These people got lights and siren responses

These are calls I have heard dispatched over the radio, or ran myself in the past few weeks or so since the implementation of the new policy that requires an “emergent response to all requests for services generated through the 911 system.”

  • A male with CHF who just got out of the hospital and wants to know how to take his meds.
  • A female with a swollen knuckle who can’t get her ring off (the ring isn’t stuck, her knuckle is just swollen.
  • A female who is depressed and ‘wants to talk to someone.’
  • A male in the waiting room of the emergency room who has been waiting too long and wants to go to another hospital.
  • A female who ‘has anxiety and witnessed an accident and is now having a panic attack.’
  • A male who ran out of gas on the interstate and is demanding PD drive him 40 miles home, but now PD wants EMS there.
  • A  very elderly male who is dead in bed, cold to the touch and stiff, with family refusing CPR instructions.*
  • A female who wants her blood pressure checked.
  • A school bus with 14 children on it was struck by the arm of an apartment complex gate. There are no injuries on the bus.
  • A male who was in a fight last week, and now has a swollen hand.
  • A male sitting behind a strip mall, dirty, and talking to himself.

There were others, but these are just the highlights.

But we want people to take us seriously.

*I sort of understand this one, but in reality, this family just needs a coroner.

Community Paramedic programs won’t work in private EMS

Money. That’s why.

There simply isn’t a financial incentive for a private EMS service to run a community paramedic program.

Hospital-based EMS services have a financial incentive to run a community paramedic program. If the hospital-based service can reduce ER visits, and therefore reduce hospital admissions, then there is a financial incentive for them to run a community paramedic program.

Fewer chronic visitors in the hospital = more ER beds = more available inpatient beds = more insurance payments for the hospital.

Plus, with new healthcare regulations stipulating that hospitals won’t be payed for re-admissions within 30 days for the same problem, hospitals really have an incentive to reduce visits by chronic users. Visit the patient in the home, keep them at home, and they won’t come to the hospital as often.

County-based EMS services likewise have a financial incentive to run a community paramedic program. Specifically, the county third services, not fire-based services, but I will get to them.

County-based EMS services have more leeway to deny or refuse transport to patients who meet certain criteria, or at least they do where I have worked. Having trouble urinating? We aren’t gonna take you to the hospital. Can’t sleep? Take a melatonin. We aren’t taking you to the hospital. But those chronic users learn how to work the system. Having trouble urinating turns into abdominal pain with difficulty breathing. Now we have to transport. Can’t sleep turns into headaches and dizziness, or general weakness, and now we have to transport.

These patients either aren’t insured, or won’t pay their bills. If, on the off chance they are insured, reimbursement from their insurer are low, and the copay won’t be covered. Transporting these patients becomes a net loss for the county service. Keep them at home, and more units are available to transport the patients for whom reimbursement rates are higher, or who actually need an ambulance to take them to a hospital.

It seems like ‘want’ and ‘need’ have become synonymous lately.

Fire-based services also have a financial incentive to implement a community paramedic program. If the fire-based service can send a community paramedic to a chronic EMS user’s house, and keep that user from activating 911 or requesting EMS, then those EMS units are available to run more calls that actually require EMS, and it keeps other fire units in service and available for fire calls. Or the EMS calls that fire services shouldn’t be running anyways.

But the private service that operates on a ‘you call, we haul’ basis has no incentive like the other three models. There is only an incentive for the private service to transport.

Transport – get paid. Don’t transport – don’t get paid. Pretty simple.

I have worked at various private EMS services for the past 10 years, and not once have I told a person that I was not going to transport them to the hospital. Every single time someone wants to go, we put them on the cot and take them to the hospital of their choice.

If the chronic EMS user does not have insurance, or doesn’t pay for their use of EMS, then the difference becomes a tax write-off, or is covered by a government subsidy of some sort. Private services aren’t concerned with readmission penalties at hospitals, and they aren’t concerned with overburdening an already busy ER.

