The devil is in the details...or is it?

I recently had some comments from instructors and students about material in one of my books. I researched the answers, consulted with Ed Dickinson, our medical editor and replied to the queries. I always enjoy and appreciate these comments.

It was after I replied that I began thinking about a bigger picture. Let me explain.

The first comment was in reference to how many weeks a woman is pregnant. One source said 37 - 40 weeks while another was 38 - 42. Which was correct? The answer: pregnancies are "scheduled" to last 40 weeks from the first day of the last menstrual period (LMP) until birth. Some babies come early, some come late. A (very) few are born on the due date. Not an exact science. We use the 38 - 42 week numbers to reflect this fact.

The next question was in reference to flail chest. The book states a flail chest is 2 ribs broken in two or more places. The reader asked if it should be three or more ribs broken in two or more places. Good question.

This is what the trauma sources say:

• Lippincott trauma manual says 2 or more in two or more places
• Tintinalli and Rosen say three or more in two or more places
• The Mattox trauma book says "severe thoracic injury causing paradoxical motion of chest wall segments has been termed a flail chest."
• emedicine.com says three ribs broken in two or more places
• trauma.org says two ribs broken in two or more places
• PHTLS 4th says two or more adjacent ribs in two or more places

That's about as clear as mud isn't it?

The last questions is: Why do we say that we can suction for no longer than 15 seconds? Another good question. The most likely answer is that the longer we suction the more hypoxic the patient gets and someone thought 15 seconds was a good guideline.

But the real questions is: What happens if a patient vomits for 20...or 30 seconds?

These three issues actually leave me with a larger concern. How do we get our students and practitioners to think critically when we present (and test) very concrete facts? Lets look at the three questions again from a field perspective:

Pregnancy - the EMT asks how far along the patient in apparent labor is. 24 weeks (holy crap) 36 weeks (early but do-able) 42 weeks (really uncomfortable overdue mom).

Flail chest - is the segment unstable and interfering with breathing? Do we care--or even have the time to count--how many ribs are broken?

Suction - This patient won't stop puking. If I keep suctioning he's hypoxic. If I don't suction and start bagging I push the yuk down his throat and he dies in the ICU later from aspiration pneumonia. (The point: some patients die despite our best efforts to save them.)

These questions from instructors and students are real and necessary. There is an urgency to know these facts because they may be on exams. No one suctions or treats a flail chest unless they get the EMT card.

Do we need the 15 second and two/three rib rule or can we be more practically oriented? Do students and new EMTs need concrete rules or can they apply concepts and consequences under pressure?

Can we test without these exact numbers? Are they necessary facts or traditions that holds us back from better clinical thinking?

Enough for today. Add a comment to tell me what you think.

How many hours can you work?

Much has been said recently about working long hours and the associated risk of errors. Does your agency have rules about how many hours you can work consecutively or in a given week?

I spoke with a career firefighter recently who told me his department limited him to 3 shifts (72 hours) consecutively. Working in a slow house might not be so bad. Working a busy rescue...bad.

Even Reader's Digest has written about this in their article entitled Night Shift Nightmare. Although this is about hospitals and hospital personnel, I think we can all relate to the doc who fell asleep at traffic lights on the way home.

Want more info on patient safety and errors? Try: AHRQ Patient Safety network.

Be careful out there. For you...and your patients.

Where in the world is Will Krost?

I added Google analytics to my web site. It is an amazing tool. I can see where people have looked at my web site from. For example, people in Torokbalint in Eastern Europe looked at my blog, as have people in Spain and Pearl City in the Pacific.

Results have come from throughout the U.S. as well. I even got a hit from Findlay, Ohio. This is where Will Krost lives. I know it couldn't have been Will because he never has time to call or email me.

It couldn't be Will...

Memorial Day 2007

Although this post isn't about EMS, you'll notice that my bio says I am a photojournalist. I do freelance work as much as I can. This past weekend I shot a parade for the Sun Journal in Lewiston, Maine.

The saluting Navy Captain and parade watcher with the flag and reflected veterans are somewhat traditional parade and Memorial Day images which I was happy with. The Somali woman wearing red, white and blue didn't make the paper but was one of those images and interactions that will stick in my memory for some time. I love photojournalism for the same reason I love EMS. It is just great to be out there.

In our long Memorial Day weekends we hopefully took a moment to remember all those who have served and are currently serving in the armed forces. And to remember all those in the emergency services who paved the way for us, some making the ultimate sacrifice.

National EMS Week

This week is National EMS Week. I feel obliged to post something about this. Plus my wife (quite blog savvy) said she would kick my ass if I didn't. Despite the appeal of that threat...here goes:

May 20 - 26 is National EMS Week.

