst idea on the mind," post trauma debriefing (e.g., Critical Incident Stress Debriefing, or CISD) scored third behind prefrontal lobotomy and the chemical imbalance model of mental illness as a pseudoscientific practice. Numerous randomized controlled trials, some conducted in the last two years, have repeatedly shown CISM to be ineffective and potentially harmful.

While this is unpopular to many--and some I know of here in Maine won't be happy--I feel the need to post this article and some excerpts. While CISD may make some people allegedly feel good, some are harmed. I personally would not participate in a debriefing and would advise anyone who asked my opinion to avoid it as well. This does not mean to avoid care altogether. To avoid the CISD model.

The purpose of the article actually runs deeper, and into the realm of how to continue to gain respect in the scientific and medical community when we stick to non-proven, potentially dangerous practices simply because "that is what we have always done" or someone emotionally preaching the praises of CISD during a back-step-of-the-rig sermon.

If EMS is ever going to evolve into a bona fide profession, we have to give up these anecdotal practices. Why do EMS professionals not go away in the face of overwhelming scientific evidence? Sometimes, convincing them is akin to killing vampires.

I remember the 70's and 80's when police officers were involved in shootings. Administrators took the officer's guns and made them get counseling. Do you know what they found? It induced guilt where none initially was. Officers sometimes don't feel that badly. If they took a life defending another or their own, sometimes the shooting isn't as traumatic as some initially thought.

I consider CISD the same. Unproven, many times unnecessary and may cause harm. I also disagree with the tenet that CISD sessions are confidential. In most cases, in the absence of a licensed mental health professional, the conversations are subject to subpoena and testifying in legal proceedings.

And what about the insidious stress that takes more people out of the game than bad calls: no calls or boring calls. We lose more people from a slow, steady diet of no excitement than we do from one career-ending call.

I've sharpened my wooden stake and joined Bryan in this noble quest.

Quotes of the day

2008-01-14T12:43:00.000-05:00

My Google desktop receives a quotes feed. Three random quotes are placed there each day. I've always liked a good quote. They can be interesting--even motivational.

Today's three quotes just seemed to combine to describe the essence of the EMS provider:

If everything seems under control, you're not going fast enough
- Mario Andretti
Oh, what a tangled web we weave when first we practice to believe.
- Laurence J. Peter
The greatest pleasure in life is doing what people say you cannot do.
- Walter Bagehot

We are fast paced believers who thrive on the challenges thrown at us. And damn proud of it, I may add.

You can see these and more at quotes of the day.

Muddy angels

2008-01-12T15:15:00.001-05:00

No, this is not the name of a porno movie (I don't think).

But it is a very important name to remember if you are an EMSer. This is the web site of the National EMS Memorial Bike Ride. I saw the new name and web site in Steve Berry's column in this month's JEMS.

This is an endeavor worthy of riding in and supporting. I see many of my fellow Mainers are involved.

I encourage you to ride and donate to this worthy cause.

Even if you don't ride, this quote from Will Rogers tells us it is OK to support it in other ways:

We can't all be heroes because somebody has to sit on the curb and clap as they go by.

If you sit on the curb and clap, please donate as well. I will.

Dead men don't cash checks

2008-01-09T11:07:00.000-05:00

An interesting story in the NY Times today which resembles a third rate sequel to Weekend at Bernie's: Corpse Wheeled to Check-Cashing Store Leads to 2 Arrests.

I know there are EMS stories out there to top this. How about sharing some of those times when you stop to render care at a crash on the way to the morgue with a body? Ever forget you had a corpse in the back of your rig?

None of these things have ever happened to me. But it has happened to friends of mine (sure, Dan)...

This blog is notoriously low on comments (thanks Chris and Libby G. for helping out). How about some sharing on this one.

Give the gift of pathogens

2008-01-08T09:44:00.000-05:00

For Christmas, my loving sister gave me E. coli. She also gave me a lovely protozoan parasite, Giardia lamblia. No, not in the potato salad and water. These lovelies were stuffed replicas (1,000,000x the size) of the actual bugs.

If you ever wondered what Streptococcus pyogenes (strep throat, flesh eating bacteria) looked like, wonder no more:

And finally, because I am a twisted EMSer at heart, my belated gift to you: the clap (Neisseria gonorrhoeae)

These are fun, great gifts for the equally twisted healthcare provider on your list and amazing props for teaching. You can see them at: Giant Microbes.

