HERBIE1

I would change the "culture" of our industry. We are an industry full of whiners and bitchers who would rather moan about what is wrong, rather than roll up our sleeves and attempt to fix it. We have too many people with opinions about what is "wrong" with EMS, we need some "workers" who want to be part of the solution.

Ask yourself this question: What have I done this week to improve my skills, my company, or my industry. If the answer is nothing, then you are part of the problem.

Good question I2k.

Culture is a relative term. The culture in your area may be totally different than mine which means many problems will be unique to a community. I do agree that we need to take control of our own destiny, which is far easier said than done. We need more people in positions of authority- not just in EMS, but as elected officials at the local and national levels. We are still very young and I think in time we will begin to assume more roles of policy makers, which is the only thing that will change the current climate. Most people have no idea the issues their local prehospital providers face, much less the problems that are national in scope. Things like public ed, PSA's, and again, legislative power will eventually help.

I never understood the notion of blasting an OD with so much Narcan that they go into instant withdrawal. Most of the time, these people DO get combative, AND many end up showing you what they had for dinner. Why would you want to deal with that?

Yes, in recent years there was also a rash of Fentanyl/Heroin OD's that required 6-10 mg of Narcan- plus a Narcan drip at the ER just to keep them breathing.

Are there bad medics- of course. Are some spiteful- yep, and I've worked with many. As with any profession, there are bad seeds. Not to excuse this behavior, but too many feel underpaid, underappreciated, and certainly overworked. Burnout is a real issue, especially for those practicing in busy urban areas. Such is also the nature of our profession, but as someone mentioned in another thread, we are STILL a young business. How many other professions can say they still have founding members working in the field?

We are going through growing pains, and I would say we are in our adolescence. As with any "teen", guideance is needed, sometimes a firm hand, and the best and brightest of us need to be identified, nutured and mentored so they can lead us to adulthood and address issues like this.

The next step is a national standardization of classifications and it's coming. The new guidelines will have 4 categories of prehospital providers- emergency responder, EMTB, advanced EMT, and paramedic. Obviously this needs to be adopted across the board, but it will certainly lessen some of the confusion. Problem is, there are so many variables- volunteers, EMTB/EMTP crews, intermediates, first responders, and just as many types of organizations that provide the service. Counties, private providers, fire based, hospital based, 2 tiered responses,- and combinations of these and many more. Point is, many of the problems are very specific to each area, thus there could never be simple solutions. The vital issues facing one area may be nonexistant just a few miles away.

A prime example and frustrating thing is that 2 people could have an identical background and training, but depending on where they work, their compensation is anything but standard. Everyone is held to the same standards but as we know, it's tough for a small town provider to make a living, but someone in a large urban area may be making double or triple their salary for providing the same care. In this economy, I would say this is probably the most important issue in that it cuts across all flavors of EMS.

You transport everyone light and sirens?

What is the reasoning behind that?

We do use the Emergency medical dispatching, however we dont base response on it. Every call we respond to. Transport priority is based on pt condition. The majority are without lights and sirens.

As far as the dispatchng our system is geared more towards pre-arrival instructions then triaging calls. Bleeding control, CPR, Pt positioning, things of that nature. In my opinion it does work for us and would state that it has benefited more then one pt.

There is no logic to it that I am aware of. As far as we can tell, it's merely to get the rig back in service quicker for the next run. Depending on time of day, location, and traffic, it could save a lot of time. Apparently this "need" outweighs the risk for running hot all the time.

Dispatch triages AND gives pre arrival instructions, but everyone also knows what to say to make dispatch "triage" essentially pointless.

We only have one type of response- lights and siren, and only one type of transport- same. We do have a tiered dispatch- ALS or BLS-and that is a total failure, but that's fuel for another thread.

I'm thinking this guy needs a head CT ASAP. I'm calling it neurological until proven otherwise and treating it as such. His PMH of a DVT makes me suspicious of a cerebral vascular event of some type- aneurysm, bleed, AVM, clot, etc. Could be cardiac based which led to head problems- he's on Coumadin, so maybe threw a clot...

Curious to see the outcome, here.

There should be a minimum age to be a paramedic- what, exactly, I don't know. Life experience and maturity are vital to this business. Think about the responsibilities were have- we literally hold someone's life in our hands. That's pretty heady stuff for the average 18 year old. ANYONE can be trained in the nuts and bolts and book knowledge needed to perform skills, but knowing how and when to apply that knowledge comes from maturity and experience. I remember precepting students who came from an accelerated paramedic program who were supposed to have experience at the EMT B level before they started their advanced training.(That wasn't always enforced- as long as they had their tuition check) It was a very rigorous program and their drop out rate was high. I recall one girl- mid 20's- very book smart, but literally could not operate a stretcher or even turn on or change an O2 regulator when she came to me a a newly minted paramedic. She had a license(or certification at that time) but had zero street experience at any level. I had to teach her the very basics before we could even begin to address her clinical skills. Her maturity wasn't the issue, but her lack of experience was.

