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.