Political choking

2008-01-07T10:34:00.000-05:00

No, not the kind where a candidate does something that causes a huge drop in the polls...the real kind.

From AP/ the Union Leader in New Hampshire:

Sununu saves choking journalist with Heimlich maneuver

MANCHESTER, N.H. (AP) -- Sen. John Sununu may get a good word from the Bloomberg News service. During the weekend he saved the agency's executive editor with the Heimlich maneuver.

A piece of chicken got stuck in journalist Al Hunt's windpipe Friday night at a Manchester restaurant. Sununu jumped up, put his arms around Hunt and popped the chicken out with the maneuver.

Hunt and Sununu were sitting next to each other at the Hanover Street Chop House in downtown Manchester.

This is as close as I will get to politics on this blog.

More news is not necessarily good news

2008-01-05T21:36:00.000-05:00

My news clippings have been quite voluminous. Worth reading is this story in reference to New Year in South Africa. Read through the entire story to the part describing the group of six volunteer tactical medics that ride in an armored ambulance. A teaser:

Throughout the night, patients were brought in by Tacmed, a specialised unit of six volunteer paramedics who looked like a Swat team in helmets and bullet-proof vests.

They specialise in working in hostile environments where ordinary ambulance services can't go and were brought in by the provincial government to work in Hillbrow for the night.

"It's f***ing chaos," said a Tacmed paramedic after a trip from Hillbrow.

The team travels in a massive armoured ambulance called Mfezi, meaning "cobra" in isiZulu.

And closer to home (depending on where home is...) deposition transcripts (obtained by the Washington Post) show exactly where one does NOT want to be in a lawsuit.

I cringed when I read it. I can't imagine what the poor physician was feeling. Remember, treating people well (aka the way you would want your family treated) is always the way to practice.

So much for mechanism of injury

2008-01-04T21:42:00.000-05:00

We are taught that falls more than three times the patient's height are considered significant. I'm relatively sure this applies:

‘Miraculous’ Recovery for Man Who Fell 47 Floors

What is very interesting--and often misunderstood--about MOI is that there really is no direct correlation between the guidelines we use and injury. How many times have we gone to a rollover crash and found the uninjured driver standing against the car smoking a cigarette? Or the seemingly minor wreck with serous injuries?

Yet we have nothing else.

While we will use MOI as a guideline for immobilization and sometimes transport decisions, and in fact we may be bound to this by protocol, we should never lose sight of the full patient picture including mental status, vital signs and your clinical intuition and judgement.

MOI is a piece of the puzzle. An important, but limited one. We should apply it to our decision making as such.

So many articles, so little time...

2008-01-03T22:32:00.000-05:00

A Florida journalist comments on EMS personnel who didn't enter the water to save two drowning men. The providers followed policy that states they don't go into water without the proper equipment or training. What do you think?
By the book right to the bitter end.

No matter where it happens we always feel sad when one of our own dies. It has been a bad few weeks for medical choppers.
Rest in peace, Allan Bragwell.

And then there are those who are accused of doing things that make us, well, less than proud.
EMS Director arrested for theft.

Although reports vary on exactly how, Man cuts off own arm to free himself from machinery. It appears he may have completed the amputation and walked to the office to call for help. That took some guts and inner strength.

Also in Texas, Firetruck strikes, kills San Antonio woman in wheelchair. When you finish reading the article, go to the right side of the page and click on the comments button. As of this writing there were 21 comments from news readers in the San Antonio area. They are worth perusing to see the varied opinions on the incident and the fire department itself. What do you think your community would say about your agency if a piece of apparatus did a similar thing? Not only did this cause a civilian death but I am sure the firefighters are deeply affected by this event.

Be careful out there.

Why is it never discussed that EMS take over fire?

2008-01-01T22:09:00.000-05:00

Did I get your attention yet?

This quote from Collier County, FL Medical Director Bob Tober (in reference to fire absorbing EMS) sure got my attention:

“Somehow, providing BLS and the initial ALS (which is all they are really trained to do) is not enough for them because of 1) control, 2) power, 3) influence, 4) some revenue from transport, 5) justification of their existence,” Tober wrote. “Do not forget that 90 percent of what fire (rescue) does is medical. Since EMS is the medical specialist job description in our county, why is it never discussed that EMS take over fire?”

Wow.

Read the rest here.

