Lies, Damned Lies, and Pandemics

 Hello everyone it has been a long while. It is without a doubt fact that I have been lulled into complacency. See when you find a good job and great protocols you start to forget. Then Facebook and the media point out how Medicine is poorly represented in public. So let me unload on the pandemic myths that are there.

              1. FDNY is mad they are no longer allowed to transport patients in cardiac arrest.

Dear NBC News, given that you obviously have no fact checkers on your staff, I guess you can be forgiven. But if you really want to get to a scandal, allow me to make it clear to you. If FDNY are regularly transporting cardiac arrests they are literally going against every bit of research and the basic standard of care that is suggested by ever advisory agency out there, including the American Heart Association.

Let me spell this out, because while I am not a professional journalist, I am a professional paramedic. If you are transporting people in cardiac arrest you are wrong. You are literally decreasing their odds of survival. CPR in a moving vehicle is ineffective. They should be following the national standard of care.

2. US not having enough ICU beds

According the the Society of Critical Care Medicine, the United States had more ICU beds per capita than any country in the world. The only country that comes close is Germany. This part of why the US is doing so well

3. The US is doing poorly in its response.

Right now, according to the projected course, only one country is actually beating it. That is the United States. We are not perfect, by no means. And there is a likelihood due to bad faith of a company that decided to cancel a government contract that was awarded in 2014. The contract was reawarded in 2018 and the spin up was supposed to be complete next month to start production.

Both Presidents Trump and Obama did what they could. The sad thing is that this will cost lives. And lets be honest, there is a lot of blame to go around. But right now, a lot of the complaining is not fact based. Its based on placing blame. We need to work together. If you are going to get the Corona Virus, you should damned well want to be in the US outside of NYC.

Folks, people are going to die. Most people placed on vents die, not most COVID patients, most patients. We need to flatten the curve to make better use of our resources. We have a lot, and should have more. But in the end we need to look at each other as brothers and sisters. I hope this gets sent around. I hope some member of the news media gets it, and realizes that they are causing harm, We need to know the truth. Citations for several things are included below.

Correction, the contract was awarded in 2012, I remembered this wrong while typing it up. 

https://www.jems.com/2007/07/23/why-are-you-transporting-dead/

https://www.realclearpolitics.com/articles/2020/04/01/low_us_covid-19_death_rate_means_efforts_are_working.html

https://sccm.org/Blog/March-2020/United-States-Resource-Availability-for-COVID-19

https://www.nytimes.com/2020/03/29/business/coronavirus-us-ventilator-shortage.html

It has been a while

 Cognitive Dissonence, is something that seems to permeate this field like nothing else. I constantly see people who are the least likely to perform a a high level think they are the types to be in place for high speed clinical roles. You know this person, they complain because their ambulance is too small, think any transfer is below them and are mad because someone called the ambulance because Jimmy the Frequent Flyer is drunk an passed out. Basically any call that isn't a cardiac arrest or major trauma is below them. They use the helicopter for any critical patient if you are in a rural service, or they are the ones that transport more patients with lights and sirens than any two other people at your service. The insist that they are going to be on a helicopter though.

I point this out because many people seem to think that a lot of the job is below them and compassion is not important. I am not saying I never over triaged a patient to HEMS or transported a patient code three when it probably wasn't warranted, but I didn't do it regularly. I don't see how a medic afraid to take a patient on a 2 hour transport with a patient who is on a antibiotic drip or has a ventilator going is going to suddenly become more competent when they get to ride on a helicopter and call themselves a flight medic. Of course, most flight services have a lot of ways to weed out those people, but that doesn't change the fact the people who want to do the job most are often the least competent people there are available.

Rotor wing aircraft are not magical things with fairy dust sprinkling from them, they are nothing more than a really small ambulance with a highly trained crew on board. This crew usually consists of a Paramedic and a RN. Once released from probation they both are expected to perform at the highest level of care, not be mad because their bird is so small. We should remember that these men and women are motivated to be the best, and ground personnel should emulate them. Work hard at gaining new knowledge and learn why you should do things, not just what you should do. If you don't know why, you won't know when the protocol doesn't fit your patient.

I write this because I regularly hear people who have no desire to learn new things talk about how they want to fly, but ignore what makes those crews excellent. In the area I used to work, there was a high washout rate due to poor knowledge base. This is something many of these people could rectify if they too the time to actually look for better continuing education and consider the effectiveness not just the hours needed. Most of them have no idea what FOAMED is. The idea of a Podcast or Youtube video on new subjects aren't important, because that doesn't count on my needed hours. But by repeating the same courses and getting the same cards, they doom themselves and their patients to either worse outcomes or high bills from HEMS coming to save those patients from poor providers. But they think of themselves as heroes.

Don't be that person please. Your patients are depending on you to excel. The truly critical ones need you to be able to make a decision. It doesn't matter what type of ambulance you are in, if you are private, corporate, municipal third service, or fire department based, if you are a Paramedic or intending to become one, learn to love learning. The biggest enemy we have is ignorance, and it is easily curable.

Thank you again,

Lone Medic  

Musings and Advice for the state I left.

 It has been a busy year and to be honest, I haven't had time to write much. The amazing thing is that I truly enjoy this and hope that my audience does as well. So given that it is the holiday season and a time for reflection, I am going to reflect now and hopefully provide some insight.

This has been a year of momentous change. My wife and I have changed states and she changed employers, for a major improvement. This year brought an end to an association I have had since I first obtained my paramedic cert. The hospital I functioned under the longest no longer has any affiliation for me. In fact I no longer associate with any Illinois based EMS agency. This has been a breath of fresh air, as the more I am free from Illinois, the more I see how bad it really is.

I have made steps to improve my health and happiness which are both working out well. The reality is, that without the above move, I would never have been able to accomplish this. I am more in control and have better support than I have had in a long time.