More paramedics in ambulances = more paramedics to transport patients. Why would a private EMS owner or manager intentionally take a paramedic off of an ambulance, and put that paramedic into a vehicle to visit patients at their homes? That goes contrary to the very mission of the private service, which is to transport anyone and everyone who wants it.

More paramedics on ambulances = more paramedics to transport patients.

I wish it weren’t this way, and I wish that community paramedic programs could flourish in a private EMS service, but I don’t see it happening.

Maybe I’m cynical, but maybe not. I would be interested to see the private EMS service that has implemented community paramedic program with success.

The Pepsi Challenge, New Coke, and Fire Department Tiered Response to EMS Calls

(I began thinking about writing this post a long time ago while reading Malcolm Gladwell’s book blink. Being from the South, I am intimately familiar with the Pepsi Challenge, and ‘New Coke’ and the ensuing disaster for Coca-Cola. I got tired of thinking about writing this post, and decided to do something about it.)

 

First, a little bit about the system in which I work: My county sends the closest fire engine to virtually every EMS-related call received in the 911 system (92% of EMS responses included an engine in 2012). That engine may be ALS or BLS, but it is always the closest engine no matter what, so ALS engines are frequently sent to BLS-level requests. The county also requires that an ALS ambulance is sent to every response, with response time requirements that don’t really matter for this discussion. For those of you familiar with ProQA, an additional ALS component is sent to every Charlie response and above, regardless of the level of care of the initial engine response.

So a 4 year old with croup in the middle of the night very well may receive three different pieces of apparatus, and between 8 and 12 responders, all because the patient is “under 15 years old” and is having “difficulty breathing” and is “making noises when he breathes.”

The citizens absolutely love this. They are just the most important thing in the world, and it only takes 3 pushes of buttons on a phone, 30 seconds with someone on the other end, and a dozen people will drop everything and rush as fast as they can to the citizen’s house.

But is it necessary?

Of course not.

I have my own issues with ProQA, or MPDS, or whatever it may be called in your area, but the bigger issue is with the tiered response.

One paramedic will do just fine, yet we find it necessary to send 3, 4, 5, and sometimes more to virtually every call.

So what does this have to do with the Pepsi Challenge? I’ll get there. But first, a little background.

In the 1970s, Coca-Cola had an almost 5-1 market share over Pepsi, and Pepsi wanted more. Like any business would. In the early 80s, the two products were virtually tied, with Coke having a 12 percent market share, and Pepsi having 11 percent. This is in spite of Coke’s wider availability and advertising spending.

Pepsi decides (brilliantly, I might add) to introduce the Pepsi Challenge, in which self-described dedicated Coke drinkers were asked to take a sip of two different beverages, in two different, unmarked cups, one containing Pepsi and the other Coke. The majority of the tasters preferred Pepsi, and the results were confirmed by Coke executives doing their own market research. Coke executives blindly ignored the inherent problem of the blind taste test, much to their later chagrin.

But why did Pepsi continue to win the Pepsi Challenge?

Because Pepsi is much, much sweeter. And the test was a sip test, or a central location test (CLT). Tasters didn’t drink and entire can, and they certainly didn’t take home an entire case to enjoy in front of the television.

So Coke decided to change. They changed their formula, after continued alterations and their own taste tests, and finally came up with a product that rivaled Pepsi. They marketed their product as New Coke.

And it was horrible. An absolute disaster.

I remember New Coke vividly. I remember people who refused to buy another Coke product until Coca-Cola Classic was brought back. People wrote letters, and executives got fired. People literally picketed in front of Coke’s headquarters. Coke was forced to tuck their tails between their legs, apologize profusely, and reinstate Coca-Cola Classic.

Only 79 days elapsed between the introduction of New Coke and the return of Coca-Cola Classic, but it was quite the time.

So what does this have to do with tiered response?