January 1/Chapter 1

2008-01-01T08:42:00.000-05:00

The thought for this morning is beginnings. It is a new year. The January EMT classes will soon begin. And in each class, chapter 1. You may recall chapter 1 if you are an EMT (practitioner or educator). Chapter 1 is the chapter you rush through so you can get to the "real" EMT stuff.

Within that seemingly insignificant chapter are the roles, responsibilities and traits of an EMT. This is where the statements "maintain a professional appearance" and "keep the rig clean and ready for the next call" reside.

My father was in the hospital recently. In each hospital room was a small whiteboard with a big purpose. It listed the names of the RN, LPN and NA responsible for that room. It also displayed the date which is important if one is in the hospital for any amount of time. The days blend together.

After spending several days in the hospital I began to notice an apparent correlation. The days the whiteboard was up to date my father seemed to get better, more attentive care. Days I walked in and it was shifts (or days) old. Well, you can guess what the care was like.

I studied this and thought about it every day. And I thought about how it may relate to those roles, responsibilities and traits of the EMS provider. And I'll admit that while I never was a slob and I keep my rig clean, I did occasionally think the patients were just happy to get good, personal care and that these alleged little things were less important.

I was wrong.

Those little things do make a difference and set a baseline for what your patients expect. On this January 1st take a moment to look at chapter 1. If you teach, think about new ways to get this important information across to your students. They'll be waiting for the important (aka gory, cool) stuff. I got a real life reminder that the important stuff really does start in chapter one.

Happy New Year.

(By the way, the nurses listed in this whiteboard photo were outstanding. Note the nicely drawn wreath and Christmas colors.)

Happy Holidays

2007-12-23T21:56:00.000-05:00

For the holidays--the next issue of Real Life EMS Magazine. (Click on photo for a larger image)

What is really stressful in EMS? Four jobs. Partner problems. No excitement.

While people continue to imply that the stress in EMS is from witnessing horrible trauma, most providers brown out from non-emergency call after non-emergency call.

Regardless of what your stress is from (maybe the holidays?), stay safe, sane and warm this season. Stay healthy to go out and do good tomorrow, and the next day and the day after that. For the greatest gift you can give your patients is to be there and take care of them...no matter how routine that may seem. The greatest gift to yourself is understanding just how wonderful simply taking care of someone can be.

Happy holidays.

NAEMSE/Massimo part 2

2007-12-15T21:15:00.000-05:00

Several days have passed since my initial post about the NAEMSE/Masimo issue. I have certainly had quite a few phone calls and many more emails. One of the most interesting and appropriate calls described Masimo's marketing activities as similar to Invasion of the Body Snatchers.

Picture it. You are one of the few people that hasn't been infected by the Masimo virus. You act like you have...always worrying that one of the Masimo people will see that you haven't been infected...and then eat your head or something.

I made my previous post at 9:02am EST. By 12:00 noon on the same day I had 4 hits on my blog from Masimo in East Irvine, CA. To date there have been 7.

Lets look at what Masimo has done to market (aka push, shove down our throats) their CO-oximetry product.

They developed curricula for EMS providers and distributed it through NAEMSE. NAEMSE sent a letter to its membership recommending CO screening and the educational products developed under a grant by Masimo. Masimo then sent out a mondo press release which was picked up on hundreds of web sites from CNBC, Reuters and market watch to industry news sites.

They developed curricula for firefighters and distributed it through IAFF. I am in the process of obtaining the CD and accompanying paperwork from this mailing. I'll report back on this.

They have a supplement to JEMS this month touting a "Standardized Curriculum on Carbon Monoxide Poisoning." How did this become "standardized?"

They are the only listed sponsor of firerehab.com. Note the dramatic scrolling list of news with a bent towards CO poisoning incidents.

The are behind firegrantshelp.com because the sponsor of this site is firerehab.com (sponsored by Masimo) Check out their sponsors page. Grants for CO-oximetry anyone?

They have sponsored most current research on CO-oximetry. They also regularly sponsor sessions at conferences which relate to their products.

They have giant booths at EMS and fire shows. They give away big things. I got a nice duffel to carry my dirty laundry home from JEMS.

While not a smoking gun, it is interesting to note that some links to materials on CO-oximetry are dead links including a link to an IAFF PDF on firerescue1.com and the Masimo Carbon Monoxide Training Center at the National Paramedic Institute

Enough already. While companies have the right to push FDA approved devices as much as they want (and make as much money as they want) this borders on exploitative and manipulative. How about taking the money you plan to spend on your next round of pointing out just how necessary and important your product is and REDUCE THE $4,000 PRICE TAG so it can do some of the good you claim it does?