Now this is mainly an EMS blog and I am going to continue on EMS here. The more I see of Illinois EMS the more I now understand why the Indiana hospitals I transport to looked at me like I was an idiot. There has to be a standard change in EMS starting yesterday. Where to start, well read on my friend.

Let us begin with the term paid on call. If you are running an advanced service the term paid on call should be nowhere in your salary description. For that matter, Volunteer should not be there either. I know some fine volunteer paramedics, but in rural Illinois, professionals are needed. Now this change means that these counties might have to either drop back to Basic Life Support or, gasp fund EMS. This is the reality of the situation. Now, there is the flip side of this, no service should have their employees showing up in faded holy jeans looking disheveled and unkempt. Nothing says I am going to help you more than looking like the guy or girl who looks like they are going to a bar or about to mow the lawn. Appearance and attitude matter.

Next, accountability, if you are operating on an ambulance you are functioning under the orders of a physician. If said physician is not involved in service there is a problem. If you can't pick your Medical Director out of a line up, how can he have any clue what type of provider you are. This is the reality I have learned. Every agency should have a regular chart review, with said physician involved, as a part of their yearly continuing education. If your reviewing charts monthly and presenting case studies, Medics know that poor care will be noted and exemplary care will be acknowledged. This accountability also allows for protocols to be reviewed because it will show a need for changing them in a more expedient fashion

Finally, vehicle operations, I work in a city that a lot of Illinois services transport to. That means I get to see you coming in lights and sirens. You are likely driving too fast, not using Due Regard, and honestly not needing them most of the time. This has to stop. Not, this isn't entirely your fault. Rural Illinois EMS has this culture that Lights and Sirens are important. Well, considering the wealth of evidence that says time is not usually of the essence and that in a lot of those time sensitive situations, the Lights and Sirens create more problems due to anxiety and increased likelihood of an accident, stop it. I really do not want to respond to an ambulance accident, especially if it is someone I know. Oh and if it is a BLS transport, there is literally no reason to have those stupid things on.

As always,

Lone Medic.

A Guest Blog from a Passionate member of the EMS community on Punitive Medicine.

My Thoughts on Punitive Medicine

      Nothing in EMS angers me more than punitive medicine, which can easily be defined as not properly treating a patient based on their “station” in life. I have recently heard fellow providers brag about using unnecessarily large IV’s, with holding pain management, and perhaps worse of all flipping a patient upside down on a back board. These acts, and others like them, are without a doubt deplorable. I am ashamed to call anyone who “practices” this type of medicine a colleague.

     I know we have all responded to that one address that calls at few times every week. What happens if this time the chest pain is not a cry of the lonely but an MI? You know the one that was missed because old Mrs. Jones calls for this very same reason at least three times every week so we didn’t do an assessment or talked her into refusing care because she’s just lonely? Sign here ma’am. Call us back any time. Empty words. Or how about the drug addict? Should we treat him any different because he’s asking for his problem and should be able to control his addiction? Then there is the inmate. 16-gauge IV just because we can, right? Single mom with three kids who called for a child with a runny nose? She should have taken him to the doctor Friday instead of interrupting our nap time. I could easily list several more examples.

       As professionals, we need to remember that every patient we meet is somebody to someone. Why is it we feel superior in our dealings with such individuals that we feel the need to pass judgement? How is that in any way our right? As professionals, we should not judge simply because we have not walked a mile in our patient’s moccasins. We cannot say “well I wouldn’t” because we have no idea how we would handle those experiences. Our actions, either appropriate or inappropriate, leave a lasting impression on our patient. How do you want to be remembered?

      First do no harm. I know that was part of my education in EMS, as well it should have been. It should have been part of your education too. It is my opinion that punitive medicine goes against the very core of this idea and is morally and ethically wrong. In utilizing punitive medicine, we lower ourselves to the least common dominator, making our profession look heartless and uncaring. Is that how we want the public to see us?

     I would like to close with two Bible verses. James 4:17 If you don’t do what you know is right, you have sinned. Luke 6:31 Treat others just as you want to be treated. Christian or not, good words to live by, not only as we take care of the people entrusted to us but also as we deal in our day to day lives.

An open letter to St. Louis Fire

Dear St. Louis Fire:

                This is an open letter to try to help you and the city solve your ambulance problem. Allow me to qualify this with something I think needs to be stated, St. Louis Fire does an excellent job in delivering EMS. It is clear that your current model delivers excellent care and allows EMS to govern its own. You also have a robust mutual aid system utilizing your local private Advanced Life Support providers to ensure your citizens are well taken care of in times of system overload. Overall your system is to be respected.

                So here comes the criticism. I recently read that you are wanting to increase the taxes on your citizens to purchase several new trucks at a cost of two hundred and fifty thousand dollars apiece. Now, far be it from me to begrudge any ambulance upfitter the significant increase this will make to their bottom line, but I can’t see this as the best solution for the taxpayers of St. Louis. So I will try to point out a better solution.

                As a paramedic in a Urban setting, I understand the city can be busy and restocking can be difficult so there is a need for modular units. So that has to be part of your bid process. But in my humble opinion, wouldn’t the city be better served by moving to a type 3 Sprinter Modular unit.

              While it has been a while since I speced out an ambulance, but I would bet that a sprinter Type 3 with custom interior designed to your needs would save between seventy five and one hundred thousand dollars. It will also fuel costs and have lower maintenance costs. These savings could be used to put more crews on the streets improving coverage.

It seems to me that St. Louis should continue their tradition of proving that Fire Based EMS can provide excellence. Many places don’t hold up to scrutiny, but St. Louis has. The City of St. Louis, and its citizens would thank you. Please continue providing the amazing care you are known for.

Just a humble suggestion,

Lone Medic.

Not my nicest post ever.

                Arrogance, ego, confidence, terms that are often used to describe paramedics. What is rarely discussed is the people behind the title and how they impact the profession and themselves. We all know the guy who has yet accept anything that wasn’t done in his course. Fellow Blogger Ambulance Driver calls this one year of experience twenty times, by the way, if you haven’t checked out his blog you should. We also know the guy who can constantly quote the newest research and is either breaking protocol or getting orders to do what he wants because he can back up his ideas. From a coworker perspective both of them are frustrating, but let’s be honest, no one wants that first guy taking care of their family.

