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.

Quotes of the day

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

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

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

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

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

Muddy angels

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

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

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

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

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

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

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

Dead men don't cash checks

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

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

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

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

Give the gift of pathogens

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


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



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


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

Political choking

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

From AP/ the Union Leader in New Hampshire:

Sununu saves choking journalist with Heimlich maneuver

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

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

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

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

More news is not necessarily good news

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

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

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

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

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

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

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

So much for mechanism of injury

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

‘Miraculous’ Recovery for Man Who Fell 47 Floors

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

Yet we have nothing else.

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

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

So many articles, so little time...

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

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

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

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

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

Be careful out there.

Why is it never discussed that EMS take over fire?

Did I get your attention yet?

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

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

Wow.

Read the rest here.

January 1/Chapter 1

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

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

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

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

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

I was wrong.

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

Happy New Year.

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