Masimo stock, in its IPO on 8/7/07, was offered at $17.00. At last close it was $40.25 (a 136.8% return in just over 4 months). Despite all the good Masimo may claim to be doing through its lectures, curriculum development and web site sponsoring, let's face it, it is about making money for the corporation.

And back to NAEMSE, the letter was wrong. Period. NAEMSE needs to disclose to its members how much it accepted from Masimo on what dates, who wrote that letter and offer an apology to its membership for this ethical lapse--whether intentional, by oversight or appearance.

Am I ungrateful? No. Practical? Likely. Skeptical? Definitely.

Beware of anyone who takes such lengths to tell us what we need. If it was this important wouldn't it be obvious? Maybe the need to spend $4000.00 isn't as obvious as some would like us to think.

Rampart, we're on the way in with a...

2007-12-14T00:12:00.000-05:00

...Cocker Spaniel with a broken leg.

In Michigan, Rampart is the animal emergency clinic and the rig bringing in the dog has lights and sirens...if a bill currently in committee makes it to law.

Siren sought for pet ambulance

Just figured I'd lighten the tone a bit after the NAEMSE/Masimo post. I'll have a follow-up for that in the next few days.

As always, thanks to Paul Maniscalco's listserv for finding some of the most unusual stories in EMS.

Be careful out there.

Has NAEMSE gone too far?

2007-12-10T09:02:00.000-05:00

I was doing my daily search of EMS news recently and found a press release on EMS1.com from Masimo touting how the the National Association of EMS Educators made a critical medical announcement:

NAEMSE Letter to Members Warns of Critical and Fatal Implications of Missing the Diagnosis of Carbon Monoxide Poisoning

IRVINE, CA - Masimo (NASDAQ: MASI), the inventor of Pulse CO-Oximetry and Read-Through Motion and Low Perfusion pulse oximetry, today announced the National Association of EMS Educators (NAEMSE) has issued guidance to all its members advocating carbon monoxide screenings for patients presenting with any of the signs and symptoms of carbon monoxide poisoning or suspected exposure. In addition, the organization is advocating enhanced carbon monoxide training programs for all EMS professionals to help improve outcomes and save lives.

In a letter to its membership issued earlier this month, NAEMSE said failing to diagnose carbon monoxide (CO) poisoning during the emergency response efforts may lead to poor pre-hospital decisions, including failure to transport, failure to transport to an appropriate facility, failure to properly treat and failure of the emergency department to diagnose. The consequence of misdiagnosis can often result in returning the patient to a poisoned environment, possibly leading to a fatal outcome. Recognizing that CO poisoning-the most common form of poisoning in the United States-is notoriously difficult to detect, NAEMSE said improved screening and implementation of proper carbon monoxide EMS training programs "can no doubt lead to improved outcomes for patients and potentially save many lives."

Too often, even the most skilled first responders can miss the chance to treat carbon monoxide poisoning early because until now there hasn't been a fast, accurate and noninvasive way to detect elevated levels of CO in the blood. However, with the Masimo Rainbow SET Rad-57 Pulse CO-Oximeter, EMS professionals can easily detect carbon monoxide poisoning on the spot in just seconds with the push of a button, allowing for prompt and possibly life-saving treatment. In addition, Rad-57 can also limit the likelihood of long-term cardiac and neurological damage that can result from non-fatal exposures.

"We see first hand the overwhelming and immediate need for carbon monoxide screening during the first response stage and the importance of standardized carbon monoxide training protocols for EMS professionals as a matter of public safety," said NAEMSE President Angel Burba.

NAEMSE will soon have a new online training program available to all its members, free of charge, on their website www.naemse.org. The program-consisting of four carbon monoxide modules developed by Dr. Bryan Bledsoe and approved by top EMS physicians and professionals-covers the physiological dangers of CO poisoning, its signs and symptoms, as well as noninvasive methods for on-scene detection of CO in the blood. The modules include downloadable student workbooks, instructor manuals and PowerPoint slides for classroom presentation. Dr. Bryan Bledsoe is an emergency physician, highly regarded as one of the premier educators in the EMS field, and the leading author of numerous EMS textbooks.