                Most paramedics fall somewhere in between. They are not actively seeking the best knowledge ever, but they do know that things change and accept it. If you are this guy, don’t hate yourself because you are probably going to be considered a reliable employee, be well liked  by your peers and do a lot of good. This is not a criticism of you.

                There is a need to criticize and worry about the person who hasn’t sought out new knowledge or accepted it. When you are constantly looking to find a reason to defend a practice as barbaric as full spinal immobilization, you are this guy. You can quote all of the cliché’s and not know any of the truth behind them. You sir are a menace to my profession and need to find a less dangerous form of employment. Please, for your patients sake.

                Then there is the research guy. You coworkers tolerate you, because you are often right, but when you make a mistake it tends to be larger. That being said, you do err on the side of your patients. Your problem is you are not considered a team player. You are great at work, but dinner with your coworkers, not so much. Often discussing a ball game, movie, or band is impossible. Here is advice, go see a movie. Let EMS go away for a little while. Remember that there is life outside of the ambulance. Believe me, you can still catch up on research and still enjoy things. Remember Isaac Asimov and Albert Einstein loved the three stooges. Nyuk Nyuk Nyuk.

Sincerely,

Lone Medic.

Sometimes things are hard to say.

                People who know me are aware of my strong support of science and evidence based care. If you’re my friend you know that as long as you don’t betray the friendship, I am there when you need me. So when I recently discovered that a friend of mine was being treated unfairly because of ignorance, it wasn’t surprising to those that know me that I was irate.

                Clint Moore is a Paramedic for Air Evac Lifeteams, a flight service that does a lot of good including educational outreach that has improved the knowledge base of many providers. When Clint learned he was HIV positive he was taken off of flight status, and told he would have to gain approval of multiple states to regain this. I understand that this is likely due to state rules, and Air Evac was stuck in a situation because of this, but the very idea that a Paramedic with HIV is a threat to his patient is both statistically unlikely and an insult to the professionalism of the Paramedics and Nurses that make up these teams.

                A quick review for those of you that are unaware of this, HIV is a blood borne pathogen that requires specific vectors for transmission that would necessitate a healthcare provider to intentionally infect a patient. Accidental transmission in a clinical or prehospital environment would be nearly impossible. Basic BSI precautions, which are used on every call, will prevent this.

                The reason I state this is because there are laws in place that prevent these providers functioning. Laws like this serve only to punish these people, and prevent good providers from performing the duties they are educated and qualified to perform. The only reason laws like this are on the books is due to the fact that the most common people infected with HIV are homosexual and bisexual men, a group that is still commonly looked down upon. It is legalized discrimination.

                So when my friend found out he was infected, he reported his status and was punished, despite the fact that he was not a serious risk to his patients. Because of archaic and bigoted rules, if you act in a responsible manner you become more likely to punished, than if you just keep your mouth shut. That is pathetic.

                That is the technical and legal side of this. Now let’s discuss the other side of this. Clint is not a friend I get to see or talk to as much as I like. Life happens and those that we are close to often leads us to be far apart. But this man is my friend. Clint has had his career and purpose stripped from him, despite the fact that he did the right thing. But, when he went public he found out something he didn’t know. His friends will be there for him. If you have this horrible disease, or know someone who does, make sure they know you care and are there for them. The stigma attached to it is known to make those afflicted feel isolated. They are still the person they were before this happened, and they likely need your support, friendship, and love more than ever.

Thank you,

Lone Medic.

The legacy of a man, Rest in Peace Dave Kaye.

                Friend, colleague, soldier, teacher, paramedic, convicted murderer, it would seem that one of these terms didn’t belong with the other. Well, allow me to tell you about a man named Dave Kaye. Dave was a flawed individual. A boisterous man who knew of the mistakes he made and never tried to hide from them. He instead chose to take another path and in the process proved that a man can change his destiny.

                When I first met this man, I never expected that he would influence as many people as he did. First impressions would tell you that he was nothing more than an arrogant, loud, and abrasive person. Till he got to know you, he was a bit standoffish. But if you wanted to learn, and he knew something, he was always willing to teach. From advice to a laugh he gave what he could and we all remembered this today.   

        

                Allow me to explain something here. Illinois used to have a program that allowed prison inmates to become E. M. T.’s. It was a successful program that lead to many people turning their life around. This program is no longer active for many reasons, but it was a success. I am a firm believer that we need to find ways to help those who are convicted of crimes reintegrate into society. This is what Dave did.    

                      

                Too many people found out about the bad part of who he had been and failed to recognize who he became. Dave owned his past, never making excuses or acting like someone else was to blame. Instead he chose to become better than that. I mention his past because unlike most paramedics, his legacy isn’t the lives saved or the families he comforted. His legacy is something greater, hope.

                Hope is what he embodied. Hope that a man doesn’t have to be defined by a horrible mistake. Hope that choosing to be different can lead to a better place. Hope that redemption is possible. Dave lived the statement, YOU CAN BECAUSE I DID.

                I come here saying this because on April 3, 2015, this man passed on to his eternal reward. In the back of the ambulance today taking him on his final trip, we laughed telling stories of this man. We all realized how he influenced us all. Too often we forget that the most important part of the journey is those who we teach and those we inspire. The end is that we are not ruled by the mistakes we made and we can all change.  Dave my friend, rest easy brother and enjoy your rest, we have it from here.

As always thank you for reading,

Roger Morgan

NRP

An Open Letter to Holly Monteleone

Dear Holly,

     I am writing this to express both gratitude and disappointment. For what it is worth, allow me to state that you are a good representative of EMS overall. You present yourself as a compassionate caregiver and professional Paramedic. You do EMS a great service and as a father and husband of EMT's I am glad to a strong, intelligent, positive female being put forth as a provider. Thank you for this above all else.