When I first started in this business, we only saw the fire department on fire-related calls. Occasionally, they were requested for extrication of victims from a motor vehicle crash, but that was not often. People called 911, asked for an ambulance, and they got an ambulance.

But now it is different. Fire departments are no longer “Fire Departments,” they are “Fire-Rescue” departments, or “Fire and EMS” departments. EMS has been taken over, and now ambulance standards are being written by NFPA.

The citizens seem to love the tiered response. As mentioned earlier, three button pushes and thirty seconds on the phone, and a dozen people will stop whatever they are doing and drive as fast as they can to get to you. All in an effort to mitigate liability, but that’s another post.

The citizens, the taxpayers, are the taste testers. They are taking a sip of this drink that is tiered response, but they aren’t being offered the alternative. This is just the way it is.

Somehow, this is going to have to change. The response that I outlined above is not just common, it is the norm. And it is a waste of money.

But money is the answer, isn’t it?

If the fire department doesn’t send their vehicles and their people to these calls, then the fire department runs a lot fewer calls. When the fire department all of a sudden runs 80 percent fewer calls, then local government wants to know why there are so many firefighters and so many pieces of apparatus for so few calls.

This tired response may not have begun to justify a larger budget, but that is certainly where it is now.

Everyone deserves better.

A post about a comment on a post

So I posted what I found to be a humorous exchange between a first responder and a paramedic that I witnessed not too long ago.

As he is wont to do, TOTW posted a comment on my post. Some times, I think he and my mother are the only ones who actually read my blog, and I enjoy his comments. (Mom never has much to say. She really doesn’t read, anyway.)

He says:

There’s a difference between knowing what’s going on with the monitor and what’s going on with the patient. Unfortunately, a lot of people don’t see that.

And he is right. Absolutely right.

I have always viewed the cardiac monitor as a tool to aid in my diagnosis and treatment, rather than as something that guides my treatment. There is a difference there. A slight and subtle difference, but one that I think is very important.

Really, it is the difference between a cook and a chef.

A cook follows directions, and adds a certain amount of ingredients to a dish at certain times. A chef knows how foods and ingredients interact with each other, and is not afraid to experiment and let the dish guide how he prepares it.

Now I’m getting hungry.

I used to work with this guy. He was a huge jerk. A stereotypical, 50-something Jersey Shore jerk. He used to wear his shirts with several buttons undone so he could show off his manly chest mane, and his gold chains. No, I’m not kidding.

But he was a great clinician, and took very good care of patients.

One day, I asked him if he wanted me to put the monitor on a particularly sick patient.

No, I already know what it is going to say. No need for the monitor just yet.”

That confused me. It confused me a lot. I was a fairly young EMT at the time, and I thought things had to be done a certain way, and here was this guy who was doing it his own way. But what he said later when we talked about it made sense:

“A good assessment will tell you what the monitor will say. A person complaining of chest pain, presenting with Levine’s sign, with pale, diaphoretic skin and weak pulses is going to have a sinus rhythm, perhaps with a first-degree block. Then the 12-lead will show ST elevation. And if it doesn’t, I will be surprised. Granny, with her 47 bottles of medications and nausea and vomiting with an irregular heart beat will be in atrial fibrillation.”

Granted, there are no absolutes in EMS, and people won’t always present the same way. But there is a big difference in reading the monitor and knowing what the monitor will say.

Well, there is one absolute in EMS: nobody will be critically injured in an MVC in which the cars have pulled into a McDonald’s parking lot.

MCI review

When at an MCI, assignments are given to you. For example “take those three patients from that car right there to Local Hospital.” But we all knew that already.

When those instructions are given, it isn’t necessary for you to hang around and give scene reports to the arriving units, directing them to where their patients are.

Incident Command is the one with that responsibility.

When informed that you are to “transport them to Local Hospital,” that doesn’t mean you hang around for another 15 minutes with your thumb up your butt then ask the IC “hey, is it cool if we leave now?”