Joe E. Kiani, Chairman and CEO of Masimo stated, "NAEMSE's recommendations for proper EMS training and field screening of carbon monoxide poisoning represents an important milestone in the establishment of new protocols for emergency responsiveness and improved public safety. If implemented nationwide, these recommendations will help reduce morbidity and mortality from unsuspected cases of carbon monoxide poisoning."

Coincidentally, NAEMSE's website welcomes Masimo as a new platinum corporate sponsor. Does anyone smell a pay-off? Can you guess who funded the development of the educational materials on the NAEMSE site? Does anyone actually think that someone at NAEMSE wrote that letter? It smells of being written by Masimo and copied onto NAEMSE letterhead--letterhead quoted on sites like firerehab.com (sponsored by Masimo) and healthcare purchasing.com as shameless Masimo ads.

Perhaps most disturbing is the between the lines implication that CO-oximetry may have a routine use to catch those sneaky non-diagnosed cases of CO poisoning.

Remember when we were all incensed when the AHA pushed Amiodarone after the manufacturer built them a new auditorium? How is this any different? And why would MASIMO do this with NAEMSE? Couldn't they get any clinical associations (e.g. NAEMSP, ACEP) to jump on with this sales pitch?

As a matter of fact, letters in Annals of Emergency Medicine are clearly divided on carbon monoxide poisoning and the role of these devices and act as a good representation of the fact that more research and technology improvement is needed.

O'Malley (O’Malley GF. Non-invasive carbon monoxide measurement is not accurate. Ann Emerg Med. 2006;48:477–478) stated:

We prospectively non-invasively measured COhgb on every ED patient. By the end of the second day of the study, we identified 5 false positive pulse co-oximeter readings. Every patient with an elevated COhgb level as described by the pulse co-oximeter had normal serum COhgb as measured with the blood test (100% false positive). The ED staff became distrustful of the pulse co-oximeter and lost interest in recording COhgb readings on every ED patient. We officially stopped the study after recording COhgb non-invasively on 328 patients and identifying 5 false positive COhgb readings

Suner, et.al. (Non-Invasive Screening for Carbon Monoxide Toxicity in the Emergency Department is Valuable Selim Suner , Robert Partridge , Andrew Sucov , Kerlen Chee , Jonathan Valente , Gregory Jay Annals of Emergency Medicine- 2007 May (Vol. 49, Issue 5, Pages 718-719) replied in a subsequent letter:

...To discredit a new technology based on 5 cases in a study which was stopped after 2 days is premature. Screening tests will have false positive results. Although confirming false positive results by performing venous co-oximetry has costs associated with it, identifying occult cases of carbon monoxide toxicity may prevent significant morbidity and mortality. With new technology in the field of medicine, frequently there is initial skepticism and growing pains. Similar complaints were evident when pulse-oximetry was first introduced in health care to measure oxy-hemoglobin concentration. It took months if not years before this technology was accepted. Now it is an indispensable tool in our diagnostic armamentarium and arguably a fifth vital sign. It is too early to determine the precise use of pulse CO-oximetry technology in the ED. The scientific community will weigh the data as it becomes available in the literature.

The take-home point in this case isn't in the statistical or research dispute. The issue is clearly stated in the last two sentences of Sumer's letter:

It is too early to determine the precise use of pulse CO-oximetry technology in the ED. The scientific community will weigh the data as it becomes available in the literature.

In short, it's not time yet.

In a position paper, "Critical Issues in the Management of Adult Patients Presenting to the Emergency Department with Acute Carbon Monoxide Poisoning," (October, 2007) the American College of Emergency Physicians states that there were 491 accidental deaths from carbon monoxide poisoning in 1998. Non-fatal poisonings were estimated at 15,000 - 40,000 with an acknowledgment that numbers may be higher because of misdiagnosis.

This post is getting long. Look at the references listed here. Make your own decisions. Here is the Dan Limmer position paper as a conclusion:

1. Masimo appears to have funded every study, education curriculum and press release out there.
2. NAEMSE went too far in issuing the press release and recommendations. I'm OK with the curriculum--generally and as a resource for educators--but am opposed to any statements or veiled implications making CO-oximetry a standard of care at this time. I believe this endorsement timed with platinum sponsorship by Masimo takes credibility away from NAEMSE as a national leadership organization.
3. I question the need for every agency to run out and buy a $4,000 device at this time. It is clearly not a standard of care. The scope of carbon monoxide poisoning cases as noted above does not warrant this designation.
4. In firefighter rehab and suspected carbon monoxide cases it may be useful (duh!) and we didn't need fanfare and press releases to tell us this. Firefighters deserve the best of care. In this area CO-oximetry may be useful and warrant recommendation.
5. The technology is in its infancy and will likely improve to be more reliable. At this time any implication that routine screening of patients is necessary or even suggested is nonsense and may in fact cause unnecessary transport and additional invasive testing.