She had no experience in speaking to patients, their families, bystanders, or hospital staff and this was probably her biggest problem. This girl did realize her limitations and ended up being a pretty good medic. She said that the reason she took the accelerated course was because she was a single mom and needed to finish quickly for the sake of her kid so she could make money. She would have preferred to take her time and gain more experience before jumping in to ALS care but her situation prevented her from doing that.

Young EMT's and paramedics need proper guidance, teachers, and preceptors. Think about how much we change from age 18 to even 21 or 22. You need to have a good handle on yourself before you should be entrusted with someone's life. Partnering young and inexperienced people with senior members is vital, but I have also seen 2 relatively new people working together because of manpower issues. To me, that is a recipe for disaster, and not fair to the providers or the people they are serving.

Obviously there are exceptions to any rule, but let's go with common sense here.

The Hatch chili festival is a true event however. It is neat to drive through the town during the fall and see houses that have the roof full of chili peppers drying in the sun. The smell of roasting chili peppers is an experience as well. Only one point of contention however. For all of the hype regarding "Hatch" chili, they do not actually process and can the chili in Hatch. That occurs at border foods in Deming, about an hour drive from Hatch. Useless knowledge, I know.

Take care,

chbare.

Edgerton Wisconsin has a local chili fest- big for the town, but not all that big. I had some of the spiciest chili I could ever imagine there- all homemade, obviously. Having a full beer at all times is a MUST at these events.

Tons of fun, but I could have done without the GI issues later...

Many places have very strict rules on gifts. In these political times, anything you take could be viewed by someone as being unethical and by "catching" a public servant acting unethically, they may try to make a statement and put you in the trick bag. I've had many offers of gifts- come by my diner and I'll buy you dinner, free hair cuts, discounts on products, etc. I've never taken someone up on that. Taking cash is another matter- especially if you work for a public agency. Be very careful. On a few occasions, I've accepted a couple dollars at the repeated insistence of a very grateful patient/family member or a gift card from Starbucks and see no real harm in that.

As was noted, common sense should dictate your actions. Often during holiday season, people are in a "giving" mood. If you work in a residential area, you tend to know the neighbors and they often bring by food, fruit, cookies, and cakes. Some people feel the need to express their gratitude by more than just a thank you and in many cultures, it is considered offensive and very rude to refuse a gift.

A good rule to live by here-trust your inner voice. We use that voice all the time when treating patients and trying to figure out whether the person is ready to code.

If the offer makes you feel odd, or you think you would have a hard time justifying it to a boss, politely decline the offer.

I'm with Richard- I always make a joke about on offer and say an "atta boy" letter to the mayor or bosses would be sufficient and to tell them we're not as bad as they think we are. If they write the letter- great. If not, that's fine too. We all know that people are far more willing to register complaints than they are compliments.

I just had a weird thought (not the first, probably not the last):

The patient, or someone connected with the patient, just left a plate full of cookies, correct?

Is it simply a case that would be described by "Daffy Duck" as,

Or...

Did the crew that worked the specific assignment have any problems with the patient or the patient's family? If yes, what might be mixed into the cookies? Did you just get a package of "Alice B Toklas" style cookies, with the LEOs notified that the station/garage/base has them, "Get the EMS people for possession of unauthorized recreational pharmaceuticals"?

Or, truly the worst case scenario, what poisons have been added to the mix?

It's sad to think someone would try to poison or drug you, but you just never know. I seem to recall an incident where a plate of pot laced brownies, left as an alleged thank-you, were ingested by an entire fire house. Possible- yeah. Likely- probably not. I'd still be careful, especially with homemade treats.

Continuing along on Herbie1's response, NYC outlawed "Drunk Tanks" around 1975 or so, due to numerous diabetics suffering the effects of their illness, which we know can mimic intoxication, who died in the tanks, which, incidentally, were IN the ER/EDs.

Are there still jurisdictions that still use them?

Well Richard, considering the overcrowding of ER's and the issue of proper allocation of resources, the idea of a medically supervised drunk tank might need to be revisited. As any provider who works in a busy urban setting knows, a significant portion of ER beds are filled with folks "sleeping it off", especially on a hot summer night. The thing is, not every one of these people are homeless regulars- many are weekend warriors who were "over served". Maybe spending a night lying in a room full of ripe old homeless guys would be a good object lesson for them. I've always felt that a bed, a banana bag and fluids is far too kind for someone who was dumb enough to drink themselves into oblivion- the "penalty" for their behavior is greatly diminished. Then again, maybe I've been doing this too long...

