5/16/2013 5:30:18 PM
The End of an Era
Over the past few months I have been doing some thinking about one of our local ambulance service, who last year was forced out of the industry due to consolidations, and "underbidding." These local people also operate a dispatch centre, of which provides MPDS trained dispatchers for fire service, as well as EMS. With the changes to EMS in Alberta, a recent recommendation was to consolidate our dispatch centres into two centres, one serving the north, and one serving the south, with a back up at another location.
Now I don’t really have a problem with a central dispatch, my main problem lies with the fact that these people have been our dispatchers for 20 years, they are reliable, and professional. They are well trained, and always willing to do things I ask of them, as well as ensure that if we are tired, or have not eaten all day they will fight for our rights to do so. With our new dispatch centre being located in Calgary, and hearing some of the horror stories from people that are currently dispatched though there, I must say I am a little more than nervous.
The reason I am writing this is because for Alberta EMS, this decision marks the end of an era. The people who run this centre have been in EMS since the very beginning here in Alberta. The gentleman was one of our very first paramedics, has educated hundreds of future EMTs and paramedics, helped set up and was president of our regulatory college, and has been an advocate for EMS in this province.
I remember in the early 2000s when I started to be an examiner for EMTs in this province, he was the person in charge, and he was always calm, and ready to give advice, and understood the stresses of a licensing exam that was highly stressful on the candidates, and at times difficult to administer.
In recent years these people have stepped back a little from the front lines of EMS, with their managing duties, and dispatch centre duties there was more than enough for them to do. However, they were always there, right in the front, calling out questions, and ensuring that those that govern are being held responsible, and at times butting heads, but as the saying goes opinions vary, and everyone is entitled to an opinion. I have always found them to be professional and dignified when their opinions may not be popular. I have appreciated them for this example of how to act.
I am sure that many people will feel the same way as I do when word gets out that this dispatch centre will be closing, many of the EMS workers in Alberta will have worked there, or for the ambulance service that they used to operate. Many of the EMS workers in this industry got their start out in the West Country, and many of them would not be in the industry if it wasn’t for the teachings that these people gave them.
So for a short Blog today, I wanted to Salute Bill and Linda Coghill for their fine work in Alberta EMS, I hope they don’t go too far away and continue to lead the way with a great example, skills, and leadership. Thanks for all the good years and may there be many more to come.
5/16/2013 2:21:20 PM
Just a note to all the wonderful people who have read the blog over the last year. I appreciate all the feedback I have read, and been told. I renewed on this site for another year, and will not be moving just yet. I do intend on moving my blogsite to a better layout and would love any input you may have on blogsites, or domaines. I do intend on launching next year around this time, so anyone that has sites or advice I would love to hear it.
Thank you again for reading, and I hope to be able to keep up the work I have started.
5/16/2013 11:42:00 AM
Immobilization of the Spine
What is the first thing we do when we encounter a trauma injury, after we ensure that our scene is safe? We place the patient in spinal protection. We ensure the patient will not move their neck in order to prevent the possibility of a paralysed patient and further injury.
The practice of immobilizing the patients spine, has been a pillar of EMS injury management for decades, beginning in our infancy, we have immobilized spines to hard, rigid boards, often explaining to the patient that if they want to remain freely walking they will lay on this board for hours on end, no matter what the discomfort may be. Spinal Immobilization has remained unchanged, and the way we place our patients on boards is still the practice in many parts of the world.
Recently EMS has been able to "exclude" some of our patients from spinal motion restriction, but many times we are not able to do so based either solely on mechanism of injury, or presenting injury, we must place the patient in spinal motion restriction. We do understand that often times we may not want to immobilize the current patient, but our protocols tell us we must, and if we are audited on the PCR we may be brought to task for not placing that patient in spinal motion restriction.
Protocols should be changed to reflect severe trauma vs. trauma that would suggest the ability to exclude the patient from placing them on a hard board. Many agencies do currently practice these types of protocols and indeed many of the practitioners out there are able to differentiate the patients who should qualify for spinal motion restriction, and those who could be cared for in a more practical manner.
So what do we do? How should we approach spinal immobilization? As with all of our treatments we need to evolve, and ensure current practice is reflective of our experience, and our research. Remember that poor patient you placed on a spine board only to have them wait in ER with you for four hours? The pain the started to experience, and how uncomfortable they were? Did that patient actually need to be placed on a board? What about the exposure to CT radiation, and x-rays, these should all be considered if we are to re write our motion restriction protocols.
Obviously some of our patients should be placed so their spines are immobilized, such as multiple trauma patients, high impact accidents with head injury, and suspected spinal injury. But research has shown that blunt force trauma patients, with little or no head injuries, or injuries to the neck or spine could possibly be placed in a restrictive collar, taped with a soft head bed, or none at all if the injury suggests.
I have been thinking of this topic for a few weeks and I decided to discuss it after a call I did on the weekend. We had a 21 year old male who had, the previous day, fallen off a roof while placing shingles. He fell between 10 and 15 feet, and had landed on a large 2x4 and injured his flank. He went home without being seen in the ER or clinic and when he woke up in the morning was unable to move due to the severity of the pain in his back. I checked his neck, and neurological response, and even though he had no neck pain, or head injury, the pain in his back was fairly distracting to him, and the pain was radiating from his flanks down to his Coccyx, I was concerned so I placed him on a board, and took him to the ER. I totally understand that this patient possibly would have been OK without a board and full spinal gear, but I was pretty surprised when the receiving nurse told me it was "a little unusual" to see this. In the province we have not yet adopted some of the recent studies that show the research that supports abandoning spinal motion restrictions on all our injured patients so I thought her comment was a little off, especially since I believe that most of the EMS workers here in Alberta would have done the same thing, maybe most of you readers would too, I’m not sure, but given the prospect for his injury, I do feel that currently I was correct.
My understanding is that globally there are many studies currently being done to ensure that we only use spinal immobilization on those patients that will actually benefit from it. Some places have removed the boards from their units, and are relying on protocols which ensure that the EMS workers are only placing patients in motion restriction when absolutely needed, or the benefits outweigh the risks; currently in Alberta we still seem to place the majority of our trauma patients on a board and full spinal gear. I do know that there are ongoing studies that will hopefully allow us to engage our patients in a manner that will allow us to treat them with better and advancing treatments.
My hope is that as we study spinal injuries further, and come to a better understanding of what immobilizing the spine actually does for the patient that we will be able to do the research, and ensure that those patients we do indeed place on our hard boards will be the ones who truly need it, and will benefit from what we do, remember we seek to provide the best care, and never ever do any harm.
Thanks readers, have a great week
Thank you to the following resources for the wonderful collumns.
5/1/2013 9:11:04 PM
What does the Code Level Mean
Often times we are asked "what is the code status of the patient?" Sometimes our response will be "I don't know" and other times we will have the understanding to know what the code level wishes are for our patients.
In many jurisdictions the goals and care designations may be far reaching, and at times difficult to understand. EMS providers must be well informed and understand local expectations, family concerns and patient wishes when it comes to which treatment the patient wishes to receive. A patient may feel that they are perfectly willing to receive blood products, and plasma, but may not be willing to have chest compressions or be intubated. More often than not the patient may feel the more invasive the intervention, the less likely they will be to be willing to receive the noted care.
Recently we assisted in the ER, for a patient that was in third degree block, and eventually full arrest. We intubated him, began compressions, IVs, and the normal full code resuscitation efforts, fully believing that he was a "full code" status. When his family Dr. arrived he informed us he was not a "full code" status, and would not agree or wish to be intubated, have chest compressions, or the pacing that was currently in place. As soon as we discovered the patient’s wishes, we discontinued the efforts, and allowed the patient to have a dignified death. This patient’s record had no indication of his code level status, or his wishes. I certainly wish that the records indicated the patient’s wishes, as we would have understood better his position on a full code.
I have also had the opposite happen; we arrived on scene once to a patient who was in full arrest, with the spouse there, holding his DNR order showing that his wishes were to have no interventions at all. The spouse was begging us to work a full code on this gentleman, and when we explained his wishes to die with dignity, and without suffering, or suffering possibly in his mind the humiliation of chest compressions, or other interventions, she agreed with our explanation, and began to accept his passing. When we got back to the hall one of my colleagues complained quite loudly that we should never have been called because she knew damn well that he didn't want to be resuscitated. I explained to him that often times the family will agree to the "no code" status of their loved one, but when the stressful time of the death actually occurs they hope beyond hope, that their loved one could be saved.
The most important thing to remember when you are dealing with a code status is knowing exactly what the wishes of the patient are. Most of the time, the hospital will have the code level on record, but this can be quite confusing as many times there are multiple levels of care and many different choices of care levels that a patient may happen to choose, ranging from full care, and "heroic" measures which would include any effort to save the patient's life. Hopefully someone has explained the finer points of what this means to a patient. Chest compressions, intubation, defibrillation, opening the chest, may all be involved in these "heroic" efforts. Hopefully the discussions with the patient and family have taken place prior to the stresses of an urgent cardiac event, or brain injury.
Knowing what each level of care includes is important too. I remember code level 1, 2, and 3. Fairly straight forward, code level 1 meant full measures, code level 2 meant no compressions, or intubation, and code level 3 meant only supportive measures. Today, in Alberta we have the form called "Goals of Care Designation Order" this form is divided up into R, M, and C areas, each area having a detailed explanation of what the goals are for each designation, and how the resuscitation may look given what the patient chooses. At first I was taken aback by this form, it initially looks complex and hard to read, but given the details, and goals of care, it is a good form, and accompanies the patient, to EVERY facility, so that each facility knows the wishes.
The difficult time I have is when I have a patient who is obviously on their deathbed, or close to it, seeing the family, and their loved ones, continually sending the patient for tests, and procedures that will have little or no change in the eventual outcome for the patient, often times causing unnecessary suffering. I totally understand the reasoning, but honestly, if the only reason you are sending the patient for a procedure is hoping it will be a miracle cure, then perhaps you need to have a family meeting, and say a heartfelt good bye to your loved one, and allow them to pass without suffering more than they may already be.
Recently my wife had to make this decision along with her father, and brother regarding her mother; this was a terribly difficult decision they had to make. She had end stage cancer, throughout her body, and together, as a family they decided that in order for her to pass with dignity, no further tests or procedures would be performed, she would move into the family home, and be allowed to pass there. It took less than three weeks, and surrounded by her loving family, she passed away in peace. We all knew her wishes, and we all knew it was coming, as the inevitable occurred, it was hard to stand beside her and not make a move, as she passed, having the knowledge that I do, knowing that she was passing in peace, and without pain helped me to enable the family to cope with the passing as well. Her wishes were to die at home, and they were fulfilled.
If you have family members who are perhaps faced with the difficult task of making end of live decisions, make sure you honor those wishes as the time comes, make sure the family understands the ramifications, and knows that the patient has specific wishes, and wants them to be honored. If you have patients that perhaps have questions for you regarding code levels, or status, make sure you answer them honestly, and explain as best as you can the need for them to consult their Dr, to aid in these choices. When you get called to a home where a DNR is in effect, and the spouse wants you to ignore it, don't get angry a soft word will go a long way in acceptance. Conversely if you get to a home and the family is insisting there is a DNR order but cannot produce any paperwork, or proof make sure you know your local duties, and protocols, and can rely on your medical control if needed.
Remember friends, discuss these important aspects of end of life decisions with your family, and know their wishes before it may be muddied by stress, and hard choices made in a split second.
Be safe my friends
4/15/2013 8:43:34 AM
Well, it has been far too long, I felt like I needed a bit of a break, we took a holiday out to the West Coast, and when we got back, I got fairly busy, and really didn’t have time to blog. Well last week on Twitter, I was part of a conversation that really caught my interest. The topic was Sepsis, and I thought that as my first year blogging approaches I would add Sepsis to the topics.
Sepsis is a serious condition resulting from an infection, chemicals released into the blood stream while fighting the infection, can trigger a system wide inflammation, and left unchecked will develop into septic shock and potentially death. Sepsis can develop in any person, with nearly any illness, but can be particularly life threatening in patients who are elderly, or who have compromised immune systems. In the health care industry we should be vigilant to ensure that none of our efforts led to a patient becoming septic, and that we do not allow our patients to become infected through some oversight of our own.
A diagnosis of Sepsis usually is accompanied by fever, higher than 101.5, high heart rates above 95, increased respiratory rates, or hyperventilation above 22, and a known infection. Not all of these signs must be present to ensure a diagnosis of Sepsis, Drs have suggested that if you exhibit two or more of these symptoms, you are already septic. Worsening symptoms such as poor urine output, changes in mental status, difficult breathing, changes in cardiac output, and even worsening abdominal pain can mean that the sepsis is progressing into septic shock. Septic Shock is the final stage of the infection cycle, and is fatal. Severe hypotension, extreme fever, unresponsiveness, no urinary output, and cardiac rhythm disturbances are the signs, or possible results of septic shock. Septic shock will not respond to conventional therapies, and left alone, the patient will die.
Causes are many, any infection left untreated properly can potentially develop into sepsis, with more and more resistant bacteria being discovered, North Americans are living longer, and having weakened immune systems can be a part of that process. People are having complicated surgeries, and some have complex devices for treating their daily medical conditions. Kidney infections, pneumonia, direct bloodstream infections, and other conditions can introduce an infection into the body, and become septic.
Patients in an ICU, with indwelling catheters, whom are already very ill, Very young patients, or very old patients, severe burns, or intubated patients are all at a high risk for developing an infection, sepsis, and septic shock. These patients have open injuries, low tolerance for infections, and direct routes to the bloodstream for bacteria to infect.
As the sepsis worsens, the blood flow to vital organs becomes reduced, blood clots can from in the fingers, toes, or bloodstream, blood flow can stop in many areas of the body, tissue death, necrosis, and gangrene can develop as sepsis worsens into septic shock, and death occurs, if not treated vigorously and aggressively.
If a diabetic child has a new insulin pump, they may not properly care for it, and become infected, if in the course of your day you have to place a Foley catheter into a patients bladder, or a patient needs an IV, or intubation, these relatively simple procedures, if not properly handled can lead to a patient becoming infected, and lead to sepsis, and septic shock. Our daily routines at work must have infection control at the top of the lists of things we need to remember.
When you start an IV do you use both of your hands to unsheathe the catheter, or do you hold one end in your mouth? Have you noticed that there is probably a hole in the end of the sheath that can be a portal to your saliva? How about placing a Foley do you remain sterile so you do not infect the patient's bladder? Everyday there are hundreds of ways a patient may become infected through our oversights, or small decisions. Washing our hands after EVERY SINGLE patient contact is a start. Changing our ambulance linen after every single patient contact is also a start. I wipe my stretcher down with a disinfectant wipe or liquid and wipe the entire surface of the stretcher, and mattress. Some have asked me why I do it every time; I tell them it helps to prevent infections in other patients. We have a general policy in our company that if a patient has MRSA, or some other form or resistant infection we scrub the surface areas of the patient compartment. In hospital personnel should change their gloves after every single patient contact as well; ambulance personnel should change gloves regularly, don’t drive with gloves on, and never reuse gloves from one call to the next.