The end.

Motorist charged in fatal ambulance crash

2007-12-07T12:41:00.000-05:00

I have several posts on this blog in reference to an ambulance crash that killed paramedic Allan Parsons and seriously injured EMT/driver Arlene Greenleaf.

Today the Associated Press reported the driver of the vehicle that struck the ambulance was intoxicated and has been indicted for manslaughter and operating under the influence of alcohol at nearly twice the legal limit (0.15% BAC).

TURNER - A 30-year-old Turner man has been indicted on charges of manslaughter and drunken driving arising from an early morning crash last summer in Turner that killed a paramedic while he was tending a patient en route to the hospital.

Christopher Boutin is accused of crashing his pickup truck into an ambulance on Route 4, killing 46-year-old Allan Parsons of Wilton. The ambulance driver and Boutin were seriously injured.

Investigators said Boutin was drunk at the time of the July 5 crash and failed to yield to the ambulance, which had its emergency lights on.

The indictment handed up Thursday said Boutin's blood-alcohol level was more than 0.15, which is nearly twice the legal limit for drunken driving.

My continued heartfelt sympathy goes out to the Parsons family. My sincerest wishes for continued, speedy recovery to Arlene Greenleaf and her family. Although nearly 6 months have passed, the impact of this crash will be ever present for these families over the holiday season.

EMS Response: Man Colds

2007-12-06T19:50:00.000-05:00

How many times have you been called for "emergencies" EMS shouldn't be called for?

Did you ever notice men are weenies when they are sick?

This video addresses both.

Accessories make the man...

2007-12-04T14:54:00.000-05:00

According to WBNG 12 news, a Johnson City, NY Fire Chief showed up to work last month wearing only a hat and tie. And I mean ONLY a hat and a tie.

JC Assistant Fire Chief Arraigned After Arriving At Work Naked

Apparently this was planned because his stepfather showed up to take photos. The chief was arrested for exposure of a person. Difficult to deny with photos floating around.

Oh, the jokes that come to mind... Wouldn't it be embarrassing to have the charges dismissed for lack of evidence?

I hope the hat and tie were at least Nomex.

Feel free to add your own.

Thanks to Paul Maniscalco's news emails for this story.

iPods for NYPD recruits

2007-12-04T14:31:00.000-05:00

NYPD Police recruits will all be issued iPods with training material on them. The iPods will contain laws, procedures and other material to study according to an article published by Reuters today.

"Now a recruit can watch a class on 'search and seizure' while going home on the subway," Police Commissioner Raymond Kelly said in a statement.

In a related story from 2005, NYPD blames iPods for subway robbery surge. I hope the recruits are armed if they study on the subway going to work...

If you would like EMS training material for your iPod I'm proud to say that we saw than need some time ago. Check out the EMT Audio Lecture Series.

Crashes and clashes...both too often in EMS

2007-12-03T19:57:00.000-05:00

The Burlington Free Press reported yesterday on a crash that killed a patient and seriously injured the EMT in the patient compartment.

The article, Crash spotlights ambulance risks, is a good review of the issues facing EMTs in the patient compartment. With winter squarely upon us we must all be careful out there.

In the clashes category, the Naples Daily News reports on a county system in transition: Power, politics and money beneath fire merger talks. And EMS is squarely in the middle of the clash. While the devil is in the details when negotiating any merger, success is measured years later by how well a central culture of quality and respect is created from several different agencies.

My best wishes to the patients and providers in Collier County for a successful merger.

Virtual hip replacement...test your skills

2007-12-03T19:49:00.000-05:00

Thanks to Libby at the Don't take life too seriously blog I am able to post a very interesting virtual hip replacement site.

See if you've got what it takes...and learn something along the way.

The award for most ridiculous medical procedures in a drama goes to...

2007-11-30T22:12:00.000-05:00

...Law and Order: SVU "Paternity"

I normally don't take TV shows seriously. I like the Law and Order series. It is always relaxing to watch a good psychotic murderer at 10:00 pm to wind down from a long day.