I used to work in a busy ER in a predominantly gay area. I've seen my share of foreign objects inserted in various orifices, but I have NEVER seen it as it was happening. I took the initial warning as a challenge, but now I cannot shake that image.

All I can say is- oh my gawd.

The physical damage caused here would be far easier to fix than the psychological issues this guy clearly had to attempt this in the first place. I can only imagine the similar stunts he has tried in the past...

That's some funny stuff. I had to stop reading for a moment to wipe the tears!

Don't forget the famous Ford Pintos and their exploding gas tanks!

In 25 years, and thousands of car crashes, I have never seen an exploding gas tank. Cars on fire, yes, and even those are pretty rare for simple crashes. We all know about calls for auto fires and they turn out to be powder from air bags or steaming radiators.

Like was mentioned above, the movies have conditioned people to think that every time someone has a fender bender, their car is a ticking time bomb and the street surgeons need to drag them out to save them.

Remember, public stupidity means job security...

I thought the VW bug was an air cooled engine prior to the 1970 models? That was supposed to be why so many had engine compartment fires until then.

(Don't hold me to the year)

I had a 66 VW convertible bug, and that era of VW engines was famous for going up in flames- don't know why. I let my sister use it while I was away in college and received a phone call one day, saying it caught fire while she was on the highway and burned to a crisp. (She was fine) Came home and saw what looked like a rather large charcoal briquette sitting in my driveway. Damn shame.

Well, in technical terms, fractals are actually used when determining optimum response times and goals. As we can see here, different systems are structured differently, meaning when determining analysis of benchmarks and needs, I think the info has to be tailored to each situation. Fractals are on objective way to do that.

I have found that well written reports- with names and PHI redacted of course- are a powerful tool to go with any power point presentation. Present a scenario, based on the info contained in the report, and have the students construct a good report from it. Compare/contrast the report generated by the student with the selected model report.

Contrast that with a poorly written report- same process. Explain why each report is good and bad, and what are important items than need to be included.

I have found that powerpoints- even the best ones- can have a mesmerizing effect and often times the student tends to miss important points. Dissecting both good and bad points in a report keep the students(and even those who are there for con-ed) focused on the pitfalls and problems of report writing. Explain personal experiences with the legal system if you have them and how a lawyer looks at a report differently than we do. Anyone who has had to testify in court or give a deposition can give first hand knowledge of how vital a well written and accurate report can be and is a great object lesson.

From the EMS side, it seems to me transports are simply a system policy issue. In our city, we try to accommodate a patient's hospital request- within reason. Obviously patient condition, time difference between closest and desired locations, capabilities of the receiving hospital, diversion status, time of day(traffic), call volume, and more- are all considerations. There are established guidelines that deal with taking OB or pediatric patients to capable facilities, trauma patients to trauma centers, but in general a comprehensive ER should be able to handle anything- at least in the short term. Now, with the advent of specialized stroke centers and cardiac centers to handle MI's, the problem is only compounded and although a stroke center is best for a patient having those symptoms, it can leave a void in your coverage area when you are gone.

There are pro's and cons of trying to honor a request, and as far as the police is concerned, often times they prefer a patient be brought to a closer hospital, in or near their assigned district- especially if there are multiple victims and may need to take statements and make reports from everyone involved. When a rig takes a patient far from their assigned area, in a busy system, it has a snowball effect which causes vacancies in areas, response times increase, and things can quickly get out of hand. Obviously when hospitals are so full they can no longer accept ambulance patients, these extended transports cannot be helped, but any efforts to "please" the patient, their doctor, or law enforcement must be tempered with common sense. In these cases, the impact on the entire system has to be taken into account.

These days, patients are considered customers and it's all about customer service in both the prehospital and hospital settings. Clearly there are many factors involved here and I think the more you know about your system, it's capabilities, and shortcomings, the better you will be able to make the best decision for your patient and for the rest of the system. You need to seriously consider the consequences of any transport decisions and how they impact everyone around you.

Also, the amount of latitude a system gives it's crews to make these decisions varies quite a bit from city to city.

Difficult question to answer. So many variables, different types of services, different schedules(24/8/10/16 hr shifts), multi-tiered responses, etc. If we could find out what you want to do with the info, maybe we can narrow it down.

The old days of drunk tanks worked out just fine- until an occasional one died from complications due to a secondary medical problem and people became upset. Now nobody wants that liability. Maybe there needs to be some type of medically supervised drunk tank so they can sleep it off without tying up an ER bed. As for shelters, most around here refuse to admit someone who is intoxicated. They simply don't want the hassle. The police here used to take drunks in transport wagons, as well as folks who had minor problems- to the ER. Again- liability(and the fear of infectious diseases)- has them now call EMS for anyone with a boo-boo.