There. I did it.

But did you know that May 20 - 26 is also:

National Public Works Week
National Hurricane Awareness Week
National Epilepsy Week
National Safe Boating Week
Schizophrenia Awareness Week
Tinnitus Awareness Week
National Medical Transcriptionists Week
Waterfall Week at Whiskeytown National Recreation Area.

So, when the public works employee is injured and when the hurricanes hit and epileptics have seizures and people aren't safe in their boats and schizophrenics need help and people have ringing in their ears we'll bring them all to the hospital giving the transcriptionists something to do. Then we'll all go to Whiskeytown National Recreation Area. We'll need it.

Happy EMS Week!

Dan

First draft of EMS education standards released

The long-awaited first draft of the EMS education standards has been released. These standards--both the content and the format of the standards themselves--will have a profound influence on EMS and EMS education.

EMS Education Standards

There are several questions with links to submit comments online. I like that. Some of the questions and issues:

Can EMS education be competency-based (rather than based strictly on hours)?

Is an EMT class that is estimated to run 166 - 198 hours too much (as proposed it includes NIMS, CPR and HazMat orientation)?

Should EMTs have a greater knowledge of anatomy, physiology and pathophysiology in order to better understand assessment, disease processes and traumatic conditions?

Are the education standards and brief outline of content enough (as opposed to providing a detailed lesson plan)? Will publishers fill this in? (I believe we do that now anyway.)

And more...

Check it out. Offer comments.

More to follow on this important topic...

National EMS Memorial Service Lists 2007 Honorees

Between EMS week and the transition between spring and summer, May holds one other very important event for EMS: the National EMS Memorial Service.

This year 17 EMS providers who died in the line of duty will be remembered and added to the National EMS Memorial which, sadly, is without a home.

Of the 17 people honored this year, 9 died in medical aviation accidents. Three were killed in motor vehicle collisions, one died from complications from rescue work at the 9-11 site in New York City. One died from cardiac arrest, one from a fall and the last during a flood rescue.

An increasing number of EMS providers are participating in bike rides (as long as 600 miles) to show support for the National EMS Memorial Service and to bring attention to the cause. The National Moment of Silence is scheduled for Saturday, May 26th at 20:00 hours.

Let's show our support for the museum and those who died in the line of duty. Participate in the moment of silence and support a permanent, meaningful home for the heroes who are no longer with us.

Do iPods cause pacemaker interference?

Almost all news outlets reported this week that iPods may cause interference with implanted cardiac pacemakers.

The web site Unconfirmed Sources provided the "real" scoop with a sneak peak at the new EKG iPod.

Emergency Services Monument Dedication

I shot photos at the dedication of a new monument honoring emergency services personnel in Kennebunk, Maine over the weekend. This photo is of Cub Scout Joey Corbett (son of FF/Medic Jim Corbett) reciting the Pledge of Allegiance at the ceremony.

While there were many politicians (and designees of those who had much more important things to do) in attendance, the most moving speech came from a woman whose husband was killed in Iraq. Not only did she purchase and dedicate a bench in the park (her husband was a volunteer firefighter and SAR) but she spoke passionately about the job done by emergency services personnel.

It was a good day for the EMS, fire and police personnel in Kennebunk, Maine.

Virtual EMS museum open for business

Check out the new National EMS Museum's virtual museum:

National EMS Museum

Does a fire chief need a degree?

The position of fire chief is open in St. Paul, MN. The city of St. Paul lists qualifications for the new chief: bachelor's degree required, master's degree preferred. Only one person in the St. Paul FD meets these qualifications.

Does a fire chief need a degree?

The union has asked the city to lower the requirements so the job is in reach for in-house candidates. Currently only 1 is eligible. The city counters that thousands of unqualified people may apply if the bachelor's degree requirement is lifted.



The bigger issue: those in the emergency services need more education. The lack of education comes easily. Not all employers require degrees in their new hires. Some require degrees for promotion. The young person lands a career job. Bennies, retirement. He or she knows a degree is important--but now it is not a priority. Then the lure of overtime and the demands of a family continue the pull away from education. (Note: I speak from experience!)

Until an injury puts a person back on the job market. Or a provider retires at 45 and suddenly has no other skills or education. Or, as is the case in St. Paul, a promotional opportunity comes up. In all these cases its too late to start now.

Yes, emergency service providers have difficult schedules. Employers should step up to the plate with some scheduling concessions to make education easier. But with the quality, legitimately accredited distance education institutions out there, is there really an excuse for not pursuing a degree?