The old saying "If it coughs mask it" goes a long way, if you feel like your patient is at risk for an infection you should mask up, for your patients protection, if your patient has a cough, mask them up so you don’t get ill. If you are ill stay away from work, what your immune system can deal with may be fatal for a patient that has a compromised immune system.
We must be ever vigilant for our patient needs, we cannot afford to have patients that are sick becoming sicker, taking up our precious beds, and using our highly stressed ambulances if we can prevent the illness that is causing these patients grief. Educating the health care professionals, allied professionals, cleaning staff, and all who come into contact with the patient, about proper infection control can help in hospitals, at home, and in the ambulance.
Treating these patients can be a difficult challenge. Many times the infections they have contracted may be resistant to standard antibiotics, and may require much more aggressive therapy. Broad range IV antibiotics, vasopressors, doses of corticosteroids, insulin to help maintain stable blood sugar levels, and drugs that modify the immune system responses, and painkillers or sedatives. Surgeries or removal of abscesses may be required. System wide septic shut down may require full life support, and advanced interventions.
Infection, sepsis, and septic shock are all fairly easily preventable. If we stand by our universal precautions with every one of our patients, and with every single procedure we perform, we can help to prevent infections. Hand washing every day, after every patient contact is the most important thing we can do as health care practitioners to prevent the spread of infection. Education of our colleagues and other professionals about these important facts will save lives, and prevent infection.
Tell your students, co workers, and others you see in your daily work, that they should be wearing gloves, glasses, gowns and masks. Try not to scold them or get angry but a word to the wise and they will come around. I have seen students, nurses, doctors, EMTs, and paramedics, all of them flout these rules without a care or concern. When you see this happen, remind them that they could be saving a life, when they practice proper infection control, and the life they save may be their own.
3/18/2013 12:51:26 PM
Lets go on Practicum
EMS treats students. One of my colleagues noted that if you had been treated very poorly as a student you would inevitably treat all your students in the same manner. He is in the business of EMS education, and in charge of students, and practicum’s, he has done some research on this topic, and seemed to show at least some preliminary results that would indicate this fact my at lease be partially true.
I gave it some thought, and thought it might make a good topic for a blog post. I have always tried to be fair to my students. I do not believe I am mean to them; however I am the first to admit that I have played my share of practical jokes, and tease them on many occasions. I have heard horror stories of students being treated so poorly that they want to just quite the whole deal, and go on and do something else for their career choice.
Do I give my students a hard time? Yes I do, but I do not believe that I treat them like slaves, or like lesser human beings, all I ask is that each student be willing to learn, be truthful and able to do what we ask them to do. I believe that each student has the responsibility to be prepared for a practicum willing to study, and develop in their professional experience and life skills. However, having a student come to your station that is not prepared, or has just skated by on their didactic courses can be frustrating for a preceptor who is dedicating time, and attention to making sure the student has a good experience, and learns how to be an EMS practitioner.
A preceptor needs to be understanding, patient, and willing to show the student that they can learn from the practicum. I tell each one of my students that there is no such thing as a stupid question, not that we won’t laugh if they ask a question that they should know, but they should be willing to ask anything, if indeed they feel like they need to know the information. The student should understand that the preceptor is not there to babysit them or be their best buddy or friend. Most dedicated preceptors will take the time to pour over many PCR documents, or recommendations from other crew members, to ensure that the student is fairly treated, with no favoritism, or conflicts of personality.
Passing most students is easy, they are dedicated, and willing to learn, others may not be so dedicated, or they may not be willing to study, or do extra work that has been assigned by the preceptor. These students represent a particular challenge to us, but honestly as long as they do the "bare minimum" we should pass them, we may not like it, but if they do their skills, and check off the competencies they need we would have no recourse if we indeed failed them.
Failing a student is a touchy subject. I know that when I am looking at the prospect of failing a student I take is as a personal failure too, I probably shouldn't but I do. When I see concerns of skills, or knowledge, I have to ensure the supporting documentation is there. As preceptors we have to remember that we have the right to recommend a student fail, but the final recommendation comes from the institution the student has attended. I know I have become angry when I have recommended a student not pass a practicum, and the institution insists that they pass, but I have to remember that perhaps my lack of documentation is the reason the failing was not held up. Perhaps the person does not belong in EMS, or has less than stellar skills, and knowledge, but we have to remember it is not us on the hook to possibly be sued by an irate student, but the institution, and if we as preceptors do not document the apparent lack of skills or knowledge some lawyer somewhere will prove that the institution was negligent in its proof that the student should have failed.
Try to understand that I am totally supportive of suggesting a student not be successful on a practicum; especially if they lack the needed skills, knowledge, or both, we just need to document the facts better. If you feel you are not being treated fairly by the institution, ask them what is expected of the student, and what to do if you suspect this student may not be successful in this endeavor.
Being a preceptor is a huge responsibility. You hold the career of the student in your hands; they will emulate what they see, and how you treat your patients. Hopefully they will grow in skill and knowledge from your example; they will look to you for advice, and learning. Teaching these new EMS professionals is perhaps one of our most important things we will do as practitioners.
I have high standards for the students I precept, I expect them to listen, and learn from what I have to show them, I expect them to develop skills and knowledge that will allow them to become entry level practitioners in their own services, and have the skills to work without constant supervision.
Have fun with your students too, make them part of your team, and show what teamwork in EMS can be like; allowing the student to become part of your team will make for a better practicum for your entire crew. Have fun with your students, enjoy them while they are willing to learn from you, and emulate your skills.
3/8/2013 7:57:20 PM
You have to get off the porch
A strange title for a blog, but I do have a reason. My partner is relatively new at this business, and EMT-A of three years. She works, as some of us et fairly do, at other services, at this other service where she works she was on a call starting a 20 gauge IV on a patient, and was told by her paramedic partner that it was an inappropriate IV access, and told her, "If you want to roll with the big dogs, you have to get off the porch." I guess this means that she did something wrong, he never did explain to her what it was so she learned nothing on the call or why perhaps this IV was not a proper access for this particular patient.
When she told me about this I thought about it for a while, and told her that he probably meant that she should start an 18 gauge IV and nothing smaller. Why he would not explain this to her is why I am writing this blog tonight.
Call it medic head, call it controlling, eating our young, or just being and ass. I get fairly upset when I hear paramedics, or any health care provider for that matter, come unglued on some "newbie" who may have trouble with ECGs, IVs, and drug calculations, do the like. I can understand the frustrations of having a partner or student who is new to this industry, who may have been told reputedly how to do a certain intervention, or skill, what I can’t abide is people who are mean, for the sake of meanness, or who think that just because someone is a little weak in their skills, should be run out of this industry.
My partner is a fantastic EMT, she is confident, and her skills are second to none, so when this paramedic called her out for starting a smaller IV than he thought was appropriate, she was hurt, she didn’t even know why he did it. I couldn’t answer her. I told her that many old school medics (me included) prefer an 18 gauge IV, and NOTHING more. However I must state that when my partners start a smaller bore IV than perhaps I would it does not bother me, more often than not if I am not starting the IV I cannot decide if the patient's vein could in fact handle a larger bore IV. If I felt it was a problem I would talk to my partner off the scene, and discuss reasoning, and use the opportunity to teach rather than make the person feel like they were inept.
I have worked with many brand new EMTs as partners, some come to us with zero life skills, and zero experience in the field. I have found that nearly 100% of them are willing to learn, and once they understand that I will not ever call them out on a question they may ask, though I may chuckle a little at the questions, I will inevitably try to teach them to the best of my ability and hope for the best. I tell my partners that if they feel weak in any area of their skills to let me know, and I will help them to become stronger. For example, if they are having difficulty interpreting ECGs, I tell them it is their job to place the ECG electrodes on any and all patients they feel the need, and interpret the rhythm. In the same manner I tell them if they feel weak in their IV skills they will get first crack at every IV we start. This way they learn to hone their skills, and become stronger EMTs and better partners for me.
I am a big supporter of continuing your education, if you are and EMT you should, in my opinion, set your goals to complete and become a paramedic, if you choose not to, that is fine, but I think to not become a paramedic after many years of being an EMT, you have missed some great opportunities. That being said, when I get a new partner and I know they want to go further, become a paramedic; I try to become a tutor. I will expect my EMT partner to become familiar with the medications we deliver, doses, and correct routes, I will grill them as they get closer to entering school I will expect them to become knowledgeable in all aspects of our ALS practice. I try to build their skills rather than make them feel stupid.
I have seen numerous times paramedics than have neither time nor patience for their EMT partners, forcing them to always drive, unless the patient has ZERO signs or symptoms, I have witnessed paramedics telling their EMT partners that it is their job to never question the paramedic, because their word is final. We have to remember that we are a team, whether it is our two man crew, or our entire shift, we work for one goal, to serve the patients needs, and use our skills to end their suffering. It does no one any good to fight on scenes, undercut a colleague’s skill or tell other EMS workers that your partner is useless, or they have no skills, and then have the audacity to not help them, or try to improve their skills. Perhaps they feel your skills are the skills that are lacking, or that you have no understanding of paramedic practice. Please remember you were once an EMT as well, we had zero experience, little life experience, and we needed someone to mentor us, not undermine us, and tell us we are useless.
When you have a partner that perhaps seems a little timid on the IV starts, or ECG recognition, or any number of skills we must have, use that opportunity to become a mentor to these people, and build them up so that e do not lose their skills, and our industry is able to retain the best people with high skill levels, just because your EMT partner may not start a 18 gauge IV on every single 95 year old woman who needs an IV is no reason to throw them to the sharks, and let them sink.
Be good to your partners you never know when they will save your butt.
Stay safe everyone
3/6/2013 11:49:35 AM
What is the cost of service
When a patient asks you "what will this cost me" what is your reaction? Do you simply ignore the question, do you tell the person you have no idea as it is not your area of concern, or do you try to explain to them the costs associated with their transport.
This can be a touchy subject as I have noted over the past week or so some definite opinions on the matter surfacing on social media. I saw opinions vary, from noncommittal acts of ignoring the question, to explaining that the responding crews have no idea of the costs. Personally I do not think this is fair, certainly if the patient is going to be billed they deserve a fair explanation as to what it may cost. I’m not saying you should explain in great detail what the trip will cost, but an overview may alleviate the person’s anxiety of a bill so to be mailed to them, and certainly will lessen the surprise they get when they do indeed get a bill in the mail.
The main difficulty arises in our industry where there lays inconsistencies in many jurisdictions as to costs, billing methods, cost recovery, and willingness to work with the patient in ability to pay the bill. I have seen services bill out for every item used on a call, a set fee for ALS vs. BLS transport, mileage, and fees for non transport. These fees vary from province to province, state to state and country to country. I am also not saying we should not bill for our services, as I do believe that payment must be made is some form.
If you have been with your present service for any length of time you will certainly understand their fees for service. Perhaps you may not know how the billings go out, but certainly you should know what it costs to have an ambulance attend a call. I am of the opinion that pretending not to understand this, or ignoring the patients questioning can lead to poor outcomes, if the patient decides they got a bum rap and goes to the media to complain about billing for needed services for example, perhaps five minutes with them could alleviate this. Having the patient fearful to call for assistance when needed for fear of an inability to pay could also end up in hot water if the patient required urgent care and didn’t call 911 for fear of a bill.
The service I work for is a private delivery service, contracted to provide service in Central Alberta. We bill for service, just as all services do in Alberta. Now a paramedic working in a large urban centre for a direct delivery system may not understand the billing process, but should explain to the patient they will be getting a bill, and could explain the range of costs associated with the bill. I will tell a patient that asks that their social services should pay for the ground transport, or failing that their supplemental insurance such as Blue Cross or something similar. If they have been in a MVC, generally the insurance will cover the cost of the ambulance bill, and in the case of seniors our Alberta Blue Cross will normally cover the costs of transport to the hospital. I also explain that our company is very reasonable when it comes to collecting fees. If the person finds they have no coverage, are unable to pay, or cannot afford the bill, our company will work with the individual on a case by case basis to arrange a payment plan, the patient can afford. I have seen people coming into the office with $10 to pay their bill, each month until it is paid off. I do also understand that not all private companies are like this and will send a person to collections just to make sure they get the money, but the company I work for is not like that.
Billing fees vary in every case, and nearly for every company out there. The Government of Alberta has set minimum fees for which ground ambulances may bill, as well as a mileage fee. Most services have a set fee for ALS transport, BLS transport, and no transport, depending upon whether the patient has made contact with the attendants, or if nothing at all was done. Some services will also bill for items used in calls, I am not sure how common this practice is, but I do know it happens.
Certainly we are entitled to bill for our services, as I saw one person state, if you call a plumber you expect a bill. I do believe that some of the anxiety that comes in with ambulance bills comes from the fact that most fire departments do not send a bill when they put out your house fire, I can imagine that three or four pieces of apparatus, with 10-20 men working 12 hours to extinguish your home could rack up an fairly extensive bill. Likewise the police department does not send you a bill for apprehending the thief that has broken into your home, and they arrest him. Someone has to bear the costs for this, whether it is the local government, higher insurance premiums, or whatever, there is a cost to everything.
Ambulance services seem to get bad media when they bill for their service, some stating the bills are unfair, or they were not aware a bill was coming. I had a friend of mine who was in an MVC was assessed but not transported come up to me, very angry stating they were going to refuse to pay the bill they got, I simply reminded him that he could call the company office directly, and either arrange to make some sort or agreement, or the cost would likely be covered in his insurance claim. He was astounded that he could do this, he never realised the vehicle insurance would cover this cost. He was also impressed that the office would be willing to talk about payment options.
Do not forget to obtain the entire information you need to complete the billing forms your service requires, all pertinent social services numbers, supplementary insurance information, car insurance information, name date of birth and current address will not only help your billing department figure out who does indeed receive the bill, but will ensure that it does not get lost in limbo somewhere, and in turn wreck a credit rating of someone who does not even realise they were being billed for service.
I try not to avoid the difficult questions of the patient when it comes to billing, I will give them the company card, and explain to the best of my ability the costs associated with their bill. Please understand that I do not sit there with a debit machine in my hand asking for a card to charge, while I am working a cardiac arrest, I will generally raise the answers to these difficult questions after the call is completed, in the hospital, or in the back of the unit after the patient does not require further treatment. I would not interrupt my patient care to concern myself with explaining the details of a bill the person might possibly get.
If you decide that explaining the billing details is not your job that is fine I don’t want to tell you that you must do this, but I have found in my experience that a patient who understands that they may indeed get billed for the service, will be grateful for the heads up, and explanation.