In general, any state statute would supercede anything your organization might have. I would check those and any applicable municipal ordinances as well as your insurance carriers and medical control and pattern your ideas accordingly. I agree that we should be held to a higher standard than the general public and our conduct should reflect than off duty or on, so think more strict.

Most insurance companies do at least an annual license check of all personnel, some more often. So even if the employee fails to notify, the insurance company will catch it. I wonder if you are dumb enough to get one, if you should just refuse the test. You will still lose your license, but you wouldnt have DUI on your driving record.

Good point. In our locale, the Secretary of State's Office regularly sends a list of any suspended licenses to the department- regardless of the reason for the suspension- failed emissions tests, proof of insurance, expired, revoked, DUI's, etc.

I spent 3 months in Philly doing ride time and now I work 911 in a suburb of the city that has as much crime, poverty, and call volume per capita as the city. The only difference is we treat patients before we leave the residence. Why? I never started a treatment for asthma on a city pt because we never brought in o2. My precepts said we work out of the truck in our environment. Now as a medic right outside the city I have to remind myself that I'm not in the city and we treat pt's before we transport them to a hospital? Is this burnout, laziness, or an overworked system for city EMS workers? My first few weeks in the suburbs I wanted to walk pt's out to the truck but my mentor had me actually treat a pt on scene. I have to be reprogrammed to treating a pt and I find that sad. I have had 3 CHF pt's and all had no resp distress on arrival to the hospital. 3 minutes to scene, 10 on, and 3 min transport vs 3 minutes to scene, walk pt to truck, increase SOB, start treatments, sit by charge RN trying to get a bed for a pt in distress. Aren't we sent to help pt's not transport? Why is city EMS so different? Does having a distressed pt help you get a bed quicker so you can clear your call?

This isn't to attack city EMS, I understand your call volume, Philly even added more units to handle the call volume, I just want to know if you feel you are actually turning distressed pt's around vs just stabilizing them for entry to the ER.

Depends on far more details than you are providing. What were the scenes like? Safe? Tons of bystanders? Unruly? Potential for problems? Surroundings? How much assistance did you have? Irate/upset/interfering family or friends?

Yes, some of it is burnout, some of it is things you may not be aware of- previous problems in these areas, who knows. If it's simply trying to get back in service for the next call- that's silly. You can only treat one at a time- except for MCI's of course. The point is, we have a lot of toys to use, but time and place.

From my experiences with DPH medics in San Francisco in the 90s and with DG medics here in Denver, I think I could offer some insights as to why larger city medics tend to put a greater premium on scene time. I'm not offering these as the right or wrong way to do medicine, these are just some of the philosophies expressed to me by some very talented medics while they were encouraging me to work on faster scene times and more efficient care.

1.) Scene safety. The shorter your exposure to the scene, the better.

2.) A sense that the back of the rig is your area of control where the scene is the patients area of control.

3.) A desire to get the rig back in service as soon as is appropriately possible.

4.) An idea that fast and efficient medicine should be practiced on all calls to improve the skill for when it is needed.

I will say this. While I remain a stay and play medic at heart I took many of these lessons to heart and I think being trained in this way was helpful for me. Overall it improved my medicine. I have great respect for medics who come from big city, high call volume systems. The DG dudes I work with are some of the most knowledgeable and talented medics I've known.

One idea that I would refute is the idea that fast = sloppy. That may be the case in some regions, and believe me, I've seen my share of medics who race to the hospital to compensate for poor skills, but I never saw that with the DG guys.

The one remarkable thing I've noticed about most of the guys that came from that "knife and gun club" system is that they are just fast … like crazy fast. They are not sloppy. They just get a lot of stuff done really fast. And if you're really sick, they'll save your life. If you do die I guarantee you'll die looking at a doctor.

Final verdict for me … if we can bring definitive care to the patient there's no excuse not to do it, but there's nothing wrong with doing good medicine fast.

One last point, Urban EMS providers don't "fear" longer scene times. They just don't prefer it. It's a matter of preference, not fear. The title of this thread slants the argument unfairly by implying that big city medics are afraid of something.

Thanks all.

Good post. May I also add that in certain cases- bad trauma- load and go is the only way. You do whatever you can enroute, but they need an OR- that large bore IV will probably do little for them. For a sick cardiac, we can definitely make a difference and at least in the first few moments, we do exactly what an ER does. Obviously they have more help, MD's, more toys, and more meds, but our first line, immediate care is ACLS and the same as an ER. In this case, extended scene time is OK and I've been told this by every doc I've spoken with.

Depending on transport times, the acuity of the patient, and the level of skill of the provider, what can be done enroute to the ER also varies widely.