Emergency personnel should get drugs during pandemics

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

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

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?

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...

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

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

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

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

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

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

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

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

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

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

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?

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...

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

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?

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

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

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

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

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

Enjoy it!

My surgeon called me "dude"

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?

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...

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

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

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?

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

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

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?

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?'

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

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

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

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?

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

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

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

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

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



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

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

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

Long Island disaster drill delayed by traffic jam

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

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

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

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

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

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

Did you ever wonder what your obituary would say?

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

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

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

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

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

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

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

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

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

And so do you.

South Carolina EMS Conference

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

South Carolina Paramedic Championship

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

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

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

Reality check for this week

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

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

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

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

Ambulance or bus?

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

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

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:

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

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

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

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

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

Hi all,

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

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

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

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

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

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

Please feel free to forward this.

Most sincerely,

Jay Wiseman, JD

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

Blowing is OK in Europe

...for CPR that is.

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

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

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

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

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

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

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

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

Hands-only CPR

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

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

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

My email to Senator Exum

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

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

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

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

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

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

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

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

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

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

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

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

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.