Take a look at:
Excelsior College
Empire State College

Both of these reputable, accredited schools provide distance education and mechanisms for evaluation of training and life experience toward college credit. And almost all local and state schools have some sort of option such as this.

$2.7 Million Spine Injury Verdict

Injured Jockey Gets $2.7M From Ambulance Company

A jockey with a winning track record received an award of $2.7 million after he claimed ambulance personnel transported him to a track first aid station without immobilization after he was thrown from a horse during a race. The ambulance company disagreed with the verdict.

This is an excellent example of how EMS providers and agencies can get sued--and lose. The stakes are high. For a moment place yourself in the shoes of the providers on this call:

If you were an EMT in a case such as this how important do you think documentation would be when you get to court?

Does your agency have spinal inclusion protocols? Do you follow them closely and document your findings?



It is important to note that there are two sides in every case. I have no direct knowledge of this case and make no assumptions of guilt or innocence. Questions are for educational purpose only.

35 Million More Seniors - Are we ready?

35 Million Seniors by 2030

USA Today reports that there will be 35 million more seniors in the population by 2030. Cities are working to prepare for this increase. Do we need to prepare? Is EMS ready?

When it rains, it pours...

JEMS.com recently reported on three stories about photos and internet text postings that allegedly violated several patient's right to privacy.

Missouri EMT Fired in Photo Scandal
Call Info Posted on Web Site
MySpace Comments Privacy Invasion?

While attitudes--and laws--about privacy have become much more strict, technology has created opportunities to capture images, then quickly and effortlessly post them for millions to see.

Employers are quickly creating policies aimed at preventing situations like this. Can it be prevented? How far will employers and agencies go?

Learning through photos

The students in our Wednesday evening EMT-I class participated in a photo shoot for EMS Magazine. After I sent an email asking for students to come to class in uniform--and for some prepared to bare their chests for the sake of education--the photoshoot began.

We shot a sequence for a CE article on thoracic injuries and an article on intraosseous infusion. Marc Minkler, who instructs the class, served as technical advisor and author of the article on IOs.

The students saw a shoot, learned procedures like trauma assessment and how to do IOs, and spent some time outside. Time outside is always a popular thing.

Medication Errors Hit Home

My 18 month old daughter had an ear infection. After a brief office visit with the pediatrician we left with a scrip for Omnicef. Off to the pharmacy. In this case I won't mention the pharmacy chain--I'll refer to the pharmacy as "Wrong Aid" to protect their identity.

After dropping the scrip off we did the obligatory 10 - 15 minutes of shopping with the unhappy child until the antibiotic was ready. When I got the bill it was twice what it normally was. The first alarm went off: this is different that the same scrip last month.

I asked a pharmacist who happened to be standing near the register (looking disinterested) about the difference in price. I was still working on the issue in my head. The dialogue (with unspoken thoughts):

Me: This is twice the cost it was last time. (I think something is wrong!)

Pharmacist: The co-pay is set by the insurance company. We have no control over that. (I got a Pharm.D to deal with these whiners?)

Me: But isn't that a big change? Has the concentration changed or something? (I still think there is something wrong.)

Pharmacist: (sigh) Let me look at it. No, it is right. Twice a day. There is enough in there for 6 days. (It is amazing that I don't dip into the Percocets because of these stupid customers.)

Me: 6 days? Isn't that a bit odd?

Pharmacist: That is what the doctor prescribed. There is enough in the bottle for that. 60ml. (Vicodin, Oxycontin...these needy parents of sick babies are driving me crazy.)

At this point I realized that the pharmacist was disinterested--and likely wrong. I decided to cut my losses and do what any self-respecting parent would do in this case: go to the Internet.

Sure enough it was more than double the manufacturer's recommended dose. The pharmacist who filled the prescription entered "twice" instead of "once per day." Interestingly that was a simple mistake and one which doesn't anger me nearly as much as the disinterested slug who could have caught the error. How?

1. When a flag is raised investigate why. My questions raised the flag--even though it was about cost--not dose.
2. The flag should have uncovered two points 1) Why treat an ear infection for 6 days? He obviously didn't pay attention during therapeutics class in pharmacy school and 2) 60ml is the EXACT amount for 10 ml/day for 6 days. Most liquid medications provide a bit extra since the dose pouring into a cup or oral syringe isn't the most exact. The correct dose (5ml/day for 10 days) would have left 10 ml extra.

"Wrong" Aid still calls me to apologize. Their risk management company called. I tell them all the same thing. The original pharmacist made a mistake. That happens. The second pharmacist blew me off and didn't care. That is unconscionable.