     EMS has needed someone like you to be highlighted. Your performance makes us look good while showing that being a burnt out miserable individual is not what we should aspire to be. Your demonstration that good patient care and being positive are needed. Personally, your being inked shows that those of us with tattoos are capable of being professional and courteous. Add in your being well spoken, intelligent, and attractive and we have a rock star paramedic.

    This is why I was disappointed in what you having a negative attitude about Dr. Bledsoe and his criticism of the PAF t-shirt. While overall I consider PAF to be a positive group, as in they tend to not attack science and are great in supporting needed EMS ideals such as the Code Green Campaign. But the T-Shirt that was pointed out is something that while it might seem fun, has a negative impact on the profession. I will go even further if PAF was private I would consider it to be a necessary page.

    Gallows humor and venting frustration is healthy, but I tend to be critical of these things in a public forum. The public can't understand it, and often sees it as being uncaring. I am a small time blogger and this is part of my personal way to relax and blow off steam. But I saw this and felt I should point out that you are now the face of EMS. No individuals like Kelly Grayson, Chris Cebellero, or other provider. You are on television and highly visible. There are those out there that would tear you down. There is a likelihood that you will wind up interviewed on EMS issues. In short you represent us all, and we could do a lot worse. Thank you for reading this if you do, have a great shift, and stay safe my sister.


Roger Morgan

Lone Medic

Depression, Change, Friends, and Recovery.

It has been a while. During this time I have changed jobs, had some family problems, and I fell back into the an old enemy, depression. We in EMS are big on hiding from our pain and acting like it doesn't affect us. We often hide through substance or self abuse. I personally became aware of it when I snapped on my wife and made an inappropriate statement in front of a patient. These are out of character for me, and this showed me that I was having a problem. My old pal depression was back.

Depression is an affliction that strikes many in EMS. We are told to get tough. If it shakes you, then you are in the wrong job. You should not allow yourself to become that close. Just put it behind you, you can't do anything about it. But that doesn't work, because to be good at what we do, we have to be able to empathize with our patients. Empathy requires that we feel. It cannot be faked or compensated for.

So on to my story, when I was shocked into action, I started reaching out. Many of those that listened to my private rants and offered help are members of the Code Green Campaign. I was also offered assistance from my employer, which was welcome. My employer has a plan in place to assist employees in trouble that is available from day one.

So far, I have been able to avoid medication, but I was forced to do some serious introspection and evaluation. I am doing better, but I am still considering medication. I am going to share some of the things that helped me. The most important thing was to admit that I was depressed. You cannot beat this or even fight it without admitting it. I know people that have ruined their lives trying to drink, use drugs, or sleep around till they feel better. This does not work. It will make things worse, causing often irreparable damage to you relationships, the very ones you will need to ensure you make it through this.

I took a step back and examined what I wanted to do with my life and was EMS part of it still. I recently changed jobs, and increased my commute for slightly less money, but it was improved by the increase in benefits. I also had a truly private problem, that I will not discuss here. But in changing jobs I left the state I started in. I was not happy working under the system I was in. Even though the system was systemically broken, I felt as though I had given up. That was part of the problem. I had also labored under that system with the goal of changing it. I had to leave.

So I took I reached out to those who were on my side. I talked to people who had been through it. I also read some articles that allowed me accept that my emotional involvement was a good thing, something I should have remembered. Also I was reminded that leaving is sometimes necessary for perspective and growth. But it made me feel like I was a failure. See in leaving Illinois, I realized I had to abandon that fight from the frontlines. It was like a divorce. Probably for the best, but still feels like a failure. So I am winning the struggle. It isn't over yet, but I am happier now.

The following blogs are part of what helped me.

http://www.ambulancedriverfiles.com/2007/07/27/perspectives/

http://www.ambulancedriverfiles.com/2007/06/23/grief-sponge/

http://www.ambulancedriverfiles.com/2007/07/24/seeking-words-of-balm/

http://thehappymedic.com/2014/04/suicide-know-when-to-ask-for-help/

http://www.lifeunderthelights.com/2009/10/28/dear-state-of-illinois-emshellip/#sthash.uyFvxhfj.dpbs

These are but a small amount of the EMS blogs out there that I read. They allowed me to accept that I was ok. Changing jobs, feeling pain, these things are ok. Asking for help when it hits is ok as well. Sometimes, you have to understand that you can't change the world alone. If you are a provider that is in this place. Message me on here. Ask your friends Ifand employer for help. Talk to someone. You are not alone. EMS Suicide it a disease we inflict on our own. I refuse to be in that statistic. I hope you agree.

To those who helped me, actively or passively thank you. To those who are in trouble, you are not alone. Please visit and donate. These folks do good work.

http://codegreencampaign.org/

Thank you for your time,

Lone Medic

A simple concept that is often forgot.

First and foremost, I would like to recommend that any EMS professionals reading this take your time to listen to the Inside EMS podcast. Kelly Grayson and Chris Cebollero. Follow the attached link and enjoy. The EMS news, clinical information, and guests provide insight into the future of EMS. Please follow the attached link. http://www.ems1.com/columnists/inside-ems/

                Now on to the new post. You sit around any EMS squadroom and you hear people talking about the calls they had and amazing skills they performed. From catching a STEMI early to quickly managing an airway. I know I am guilty of this myself. We have a lot of bravado in this professional. But we are often missing what makes people remember you in a positive way.

                Taking time to do little things often improves the patient’s opinion of you. There was recent discussion online about whether or not you should allow a patient take a selfie with you after appropriately managing their pain. Really, a patient wants to brag on how you helped them in an extremely modern way and you think it is a bad idea.

                I have saw and helped other EMS personnel take a few extra minutes with a patient ensuring their dog was fed or their lights were off. These might seem like small things but they relieve anxiety. These acts of kindness also help providers reconnect with the humanity we often try to leave behind. They are a form of compassion that should be encouraged.