I thought I would add a few words about costs structure. Depending upon your service the cost for ground transport will vary. Generally speaking the person will be charged a response fee, as well as a mileage fee. The fee for ALS response will very likely be higher than for a BLS response. Some services will charge a fee for a response with no transport, while others will not charge for this option. Services will usually bill for service rendered where no transport is initiated as long as there is some assessment perform. Other urban centres may charge an extra fee if you are not a resident of their city, to offset the cost of the taxpayer of that city. Province to province, and state to state, the costs can be large. In British Columbia they are charged a minimal fee as the ambulance service is owned by the government, and therefore paid for by the taxpayer, in Alberta a fee for service would run about $450 for an ALS response, plus any mileage to hospital. I would say the average cost for an ALS trip across Alberta with an average 50 KM mileage fee would cost the patient around $550- $750. Again this is dependent upon what the service charges for mileage and call out. Also note that ALL interfacility ground ambulance transfers in Alberta are paid for by the health region, or hospital. If the patient is being sent home from a hosptial to a NON Approved facility, or home the patient will be billed, and Blue Cross will not cover the cost. The cost int his case will be the patient's responsibility. Also of interest is the fact that if you call in STARS the costs for this is covered by Alberta Health Services. in many other areas of North America the costs associated with a fixed wing, or rotary wing transport will be borne by the patient, this coould run into the thousands of dollars.
Thank you for pointing out the fact that I missed talking about costing
2/26/2013 10:03:41 PM
Think back to your school days, elementary school, middle school, high school. Even in college and university. Was there someone who was a bully? You can probably answer yes. Even in our daily working lives there are people who bully others, whether it is a peer, supervisor, or manager. What is there to be done about it?
Today is anti bully day, and I thought I would jot down a few words that may help you to end bullying.
I had my fair share of run ins with bullies when I was younger, getting beat up seemed to be a normal part of childhood for me, name calling, and meanness seemed to be abundant at our school, I also participated in being a bully, to a few of the kids we felt were not popular, or as well off as the rest of us. This was in the 70s, and seemed to be acceptable to the educators of the day, not that it was condoned, but there was not a lot of punishment going on and teachers and parents seemed to look the other way, unless it got really out of hand and someone complained about it. Rarely was anyone suspended, or expelled from school for merely being a bully, usually it took a little more.
Bullying can be described as physical, emotional, or verbal abuse and can be repeated, aggressive behavior intended to hurt another person. The aggressor may feel the need to show their "superiority" to others by making threats, verbally abusing people they see as inferior, or as some have suggested may be poor academic achievers. Bullies may also be in turn abused at home, or feel they need to act out in some manner as they may feel a person they see as inferior to them as a threat in some manner. Bullies may or may not grow out of this behaviour as they mature, and they may gain social skills that they were lacking in their adolescence. Others do not ever grow out of the pattern, may be bullies at home, church or the workplace.
Cyber bullying has become a problem in recent years where people are abused on any of the social media we have access to in our daily living. Pictures, rude comments, and rude behaviour can all be a part of this trend, knowing what your children are looking at, and experiencing online can help you to end a cyber bully's reign of terror.
Male and females bully, there is no gender separation, a male will bully males and females, and vice versa. The real difference is in how the bullying occurs. Males tend to be violent and degrading in public forums, with abusive behaviour coming in the forum of physical abuse, more often than mental abuse. Females on the other hand will bully in a manner that may seem more deceptive. We have five girls and watching them in their social circles I became aware at how mean girls can actually be. Mockery, gossiping, excluding others, mental, and emotional abuse was at some point, a part of most of their lives. We were lucky with these five because for the most part we didn’t have a huge problem with bullies, but we did see the behaviour in even the "best" girls. One of our girls was a bit of a bully though, and we did have to intervene on behalf of the school and end her abusive behaviour, it took a while but she grew out of this type of behaviour, and is now a fine young woman.
In recent years bullying behaviour has come to the forefront of our knowledge, the detrimental effects have been seen in school bombings, shooting, suicide rates, and self mutilation. Most of the bullies have been abused at home, or have had a history of sexual abuse. Parent’s educators, local law enforcement, and others should be familiar with school board decisions on bullying, laws that govern bullying behaviours, and report the bullying behaviour to proper authorities.
What can we in EMS do to end bullying? When we get a call out to a home we can observe and report activities such as physical abuse, sexual abuse, and any other type of abuse that we can report to the hospital, or local law enforcement authorities. This may not be easy, but if you see it, you should report it. If we see behaviour at work that is bullying, make sure you step up and say something, end the bullying now.
Anti bullying laws, and statutes have been made in most jurisdictions these days, be aware of them, talk to your kids, and their schools, make sure that if they are being bullied at school they can talk to you about it, they do not have to suffer in silence. On the other hand if they are the aggressors, make sure you also talk to them, and end the abuse. Explain to your child that when they bully someone it degrades who they are, and shows that they may have problems of their own that need discussing. Do not be afraid to send them to a councillor, and let them talk openly. If they are the bullied the same should apply, help them to talk, and open up to help them overcome the feeling the bully is making them feel.
We must end bullying, and having awareness campaigns like anti bullying days, or bullying awareness days will help to end the cycle, keep a watchful eye on your communities, and become involved in their anti bullying awareness. Keep your loved ones safe and stay safe yourselves friends.
2/25/2013 4:33:56 PM
The Frequent Flyer
If you have been in EMS for even a little bit you have probably heard of, or transported a "frequent flyer" in your service area. These people can be any type of person from a lonely widow, to a drug seeking vagrant that wants their daily fix by calling EMS. We all know them, we all see them, we have all had to deal with them, and the question is how we deal with them in a professional and upstanding manner.
I read a page the other day about a patient in an area that has the local EMS Company stymied. He is abusive, flaunts the fact that he is able to call EMS and have nothing happen to him, and treats the responding crews like garbage. They seemed to be at their wits end on how to handle this patient. To be honest with you I do not believe I am perfect to answer this question, but I felt a blog may help us understand why these people may call EMS to begin with.
In our area we have a person that calls on a very regular basis, we have all had to deal with his abuses, and false claims of chest pains, and "unresponsiveness" I had a newer paramedic come to me the other day who had his first experience with this man, and was at a loss for words on how to go about treating him. When I have gone to this man's home, first off I noted that he lives with his mother, and is in his mid 50s, he also has had some addiction problems, and is addicted to Morphine. He generally calls, ensuring his mother has seen has seen him "pass out" and then she calls EMS on his behalf. This man has been talked to by our management, our provincial social assistance people, as well as police, and local authorities. I told this young paramedic that really there is not a whole lot we can do, when he calls we respond, however, we are not to tolerate his abusive behaviour, and if he becomes abusive to the point of violence (which he has done) to call the Police, or restrain him. The unfortunate thing about this man is that he seeks the attention and the Morphine that the ER will usually administer to him. Our EMS department has not given him any Morphine for a long time, but he still gets his fix at the ER. This man has burnt so many bridges with emergency services that the local volunteer FD will not respond to his home, in the event of a medical callout because of the abuse delivered to them.
I must also admit to the frustration that comes when we get the call out to some of these people. At two in the morning, going to the home of a person who has called you three or four times that week, called Health Link, and has convinced them they should be transported to an ambulance. We had an older person in our town that used to call us at least three times a week, sometimes more, once we would get there she decided not to go to the hospital with us at one point complaining to our supervisor that we had interrupted a TV show and wanted to know how it ended. The solution I found for this patient was transporting her to the hospital each time she called telling her she called us so she must need to go in. The ER staff didn’t like it too much, but after a while she stopped calling, and finally her family moved her to a location where she was able to care for herself better.
In Alberta we have what is called the CHAPS this is a programme to help EMS staff refer patients who may need the intervention of the health care system such as home care to come and assess their needs. Currently in town we do not have many people that are calling us on a "frequent flyer" basis, but I think if we did I would refer them to this program. Perhaps this type of intervention will alleviate the problem.
When you get the problematic patient that will not stop calling for no reason, make sure that you have proper back up so that if the patient does become abusive or violent you can have police back up or the ability to intervene so you, your patients, and the patient can remain safe. Make sure your local police understand that you need their help with these patients too, often times these departments get just as fed up with these patients as we do, and refuse to respond. Talk to your management team and voice your concerns for these patients, showing that you do care, but the patient needs to understand also that abuse of the EMS system cannot be tolerated. If the abuse of the system continues often times the patients social services system will no longer pay for ground ambulance, their Blue Cross may also tell them they are no longer going to pay for ambulance service if the patient continues to call EMS for no reason.
The "frequent flyer" patient is a problem that is probably not going to o away anytime soon, and we have to be careful not to overlook a serious EMS call to a patient that has called us 30 times in the last 30 days, you as a practitioner do not want to lose sight of your primary concern which is the health and safety of our patients, I remember telling this at one point to a student who was just days away from passing her practicum, only to be called to a person whom we knew very well as he has called us multiple times while she was on her practicum, well this poor man was actually having a large heart attack, and she totally missed it because she was only concerned with how many times he had called. Please remember that even though these people do certainly abuse the system, and must be called on to stop, they also can suffer from any ailment known to us, and will call when we need them, do not shirk your skills, and responsibility just because you have seen them four times this week.
I have read different solutions for this problem. Buying the offender bus tickets to another state or province, having the person arrested, and many theirs, the truth of the matter is that even when the patient has called 10 times in the same week, we will transport them to the hospital, and ensure they get some help. Please remember that if these patients become abusive to you, or your EMS team, you have the right to tell this person that you are not going to accept that treatment. Violence cannot be tolerated remember that if the patient is violent you can file charges and have the patient prosecuted. This may not be a very decent thing to do but I can tell you with certainty if the patient is going to strike me, or spit on me, or become violent in any other way, I will charge them with it.
The "frequent flyer" patient can be a handful, perhaps you are fed up with the nonsense they are spouting for the tenth time that month, perhaps they are becoming violent toward you and you partners, or the police have refused to back you up because they are also fed up with the behaviour. You are a highly trained health care professional, you know the proper signs and symptoms to look for, certainly these people can fake it, but hopefully you can see through the facade, ensue these people get the proper treatments for their real illness, and pass onto the receiving ER your concerns, especially if the patient is drug seeking.
In the meant time friends, be as patient with these people if you can, talk to your crews and managers about these frequent callers, and have a plan before you get so frustrated that you are losing your patient advocacy.
2/20/2013 12:15:21 PM
Controlling the Airway
We have all faced this question, "When do I intervene to protect the airway?" I have had these questions from new practitioners, as well as seasoned colleagues, and students. Most of the questions I have faces are along the lines of when to intubate, or set up for an RSI, or when to do a cricothyrotomy. What is your advice to these people when they ask you these sometimes difficult questions? I know what I answer and I’ll try to help you with yours.
First and foremost, you need to remember the basics; airway protection is one of our grounding, founding concepts. Whether it is a complete airway obstruction from a choking hazard, to a full on silent chest from a severe asthma attack, we need to remember the basics come first before any medications, interventions, or manoeuvres. The old adage "Air goes in and out, blood goes round and round" is one I like to quote when I am talking airway protection.
When you receive a call for a code 6 (enter designation here) how do you approach the scene? What equipment do you bring into the call? Certainly oxygen is the most important item you will need for a difficulty breathing call. I usually begin thinking of possible treatments I will need to deliver as I approach the scene, and the patient. Remember to listen to the patient, look around for medications they are currently using, and hear what they are saying to you. Clues will be evident everywhere, when you have a student make sure you point out the canisters of oxygen, or home nebulizer that the patient is using. Be sure to look at expiration dates of the medications the patient is using, and how often this patient is taking the medications.
Commonly we will be called to patients suffering from asthma attacks, their bronchioles are swelling, filling with fluid, or in spasm. These patients need oxygen, and medications to help increase their blood saturation, and free the lungs of spasm. In severe cases the patient may be close to respiratory arrest, and stop breathing altogether. Left untreated a severe asthma attack will cause the patient to get worse, and will eventually go into respiratory arrest. Medications such as Salbutamol, Ipratropium Bromide, Magnesium Sulphate, and various steroids that are in your protocols will allow you to treat the asthma attack without much difficulty. With severe attacks where the patient may be getting tired or minutes away from respiratory arrest, you may have to prepare for more advanced airway protection.
Another large call volume we see is the COPD call. Remember how some would say you have to with hold oxygen from these people? Yes that has actually been said. Certainly the pathophysiology of the COPD patient makes it wise to be careful with the oxygen on these patients, but you should never with hold it. If the patient is so severe that they in fact do stop breathing due to a higher than normal oxygen saturation in the bloodstream, if that does happen take the precautions you should normally take, I personally have never ever seen this in a COPD patient.
In the patient that is in respiratory arrest, or who is not able to protect their airway due to alcohol, drugs, or unconsciousness, start basic, begin by using your simple airway opening manoeuvres. Use an OPA, or NPA, while you are setting up for placement of an advanced airway you can ensure these patients receive adequate oxygenation by either using a BVM, High flow oxygen masks, and either the OPA or NPA as mentioned. I have inserted NPAs in both nostrils if I feel it needed, and bagged the patient if they will not accept the OPA, I have found many of these patients will accept the NPA over, the OPA, especially in the overdose situation. The trauma team may look at you funny having two NPAs in the nose, but it does indeed work.
Preparing to place an advanced airway can be stressful and full or questions, when to place these devices, and when you should think about medically placing the patient into a coma to protect their airway is a very big decision you will make when the call may be stressful, and there may be extenuating circumstances, such as heavy traffic, multiple patients, or doctors on scene yelling at you to let them do this job. The decision to place a patient in a coma to facilitate placing an airway, to save a life in not your everyday situation, but it does arise. When you are preparing to do this RSI make sure you pre-oxygenate the patient, if you can’t get a weight on the patient use your best guess, I generally try to guess a little less than the patient may indeed weigh, this way you won’t be delivering to much medication to the patient. The medications you will be delivering will be narcotics, benzos, and paralytics. These medications will stop breathing and all musculature movement so you must be certain you can gain airway protection in rapid order after the medications are delivered. In the event of a total airway collapse, or total airway obstruction, you may need to perform a cricothyrotomy. This will be a high stress call; you must remember your landmarks, and the correct method you are authorized to use. In Alberta we use the "Cric kit" we have found they must have a scalpel added for better penetration of the skin, if you use a prepared kit of some type, please be familiar with it, so that you are not asking difficult questions as the stress of a difficult call is hitting you square in the chest.
Don’t forget of course you will need IV access I generally try for two large bore IVs, and please attach the cardiac monitor to ensure you can monitor the cardiac condition of the patient. Do not forget the valuable end tidal Co2 monitor as usually changes in this monitor are faster to see than the SpO2 monitor. The clues such as rising blood pressure, teary eyes, and rising pulse rates will guide you and help you evaluate when the patient will need to be re-sedated during a longer transport. Don’t forget to have a rescue airway at hand, and a bougie tube ready for assistance in the event of an airway that you are unable to capture immediately, or if you are unable to visualise the entire vocal opening.
Do not underestimate the value of the "non visualized airway" these airways can save you in the event of a very difficult intubation, or when there is a crew that has no access to intubation such as a BLS crew with no ALS back up. DO not discount the use of these devices, they will protect the airway and save lives just as the "gold standard" of intubation can.
Obviously I could go on for hours about airway protection, and control I wanted to scratch the surface, and give you some food for thought, so that the next time you hear a tone out for a code 6, you may be under a little less stress, or when you walk into a patients home that is lying in a pool of his own vomit, unable to protect his airway, the stress you feel will be a little less.