I tuned in this past Tuesday night (11/28) and saw a nanny murder with a side dish of infidelity, paternity issues and a botched murder-suicide. This only took 40 minutes. What could happen in the last 20 minutes? The worst medical procedural scene I have witnessed in some time on television, that's what.

Elliott Stabler's wife (pregnant, full-term) is being driven to a doctor's appointment by Stabler's partner, Detective Olivia Benson, when they are t-boned by a drunk. During the ensuing rescue the police detective (played by Mariska Hargitay) climbs back inside the wreck and starts an IV under the direction of a FDNY medic. She doesn't just start an IV...she starts an IV from a position an experienced medic would cringe at (but do). Then, without instruction, she tamponades the vein. The medic then hands in a small bag of fluid and instructs Benson to "squeeze the bag." She does, but rather than squeeze and hold the bag she performs this rhythmic squeezing thing that miraculously brings the patient back to life.

It is fortunate that she was brought back because she was then able to push like a fiend to get that baby out in the moving ambulance (sans stretcher straps) on the way to the hospital. Like we would want to intentionally deliver a baby from a woman with internal injuries, in a moving ambulance, alone.

Not surprisingly, she does easily deliver the baby (two pushes), who arrives in the world as all TV babies do (clean, without an umbilical cord, APGAR=10 and crying for mommy). Also without surprise, the patient loses consciousness again after delivering the baby.

I know it is a cop show and this was alleged drama but you really have to see it. If you have a PC you can watch the episode online. Or just watch the last 20 minutes. If you do, please leave a comment here to tell me what you thought.

I suspect that some (if not all) of the FDNY personnel portrayed in the episode were actually FDNY. My sincere condolences to you for having to participate in such dramatic fluff.

Remember when Johnny Gage started the IV on himself in the hose bed of the engine after being bitten by the snake?

Those were the days.

Just when you thought you knew the AHA CPR guidelines...

2007-11-26T23:10:00.000-05:00

It looks like more changes will be coming in the future. Studies--and the newspapers touting the results--all seem to point to doing even more compressions and fewer ventilations.

Compression most important in CPR, an article from the Houston Chronicle, reports on a presentation at the AHA sessions in Texas this month. A 50:2 compression to ventilation ratio reportedly improved survival significantly. Devices like the ResQPOD as well as hypothermia seem to also be quickly rolling down the pike.

What I find most interesting--and even refreshing--is movement away from blindly and fanatically following CPR guidelines. In years past you would've had all those cool patches ripped from your sleeve if you one-one-thousanded when you were supposed to one-and-two-and. Gasp!

This reminds me of an article I saw this summer from Wisconsin, Simplifying CPR, saving lives. I like these guys. Do compression only CPR to the tune of "Another one bites the dust?" Sign me up.

Is this medical heresy? Anarchy? Revolution? No, its maturity. We finally realized that guidelines are, well, guidelines.

It looks like I will soon get to add another item to the "things I was trained to do that we now know kills people" list: ventilations. It will have some great company. Stabilizing trauma patients at the scene, gallons of IV fluid, bicarb... Ah, the good old days.

EMS in paradise--and the training is free

2007-11-25T20:59:00.000-05:00

18% of the EMT positions in the city of Honolulu, Hawaii EMS are open. To remedy this (apparently sun and surf alone aren't enough) the city is offering paid EMT training. The string attached: you must work for two years after training.

City's offer: Get paid to become a Honolulu EMT

Before you sign up you should know the EMT course in Hawaii is 420 hours. If you would rather take the course on your own for college credit it can also be taken at the Kapi'olani Community College. The EMT course is 20 credit hours.

Aloha.

Real Life EMS

2007-11-24T20:24:00.000-05:00

I shot the photo you see on the right while riding with the Portland Fire Department MEDCU. I liked the photo because it was a slice of real-life EMS. Not blood. Not guts. Not dramatic. Just real life EMS.

It has been my contention for some time on this blog that EMS is about taking care of people. Finding the pleasure in simple moments with a patient will keep you vital in EMS when there isn't enough trauma, sirens and excitement any more.

I submitted this photo to an EMS magazine for consideration for cover placement. No go. I'll admit that it isn't the most dynamic photo. But it is real. And it is a moment.

Are we being fed a diet of excitement when in fact we really nibble on routine call after call?

I took the rejection relatively well. Then I thought more about it. Maybe I should create my own magazine: Real Life EMS. Imagine what would be between the covers of this magazine every month.

