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