2/8/2013 9:21:33 AM
How Much is EMS Worth
I had a Twitter conversation this past week about wages in a large urban center in the states, and indeedacross his entire state, he told me that even medics working in a large urban fire setting are getting just over minimum wage. This statement made me think about a few things, and wonder, how much are we really worth.
An EMS worker whether they are an EMR, with very little basic training, EMT, with more advanced training, Paramedic with advanced training or Critical Care Paramedic, these men and women dedicate their lives to learning, training, and living in an ambulance for long shifts, hardly any breaks, and stressed to the max. Are they not worth more than some kid flipping burgers at the local choke and puke? They certainly are. Most allied health care workers, when they would like to move to another area of the world wouldn’t have to worry too much about how it would affect their wages, because most other allied health care workers receive much better than minimum wage. In EMS, if I wanted to move to a different area of Canada, I would worry that I would have to give up what I make at my current employer, to pray I would make at least the provincial minimum wage. How sad for EMS workers that municipality, counties, city officials, private owners, and others feel that the hard working dedicated individuals that work in their EMS systems are worth a poor wage.
So how much are EMS workers worth? Well for starters I am not a policy maker, I am a paramedic. I go into darkened hovels, praying there isn’t a gun wielding maniac waiting for me, I perform life saving invasive techniques on a dying baby, I deliver breech babies, I comfort family members who have just lost their loved ones of many years, I walk into an accident scene on the highway while traffic screams by, praying I don’t get hit. I work for 14 hours straight, and never get a break for lunch, never mind to empty my bladder. I endure countless beatings by some hospital staff that thinks I am too stupid to understand simple orders, or because I was late for a "STAT" transfer by 3 minutes. How much am I worth, when I am called to your house, maybe you will understand how much I am worth when I pull your wife out of the jaws of death's icy grip, while your children ask "is Mommy OK?"
EMS workers are often times declared an essential service, I think for sure we are, but don’t you think an essential service is worth pay that reflects their skills, training, and hazardous duty? City councillors, town councils, owners, operators, and people in charge of the EMS system where ever they are located should take a look at their annual budgets and see what they are paying their essential workers, look at the money they are bringing in, and pay these people what they are actually worth. Of course there will be EMS workers willing to work for the minimum wage, what else are they supposed to do, they were trained for this, they love the job, they are dedicated, but when the only wages offered is the bare minimum, they will work for it, because after all they do need jobs. Just because someone is willing to work for the minimum wage, does not mean it is right to pay them that.
I make a decent wage where I work, I am very happy that I make much better than the minimum wage. It makes me sad to know that there are EMS workers who do the exact same job as me, but have to live below the poverty line; I truly believe that we in EMS are worth much more than the local minimum wage, we should be paid for our work, and we deserve to be paid a decent wage.
Stay safe out there friends.
2/6/2013 3:14:25 PM
The Black Sheep of Health Care
In EMS we have been called many things over the years, with names like ambulance drivers causing offence to most of us, I am wondering why we are sometimes treated like we are the "bastard children" of the health care system.
Recently at one of our local hospitals, we had a triage system pilot program that was color coded, now for the code system to work EMS came into the stretcher area, grabbed a small color coded tag, and dropped it off at an area in triage, never discussing the patient condition, unless he or she was unstable, then another set of rules was followed, if your patient was stable you left the triage area, and waited to be called upon. However, this system made our local EMS feel neglected and, left out, and out of the loop for proper turnover of patient care. I know firsthand of one crew that was totally forgotten for over an hour left in the stretcher area, and finally got a bed when the triage person saw them and remembered they had an EMS team waiting. This pilot in my mind showed me that sometimes hospital systems, and the health care system in general feels like we in EMS are the black sheep of the industry.
Think about this for a minute, whenever you see a TV series or movie depicting EMS providers generally speaking they portray them as bumbling, morons, that can’t find their boot straps to tie them up properly. When we see EMS in TV shows, we generally are yelling at the TV something like "SECURE HIS C-SPINE YOU IDIOT" when the hospital staff, are usually shown cleaning up an EMT or Paramedics mess. When we watched Johnny and Roy in the 70s, certainly their protocols were limited, but remember that at that point in history EMS was relatively new, and the Dr would require you to beg to start an IV, or give a certain medication. Now at least in our history we go to school to learn what to give, when to give it, how to think on our own, and how to make correct decisions based on our patients presenting illness or injury.
That’s right, we go to school. I’m not sure how it works in your jurisdiction, but here in Alberta it would take you roughly three years to become a fully licensed paramedic. With hands on practicum’s, and difficult curriculums we should be demanding more respect within the health care community to recognize the fact that we are highly educated, highly skilled, and highly dedicated to our chosen career. Perhaps we need to look at ensuring all paramedics are degree programs, would that be so bad? I do not think so and the EMS people I know are all in favor of better education to ensure we do in fact get degrees at some point in our careers. Nurses, and Doctors have degrees, as they should, as do many other allied health people. Why not EMS? Would you be willing, if you are not already, to attend school and be required to have a bachelor’s degree of paramedicine? I would. I should have when had the chance, but alas I couldn’t at the time. What about the critical care paramedic, should that require a master’s degree? I don't know, I think that if these titles had degrees attached to them we may gain a little more respect in the health care industry.
It is not all education though, at least not for us, it is also about educating hospital staff, RNs, Doctors, and others what exactly a EMR, EMT or EMT-P can do, I use our Alberta designations because I am familiar with them, if your areas the designations may vary, but are essentially the same. Perhaps better education of our health care partners will gain us the respect we so desire. When we show up to a health care facility and are told "We called the ambulance drivers because this patient has an IV lock and we needed a paramedic." What is your reaction? I know mine is initially anger, and frustration at the facility for possibly a misuse of resources, but this could be an educational opportunity. Possibly explain to the sending facility the fact that possibly a paramedic does not need to go on this call when there are more appropriate resources available, perhaps BLS crew, or transfer van could take this patient rather than pulling a much needed ALS car off the road for three hours. The point I am trying to make is that educating the entire health care industry on our skills, and abilities is probably the best way to get the word out on what we are capable of doing.
Medical oversight vs. Medical direction has come to the forefront of many EMS systems, do we have to call in for every single call when the presenting illness may not look exactly like it is in the book, or when we feel we may need to use a medication that we KNOWS works for a certain problem but is not in the protocol so we have to call in, talk to a Dr that may or may not like EMS, and beg him or her to allow us to step outside our set rules. How about a set of guidelines that allows us the ability to work to our full scopes of practice, without calling into the Dr to see if it’s OK with him/her. I think the ability to work to our full scopes of practice, with medical oversight would be a wonderful way to work in EMS, perhaps at that point our health care brothers and sisters will allow us to come in out of the cold, and no longer be the black sheep of the health care industry.
Be safe my friends.
1/29/2013 6:16:24 PM
Throughout our history, from the very beginning, we have had researchers tell us on the streets how to treat our patients, what medications to deliver, and what equipment should be standard on every EMS rig. It seems that every few years we are either dusting off old "obsolete" equipment, or relearning a drug dose that was seen as either non therapeutic, or the drug was no longer delivered in the Prehospital setting.
Remember your high doses of epinephrine? What was the dose, for a 110lb man in cardiac arrest, what regimen did you opt to use, did you get a pulse back, and did the patient end up leaving the hospital on his own two feet, or on the wheels of a hearse? How about Aminophylline, Theophylline, or Bretylium? How about MAST pants or HARE traction splints, these items used to be standard issue, and standard learning in ACLS courses, EMS courses, and stocked on ambulances. Remember the Venturi masks for our COPDers?
Now before I got any further, I must say that I fully support EMS research, that finds better ways to treat the patient, and indeed some systems may still use the ideas, and medications I mentioned, each system should use what they find best for them, however, if current research is suggesting certain items, or medications are harmful they should be discontinued.
I decided on this topic because I read an interesting article the other day about spinal immobilization in MVCs, and how we treat the possible injuries, and how we use spinal immobilization on the scene of an MVC. This issue is hardly new, I have a friend of mine that discussed this issue in 2002, only to be howled down saying what we do currently is best for the patient. What will come down the research pipe as far as spinal immobilization goes? Why not have a guess, I’m not entirely sure. Will we continue to pull a patient out of a vehicle, holding their neck, slapping them on a spine board, and securing their entire body to this device? I’m not sure, but research is being done on everything on allowing these patients to self extricate, to leaving them on the stretcher un-secured. Until we see concrete results we should continue what we are doing. Maybe one day our rigid boards will give way to something new and exciting.
I was trained, as I am sure many of you out there were, on an "artifact" 5, hard to tell V-Fib from NSR with one of those on a country road. I remember sitting in my first ACLS class, laughing, wondering how we were expected to deliver a 12-lead ECG to rule out a STEMI. Remember your first ACLS course? Mine was hell on wheels, and that is being nice. I have joked that ACLS today is ACLS "lite" but with experience, and the research that has happened, we should be grateful that we can ALL take ACLS, not come out of it with a basket full of ulcers, and treat our patients with the best knowledge, and treatments that we can.
EMS research may still be in its infancy compared to the rest of the established health care industry, but with EMS coming into focus, we will see paramedics with master’s degrees, possibly PhDs, and who knows what else is in store for our educations, and research. With those degrees, we will see a new era of EMS research, and who knows, in 25 years maybe we will be performing HD invasive treatments, never before thought of, at home, so the patient can recuperate at home, without a trip to the hospital.
Stay safe my friends, and stay current in your treatments, and trends.
1/17/2013 11:33:19 AM
The Mass Casualty Incident can strain your resources to the breaking point. Having a plan for your department in place for these stressful, difficult calls, will enable your department to respond quickly and effectively to these calls. If your department does not have a plan for the eventual MCI, you should meet with your managers and ensure you make a plan. Perhaps these calls don’t happen every day, but they do occur on a regular basis.
An MCI does not necessarily mean 150 patients, or even 10, an MCI is any call that has more patients than your department can handle or crews can handle on any given call. Recently we were called to an MVC with fairly vague injury reports, and unknown pt numbers. When I as the supervisor made the decision to send our three ambulances to the scene that decision was based on my years of experience, and the feeling I had that there was more to the story that dispatch actually knew at the time. It was a good thing we did send the three crews because there were three patients all non ambulatory, and two of them requiring eventual surgery. This call may be typical for your area, and it may not. How many crews do you send into an MVC? Do you send more crews into a fire standby, or do you wait and see if more units are required once the initial crews are there. I’m not saying either way is correct, it’s up to you, your management, and crews what you want to do, and how you want to stage and how many units you want to send on these potential MCI calls.
When you do have an MCI, you need to have a clear understanding of the chain of authority. You need to know how to implement your MCI plan, and how it will all come together on scene. Trying to figure these things out while you are trying to deal with patients, the press, and incoming units will not work for you. You will bog down, your resources will not be allocated properly and lives could be lost. I hope that today's blog will help with your MCI plan.
Arrival on scene, when you arrive on scene hopefully you will be aware already that this is an MCI situation, if not you are in for a bit of a nasty surprise. You need to start triage right away; probably the most important job is triage. This person is responsible for lives. They must understand the need to evaluate, and move on; this person must also understand that they do not treat the patients they are presented with. Speaking from experience this job is not an easy one, you MUST be able to stay aloof and not treat the patients you usually would try to save. Patients that are not breathing or have a pulse after airway manoeuvres should be triaged as not salvageable, and move on. Patients that have head injuries or chest injuries that are critical should be triaged as first in line, and so on. I’m not going to go on and describe every injury or who goes where, when you make your plan or when you discuss this with your department; you will make those decisions ahead of time, to save time on scene.
You will also need to set up a command area. This area should be central, with easy access for your incoming crews, and other agencies to identify. Many large departments will have busses, or mobile command centres that they utilize in such incidents, and perhaps if they are close enough,a nd willing, they will respond to the scene, and allow you to use their system to run your MCI. "Borrowing" other agencies command centre may cause some friction because they may feel they are the only ones able to utilize this, however you need to remember that it is your scene, and they are allowing you to use these means. When we bring in these agencies we must be willing to work as a team, together for the betterment of the patients.
Another area you will need to set up for is a staging area, this will probably mean a helipad someplace, and an area for incoming ambulance units or fire apparatus, or police officers to stage while you assess the need, and who will transport what patient. A staging area can also be a holding area for equipment that incoming resources will "put into the kitty' for crews, and personnel to draw upon if needed. A staging area will keep your scene clear of chaos, and have the inbound units, and crews clear the area in an orderly fashion, not a free for all that would probably end up in gridlock. Setting up a helipad can be difficult but usually a fire department officer can help with that, as they will be able to scan the area for clearing, free from obstructions, even better if you have an airstrip within a decent transport time, you may even be able to have fixed wing aircraft come in, and stage to take patients to distant hospitals. When the Pine Lake Tornado happened the scene commander was able to set up at the Red Deer Airport a staging area that eventually had surgeries performed and fixed wing airplanes taking these patients directly to area hospitals, and far distance hospitals.
Essential to your MCI plan is the plan for communications. Many times your radios, or cell phones will be overwhelmed with requests, or traffic, often times cell phone towers are so overwhelmed they will cease to function, or you may be in a rural area that has no coverage for your phones or radios, this can be a very difficult challenge, and must be discussed prior to your call outs, and should be covered in contingency plans during your MCI planning and policy making. Proper communications is a key part of your MCI plan, and should be a high priority.
The media may want in on the fun, and may show up on your scene, they can be your friends, they are merely trying to do their job, and will only want the facts from you. You should try to update the media if possible, every hour or so, this way the media people will be happy, and continue to support you, and report your fantastic work. The area you set up for them you may also want to delegate to someone, as you are still in charge of the entire scene, and will need to remain worry free about a media circus if you do not place them in an area they can properly set up to do their jobs from. Try to be as respectful of their requests as they are of your scene, they will honor your boundaries if you give them boundaries, and information on a regular basis.
You may also need to set up a morgue. Not a very nice thing to do, but better than having the deceased lying around on a highway, road, or field. Make sure you clear this with the local police force before moving the bodies. At the Pine Lake Tornado the scene commander used the garage of a local home that had been affected by the tornado. If you are on the scene of a major crime you may not be able to set up a morgue, in my opinion you probably won’t be moving bodies in that case anyhow.
Closing highways and rerouting roads is also a valid point when there is an MCI, you don’t want traffic to increase the hazard to you and your inbound crews, or responding agencies. Keep in mind that if you do not close a section of the road, you may have trouble with "lookie loos" who may cause more accidents, I have been in this particular situation, and trust me all it does is add stress, and more casualties to the problem. Your local police officers can help you with this, as closing a major highway may involve the provincial or state authorities, especially if it is a major highway, or interstate.
An MCI can go very smoothly, or may be very difficult for you to manage, it involves pre planning, and policy making to ensure your department understands how an MCI will be run, who is in charge, how much authority they have on scene, and who they are able to call in for overtime if needed, where the resources are coming from, and how the scene is run. After the major event, MCI, or disaster you will want to have a debrief with those involved, to discuss things to improve, how to ensere the good things are repeated, keeping our MCI plans uptodate, and ensuring our crews know how to access the polices for the eventual MCI.
Good luck with your policies and good luck with you’re planning of the eventual MCI that will happen in your response area.
