Bieber

Don't sweat it, man. Experience is experience, and even if CCT isn't exactly the same thing as 911 work, the things you learn from having that kind of background are invaluable. And considering many paramedics nowadays went into medic school without any previous experience--myself included. The fire based EMS services may not understand or respect non-911 or private based EMS services, but instead of fighting and arguing with them about it, maybe you could try educating them on non-fire based EMS models and on CCT transport in general? Despite the stigma, plenty of CCT transfers go downhill during transport and, really, very few 911 calls are actually critical.

CPAP for pneumonia patients in imminent respiratory failure is definitely a better alternative than having to tube 'em. Our (yet to be implemented) new protocols include CPAP for everything except patients with a history of asthma.

Congrats on the promotion. And I haven't yet been involved in any medevacs, alas.

Considering I'm working on getting started on a BS in paramedicine degree this year, I sure hope so! Seriously, though, a bachelors degree DOES confer a lot of benefits, although they're not always immediately received. You make yourself more competitive for employment and promotion, learn a lot about management and business and hopefully get some additional clinical knowledge out of it as well, and--arguably most importantly--give yourself the option to continue on to to graduate school or some other non-EMS profession if EMS doesn't pan out for you. Where I live (Kansas), an associates degree is required to become a paramedic here, however unfortunately we don't have any bachelors degree programs in EMS here. I'm currently looking at Northern Arizona University and the University of Pittsburgh for my four year degree (as they have online options and also give credit for existing paramedics/paramedics with AAS degrees).

A Beeber! Surprise! We make our nests in the bellies of those infested with our larva, however censorship laws prevent me from posting a picture of THAT monstrosity on here. No, but probably just fluid and the sorrows of a thousand empty beer cans.

1. Yes. YES! A million times over, YES! I would make EMT an associates and paramedic a four year degree if it were in my power to do so. We're taking care of people's lives and practicing medicine in a semi-autonomous manner... we need more than a high school diploma and a cert from a six month medic mill. 2. Education will change this, but only after the medicare schedule of billing changes too. I can guarantee that the wages we'll see after a medicare change will not be as high as they will if we improve our educational standards, though. 3. Our mission can no longer be to just "treat and take to the ER". Definitive care =/= the ER. Definitive care is whatever care is necessary to resolve the patient's condition, if any aided resolution is needed at all. Sometimes that's the ER, sometime's that's the patient's family doc, sometime's it's us. The idea that the ER is definitive care is nothing more than a treat for the lawyers combined with the cookbook medic's copout for true patient care. We have to think, we have to accept that the cookbook doesn't have all the answers in it, and we have to put on our big boy shorts and realize that if we want to play in the big leagues we're going to have to use our brains a little. What's right for 90 year old septic grandma is not what's right for the uncomplicated asthma attack resolved with x1 inhaler that was only dispatched because their friend didn't know what to do--let alone the high schooler who stubs their toe. 4. See number 3. 5. Patients are humans, and they deserve humane care. Pain should be treated, same with nausea. Emotional distress should be comforted, counsel given, and an extra minute taken to ask about and administer any non-medical palliative care that is warranted (extra blankets, a shoulder to cry on, calling the husband/wife, mother/father, etc). We're not just here to get you alive from point A to point B, we're here to TREAT suffering humans, and to improve our care continuously through constant reviews of the current practices and adjusting them in whatever way they need to be adjusted to make sure that our patients not only make it to the HOSPITAL alive, but OUT of the hospital alive and as much intact as we can make them. If that experienced farmer is one from the Medieval era who has never been exposed to the science of agriculture, and who lacks an understanding of plant biology, ecology, meteorology, advanced production techniques, prevention and correction of adverse conditions and agronomy, and whose entire practice is based principally on anecdotes of trial and error and their ensuing results, then your analogy works great! There's something to be said about experience, but unless it's paired with formal education, what you're left with is largely anecdotal evidence--which is, at best, anecdotal evidence.