                Compassion, that is often considered a word of weakness. In a world where providers grab up t-shirts that say things like here to save your ass not kiss it or drive safe or I get to see you naked. We celebrate the burnouts and listen to people who actively encourage negative attitudes about the profession. I know those dialysis appointments are a total waste of your time, even though you are providing an actual lifesaving service at the time. Yet being nice and compassionate is often the most effective way to have a real impact on your patient.

                I was recently called to a patient where I had transported a member of the patient’s family. The patient was a pediatric and was apprehensive until they were told by the family member how I treated them. One seemingly unrelated act allowed me to effectively manage a situation. Learn to be proud of getting the hugs from your elderly patients. When you are getting these responses you know that you are providing compassionate care.  They won’t remember you starting an IV or rapidly intubating them to save their life. They will remember you treated them with respect and care. In the end that can make the difference between being able to appropriately intervene and not.

 

                                                                                                                                Until we meet again,

                                                                                                             Lone Medic

Listen to the cry for help.

                I recently read Kelly Grayson’s new article on EMS1. Now most people who know me, know that Kelly is on my required reading list, and that I am occasionally fortunate enough to speak with him. So the linked article was a final push that lead me to posting this particular post.

                In 2006, I was clinically depressed. My marriage was on the rocks, I hated EMS. I had no prospects for improving things. I was near the end of my rope. I had a continuous stream of bad calls, which sooner or later gets to you. But I was fortunate. I found a job that allowed me to use my talents, knowledge, and experience while lowering my overall stress level. I jumped at it, and will forever be grateful.

                I was lucky. Many are not. We need to look for the signs of depression and burnout in our fellow EMS types. We often hide our problems from fellow EMS personnel, as well as friends and family. We have to look out for one another. Please help your brother and sister EMS personnel. If you’re in trouble, please get help. Use whatever recourses you have immediately. We lose to many to despair and depression.

 

Kelly Grayson's Article. http://www.ems1.com/ems-advocacy/articles/1679642-Why-we-should-always-look-out-for-each-other/

Thank you Kelly, We need more like you,

 

Lone Medic

Mentorship and professional development.

   

              I had an encounter with a decent young EMT who was leaving the field. This young man had a strong sense compassion, the ability to think, and truly wanted to help people. He was not helped grow as an EMT. He was not taught the things he should have been. His partner was quick to blame him for any failures. He seemed to think that he should take responsibility for things that went wrong. I happened to be driving while he was finishing a PCR when we were dispatched to an emergency call. It took us an inordinate amount of time due to confusion on my part. He was willing to take the blame for this as he was quitting, and thought it was ok. That’s when I started seething.

                When I started in this business, I had several Paramedics and senior EMTs who took time to ensure that my questions were answered. They reassured me when I thought I did something wrong. I was corrected when I actually was wrong, but at no point was I belittled. I was mentored. We didn’t call it that, it was just how things were done. If someone wanted to be an EMT and was willing to listen we helped them. Now to be honest, we often eased or tried to force people out who we noticed were dangerous.

                Everyone was given a chance because you never knew who was going to have the ability to do the job. We took time to cover skills that were often neglected in class. We listened and took time to help them deal when that bad call came. We had a lot of people turn out to be good EMT’s and some of them became Paramedics with the talent and understanding. It seems silly but it worked.

                This seems to be gone these days. People make mistakes, and new people are unsure of themselves. Someone’s inexperience should not be an excuse to shift blame to them. These people need your guidance. When you make a mistake, own that mistake. Show the new person that mistakes should be a chance to improve. Learn from your errors and grow from them. Teach these things to new EMTs.

                I mentioned a bad response time earlier. I went to the Supervisor on duty and took my concerns to him. I readily admitted that I was the one in error. I also took my concerns to him. As an employee I felt it was my job to pass on my concerns. I also explained to the young man that he did not want to burn his bridges. He might want to come back one day. I hope that he returns to EMS, as we need people who have the passion to help others.

                A blogger who I respect has stated the good judgment comes from experience and that experience comes with bad judgment. Bad judgment seems to cause a lot more situations like this. If we refuse to mentor people EMS will continue to be a job and not a profession. EMS will not be a destination, but a stop towards something else. We often discuss better treatment modalities, appropriate response types, and bases vs. SSM. But we never discuss how to improve the profession from the inside. You are the first person that young EMT gets to work with. You are the one that will influence their mentality. Don’t treat them like they should be perfect. Remember someone took the time to help you.  Good mentorship will give you that partner that you want. The one that can anticipate your moves and sees patients as a human beings.

 

Thank you for your time,

Lone Medic

EMS, John Henry, and Providing Care

Another blogger has pointed out the useless ness of the Glascow Coma Scale outside of trauma and the under 8 intubate idea, and I hope you take time to read this, http://theambulancechaser.com/2013/12/01/i-broke-an-ems-rule/.

But what about where it applies, trauma, RSI is known to improve a patient’s outcome in traumatic head injuries, unless it is performed by EMS. The cause of this is often EMS providers freaking and hyperventilating a patient. Folks, oxygen can hurt, and over oxygenation has a negative consequence involving morbidity and mortality.

So what am I getting at here. RSI is a very important tool that should be in every Paramedics tool bag, as long as they can ensure it is done properly. So what do we need to do this properly, two things, End Tidal CO2 Capnography and a ventilator. This is going to hurt some peoples feelings, but a ventilator does the job better than you because it doesn’t have adrenaline. You set the rate, tidal volume, and voila perfect controlled respirations.

This is something no one wants to admit, machines can do things better. I am an advocate of taking CPR out of people’s hands as well. These things involve a level of control that humans are not capable of. IV access is an art, but EZIO makes IO access better, easier, and safer so we can use it in the most critical of situations.