Be safe my friends
1/5/2013 12:42:01 PM
In EMS we respond to many calls where geriatric patients are having some sort of emergency. The study of aging is known as Gerontology, and has been at the forefront of health discipline since the early 1900s. Gaining momentum and recognitions as a much needed area of health care, we now know more about this aging group of people, and the ageing process than ever before. With ageing populations, possibly declining birthrates, and other factors we can expect out call volume in this demographic to explode over the next 10 to 15 years.
The calls these people dial 911 for can be varied, strange, or even for reasons we cannot fathom. Have you ever been to an elderly person's home, and wondered why you were there, because their chief complaint seems to be loneliness? What do you tell them, do you get angry, or explain that possibly they do not need to go into the hospital, but they could see their family Dr for the malady they are currently worried about? I have seen both. Anger at the poor person who woke us up at 2:30 in the morning, just to complain about a toenail that has been bothering them for 6 months. I have also seen care, and compassion on the same type of call. I hope that I am the person who displays compassion for these people, and not anger.
The ageing process can take a terrible toll on the body, systems, and organs begin to fail, parts stop working properly, disease becomes more frequent, and we lose our friends and loved ones to the grave. Loneliness can be just as scary as disease, and medications become complex, and hard to remember when to take, or what to take. Geriatric patients often have multiple medications for multiple problems, hopefully they are able to remember what to take and when.
If you have read these blogs, you will know that I feel very strongly about helping people, and when we go into the houses of these geriatric patients, we should look around, see how they are eating, coping, cleaning. Does the patient have access to home care, loved ones to help, or people to come into the home and assist? Are they bathing, and is the home livable. Also you should know the routes you can take to ensure these people are taken care of. Report abuse, or suspected abuse to the proper authorities.
These patients may not be able to even comprehend what is happening to them, a once active and happy senior, after suffering a stroke, may need care every day, for even the smallest part of daily living. Falls can cripple these patients faster than you can say "hang onto something" with fractures due to brittle bones being commonplace. When we treat these patients we must remember hepatic function, and renal function can be diminished, so we must adjust our medications accordingly. For example, if we deliver a 10mg dose of Morphine to a 25 year old patient with a fractures femur, we should not expect the same results when delivering the same dose to a 95 year old patient with the same injuries. We should expect to reduce the amount of medication delivered, in order to gain the same expected results.
These patients may not want to leave the comforts of their homes, for fear of never returning, they may be in denial of their living conditions, thinking they are doing well, but in reality they are unable to care for themselves any longer without constant help. Consult family members or neighbors if they are there, to see how the patient has been coping with being alone, or how they are taking their meds.
Medications for this age group can be a difficult challenge as they are usually on multiple medications. We have all seen the listings of their medications which can be numerous, and confusing even for the most experienced practitioner to sort out. Hopefully they have a list, or a little case they keep the medications in. Sometimes you will see a pill bottle from the late 90s with pills being used still in the bottle, this may mean the patient has decided to keep this bottle and fill the new prescriptions into it. I usually tell them this is not desirable as it looks like they are non- compliant with their medications. Hopefully someone who cares for them can cease this practice. Overdoses and under-doses can be commonplace, more so if he patient lives alone, or takes their own medications in an assisted living centre.
The best thing we can do for these patients is give them our best care, concern, and treatments. Show them compassion, and treat them with respect, and dignity. These people are our elders, have been our leaders, and have built our communities so we can enjoy our way of life. Give them the dignity, and respect they deserve.
12/31/2012 11:11:43 AM
Are you one of the many EMS workers who cringe at the thought of the tones going off, and hearing dispatch tell you it is a pediatric patient? If you are you are not alone. It seems that no matter the skill level, or years of experience, when you hear of a pediatric patient in trouble, your heart sinks.
Perhaps it has been a while since your last PALS, or NALS course, or you feel you just don't have what it takes to deal with these kids that need us. Perhaps your service has neglected the pediatric equipment, and it is out of date, expired, or lacking completely. Whatever the reasons may be, you need to be prepared no matter what your personal misgivings may be, when the time comes, to answer the call.
Pediatric patients are not just little adults, the pathophysiology the anatomy, the way the pediatric patient feels about your treatment, nearly everything is different from treating the adult patient.
Neonatal patients: Birth- 1 Month. Have large heads, small bodies, can’t tell you a thing about what is going on, and can be a particularly difficult challenge, if you are unprepared. If you feel your skills are lacking take a NALS course, a very good preparation for you, and will improve your skill level. Hold in service within your peer group at work, and help each other out with the knowledge you share. Your co workers feel the same about these patients as you; have skills, and questions about treating these patients. You will find when you pool your knowledge, skills and advice you will be able to overcome some of the anxiety that comes with treating these children.
Infants: 1 month- 12 months of age. Also have large heads proportionality to their bodies, are unable to speak, and can’t help you with symptom description. The physiological changes in this age group are rapid, and many. During this time the infant will be developing the beginnings of a personality, teething, breathing patterns, learning patters, and the development of speech. Some will walk by the age of 12 months, most will crawl, scootch or develop some other mode of mobility.
During this first year of life, development is rapid, changes in the brain structure, lungs, and bowels allow the child to eat more, develop their sight, and hearing. The first illnesses have been experienced ear infections, allergies, colds, and other illnesses have probably been experienced, and overcome. In some cases developmental disorders or genetic problems may have been identified. These children are learning daily, and though they can’t tell you what is wrong with them, if you use your skills you will be able to identify the problems you have been called to treat.
Toddler: 1-3 yrs. If you have kids, you have dealt with the toddler. Toddlers can be very busy, learning new things daily, trying out limits, stretching their imaginations into the far beyond. Toddlers have hardly any fear, and can sometimes tell you what has happened. Most toddlers are scared of injury, and are afraid what you will do to them will hurt. Some toddlers can ask you questions until you are ready to pull your hair out and pass out from lack of oxygen answering their endless, wondering questions. These children will not take pain very well, if you have to begin a treatment, and you feel it will hurt tell them it will be like a sting, or a pinch but do not tell them it won’t hurt a bit. Be resourceful in your treatments; make it a game if you can, or fun. The child will appreciate your effort, and though they probably won’t say thank you, they will be able to understand if you help their symptoms.
Child: 3-8yrs. These children have begun to create their identities, they begin to see themselves as individuals, and have the need to explore the world around them. As they begin to attend school make friends, and develop further, they are exposed to more illnesses, disease, and allergens. These children for the most part will be able to tell you where it hurts, or if they can't breathe properly, or what the circumstances were when the problem occurred. They are talkative and attentive, like games, and will be able to tell you if the treatments are working, or not. They don’t like pain, but will appreciate you telling them if a treatment is going to hurt. You may have to play games with this age group too, in order to get the treatments you need, you may need to restrain this group also.
Preadolescent: 8-11. These children experience life daily, at school, play, dance, swimming, gymnastics, or whatever they do, they are independent, head strong, learning, and testing their limits daily. When they get injured they are fearful of lifelong injury, or maiming, they may be hyper aware of an injury, they can tell you the circumstances of the injury or illness, and can also tell you if the treatments are working. They will appreciate your ability to help them, though if you have to give a painful treatment, you may have to restrain them as well. Do not hide the fact that you are going to treat them, they want to feel better or the pain to go away, they will tell you as much.
Adolescence: 12-19yrs. Finally these children are nearly grown into adults. Puberty can bring huge changes to boys and girls, and can have profound effects on the physiological changes each gender develops. The Teenager can be a challenge to treat as well, they may be experimenting with drugs, alcohol, or other prohibited things, and may not want anyone to know. Peer pressure with this group is heavy, and can cause the child to abandon ideals their parents held dear, and can cause problems at home. This group also fears lifelong maiming after an injury, to help alleviate this concern you should help make the child aware that you will treat them to the best of your ability, and they will appreciate your honesty. Modesty is of great importance to this group, their bodies are changing, and they may feel embarrassed by this, if possible have the same gender treat these kids, if not possible, you must ensure their modesty is honored. They will also appreciate this. The teenage mind can be a mystery for adults to comprehend, they are learning and experimenting trying their wings out in a world that they may not fully understand, or see the dangers. We in EMS should be ready for nearly any eventuality with this age group, and be ready to treat them correctly.
When you treat any one of any of these age groups you should try to have the parents around, holding the younger ones, and consoling the older ones. Having a parent with you at all times, may not always be feasible, but you should try to have them with you when able, and appropriate. Protecting the patients modesty will keep the child happy and willing to talk to you, will ensure the parents trust you, and can protect you in the case of false allegations. treating any one of these age groups can be satisfying and scary at the same time, knowing you have helped a child can be a great feeling, but losing a child is a terrible loss for any emergency worker.
You should also remember that if you find cases of abuse, mistreatment, sexual misconduct, or molestation you must report this to the proper authorities. Not only will you be saving a childs life, you will get a sexual predator off the streets.
Pediatric patients are a challenge; there is no easy way for me to tell you how to treat them in a short blog, but there are resources out there, and courses you can take to increase your skills. Consult with your peers and co workers, ensure your equipment is up to date, and in correct working order. Check your equipment regularly, and ensure it is proper order.
In the mean time friends may the New Year bring you all peace, and prosperity, may you stay safe, and treat you patients with the high skills and great experience you have.
12/21/2012 10:25:56 PM
Definition of Ethics according to Collins English Dictionary
- functioning as singular the philosophical study of the moral value of human conduct and of the rules and principles that ought to govern it; moral philosophy See also meta-ethics
- functioning as plural a social, religious, or civil code of behaviour considered correct, esp that of a particular group, profession, or individual
- functioning as plural the moral fitness of a decision, course of action, etc ⇒
he doubted the ethics of their verdict
When you were in School and your instructors talked about Ethical behaviour in EMS, and Medical Ethics, did you listen, fall asleep, or just roll your eyes, and study your ACLS that was forthcoming in the next two weeks. I know that in my early schooling, and practice I put Ethics into the back of my mind, not fully understanding what it meant to be ethical, or even what medical ethics may encompass.
I remember early on in my career, an EMT that thought nothing of returning to the site of an MVC and taking power tools that were strewn about, figuring the drunk driver would never remember having them in the first place. I knew that was wrong, and though I didn’t know the routes to report this person, in those days, I know what I would do if the same thing happened today. Perhaps this person felt that a drunk driver needed to be penalized in some manner, or the EMT just needed some power tools to fill the shop with. I don’t recall, but I do know it was wrong.
If your state, or province does not have a regulatory body to file an ethics complaint to, or you feel you do not know what to do, or how to deal with an ethical problem, quite possibly a manager, supervisor, or co worker can help you through it. Many times what may seem like a moral or ethical dilemma to you may be a simple fix, when viewed from a different point of view.
We must be honest, and our integrity must withstand the test of time, and must be able to stand alone with you, and allow people to know that your integrity is second to none. We deal with controlled medications that we are trusted with to deliver properly and effectively in our daily duties. We are responsible for lives, and property of patients, that requires us to be honest 100% of our daily lives.
There have been times at my work place when my boss will call me over to a unit to find a new dent or ding in the side panel, one that will cost the company money to repair, one that was not reported. This does not happen too often but it has happened in the past where there is now ownership of this type of damage. Certainly, people need to be careful, but accidents do happen, and you may get a reprimand for what has happened, but your integrity should never come into question.
The most important thing we are held responsible for is the lives of our patients. We have protocols, and guidelines, and scopes of practice that we are held to account for when we deliver our treatments. If we break protocol, we must be willing to accept the consequences of our actions, if we do happen to make a mistake with our medication delivery we must document it and rectify it, and let the receiving hospital know in case there has to be some sort of intervention needed. If you try to cover it up, or make it look like nothing happened the consequences of those actions will likely be worse than if you were honest. Facing disciplinary action may be distasteful, and scary, but will go better if you were honest to begin with.
At your workplace you may face ethical challenges with some of the things you see going on, or hear others discussing. You may witness behaviour that you should report, the question is to whom do you report, you may be fearful of being tagged a "rat" or a *hit disturber, only you can know what you need to report, and usually a supervisor, or manager will help guide you. Your service will probably have a policy manual for you to read that may have some guidance as well.
Medical Ethics are not limited to what you see or hear around the water cooler, but on duty as well, perhaps you have a pediatric patient that requires treatment with no consenting adult around, or you find a wallet card after you have started to treat a patient that limits the treatment based on religious beliefs. Perhaps you are told by a spouse that the patient never wanted CPR, but cannot produce any paperwork. I can't tell you every ethical situation you may face, but you will in your career face them, inevitably every EMS worker sees these types of decisions. Some of these situations will not be easy, but then having strong ethics never is easy.
You should try to discuss questions you have on these types of ethical questions, ask a supervisor, manager, or co worker before you have to face these difficult questions during a call, you will be glad you did.
Have a fantastic holiday season my friends, stay warm, and be safe.
12/17/2012 3:42:15 PM
Mental Health Issues
We have come a long way in the way we treat our mental health patients, we have also slipped a long way in our treatment of the mental health patient. Does that make sense to you? It may seem contradictory, but it’s true. Think about it, straitjackets, and padded walls have given way to drugs, and quiet rooms under constant observation. We still physically restrain, or chemically restrain people whom we deem to be a threat to themselves, or others. Now please do not misunderstand me, these patients are sick, perhaps they do not have cardiac, metabolic, or other health issues, but their mental health is just as important.
I don’t want to pretend to be an expert on the mentally ill, I want to make it clear that there are many different types of mental illness, and we as health care providers should be able to at least identify some of them, recognize the signs of a mental illness, and be able to treat the symptoms of the mental illness we do see. Many times in EMS we see a patient only as their symptoms become so bad that they have already harmed either themselves, or another person.
In Central Alberta, we have at our disposal The Centennial Centre for Mental Health and Brain Injury. This centre was founded over 100 years ago, as a "Mental Hospital" My own great grandmother worked there as a psyche nurse in the 20s, I can’t imagine the conditions there in those days. Some of the old timers in Ponoka still refer to it as a "Mental" hospital, where in fact it is a state of the art treatment centre for brain injury, and psychiatric illness. But even having this wonderful facility at our disposal it seems that it is abused, and misused. It is always a fear around these parts that if you are suffering a Mental Illness, you will be shipped off to "Ponoka" just because the Dr does not want to deal with you. I cannot comment on whether that happens or not, but at times it does indeed seem true of some of the patients we have taken to this facility.
When you are dealing with a person suffering a Mental Illness, you need to approach them with a different set of rules than have been established for other patients. These patients may be hearing voices, seeing strange visions, or having hallucinations from a brain injury, or other illness. Approaching these people in our usual manner, possibly aggressive, or very authoritativemay not be the best way to deal with these people. Try speaking in a calm manner, do not lie to them, if they are under a "form 1" order which is to say they have been committed under a Drs order to attend a facility for mental health care, please make sure you tell them. Nothing is more upsetting to a patient than finding out five seconds before the ambulance takes them to a facility that they have no choice but to go with them. Talking in a calm manner, not raising your voice, not getting angry with them, understanding their plight will help you to be able to transport these people safely and with the dignity they deserve.
