Estoy aprendiendo español

Slimm is out again today. Sometimes, I think that guy calls out just because he doesn’t like me. He gave me some lame excuse about his daughter getting her tonsils removed.


My partner today seems to be a nice guy. He obviously showered, doesn’t make me listen to country music, and leaves me alone while I’m reading.

We get a call for a “person down at a bus stop.” No doubt called in by some hero roaming the streets of our county, saving victims from themselves with phone calls. We never get to meet this hero, likely because he or she is always off in a rush to save the next poor soul, and can’t stick around the scene.

It’s a drunk guy laying on a bench at the bus stop. He is obviously Hispanic, or a really tan Texan with a penchant for western wear. He’s awake, but groggy. I think ‘somnolent’ is the correct medical term.



“Hola. Cómo estás?”

“Estoy bien.”

“¿Habla usted Inglés?”

“Eh, pero un poco. “

“Mi español no es muy bueno, pero lo intento.”

“Suena bien.”

¿Estás bien? ¿Tiene dolor en alguna parte?

“No. No tengo dolor.”

“¿Está usted enfermo?”

“No, cansado.”




“Sí. Muy borracho.”

“¿Beber toda la noche?”

“Toda la noche. Muchas bebidas.”

“¿Cerveza? ¿Vino? ¿Tequila?”


“¿Cuál tomaste?”

¡Todos ellos!”

“¿Quieres ir a un hospital?”

“¿Por qué?”

“Mi jefe me pregunto.”

“Su jefe suena estúpido.”

“Buenes noches.”

I look at my partner and the fire guys. “Alright, let’s pack it up. I think we are done here.”

“What the hell just happened?

“He says he is just tired because he is absolutely wasted, then he called our boss stupid.”


“Yeah. He doesn’t want to go to a hospital, either.”

“He called our boss stupid?”


“Smart guy.”

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.