The idea here is to ensure that we are doing the best thing for our patients. We need to accept that our egos are not more important than our patients. As a Paramedic, we are expected to make proper decisions in high stress environments. So why not push to make our lives simpler. We all know that we need to ventilate the patient 8 times a minute after the intubating. We know a patient needs 100 compressions a minute with minimal interuptions. So why not seet it and forget it.

I know, I am probably giving up my title as a Paragod by saying this, but we need to perform better. We need to learn to cheat. From Video Laryngoscopes to Thumpers, there are tools out there that can help us perform better. Agencies need to determine which ones will cover their deficits and budget appropriately. Providers, you need to be honest. Admit your faults. This is how we get better, and remember that when John Henry said he was better than the machine, he died beating it.

 

                As always I value your input and comments,

                Lone Medic.

Shotgunning changes, because sometimes there are a lot of things on my mind.

Here we are again, musings of someone who wants to much change. So here we go with a list of changes that need to be put in place if you haven’t already.

 

CPAP

                Every EMS agency should have CPAP available on their trucks. This is a simple program that we can solve. There are affordable options that can allow agencies to perform this. Medical directors, if you are not insisting that your providers are performing this treatment you are leading to patients being intubated needlessly.

 

D10W   

Why is D50 still the standard when we know that 250cc of D10 works as well without the system shock or possibility of necrosis? We are overloading our patients with dextrose when we could titrate it easier. It is less expensive for the service and better for the patient.

Pain Control Protocols

                PAIN IS A DISEASE AND IT HAS ITS OWN PATHOPHYSIOLOGY. Why are we trying to do nothing help this? We have placed that still think 2 mg of Morphine is effective for patients that have a midshaft femur fracture. If a patient is in pain we need to treat them. And we need pain meds that will do this. Dilaudid, Fentanyl, and Toradol should be used more and be available. Pain does cause harm.

RSI

                RSI has a positive effect on patients with head injuries. There should be no doubt about this. EMS has been doing this wrong though. We need to be putting patients on ventilators because there in the situations that we intubate in adrenaline is pumping and we are not ensuring that we are only ventilating the patients for 8 – 10 breaths per minute. RSI should only be allowed when the ambulances are equipped with automated ventilators.

Oxygen

We are taught to be cautious with every drug we give, except oxygen. Despite science proving that over oxygenating patients causes vasoconstriction and releases free radicals both of which have negative effects on the morbidity of patients, EMS personnel continue to give non titrated oxygen. Worse, medical directors are not stopping this. We need to be educated on the negative effects of these things.

Spinal Immobilization

                When long spine boards are looked at in the future, people are going to ask what in the hell were we thinking. These devices have no benefit and are proven to cause harm. They should be relegated to patient movement only. That is all that needs to be said.

 

As always I value your opinions and comments,

 

Lone Medic.

Professionalism in EMS and why the lack of it is hurting us all

                Oh no, this one is going to hurt. See there is no EMT or Paramedic that is professional all of the time. So in posting this one, I had to look at this from a very introspective point of view as opposed to the usual looking at problems that I see others needing to solve. See, despite my personal crusade to end the lack of information and poor patient care modalities, I have personal flaws. While I am aware of them, it isn’t always easy to fix them. So when you read this, understand that I am working on mine as well.

Professionalism as an EMT or Paramedic

                I have described getting EMS personnel to get on one page to be like herding cats. We are the guys and girls that walk into chaos with the determination that it will conform to our desires. It breeds arrogance and cynicism. We often speak of a patient complaining of neck pain as being a drug seeker. We become irritated when we pick up a diabetic patient regularly with hypoglycemia. The drunk with psych issues that we treat with contempt as being below us. The welfare mom with five children who is pregnant with the sixth, and she calls because her water broke.

We become immune to human suffering and consider ourselves better than these people. Our contempt often bleeds through in our communication with these people. I mean they are just abusing the system right. The person with neck pain should go to his local doctor, pain never hurt anybody. The diabetic should just eat a sandwich. The drunk is worth a couple of laughs at his expense. The welfare mom should have her damn tubes tied. I know you think this. So does the rest of the word. You post it online for the world to see. Then you wonder why people look at you with no respect.

Facebook pages like Paramedics on Facebook and The Most Interesting Ambulance Crew in the World have individuals that post on there in ways that are detrimental to the profession. We put cocky stickers on our vehicles. We wear T-Shirts that advertize our lack of empathy and caring. When people refer to us in terms that we consider derogatory, despite the fact the speaker may have no knowledge of what we do, we often flip out and act like they initiated a hate crime. Never mind that the person has no clue about your ability to recognize a posterior MI and act accordingly, or that you can make a snap decision that can improve their life, the know that you and your partner are coming in an ambulance and one of you are going to drive them to the hospital.

Then there is the condescending attitude we take with coworkers. We all know what we feel like when a new EMT walks in the door. We fear taking them out on the street the first time. We treat them as if they have communicable disease. We laugh when they hold a little old ladies hand or they have trouble working the suction. These people are coming in looking for mentors and they get bullied. I remember starting a job, walking in wearing my new white shirt and BDU pants and the first thing I heard was “Who the Hell are you”. Nice way to start a new job. This was two days after being suspended because I had to be so I could pay for my EMT-I class.  That is enough to make someone not want to work in the career field.

                The only person that catches as much crap as the newbie is the person who actually reads EMS research. The guy who was pointing out that 12 Lead EKG’s were going to be the standard in 1998. You know the guy who gives out pain medication to “obvious” drug seekers, then explains himself by talking about patho-physiology of pain. That nerdy guy who “can’t hack it on the streets” as opposed to the street medic who “knows” what to do.

                Carrying yourself in this way shows the world that you are not a professional. You allow the gallows humor that we use at the station or in the ambulance to cope with the stress bleed out into of pain. That nerdy guy who “can’t hack it on the streets” as opposed to the street medic who “knows” what to do.

                Carrying yourself in this way shows the world that you are not a professional. You allow the gallows humor that we use at the station or in the ambulance to cope with the stress bleed out into your dealing with the public. We also forget to shave and neglect our personal appearance. We yell at our coworkers and management. We look and act like we don’t give a damn. We have reaped what we have sown. We need to fix this. Now, that’s enough on ripping on crews

.