Having a patient go ballistic with you is always a concern, and threat that you need to be aware of. If you are attending a home of a suicide attempt, or aggressive patient, you need to be wary of weapons, and escape routes that you may have to use if the situation becomes unstable. Many times the local police force may have to help you back up, and ensure the scene is safe, and secure. Sometimes though the police do not understand the issues surrounding mental health issues, and perhaps may make it worse, if they are becoming too aggressive. If you have to take a patient down to sedate them, or restrain them you must remember to do so in a safe manner, with all of your responders’ safety in mind. Be wary of bystanders who may not understand what is happening or even the family pet who may not like it if you take down his master to sedate him or her.
Mental Health sufferers around the world seem to have difficulty coping in our health care systems, whether they be a system like the USA, Canada or elsewhere, these men, women and children are often misunderstood bullied, and hated for what is exhibited as "strange", "different", or "scary" behaviour. Often times the Drs do not even understand what is going on in the patient’s life to make a complete diagnosis. We as EMS workers must try to wrap our heads around symptoms, and signs we may not see, or we ourselves may not understand. We are not really able to cope with some of these long term mentally ill patients. Sedating them and transporting them isn’t really treating their illness. Treating their illness can be a lifelong treatment regime with multiple Drs and multiple medications.
Remember these people are NOT crazy, they are ill, mentally ill; they need the entire health care system to begin working for them, not against them. They need access to proper mental health care, and not just chemical or physical restraint. These people need our empathy, and our high quality patient care, they need us to understand. Most of all they need us to recognize a Mental Illness when the symptoms present. Learn the symptoms, learn the signs, and know what you as a patient care provider can do for these people. Learn how you can talk to your family members and loved ones about Mental Illness; don’t sweep it under the rug when you see it. Help these people, they are crying for it.
I didnt want to talk about the many forms of Mental Illness, instead I have added a few links for you to go look at and learn yourselves what to look for and leading treatments.
In the mean time, be safe and treat your patients well.
12/6/2012 5:47:21 PM
Do you have the mind for this?
I was talking with a colleague of mine in the hallway today, and we had a fairly interesting discussion on critical thinking, students, audits, and how things seem to have changed in EMS over the past 20 years. I entered school in 1992, a snot nosed, green behind the ears "EVO" ambulance driver, with a penchant for trauma, and the adrenaline that goes with the "good” calls.
Critical thinking has always been a part of being in the EMS industry, trying to find out why granny is suffering from flash pulmonary edema when she has no medical history to speak of, or trying to figure out a drug calculation that would scare the pants off any 4th year resident in medical school. We in EMS seem to thrive on trying to figure out what is going on with the patient, why it is happening, or what we can do to prevent the symptoms from getting worse, possibly saving a life in the process.
In my paramedic class in 1992- 1994, when we went to learn our ACLS or our "mega codes" we were scared, I mean really scared of what the instructors, and other seasoned medic students would throw at us, to see if our critical thinking skills were up to the task. Now I’m not saying ACLS should be scary because having simplified protocols and research base protocols is beneficial to the patient, what I am saying is that we seem to have lost some of our critical thinking base, and in EMS that is a sad day.
Certainly protocols are part of our lives, it is how we conduct our business, and how we treat our patients, but having said that, we should be able to, if necessary think outside the box, if some patient does not fit a certain set of protocol do we suddenly quit treating them? Of course not, we are alpha thinkers, we take the bull by the horns and figure out what is wrong with the patient, I have heard it said that it’s better to ask for forgiveness than permission. I am not advocating stepping outside your protocols just because you feel the need, but I believe that medical directors should be willing to allow paramedics and EMTs the ability to work outside the box a little more, if they can explain their actions, the benefit to the patient, and demonstrate the ability to think critically.
I have seen some students in the last little while who seem to have lost this ability. Ask them what to do in a certain situation, and the answer is “I’m not sure, we should call medical control" or, what does the monitor say. For instance, if you have an 80 year old female, who is allergic to walnuts, was accidentally given a brownie with walnuts in it, began to have an allergic reaction and dialed 911, when you arrive on the scene, your cardiac monitor is not working, and you have no B/P cuff. You notice swelling around her lips and face, and hives on her chest and arms. What is your treatment? Is her reaction anaphylactic? How do you know without a blood pressure? Do you give epi, and Benadryl, or just Benadryl, and fluid? How do you think this through? Does your choice of medications change if you know she has a heart condition, or suffers from chronic liver failure? If you knew her blood pressure was 80/40 how would that change your treatment? These are all decisions that can face every single one of us in the field every day, certainly protocols cannot account for every single variant on every single call we shall see, even on our routine calls.
We have all been told "DO NOT TREAT THE MONITOR" yet at one point I had a paramedic student tell me that in one of their previous practicums they were told that even in a patient is short of breath, and the monitor shows 98% SPO2, they should withhold the oxygen. What if that patient had been exposed to CO, or the machine was malfunctioning, the patient states they are short of breath, and should be given some oxygen, even if it is in a low concentration, or perhaps they are just hyperventilating, and need to be coached to slow their breathing. My point with that student was not to treat the monitor, and to treat the patient. We should all remember that. When the blood pressure monitor suddenly shows a B/P of 235/160, perhaps we should look for a cause before we reach for the Sodium Nitroprusside for a hypertensive crisis. Remember the first time you saw a re-perfusion beats in the patient that had received thrombolytic right before transport? What did you do? Hopefully you didn’t grab the defibrillator and Zap them.
Lately there has been some thoughts on the need for medical oversight, rather than medical control, that would give the EMS worker the right to actually think again, expand their treatments, and finally be able to treat the patient as they present, and not just following some "cookbook" or catch all for treatments, when some patients will definitely fall outside the desired perfect treatment regime.
As we grow and develop as a profession, in Canada we will hope to see more degree programs, more scope of practice for the critical care paramedics, higher standards for entry level EMRs, and critical thinkers at all levels. Take pride in your profession, do not allow your protocols to end your thinking, your patients will not always fit that square, or trapezoid that states, if the patient is hypovolemic, them give a 20ml/kg bolus of normal saline. Our critical thinking skills is what brought us into EMS to begin with, the challenge of trying to figure out why a patient is exhibiting these symptoms, on this day, and at this time, is what challenges us as EMS workers. Our only limits to our abilities should be our scopes of practice, we are trained professionals, we should be able to deliver all that we have been trained to deliver. Critical thinkers is what we are, critical thinkers is what this industry needs in order to survive.
Experience, knowledge, and common sense give us our critical thinking capability, hopefully the medical community can see where our great industry can take us, and help us to become peers with them rather than subordinates below them. Show your critical thinking skills, show you are able to work within your scopes of practice, work with your medical directors, and bring EMS to where it should be in the medical world.
12/4/2012 10:14:19 AM
This time of the year, blood banks, and blood services are in constant need of blood donors to resupply their stocks of blood, and blood products, for those unfortunate people that require it. Accident victims, new born babies, cancer patients, and trauma patients are just a few of the people that require Platelets, plasma, packed red cells, or whole blood. The only way these people can gain access to these products are through blood donations. When you agree to donate blood, you can save lives, and donating blood on a regular basis can help you feel better too. Blood products are replaced in your body, and once you donate, Donated plasma is replaced after 2–3 days. Red blood cells are replaced by bone marrow into the circulatory system at a slower rate, on average 36 days in healthy adult males. In one study, the range was 20 to 59 days for recovery. These replacement rates are the basis of how frequently a donor can donate blood. Typically blood donors can donate every 60 or so days, check on the rules where you live, and you will know more.
Donating blood will take about 1 hour out of your busy day, when you plan to donate, make sure you have a decent breakfast, or lunch before you go, that way you will feel strong enough after the donation and can have a normal day afterwards. The actual blood donation will take about 15 -30 minutes. After you will be asked to stay a few minutes, have a light refreshment, or lunch, and then be on your way. Donating a unit of blood, plasma, or platelets will make you feel better, and the much needed blood products will save lives.
Donating blood can have adverse reactions, which include bruising, fainting, hypovolemia, hypocalcaemia, and other reactions but these are rare, and should not scare anyone off of donating blood. If you are ill, or feeling nauseated, or have the flu, you should not donate blood. If you have had a recent tattoo, you may have to wait one year to donate blood, or if you are iron deficient, you should wait to donate.
Donor programs throughout the world are working on becoming totally voluntary, with no compensation given for donated blood or blood products. Most centres will give some type of non monetary recognition for donors who have donated many times. Pins, plaques, first aid kits, small trinkets may be given as a token of appreciation from different blood organizations throughout the world. Some organizations will also give monetary compensation for the donation of blood or blood products. Check before you donate so you know what to expect.
When you donate blood you are replenishing a supply that is in constant need. Normally the blood is stored as separate components, each having a shelf live ranging from a few days for platelets, to up to 40 or so days for packed red blood cells. Freezing the PRCs can extend the shelf life to up to a year, but is expensive, and rarely done. Plasma can be frozen, and is typically given an expiry date of a year.
Historically there have been some problems with the recipients of donated blood receiving blood that was tainted, or not screened properly, Hepatitis, HIV, and other diseases have in the past been a problem that has been eradicated by proper screening, and ensuring the blood supply of the donors is safe. Today's precautions ensure that the blood supply is safe to use, at anytime, all the time.
Please, this seasong, take a little time off, and donate some blood or blood products, it will take a few minutes out of your day, but may add years to a life you will save. Everyone needs blood, and every one has blood to donate, so take the time, and donate. You will feel great, and save lives.
11/11/2012 10:11:46 AM
Today all over the world we remember Veterans who have sacrificed their lives so we can hold dear our freedoms, religions, and customs in our day to day lives. One day is hardly enough to remember these strong, dedicated men and women. We should try to thank them when we transport them in our ambulances, I know I do. I’ll ask where they served, and what they did, and they usually tell me. I then usually just thank them for their service. When I see a veteran, whether they are currently serving or retired, I try to remember to thank them for their service.
When evil floods the earth, we rely on our soldiers, and support teams to eradicate it. In the course of human history there have been many conflicts and many wars. We celebrate Remembrance Day to honor those who served their country. We honor those who served in WWI, WWII, Korea, Vietnam, and Afghanistan.
When the call to fight came, these young men joined up by the hundreds of thousands, they didn't question the reasons, they didn't question why, they just knew that in order to rid the world of these horrible evils, they must fight, and risk their lives. They went into unknown conditions, on unknown countries, and did a job that is unimaginable to most of us. These young men, most of them in their late teens to mid twenties, saw things so horrid they could never talk about them after, caused them to die before their time.
We wear a poppy in Canada on our left breast to show respect for these men and women who died. We wear a poppy because during WWI the Canadian Dr LT Col John Alexander McCrae. He observed the blood red poppy growing in the battlefields, and felt a lasting tribute would be the poem "In Flanders Fields"
In Flanders fields the poppies blow
Between the crosses, row on row,
That mark our place; and in the sky
The larks, still bravely singing, fly Scarce heard amid the guns below.
We are the Dead. Short days ago
We lived, felt dawn, saw sunset glow,
Loved, and were loved, and now we lie In Flanders fields.
Take up our quarrel with the foe:
To you from failing hands we throw
The torch; be yours to hold it high.
If ye break faith with us who die
We shall not sleep, though poppies grow In Flanders fields.
- John McCrae
Perhaps you are working today, or perhaps you are off, it’s cold in most of the country with snow and ice falling on places. If you can't make it to your local cenotaph, watch the ceremony on TV, if you can, make sure you shake the hand of a veteran and thank them for their service. Make sure you wear your poppy proudly, and visible. When you buy a poppy don't just pay a loonie, remember the finds raised go to support veterans needs across the country.
Remember my friends today is about thanking someone who served in a time and place that we cannot imagine, these men and women suffered so that we may have what we have today. In Canada we have freedoms, and rights, that many into the world only dream about.
I have included a link to a report on the air support at Dieppe where my Uncle Bob was supporting the troops as they withdrew from a massive disaster. He is mentioned in the report as "Mehew Zobell" and mentions how he made a perfect landing in a badly damaged Spitfire. I hope you at least skim it; it’s a very interesting read.
My Grandpa Tewson was in the South Afrika Corps as an engineer, and he fought Rommel, in the deserts of Northern Africa. My Cousin Blake currently serves as a Marine in the US Marines (Semper Fi)
I dedicate today's blog to all the men and women of our military past, and present, who refuse to let evil take over the world, and who refuse to let our basic rights and freedoms be trampled upon.
May the dead Rest in Peace, may the retired Veterans always know we will NEVER forget, and may our current soldiers also remember we will NEVER forget that you are in harm’s way, you are missed by your family and friends, and your country thanks you.
Something I wrote last year for Remembrance Day, I hope you like it.
When you practice your religion fearless and free
When you vote for the candidate you choose,
As you cross an international border and have no guns pointed at you,
Or when you cross a provincial border and have to show no papers,
When you can buy any type of food you like,
And fill your pantry to overflowing,
Or when you can fly whatever flag you want,
In the morning when you wake up, and go to your work,
Knowing you can be free from ridicule and persecution,
As your kids at school, learn everything about the world,
Or when you are free to do whatever it is you plan for the weekend,
Remember those men and women who sacrifice their time,
Sacrifice their future, and pay with their lives,
This is their legacy to you, and their country,
That freedom might not perish from the earth,
The ones who died, the ones who live,
Remember, thank them, honor them.
Remembrance Day 2011
Thank you vets, you are loved and remembered.
11/1/2012 10:53:28 AM
It is upon us again the yearly visit from the hair fairy that causes men all across the world to grow cheesy, greasy, strange, and weird moustaches. We hear comments from our wives, mothers, and girlfriends "WHY ARE YOU GROWING THAT", or "WHY DID IT HAVE TO LOOK LIKE THAT" I know my own wife shakes her head in wonder at my taste in upper lip hair, and wonders how fast Movember will pass so things can get back to normal around the house.
You'll notice I chose Lanny McDonald for my image today, the reason I chose him is his Moustache is iconic, legendary, and easily recognizable. My own facial hair though famous in its own right, is not merely as famous as Lanny's. Why do men all over the world risk being celibate for a month to grow facial hair their ladies hate? You would think we would know better and leave well enough alone. We have a few great reasons for this, and I'll try to explain why we men do this for the month of November every year.
There is some controversy as to how and when Movember got started; basically the movement got started in Australia by a group of men who wanted to bring to the forefront the issue of men's health. From Australia the movement grew, globally, and exponentially. As of 2011 Canadians are the largest contributor to this cause. The Movember movement continues to grow, and raise awareness for men's health issues. Not only is the prime issue prostate cancer but also Mental Health, testicular cancers, awareness of family history of cancers, and men's health in general. Globally as of 2011 the Movember movement has raised over $174 million.
The CDC site states "Prostate cancer is the most common cancer in men. In the United States in 2008,* 214,633 men were diagnosed with prostate cancer, and 28,471 men died from it.† CDC provides men, doctors, and policymakers with the latest information about prostate cancer" † denotes the latest year of which stats are available.