Imagine no longer. This blog will frequently host covers of Real Life EMS Magazine. The magazine covers you will see are a combination of satire and commentary. I'm sure you have experienced more than one of these situations during your real life EMS experience.

Here is the first cover. Click on it to see a larger version. Enjoy!

And you thought YOU were having a bad day...

2007-11-19T23:40:00.001-05:00

At least you're not this crew from Durham Region EMS in Ontario, Canada:

Ever loose your narcs and RSI meds?

Fortunately a citizen turned them in to a pharmacy who called police. Durham Regional EMS was quoted by the Durham Region News saying:

“Our thanks go out to the local resident and the pharmacy for their vigilance in noticing the container and contacting police so quickly,” said Richard Armstrong, the director of Durham Region EMS. “While this is an isolated incident, we continually review our procedures to ensure that proper protocols are in place to help safeguard against such occurrences.”

What else can one really say? I wonder what the conversation was like in the rig?

"Do you have the narcs?"

"I don't have the narcs. I thought you had the narcs."

Pause.

*&%$#@#()&^%$#$

Allan Parsons slide show

2007-10-29T22:03:00.000-05:00

It is difficult to believe that almost 4 months have passed since Allan Parsons was killed in an ambulance collision. I shot the funeral for the Sun Journal and also recorded audio.

I recently created an audio slideshow of the funeral which I am releasing so it will be available on the 6 month anniversary of his death. The ceremony was profoundly sad, yet remarkable in the number of providers present and the depth of the respect paid to Allan.

Alan Parsons' funeral slide show

Please feel free to place the link on your web site and forward this to anyone you wish.

Please take a moment to remember Allan and all those in the emergency services who made the ultimate sacrifice.

PowerPoint Slides

2007-09-07T22:39:00.000-05:00

This video will undoubtedly show you an EMS instructor you had at some point in your EMS experience. Enjoy

Life After Death by Powerpoint

NAEMT (again)

2007-08-13T09:31:00.000-05:00

You may recall that I recently commented that NAEMT was moving in the right direction.

Dan Gerard doesn't seem to be in agreement with this (at least in some regards). His blog gives his reasons for this. I'll let you read those and make your own determination.

I will say that, if true, comments by Ken Bouvier about the numbers of people voting is disruptive and seems to take remove some level of credibility from the process. It is also disturbing that some people received three ballots.

When I ran for president of NAEMSE a few years back several people called me alleging election manipulation at the NAEMSE office. (This is not sour grapes, by the way). It is an example of how organizations can lose credibility--both NAEMSE and NAEMT. And is in fact one difference between a powerful membership organization and a social club for a chosen few.

I have respect for Jerry, Ken and Dan. But it is now time to make this right, NAEMT. Get your records in order, create visible policies that prevent manipulation and walk the walk of the powerful membership organization. Not the social club image you appear to be trying to shed.

Aren't you glad you don't have Orland Park's trustees?

2007-08-13T08:51:00.000-05:00

I am continuing my "Aren't you glad you don't work in..." feature which highlights cluelessness, ineptitude or general bizarre behavior by municipalities toward those providing EMS. This week we'll talk about Orland Park, Illinois trustees.

The Orland Park Star printed an interesting article in reference to fire response to medical emergencies.

Orland Park sends an engine company if one is closer than an ambulance. This is pretty common practice and makes sense. In fact the Orland Park FD has an interesting web site explaining their "4 personnel in 5 minutes" benchmark. The site includes this video explaining their services and policy.

It seems the trustees don't get it. For example, trustee Kathy Fenton is quoted as saying:

"I live in the area of station five," Trustee Kathy Fenton said. "If we call for an ambulance, we get a fire engine, and if someone has to go to the hospital, we wait there for an ambulance to come take them to a hospital. I don't understand."

Let me see if I get this right. It is better to wait alone, without medical care, until the ambulance arrives?

Trustee Ed Schussler adds meaningful dialogue (NOT!)

"I think it's an accident waiting to happen when you have these big fire trucks. If they get into an accident with a vehicle, the citizens in the vehicle are going to lose," Schussler said.

Orland Park is doing the right thing for their citizens with the right attitude and getting their chops busted by politicos who just don't understand.

I originally thought that the fire department may not have educated their trustees properly. I did see that it was an acting chief addressing the group. But after seeing Orland Park's web site it doesn't seem education is the issue.

Perhaps the only thing that can fix this is the next election.