Professionalism and management

                Supervisors, managers, and dispatchers, this one is for you. We will start with dispatchers because while they are not actual management, you are part of the office staff and the initial point of contact for both employees and the public. A hateful or panicked voice portrays nothing more than you are too good or incapable dealing with the situation. The public and the crews know that you are their lifeline. If a crew needs help, you are the first person they are going to tell. If there is an emergency and the public calls you, they are going to expect you to keep calm. Be honest with them, and try to help them. When a hospital calls do not give them an unreasonable time that your crew will be there. Remember that whatever is going on is that person’s emergency not yours, and you have the ability to think clearly.

                Supervisors, you are in a precarious position. When your crew messes up, you have to be able to discipline them while maintaining your composure. Yelling and screaming at people proves that you are not in control. The fact is, whatever the person has done that is wrong has already happened. You cannot make it not happen. But yelling and insulting the person is not a solution. Your crew may also come to you with a problem with a patient, hospital, or other customer. The problem may actually be with the customer. Keeping an open mind will allow you to adjust for this. No matter what, no disciplinary action should take place in a public forum. This leads to belittlement and can lead to a loss of morale, even among the employees that act the manner you want to encourage. Be free with praise and encouragement. It never causes problems to tell someone they did a good job.

                Management, you are the ones that truly worry. You know how much operations cost. Losing a contract might cause you to have to fire people. You have to make the decision whether to purchase new or refurbished equipment. You deal with billing. You know what these people’s actions cause. Everything stated about supervisors applies to you. You should also never seem flustered. Rant and rave behind closed doors, but never let the employees see that side of you. You have to be cool, calm and collected. See from an employee’s stand point our livelihood depends on you. Often employees do not understand that your job depends on them as well. You have to be firm, fair and consistent with employees. You should not reward employees for not doing the requirements of the job. It might make things easier, but rewarding people for not doing the right things sends a message that being a problem is what gets rewarded. This leads to good employees being more likely to turn into bad employees.

Professionalism conclusion

                If this sounds like I am preaching, I am not. I have done most of these things wrong. I probably will again. That being said, I am trying to act in a manner more befitting of my profession. See most of the people reading this are my brothers and sisters. I want people to look at them as the people that come into their lives and make them a little better. I promise you I am trying, and maybe you will as well.

As always, I welcome your comments,

Lone Medic.

Illinois should go modular

                I work in Illinois EMS and I complain about how it is administered. If you know me you know that is not surprising. Illinois EMS has a system where 90% of EMS is administered by nurses. A lot of these nurses are good people who try to perform their job with the best goals in mind. EMS agencies are required to join EMS systems that are administered by these nurses. While there is a physician above them, this Dr. has no real knowledge of the people that work for him or her unless they transport to his or her hospital. So we wind up with cookie cutter solutions that only work for the people they see. Because there is no real interaction, the protocols tend to be designed to hold back the exceptional to ensure that people they never see do not screw up.

                So, how can we fix this problem? My solution is that we require the systems to become modular. Each resource hospital has a set of base line protocols, and then has modular enhancements. These modular enhancements might include mechanical CPR, field clearance of C-spine, community paramedicine, and Critical Care Transport. These are just examples obviously, but it would be a start. Allow the providers to know what they have to do in order to allow these things to happen. Then you allow them to do it. Voila, a simple solution to a real problem.

                The best solution is to allow agencies the option to allow EMS providers to hire their own Medical Director. This would allow for EMS agencies to put into place the protocols that actually serve their patients and communities best.  But the reality is that this is not going to happen soon. Despite this being the reality on all surrounding states, Illinois resists change more than any other state. So we need to consider modular systems. It at least allows us to move in a more modern direction, instead of being stuck in 2002.

                Now this is only slightly related, but I am going to encourage you to join the NAEMT and your state EMT association. The NRA is one of the most effective best lobbying groups out there for a reason. That reason is membership. NRA members donate and teach the majority of the gun safety classes out there. These things raise revenue for the NRA to lobby for gun rights. The NAEMT is that for EMS, yet less than 1% of EMS personnel are members. NAEMT membership pays for its self in discounts and benefits, while allowing for better representation at the Federal level. Most states have similar statewide organizations.  NAEMT also provides AMLS and PHTLS as both an educational and fundraising opportunities. Please take these courses. They benefit you greatly.

As always, I value your comments and feedback,

Lone Medic

Proper and Judicious use of HEMS

                Tell me you haven’t had this discussion on the truck before.

911 Dispatcher “Small Town Ambulance Service Call, Middle of nowhere. Small Town Ambulance please respond to a 2 vehicle MVC head on, unknown injuries”

JG “County Dispatch Rescue 51 is enroute do we have any word on injuries”

911 “Unknown at this time 51”

JG “51 is clear.”

RD “JG Should we get F&U to send mutual aid”

JG “RD Why don’t we launch a bird, we know how bad it can be out there.”

       Herein lies the problem. Helicopter EMS is a growing and vital service in rural America. It is also overused, causing increased costs with no benefit to the patient. Helicopters save live, I truly believe that. There is very good evidence that they do in rural settings. The jury is definitely out in urban ones though. So in typical EMS fashion there are some of us that take it to a ridiculous extreme. I mean oxygen helps, so let’s put more people on more of it. Wait, there is evidence that Oxygen has negative effect on CVA patients increasing mortality.

      Helicopters are a finite resource that needs to be used judiciously. There needs to be sensible guidelines for HEMS usage. So in the interest trying to improve this, lets look at some sensible guidelines.

Lone Medic’s HEMS Guidelines

Helicopter should be considered in the following situations:

Pt. requires higher level of care than is available locally.

Helicopter can be at scene before EMS unit can have patient at a local hospital for stabilization

Pt. is suffering from immediate life threatening illness or injury.