The Mo Bros are a far reaching group with hundreds of thousands of men marching together to raise awareness, " Changing the Face of Men's Health" is the rally cry, and seeing a "Mo Bro" sporting a new, possibly cheesy, moustache can be a fun experience, especially if they have decided to grow a fun moustache, and see how crazy they can be. The main reason to do this weirdness is to raise money, five dollars, or ten, whatever you can afford in your budget, would go a long way in the global effort to make men's health come to the forefront of your mind, and to help you realise that men's health issues though sometimes not talked about are just as important as women's health. The reasons for this may be many. Men may not like the exam that comes with checking their prostate, may feel embarrassed about talking to their Dr. about men's issues, or may not even care to know what the issues are.
Men: These issues are important, yearly prostate checks when you are over 40, fitness, healthy eating, and awareness are only some of the things you can do to ensure you remain healthy, and active in your lives. Go to the gym, get active in your lives don’t be sedentary, and above all get your Dr to check you out and make sure you are indeed healthy and are aware of issues that face men every day. Women: support your men in this great cause, if he wants to grow some weird moustache this month, try to ignore it, and remember it’s only for one month.
The best advice I can give friends is this: Make sure you know the issues surrounding men's health, get regular check ups, stay fit, and stay healthy.
Have a great Movember my Mo Bros. Please follow the Movember.com link and donate, or make your own Mo Space and raise some money your self, My Mo space link is also included join my site if you wish.
10/19/2012 10:31:16 PM
Many of us in the Northern Hemisphere are gearing up for another winter season. This means our personal vehicles are ready to face the challenge of winter driving, andour lives are ready for another long haul of long dark nights, and shorter cold days. With emergency services it is time for us to make sure we are ready to face the conditions that many millions of people dare not brave, and especially road conditions not for the faint of heart.
With winter driving high winds, blowing snow, deep cold, and black ice are all very common. When the local police have shut down the highways, emergency services have to ignore the conditions, and go to the rescue. As the weather worsens, blizzards set in or blinding ice storms wreak havoc on the countryside, police, fire, and EMS, must head out, and save those unfortunates who have been injured, and need our help.
We must be ready for any winter conditions. Make sure your duty items are ready for the cold. Your high visibility jacket should have its liner placed, your touque, and liner gloves should be stashed somewhere in your coat. You should have liner socks, and winter rated socks already purchased. I also use YAKTRAX (tm) for stable walking on icy or very slippery roads, also good for walking on arena ice when you get called to a skater down. I received these for Christmas a few years ago, and I love them I do not leave home without them during the winter months. Hand warmers, and high quality snow boots could also be a part of your attire for the winter. Remember the people in jeopardy are relying on you to rescue them, you need to keep yourself safe and warm to save them, and it’s no use having you in the ambulance shivering away, while the victims are dying on the roadside.
I trust you are aware of the personal items you need to keep warm, during especially cold snaps I wear an additional layer, and an EMS sweater to keep the cold locked out. Facing temperatures of -35 or greater at times can be very challenging, with the wind howling, and snow blinding you, your patient care may change a bit as well, rather than doing a full assessment in the roadside ditch, you may elect to load onto the spine board, secure, and move to the ambulance for a proper primary survey. Remembering low temperatures, high wind, and snow conditions are ideal for hypothermia, frostnip, frostbite, and other cold related injuries. Keep your local protocols in mind when treating these cold related injuries, and they will guide you through the worst of the calls.
Driving in winter conditions can be stress inducing to say the least, heavy snowfalls, blizzard conditions, closed highways, and conditions that change very rapidly are not for the faint of heart. I remember one transfer I was on my EMT driver was doing his beast, 6-8 inches of snow on a closed highway and a stat transfer to Calgary with nary a plow to be seen, the patient had a much needed nitroglycerine drip running, and I only had enough to barely make the 1 1/2 hour trip to the city, with conditions that were horrid, luckily the EMT driver was highly skilled, and got us there in one piece, just as the last few drops of medication ran through the chamber. He drove safely for the road conditions, and even though I was a bit stressed I was happy he drove correctly for the conditions. Other times we see ambulanced wrecked during bad conditions, and wonder what happened. Sometimes its speed, other times it’s the conditions, most times I would imagine that it is an inexperienced driver not realizing the conditions have changed so fast, as to denote a change in driving behaviour. Talk to your EMS management, and ensure that your units are ready for the winter, with proper winter tires, winter fronts, wipers in good condition, jumper cables, tow ropes, and ever else you need to ensure your trips are covered in the winter. Remember not to use your cruise control in these conditions, as you could cause an accident.
When we are on scene on the highway please remember that black ice can cause people to be unable to slow properly when they are passing you, we have all seen the guys driving down the highway at break neck speeds, knowing full well the ice on the highway is dangerous, and invisible to see. We also all know that the "lookie loo" driver can be especially dangerous, as they may not see you and may be trying to get a good picture for the local news on their cell phone. Be wary on the scene, watch your personal protective behaviour and you will return home to warm your body up, after a long cold day on the roads.
Winter is here in my neck of the woods, cooler weather, icy roads, and high winds have already begun to cause accidents around this area of the world, please drive safe out there, be ready for the changing road conditions, and when you are on scene make sure you protect yourselves, and your patients from harm.
Have a safe winter my friends
10/8/2012 7:12:30 PM
When do you visit the ER, or call 911?
How many times have you gone into a 10-D lights flashing, siren blaring, adrenalin pumping, wondering if this will be a big cardiac arrest, symptomatic bradycardia, possibly a really nasty V-Tach. When you arrive on scene you find a healthy person that has had a cough for five days, and decided to call the ambulance because they just couldn’t take it anymore? I think we all have been on calls like this, and it can be frustrating to say the least.
Making it worse after you arrive on scene, you hear dispatch calling out a status seizure, or verified real emergency, where you could have made a real difference, rather than sit on scene with a patient that probably should have gone into their doctor, anytime over the last few days.
This type of situation is very frustrating to everyone in healthcare, and people need to be reminded of when and why to call 911, or visit their local ER department. I do understand that some people just don’t get it, and will continue to call us no matter what we say, or do. In our department, we have a person that calls on a regular basis, states they have chest pain, and usually gets dispatched as a 10-D this person is a drug seeker, we all know who this person is, the local FD has refused to back us up on calls to this person's home due to their abuse when they arrive first. I have been on calls helping this person and been abused verbally by this person. I find it very difficult to treat him correctly and appropriately knowing he is probably faking his illness, and taking a much needed ALS truck out of service for a couple of hours in an area of Alberta that we need every truck available. He has been talk to by our management, the RCMP, his social workers, and by others stating that one day he will actually require emergency intervention, and it may not come due to his past. His behaviours have not changed much, but it does seem to be getting less often that he calls. This is only one example of many people who use the system incorrectly. I have witnessed people in the ER demanding that they get their prescriptions refilled, or abusive patients yelling at the ER nurse questioning why they are being forced to wait "forever" for a doctor, when a patient walked in and was whisked away to the back right away.
PEOPLE: The ER is not first come first served. If you are there with a snotty nose, or non priority symptoms, you will more than likely wait. Non priority symptoms should be taken care of at your family doctors office, or at a walk in clinic. Don’t clog up the ER, or take a much needed ambulance off the street simply because you want to talk about your problems, or feel like you need to visit the ER because your snotty nose won’t stop, or your broken finger hasn’t healed since last night.
Legitimate emergency calls should be saved for chest pain, sudden loss of vision, speech, balance, or neurological function. Trauma victims, patients with sudden onset of gastric pain, or distension, nausea or vomiting that hasn’t stopped, along with diarrhea that hasn’t stopped especially in children. Suspected or obvious fractures, high fevers that haven’t broken. Severe asthma attacks, difficulty breathing, coughing up blood, or the inability to breath are all reasons to call 911 or visit an ER. If you are experiencing chest pain, or know someone that is, and you live more than 2 minutes from the hospital, you should call 911. Do not put the patient into the car and drive 45 minutes to an ER, more than likely if they are having a cardiac event, it will make it worse, and the patient could die.
Once you call 911, and an ambulance is dispatched, you should make your house ready, put any lose animals away, in another room, even though they may be friendly, a strange face working on a family member may bring out the protective instinct, and they may turn aggressive. If you live out in a rural area make sure the ambulance knows exactly how to get to your house, have a person waiting at the end of the drive, or ensure the dispatched knows exact directions to the home, or area of the incident, having a unit driving around looking for an approach to a home or field is not good for the patient, and only prolongs their pain and or suffering. Have legal documents ready, if the patient has orders for types of care, or care to be withheld, you should let the EMS personnel know this, and accompany to the hospital. Certainly your loved one will be cared for in a great professional manner, but we in EMS want to honor their wishes, and dignity. Also please remember that if you can’t produce the legal documentation, more than likely we have no choice but to give a full effort at resuscitation, or life saving procedures.
When you are thinking of calling an ambulance or visiting the ER, think about your symptoms, and think about possible other or alternate choices you may have to visit. In EMS we need to ensure that our compassion is all the time, day or night. It is difficult to see the same patient over and over again, knowing they are abusing the system, it is easy to get angry or frustrated with these people, but we must try to remember that they are feeling the urgency of their symptoms, possibly talk to them and give them a little education on when to call 911, or visit the ER, there are also agencies that can help these people in their homes, in Alberta we have the CHAPS system which is the Community Health and Pre-Hospital Support Program. I utilize this system all the time, for all manner of patients, hopefully these people are taken care of their non emergent issues are dealt with, and they can get on with their lives without having to call 911 because they tripped over the toaster on the floor again.
In EMS we have a responsibility to help educate our patients, on the proper use of the 911 system, certainly some will not be as receptive as other, but most of our non urgent, or patients that really didn’t need to call, are simply looking for help with their new medications, or medical equipment, they may not understand the why or when to call 911.
I try to remember this, I can't honestly say that I am always as patient as I need to be, but I do try to treat every single one of my patients with dignity and professionalism. I hope you do too.
Stay safe my friends.
9/23/2012 9:10:06 PM
This time year, in Alberta, we hope to enjoy a little more summer, with warm weather and sunny skies for a few more weeks until our bitter winter rears its ugly head. In the mean time, the nights are a little nippier, and the frost warnings are prevalent. Our thoughts will soon be turning to the dreaded flu season. Workers and colleagues will get sick, and in EMS we will start getting calls for flu like illnesses, and illnesses of an unknown nature, more often that in summer months.
The flu is an infectious disease, caused by RNA viruses. The flu viruses can be transmitted in many different ways, breathing in the aerosolized virus, touching a virus on a door knob, shaking hands with an infected person, are only a few ways one can catch the flu. Usually flu season brings with it epidemics with varying degree of severity, pandemics occur when a new strain causes millions of illnesses and possibly millions of deaths. Yearly the flu will infect up to five million people, and kill up to as many as half a million. In order to combat these illnesses, virologists try to build vaccines, usually from subtypes of the influenza virus A, and types B. Although these vaccines may be effective for the year they were created, they may not be effective in subsequent years. Anti viral agents may also be used, but to limited efficacy, and may be effective if given early enough. When you go to get your annual flu shot, make sure you do your research, allergic reactions, and other reactions can make the experience a bad one for you. If you have a chronically ill person at home, or a person with an immune system that may not be as strong as yours, you should get a flu shot. If someone in your house hold, or close family is going through chemo or radiation treatments, you should get a flu shot, this will help protect them.
A person might be infectious the day before symptoms appear and virus is then released for between 5 to 7 days, although some people may shed virus for longer periods. Children are more infectious than adults, and a high fever will shed more virus than a nominal one. Any parent will tell you how fast a virus can move through a household once a child brings it home from school.
How do you know you have the flu? You may not ever know if an illness was the flu. Typically, symptoms can be coughing, fever, nasal congestion, runny eyes, sore throat, and diarrhea. These are only some symptoms you may exhibit; you may not ever even exhibit symptoms. Remember that even though you may have had a vaccination, you may still be at risk for catching the flu. The reason for this is because virologists cannot possibly create a vaccine for every single type of flu being exhibited in the world; typically they concentrate on two or three strains, worst case scenarios, and create the vaccine for those.
When we see these cases in EMS, we must remember to treat the symptoms as they present, if you have a coughing patient mask them up, do not use a nebulizer on someone with a cough. If you are ill do not come to work, in our industry it is sometimes jokes that e have a very strong immune system, and no virus can get to us, I would remind you of the H1N1 virus that became a pandemic, and closed schools, churches, and caused millions of people to lose time at work. Sometimes symptoms get so bad that they mutate into pneumonia, and become more deadly. Remember our colleagues that died in Toronto during the SARS outbreak. We must protect ourselves first so that we can protect our patients, and our families.
As we approach the flu season, many of you will try "fly by night" treatments, home remedies, and over the counter flu treatments. Remember if you do get the flu to get plenty of rest, drink lots of liquids, acetaminophen and other antipyretics can help you beat the flu, do not take ASA, as it could lead to reyes syndrome. In order to keep from becoming infected get your annual flu shot, wash your hands after EVERY SINGLE patient contact, clean your patient surfaces, and wear your universal protection. Don’t forget gloves, masks, gowns, and proper eyewear. These could save your life, the life of a co worker or the life of a loved one.
Be safe friends.
9/19/2012 9:26:57 AM
Asthma is defined as a chronic inflammatory disease of the airways Have you, or someone you know, been diagnosed with asthma? If so, you probably have lots of questions. You may wonder, for example, just what asthma is. The medical definition of Asthma is simple, but the condition itself is quite complex. The cause of Asthma is not known, and currently there is no cure. However, there are many things you can do so you can live symptom-free. Shortness of breath, tightness in the chest, coughing, wheezing are some of the symptoms you may experience when your Asthma acts up. Symptoms may be mild, moderate or severe. Asthma symptoms can vary from person to person, and may never present the same for each person. Asthma symptoms may appear suddenly, then not appear again for long periods of time, and are usually the cause of some type of trigger.
In someone with normal lung function, air is inhaled through the nose and mouth. It passes through the trachea before moving into the bronchi, which are branching tubes leading away from the trachea. The bronchi branch into smaller and smaller tubes, ending in many small sacs called alveoli. It's in the alveoli that oxygen, which the body needs, is passed to the blood, while carbon dioxide, which the body doesn't, is removed from it.
People with asthma often have trouble breathing when they're in the presence of what are called "triggers." When someone with asthma has asthma symptoms, it means that the flow of air is obstructed as it passes in and out of the lungs. This happens because of one or both of the following:
- The lining of the airways becomes inflamed (irritated, reddened and swollen), and may produce more mucous. The more inflammation the more sensitive the airway becomes, and the more symptoms.
- The muscles that surround the airways become sensitive and start to twitch and tighten, causing the airways to narrow. This usually occurs if the inflammation is not treated.
Both of these factors cause the airways to narrow, making it difficult for air to pass in and out of them. The airways of someone with asthma are inflamed, to some degree, all the time. The more inflamed the airway the more sensitive the airway becomes. This leads to an increase in breathing difficulty. Anyone can get Asthma, although it's usually first diagnosed in young people. Currently, about three million Canadians have asthma. Living with Asthma Most people with asthma can live full, active lives. The trick is learning how to keep the Asthma symptom-free. If you have Asthma, you can control it. Living with Asthma is not easy but as you become familiar with the symptoms, and signs, you will be able to avoid your triggers with greater ease, and you will be able to control your attacks when they happen.