“Your ambulance should have left 15 minutes ago!”

MCIs work much, much smoother with just a tad bit of cooperation.

Guns are a bad idea for EMS

The gun-carrying for EMS debate is getting stronger down here. It hasn’t totally died down, but for some reason it is becoming more and more of an issue.

I really think that EMS carrying guns is a bad idea. For several reasons.

People call us for help. They don’t call us to protect them, but to help them. Carrying guns on our persons will change the relationship between the public and EMS. I want patients and caregivers to trust that I am there to take care of them, and not there looking for a reason to punish them.

Guns will change the perception that the public will have of us, even if that gun is concealed.

What are we really doing to ensure our safety on scene? How often do we walk straight to the door of a house without even a cursory glance at windows, shrubs, cars, or any other part of a house? Do we walk straight across a broad lawn, or are we in the habit of walking down a driveway? How often do we make our way to a house with our hands full? Is it not a good idea to keep a hand free, in case something bad goes down? Do we allow people inside homes to get between us and the door? Do we even notice when people get between us and the door? Do we look for other methods of egress when we walk into a house? Do we really perform an assessment on our patients, touching their body, looking for something wrong with the patient, and something on the patient that shouldn’t be? How often do we practice contact and cover?

Does every provider in EMS even ask one of those questions? Ever? Or are we complacent?

Slimm and I have safety plans, and we have discussed these things. We have two wives and 6 children between us, and we are going home at the end of the day. We have a safe word, and we are willing to do whatever it takes to get both of us out of any situation. That is also a benefit of working together for a few years now.

We trust ourselves, yet we still don’t trust each other with guns. We know that if something bad went down, and a gun was involved, the chances of neither one of us going home at the end of the shift is much higher.

We are both comfortable with guns. I carry, both concealed and open, virtually all the time when I am off duty. I own several firearms, and I train with them. I am a good shot, and safe. I can, and have, shoot well enough to qualify with my handgun at a police qualification. But this isn’t about my resume’.

I want you to think about this: Imagine every person you’ve ever worked with in EMS. Every person at your service, or your department, or in your hospital, or whatever. Even that guy with the short temper and the bad attitude. We all know and work with a jerk with a bad attitude. Take out a piece of paper, and write down the names of the 5 coworkers who are most likely to create a violent incident.

Now, do you trust your life to that coworker? Do you trust that coworker to change his ways, minimize emotions, and react rationally to a scene? You’ve never met me, do you trust me with a gun on your scene?

Or do you just want to be a badass and carry a gun on your ankle?

A conversation about plethysmography

“What’s that?” asks a student on another ambulance, pointing to my cardiac monitor.

“It is the plethysmograph” I replied, most likely butchering the pronunciation.

“What’s it for?”

—–

After dropping my patient off, I made my way back to the EMS room where I found the student. It turned out he is a paramedic student, just finishing up his intern rides. He has a few weeks to go before he takes his exam. He has been an EMT for roughly 4 years, and by all accounts, is a good student, and a fast learner.

The fact that he asked a paramedic whom he didn’t know bodes well for him. He is engaged, and wants to learn.

We spent the next 15 minutes or so discussing the plethysmograph and its usefulness in assessing patients. What struck me most about our conversation was the fact that he had no idea whatsoever that there was even such a thing, much less that it could be used to assess patients.

We talked about how vasoconstriction can cause an increase in amplitude, and what could cause vasoconstriction. We talked about how vasodilation would cause a decrease in amplitude, and the causes of vasodilation.

We discussed how waveforms would change in a hypertensive patient with chest pain to whom we were administering nitroglycerin. The mechanism of nitro’s action, in decreasing systemic vascular resistance through causing vasodilation. It seemed to make sense how waveforms would change, and how that was directly related to afterload.