Consider ground transport in the following situations:

You are able to arrive at an ER before the Helicopter is able to be on scene.

If you are able to transport a patient to an appropriate facility in less time than a Helicopter can.

If the Patient has non-life threatening illnesses or injuries.

        Now you notice that I stated that if you can have a patient to an appropriate facility before a Helicopter can. I know your ask, LM aren’t Helicopters always faster. Well let me take you through the process of activating a Helicopter in a STEMI situation. Something I think is appropriate, if time is saved.

Upon arrival you find a patient is having a Anterior Infarct after performing a 12 Lead ECG. You know there is a Reperfusion center 35 minutes away. Being a caring medic you contact the Helicopter. 3 minutes later they accept the flight and weather is clear. You give them the GPS coordinates and the backyard is clear enough to be a effective LZ. 10 Minutes later they lift off. They have a Flight Time of 15 minutes. After they land it takes the flight crew 10 minutes to prepare the patient to for lift off. They have another 10 minute flight to the Cath Lab. Diagnosis to balloon approximately 55 minutes depending on where the Lab is in the hospital. You could have had the patient there in less time, saving 13 minutes.

       This does not mean you shouldn't utilize HEMS, like I said they save lives. But use them judiciously. The other problem I have is using them when they are not needed. Mitchell Mightymedic gets called out to a man who fell off of a ladder and has a Tib-Fib fracture. Patient is hemodynamically stable with good pedal pulses. Mitch decides to fly this patient to a trauma center due to a  transport time of 24 minutes to the nearest facility.

       During this time, Gina Ditchdoc is called out to a ATV accident that requires a 25 minute ride on a Fire Department rescue UTV. Upon arrival Pt. is found to have systolic BP of 84 and an unstable pelvis. Gina contacts dispatch and there is only Helicopter available is 1 hour away due to Mitch’s patient being enroute to a nearby Trauma Center.

       Helicopters are also unable to fly during lightning, high winds, or other inclement weather. Do not delay transport to ask for a helicopter that is obviously unable to fly. If it is that time sensitive, they need to be in a Doctor’s care.

Your Feedback is always welcome.

Lone Medic.

Lights, Sirens, Stupidity

It has been a while since I posted. During that time I started a second job. My wife has started the journey that is Paramedic Class. I honestly envy her in this, as her program is far superior to mine. If you have read my posts before you know that I am an advocate for improved education for EMS in Illinois. But there are changes that need to happen on the personal and agency levels as well. Personally, I want to drop at least 80 pounds by June of 2014. I have changed ADD Medication to one I tolerate better, which helps me in this goal.

But this is not my personal blog. This is for my profession and how to improve it. The subject that I am about to discuss is one I have personal experience in and how it can go bad. I am going to discuss Vehicle Operations. When I first started the culture was based on drive fast, seconds count, and damn the consequences. That was wrong. I hit another vehicle while driving non-emergency. There were numerous close calls. I once made a normally one hour and forty five minute trip in 59 minutes. Folks, I was a menace.

You combine this with sleep apnea, multiple 24 hour shifts in a row, and my ADD, well it is a miracle I never killed someone. I tell this as one of the lucky ones. I now have the ADD and the Sleep Apnea under control. I have my shifts scheduled so I usually am able to sleep an adequate amount. These things improve my safety as well as the safety of those around me.

Now I mentioned a second job, it is with a really large EMS provider. I will leave it at that. Their driver’s safety program is not quite as extensive as I think it should be, but it definitely works. Every EMT and Paramedic should be taught low forces driving. Every EMS agency should have an effective driver monitoring and feedback program. This is something that will save our lives. Driving is without a doubt the most dangerous activity EMS personnel take part in, and we forget it.

Remember this if you are operating an ambulance and you kill someone, you might not be held legally liable. Different states have different laws about this, but you most likely wanted to save lives when you started in this. Do you want to be the guy that has to face the fact you killed someone. That person you kill could also be yourself. Do you want your friends and family to live with that loss?

As always I value your comments and opinions,

Lone Medic.

The Death of the 24 hour shift, I hope.

                

The 24 hour shift is a dragon that needs to be slain. I hear way too many EMT’s tell me that they like 24 hour shifts and prefer that they be scheduled back to back. I mean this sounds great to me, do my 48 and have 5 days off. I mean who cares if it actually risks people’s lives including you or your partners.

              

  A big problem I have with this type of scheduling, and we have to do it at my current job, but we are working on ending it, is that it makes EMS into a hobby not a profession. There are people that do EMS as a hobby. They are called volunteers and many of them d a damn good job because they want to. But if EMS is how you earn your living, you should look at it as a profession and treat it as such.

               

  As someone who is officially a dinosaur, I ask those of you who have done this for a while on 24 hour shifts, are you as good near the end of shift as you are at the beginning? Most of us will tell you no. Think about it, you have either been awake for nearly 24 hour or you were woken up from sleep that was interrupted by other crew’s tones, radios, or telephones. You or your equally tired partner are driving in excess of posted speed limits weaving in and out of traffic, and avoiding obstacles.

  There is a link between sleep deprivation and depression in EMS personnel. Many of the people I work with, including myself, have been on anti-depressants. Most of us consider this due to the on the job stressors, and they do contribute, but getting more rest would improve the situation as well as our overall health. I have a link on this below.

 

   If you were to come in at a set period of time, you do 8 to 12 hours and you go home. You and your partner are well rested and are able to perform your skills in a prompt and effective manner. You finish your shift and are able to leave to go home. No more listening to radios and telephones at night. You an EMS professional, so you goal should be better patient care and outcomes. In the fight for EMS 2.0 remember that we have to be able to perform at a level that ensures we are not making more victims of death by paramedic assistance.

http://www.jems.com/article/administration-and-leadership/studies-prove-24-hour-shifts-unsafe

http://www.fireengineering.com/articles/print/volume-166/issue-02/departments/fireems/sleep-deprivation-in-ems.html