The medications to deal with Asthma are controllers, and relievers. Control medications are taken daily to help alleviate the symptoms over time, the controller medications reduce the inflammation of the airways, do not stop taking them, if you do you may find that the symptoms of your Asthma return, and may possibly be worse. Reliever type medications are taken during an actual flare up of the symptoms during a sudden Asthma attack a reliever medication will help stop the symptoms of the attack are alleviated. Reliever medications are not a long term solution, you should monitor how often you are using your reliever type medications, and note that if you are using these mediations more over time, and your Asthma may be worsening.
In EMS, we see Asthma attacks frequently, often times we see the sufferer in extreme difficulty because the patient has waited for the symptoms to get so bad that they cannot wait any longer for an ambulance. We in EMS generally use two types of devices for reliever medications to be given to the patient. We use nebulizers, and MDI (Metered Dose Inhalers) or puffers, with a spacer. Both of these devices have been proved to work, and both have their supporters. Evidence shows that both devices are excellent delivery systems for medication delivery. We should remember though that with a nebulizer there is increased risk for exposure to airborne pathogens if you have a patient that has a sudden onset of cough and fever perhaps you should use an MDI rather than a nebulizer to ensure your safety. You should note your local protocols and hospital guidelines for bringing in a patient on a nebulizer as most hospital guidelines have you removing the nebulizer before you enter the ER. At times these people will not be able to talk more than once sentance, and may be cyanotic, or pale, treating the symptoms of the attack as they appear according to your local portocols will allow you to help these people through their attacks, and aloow their loved to return to normal as soon as possible.
Have a great week my friends, and be safe.
9/9/2012 10:39:06 PM
I woke up to the sound of the news on at about 6 am; my roommate had turned it on so we could get ready for the coming day's classes. I saw a plane strike the World Trade Center, and wondered what kind of movie was being advertised. My roommate told me a plane had hit the WTC, and I thought, oh a small Cessna, or Beech craft must have gone in. It took a few minutes as I’m sure it took you, to realise what was unfolding in front of our eyes. Thinking of the thousands of people that work there, the responders, the pilots, and passengers, it was almost too much, nearly overloaded the brain, and we were just watching it on TV.
When we arrived at school I called my wife, and simply told her to turn on the TV and watch, in our classroom we had the TV on all day, watching the events unfold, hoping the responders would be safe, and hoping the death toll would be low. We all watched in horror as the buildings collapsed, and we began to realise the far reaching implications of such an attack.
Being in EMS has been my career choice for 22 years, I know my life is on the line when I go to the scene of an accident, or a domestic dispute, I know I may have to sacrifice my life for another at some point. I don’t necessarily want to die in the line of duty, but I do understand it may happen. My brother is a career fire fighter, and he too knows these risks, and has accepted them as part of his career.
On 9/11 hundreds of men and women answered the call; they came to work, and saw what they had to do. They entered the buildings, knowing full well they could collapse at anytime; they set up their command posts, knowing that they could be crush by falling debris, and they pulled their ambulances closer to the scene, so the injured could be brought to them, understanding that at any time, they could be extinguished. The men and women who gave their lives never pulled back, and never stopped trying to save lives, and when it was too late, they stayed on their posts, and became heroes.
Hundreds of innocent men and women climbed onto airplanes, perhaps to go see family, perhaps to go see friends, or simply a much needed vacation, away from stress, and strife. These people had no idea that they were climbing into walking bombs, with men who had an agenda of death, men who were fighting an undeclared war, men who didn’t care about non combatants they only wanted to strike fear into the hearts of American and her allies. They succeeded. The men and women who boarded these planes had no chance of survival, they probably knew this once their planes were hijacked, and flight 93 was the only flight able to overpower the hijackers. All of the passengers and all of the crews on the flights were killed.
Thousands of men and women worked in the towers of the World Trade Center, thousands of visitors daily, a ripe target for terror, as had been demonstrated before, the twin towers were a hallmark for American ingenuity, and prosperity. These men must have felt like they were slaying a dragon, or toppling a giant knowing they were on suicide missions, probably believing they would be heroes in their own right, after the massacre. The heroes on rescue helped hundreds if not thousands of people out of the towers, getting them to safety before the death throes and collapse of the towers. If not for their efforts surely many more would have perished. The Pentagon was also of prime importance in this attack, and the terrorists couldn’t resist gunning for America's political, and military headquarters, as well as the financial districts in Manhattan.
As the events unfolded that day, I remember sitting in the pub after our class let out, and discussing the future of not only our chosen profession, but of the US, the coming war, and indeed what may or may not happen to the world, now that this had occurred, I do believe every one of us no matter where we were that day recognized the history of that day, and the possible ramifications of retaliation, and the need for justice.
Now here we are 11 years later, 9/11 is still fresh in our minds, the death and destruction of that day forever engraved on our minds. We will reflect and we will remember. Remember the 343 NYFD members who gave their lives, the Paramedics, EMTs, Police, and Port Authority personnel, among others who gave their lives while protecting the citizens of one of the great cities of the world. We will never forget the sacrifice, we will never forget the heroes day to day who do their job and risk their lives. Take a moment on 9/11 to remember your brothers who perished, take a minute out of your day to pause, and give thanks to those who protect you daily, and may we never forget the fallen of 9/11
9/4/2012 4:37:40 PM
Working on a scene or in the hospital we are always surrounded by members of the health care team, fire dept, or police responders. Whether we see them in the hospital ER, on a floor, on a highway, or in cells, we have to try to remember we are on the same team.
I have worked in this industry since 1990, and for the most part I have worked with personnel that work well together, having the same goal, and ensuring patient safety and advocacy. Working with hospital personnel is the same; we all work to the same outcome, and hope to have the best outcome for our patients.
Why then is it at times we feel the need to degrade, or besmirch other crews that may not be from our area, or may not be the same designation as our crews, or a volunteer crew, rather than paid full timers. I have seen some crews berate other crews simply because they are a volunteer crew, and work in a small rural area of our province.
In the case of a volunteer EMS person, we should try to remember that their main career is not EMS, they may have very limited training, and they may not have the equipment required to do the job in a correct or even a professional manner. We need to keep in mind that a volunteer is just as committed as a full time career EMS professional, and perhaps could use some training, and if offered probably would be happy to learn a new skill.
I worked in a small town in northern Alberta a few years ago, and the police in that area really had a problem with EMS. It was hard on scene and they refused to help us much. After a little digging, I found out that a few years previously, an EMT had done something to offend the local police force, and they seemed to want to hold a grudge. The crews we had in the area at the time worked hard to rebuild fences, and respect for the paramedics, EMTs, and EMS in general. I was there for a year, and by the time I left the relationship had been mostly rebuilt, and feelings seemed to be much less heated when we had to work together. We need the respect and relationship with police services, if we require back up or a police presence it is a good feeling to know that these men and women have our backs, and there is no hard feelings or feelings of regret on our parts, or theirs.
With other EMS agencies, the respect must be a mutual one; we are all in the same boat, all with the same purpose. No matter where we work, or our level of training, we need to try to remember that we are all about patient advocacy. The sad truth of the matter is that even in today's world, when I sit in a trauma centre's hallway with a non critical patient, I still hear remarks about services that are unpaid volunteer, or non full timers, that seem to have less training, or are "crappy services" based solely on one or two patient contacts. A full time fire service that employs fire medics in their rotations should feel at least some need to help with these smaller services and help train the personnel working there, to perhaps increase knowledge, or skills, if the need be. For the most part, in services that I have worked for, our relationship with fire services is good. We provide back up for large fires, and they help control traffic or set up landing pads, or help drive us to the hospital, they keep us safe, and help with patient care when we need it, and when the skilled providers are a part of their services. I have heard of fire services refusing to do medical calls in their towns, either as medical first responders, or as front line medical responders when their town is without EMS services. I would not be able to imagine why this would be, perhaps some long forgotten slight or offence was given, or perhaps the chief of the day may not agree with EMS as part of a fire services duty. Perhaps if you work in a town such as this perhaps it’s time to have a tri services meeting to clear the air, and ensure that when you as an EMS provider are out of town, or there is no EMS it town, your citizens are protected.
In a hospital setting, things seem to get a little more complex, with some Drs unwilling, or unable to have any respect whatsoever for EMS professionals, it can be very difficult to turn over care without getting yelled at by a Dr who may not understand your protocols, or scope of practice. We may see them as power hungry, or just "high on themselves" I really don’t have the answers, but I would suggest that if you are experiencing difficulties of this nature have a word with your manager, supervisor, and perhaps a meeting with your medical director, the Dr, and management can help smooth things over. I am lucky in the fact that in the current town I work in we have a pretty good relationship with most of the Drs. They know our skills, know we are willing to help, and more often than not will allow us to work alongside them, rather than as their subordinates. I know I know, sometimes this is very far from the truth, hopefully if you are having trouble with Drs the relationships can improve, as you are able to show your skills, and professionalism. I also realise that not all Drs like EMS, and will never come around, with those ones, we just have to realise that no matter what we do, we may still get a chewing out, and sometimes for no good reason.
With our relationships with RNs, these can be tested as well we may have had a bad experience with an RN in the past, we may know an RN that needs to update their skill level, and we may even get into arguments, or have little respect for nurses we suspect may not be as skilled as their profession demands. I am guilty of this as well, it can be hard to see a professional who does not seem care about their skills, that can said for EMS professionals also. With an RN that perhaps seems to have skills lacking, this can also pose a dilemma because we as EMS professionals want to appear at least professional and compassionate to our patients, if we have disagreements we should air them away from patients, and where it will not cause embarrassment or make you look like unprofessional. Giving a report or taking a report from a nurse that is not aware of our needs can be a huge challenge. I’m not sure why, but this seems to be a great hardship for some to understand. We require just about the same information as has been delivered in a shift change report, of a regular floor, and sometimes we don’t even get a name, or a chief complaint. This can cause extremely bad feelings on the part of a paramedic or EMT who simply wants to understand the patient condition. I was told last week by an RN that I was taking a report from, that I COULD read the procedural report of what the patient underwent, but was told in a VERY derogatory tone, and arrogant manner that I WOULD not understand it, nor would I be able to get anything out of the report. I usually read the procedure reports anyway, and this made me even more curious as to what the patient had done. I did read it, and I was able to glean some information on what happened, the results, and how the procedure is run. Perhaps I didn’t understand the entire procedure, but I did get the idea, and I did learn a lot about it. I'm not sure why the RN would say what she did, perhaps she had no respect for EMS, perhaps she was close to her shift change, and didn’t really care, I’ll never know. I know what she said made me think about our teamwork with the RNs, and although I don’t usually get this type of response from a nurse, I will try not to let it offend me, and perhaps next time I will just tell her that I would prefer to read it and find out for myself. We should all remember that we need to understand the patients needs, and we need to work together to ensure patient care is never compromised.
As a team of EMS professionals, we work with many other professionals, caring individuals, and people that donate their time to ensure the safety of their citizens. We should all try to work together, and as we do, our patient care will only improve, our professional relationships will improve, and we will have better experiences in our chosen careers.
Be safe out there everyone, have a great week.
8/26/2012 7:18:03 PM
Scope of Practice vs Protocols
Many of us in EMS get fairly frustrated with the debate raging on the topic of protocols vs. scope of practice. This debate is not a new one, nor is it without staunch supporters on either side of the debate. Back in 1992 when I entered school, we learned a fairly comprehensive scope of practice, in 2002 when I was back in school that scope of practice had expanded to include 12 lead ECGs, paralytic medications, and other leading EMS practices. Coming out of school the EMT, and paramedic graduates are excited, eager, and ready to try out the skills they have learned in school. They are proficient in these skills, and many of them had put to use these skills in hospital settings, or on ambulance practicum. These skills we learn are in our Scope of Practice.
Reality soon comes into play, as these young eager medics, and EMTs go into the field, and find out that there exist rules, and regulations regarding the use of these skills. These rules are called protocols, usually these rules are set up and agreed to by a medical director, a Dr who has agreed to allow the medics, and EMTs to practice their trade under his/ her license, these Drs usually are the ones who have been sitting on a committee of the managers, supervisors, and owners of EMS services, and have agreed to the rules and circumstances the medics, and EMTs can use their scope.
The protocols from service to service can vary greatly. Some Drs are willing to allow EMS workers to do many of the skills they have been trained for; others are unwilling to allow this. This can be very frustrating, for we know that EMS workers are skilled, and highly trained, we know our scopes of practice, and can work to the full extent, if need be. Finding a Dr who is a medical director who is unwilling to allow this can make some wonder why they are in the EMS business anyway. I have asked some of my colleagues this question, and some of the answers have been so they can babysit us, make sure they have a strong arm on us, and to ensure that when we screw up they will ensure we answer for it.
In Alberta, we have provincial protocols, and though they do not allow us to work to the full scope of the AOCP, the protocols are fairly liberal, and do allow us to work in nearly every possible call we can find ourselves in. Am I saying these protocols are perfect? No I am not, these protocols could be expanded, and raised to the full scope of practice which would then allow a paramedic to work in the ER, without direct supervision, on patients that require sutchering, or if the scope was expanded perhaps setting bones, or prescribing non controlled medications. The Alberta protocols can seem restrictive, as some of the medications that we were able to use a few years back, were taken away, and no longer carried on cars, as were things like NG tubes, and MAD devices for nasal delivery of medications. This may seem like a backward move in some ways, but if we continue to meet, and discover research that proves these medications work, or devices new to the market work, they could be placed within the protocol.
What about working outside the protocol, this can be a bit of a scary situation when we meet up with it. Each of us has our own way of going about asking an online medical doctor for permission to work outside the protocol, or to give a medication that must be approved by them. It may be had because the online or direct medical control physician may not know you, or may not get the full picture of what you need, or are asking for. The last few times I have been online with a Dr, I have found them to be reasonable, and polite, and easy to talk to, I know this may not always be the case, and I hope that as you try to talk to these men and women, they will show you the professionalism you are showing them.
If it has been a while since you have looked at your protocols, you should re read them, become more familiar with them, and be ready to use them at anytime. If you are on a protocol committee and you are looking to expand, you should do your research, and ensure the new protocol you are asking for is not outside the scope of practice, present the new protocol in a professional manner, and even if the Dr refuses to give it approval at this time, don’t give up, and perhaps sometime in the future you will have the protocol you need. Go over your provincial protocols often, make sure you download the App to your phone, and stay current on trends, and developments on the site. Make sure your staff, of all designations are aware that there are protocols, keep them aware of your medical directors number so if they have a possible breach of protocol call, they can ensure compliance with standing orders, and policies that are in place for such a difficulty.
Protocols may not be as wide as you like, the scope of practice in your particular area may need to expanding, but if you don’t get involved in the legislation, or committees that make the protocols, or scopes you shouldn’t complain too much. The lawmakers need your help, when you learn of a protocol that may not be up to date, make someone aware, do something for your profession, keep your pride high, and your skills will not deteriorate.
Have a great week, stay safe out there