My patient happened to be septic, and I could show him how plethysmography could help confirm that diagnosis. My patient was an infirm older woman who had a mildly altered mental status, hypotension, and some mild tachycardia. The fact that she had a chronic Foley catheter with cloudy urine in the bag made the diagnosis of a UTI fairly easy, but the plethysmograph showed a very deep, prominent dicrotic notch.

He asked, appropriately, how the waveform would help me in my assessment, and I explained that the deep dicrotic notch showed me a low SVR, and there was no need to assess orthostatic vital signs.

He was receptive, inquisitive, and it was a refreshing conversation.

—–

I’m just a regular paramedic, and nothing special. I only learned about this stuff because I asked and because I wanted to learn. I enjoy showing students, and other EMS personnel, things that I have learned along the way, and I enjoy learning from others. Our education doesn’t stop when we get that paramedic patch, it begins.

What is disheartening is the fact that a paramedic student, only weeks away from testing to become a paramedic, had never heard of a plethysmograph, a dicrotic notch, and did not understand the relationship between waveforms and vascular resistance.

We have a very, very long way to go in the education of our paramedic students.

 

Blatant unprofessionalism‎ on display

How often do we complain that we don’t get the ‘respect we deserve’ from the public and other healthcare workers? Usually we deserve respect but then something like this happens.

I do not “like” or follow The Most Interesting Ambulance Crew in the World on Facebook, but some of my friends do, so I will occasionally see their posts. This one caught my eye this morning:

The medic I’m working with is openly gay. He’s a great guy and one of the better medics I have worked with in a long time. 

I told you that so this part will make sense. We got a discharge out of a VA hospital taking the Pt back to the nursing home. We got the guy over on the stretcher and I began some small talk with him. Asking him what branch he was in, what his M.O.S. was etc. I told him I was in the Marine Corps what I did. We talked a little about our war stories, etc. 

Then out of nowhere my partner goes “My god I love semen so much. It’s like my favorite thing in the world(in the gayest voice possible) The old man didn’t catch on to it. 

So for the next 5 minutes on our walk down to the truck my partner talked of how he wanted to personally thank all of the seamen for their semen on submarines and on any ship that would let him board.(slurring all of his “S’ s”,) How men in white uniforms do it for him etc. The old man still didn’t catch onto it. So when we finally got him loaded up and I climbed in the back the old man says “it must be nice being a Veteran and working with someone so patriotic. “

I almost lost it.

This is why are looked down upon. Because we laugh when childish coworkers act inappropriately around patients.

As I write this, there are 80-something comments on the post. It seems to be evenly split between those that think this is incredibly distasteful, and the other half think it is hilarious. Some of the commenters think this could be sexual harassment, which it certainly is. Sexual harassment is a very broad brush.

This behavior in the station is one thing. This behavior in front of any patient, much less an elderly veteran, is unprofessional. The fact that a member of this community who thinks this kind of behavior is neither, and is in fact, funny, is just disgusting.

Yes, Community Medics

I’ve been low on blogging inspiration, so a big thanks to Mr. Morse for his post on Community Paramedicine. He seems not to care for it much, and lists 10 of his top reasons why.

My reply to his ten reasons:

  1. I may not know much about insulin pumps and how best to maintain proper insulin levels, but I want to learn. I don’t care to learn about how to perform high-angle rescues, but I won’t put down the person who wants to learn how.
  1. The emotional well-being of our patients should be a priority of ours. This includes counseling drug addicts, or at least referring them to the persons who can provide them with adequate psychological care. When we revive a heroin overdose, do we just spend the next several minutes ignoring the patient in the back of the ambulance? Or do we initiate a conversation with the patient?
  1. See #10. Why are we afraid to learn about drugs and therapeutic regimens?
  1. “Ambulance” is not synonymous with “Paramedic.” If a registered nurse can provide the same level, or higher level of care than a paramedic, then why are we concerned? Isn’t the care of the patient our foremost concern?
  1. I don’t see this as a “cradle to grave government funded approach to healthcare” at all. Even though Congress and our President would disagree with me. But I also work for a private service.
  1. It probably takes more thought to learn how to counsel people on how to avoid things that may trigger allergic reactions. We might as well stick with what we know, right? See # 10 and # 8.
  1. I also like nurses. Especially pretty ones who smile and talk to me. Nurses like what I do as a community paramedic, because I can reduce their workload. If I can prevent one readmit to the Emergency Room, that makes triage times quicker, allows nurses to focus more on their patients since they have less of a workload, and can raise reimbursement rates for the hospitals.
  1. At least 80% of our job consists of responding to non-acute problems. But yes, we should forget about that 80 percent and instead focus on the remaining 20. I work in a very busy area of the country, and probably run one or two true emergencies per month.
  1. Why would the concerns of another group be a concern of the community paramedic? There is a void in healthcare, and nobody is stepping in to fill it. Paramedics already work in the community, and are a logical solution to the puzzle.
  1. Ah, yes, the image of EMS.  Maybe, just maybe, members of the community will see the paramedics in a different light: perhaps they will have the image of the paramedic that is willing to make appointments to follow-up, check-up, and to help them meet their healthcare needs.

He is right, we should “be excellent at what you do, and respect those who are excellent at what they do.” Mr. Morse seems to only focus on one-third of the initials in our profession: the “E.”

Emergencies is what we do. But we also do Medical Services. There is a huge gap in our healthcare system, and we are positioned to fill that gap.

We should be more invested in the health and well-being of the members of our community. We should be proactive and prevent emergencies from happening, instead of reacting to them.

Community Paramedicine isn’t just about checking insulin pumps or reconciling med lists. It is about preventing the little old lady from the fall, and answering questions, and so much more. It is about keeping people from needing the trip to the Emergency Room. I believe community medicine will play a large part of the future of EMS and healthcare in general.

We can either lead or follow.

Those who don’t want to lead, and aren’t willing to follow, should simply get out of the way.

What is said and what is heard

What it said is “treat the patient, not the monitor.”

What I really hear is “I don’t know how to accurately interpret the monitor, so I can just ignore what is on the monitor.”

For example: your patient is a 73 year old male. He is pale, cool, and diaphoretic. He has normal mentation and complains of weakness. His heart rate is 40, and weak at the radials.

Do we seriously not base our next treatment off the interpretation of the monitor?

He could be in symptomatic bradycardia, and might need a little atropine. He could be having a humongous inferior MI and need a large bolus of diesel. He could be in a complete heart block and need to be paced. He could be in ventricular bigeminy and need some oxygen and a fluid bolus.

But no. You treated your patient, and not the monitor.

What is said is “I know he doesn’t have neck or back pain, but I’m going to board him anyways because of the mechanism.”

What I really hear is “I totally have no idea that immobilization causes harm, and besides, I don’t know how to perform an accurate assessment anyways.”

For real. If you are going to immobilize someone to a spine board, at least have the cojones to say “I was legitimately concerned about the possibility of an unstable cervical spine fracture, so I performed the immobilization.”

We shouldn’t base any treatment based on mechanism alone. Should every victim of a gunshot wound get bilateral lines, oxygen, and transport to a trauma center?

What is said is “I have to do treatment x because it is protocol.”

What I really hear is “I’m just doing what I’m told, and may or may not know better. I might be interested in changing the protocol, but probably not.”

If your medical director wrote a protocol that instructed EMTs to apply a brown paper bag to the face of any tachypneic patient, would you do it?

If your medical director wrote a protocol that instructed you to perform spinal immobilization on every patient who might have a head injury, would you strap down the old demented lady with kyphosis who rolled out of bed on the wrong side?

Or would you stand up for your patients, and for your profession, and point out the wrongs?

I guess I’m just irritated.