My "goodbyes" generally consist of having the patient sign the consent form (if appropriate for their condition) and I tell them what it is their signing (written consent for treatment/transport, consent to receive the bill, acknowledgement that I've explained HIPAA to them "it says we're not gonna go talking to anyone about your protected medical information except for people who have a need to know, such as the hospital"), and then I ask them if they have any questions for me. Most of the time they don't, but I feel like it's important to give them the opportunity to ask me whatever they feel I haven't covered already, and there's been a few times where they've asked me some questions. I try to give them an idea of what they can expect from the hospital in advance. Once we have them transferred over to the bed and I'm done giving the report I usually tell them to "take care" or "get to feeling better". Great video, I like the message in it and I'm going to look at how I terminate care and see if there's anything more I could do for my patients. The "is there anything more I could do for you" I think is a great thing to add in there, even if you're busy. I work in a pretty busy system, but as far as I'm concerned, when I'm on a call, that patient is going to get the exact same care from me that they would under any circumstance--whether we're busy, slow, whatever. They deserve the best care from both a medical and a human standpoint, and that should never be compromised due to operational issues. Patients are humans, not numbers. P.S. CrapMagnet, I'm glad that it's worked out so well for you! I'm definitely going to give it a shot now!

Our trauma triage protocols mandate any patient who suffered from a loss of consciousness greater than five minutes be transported as a level II trauma patient to one of our trauma hospitals. But our trauma triage protocols aren't that great, in fact they're pretty much entirely MOI based with the exception of that one.

At the start of each shift and after every call that we use an IV on I set up an IV bag and throw it in the warmer. We also keep two bath blankets plus a sheet on our cot and (when I can get my partner to slow down for a second) I try to put a blanket or two over the backboard if we're gonna spinally immobilize someone. At least, I've been doing that since the weather got cold.

It sounds like you're agreeing basically with what's been said, either we get them back or we don't. In those unusual circumstances where we get a persistant rhythm and run out of medications, that's when CONSIDERING transport only WITH a mechanical compression device would be warranted. Also, I don't know what it's like where you are, but I haven't seen or heard of anyone around here doing organ donation on a persistent code that was brought in by EMS. To my knowledge, they work them up and call it if we bring them in. First point: You can't make them anymore dead, but you can decrease their chances of regaining ROSC. Primarily by delivering crappy CPR because you transported them or by halting compressions to get a tube or just plain doing bad CPR on scene. Second point: WRONG. If you're a patient advocate, you had better be cognizant of the money, time and resources that go into patient care. It may not matter to you because you're not footing the bill, but somebody has to pay for us and it's usually our patients or our constituents. EMS is a business, like it or not, and in order to stay in business we have to manage our resources appropriately and management can only do so much--ultimately it's up to the field provider to make sound clinical and operational decisions that are not only in the best interests of their patients but also their service, because if the service goes under that affects our patients. And especially in the changing face of the Medicare schedule of billing, we've got to be even more conscious of the cost/benefit of our services. Pretty soon there's going to come a day where we're paid for our actual benefit, not just transport, and if we don't adapt and prepare for that and make our service cost effective, you, me and every other EMS provider may go the way of the dinosaur. We're not invincible, we're not invulnerable, and there's nothing set in stone about our job. We've got to get our minds out of this "the ER is DEFINITIVE care!" mindset and recognize that definitive care is different for every patient. Just transporting folks to the hospital is bankrupting and straining an already economically precarious and overtaxed system. Finally: Emergent transport is something that every service needs to take a long, hard look at and strongly consider the risk/benefit ratio. There's very few patients for whom time on the order we look at has any significance at all, and a LOT of associated risks with running hot. I think as time goes by, we may even see emergency traffic operations reduced to only those calls for whom science has shown to truly and definitively benefit from the few seconds you gain (i.e. going hot en route to a cardiac arrest call). I would even say that your example is one of those that wouldn't meet the mark, as I can't imagine that the couple of seconds saved by emergently transporting a surgical patient will have any real clinical significance. Put to the test, I think you'd find that you haven't been doing real great CPR in the back of an ambulance at all. And the scientists would probably agree with me.

It's due to the popular misconception that there is some magical treatment held only at the hospitals which has mysteriously been left out of the hands of the medical providers in the most crucial position to make a significant difference to patient's suffering from out of hospital cardiac arrest, the potency of which is so great that it overrides and undoes the irreparable damage that results from ceasing CPR to transfer patients from scene to the ambulance and the additional damage incurred by poor CPR in the back of a moving vehicle. What I would consider an ideal system: ROSC or bust, or in special situations where there might be some treatment or diagnostic measure not commonly carried on ambulances due to prohibitive costs or other factors that could possibly make a difference, place that tool (be it iStat, equipment for non-routine resuscitative procedures such as a portable ultrasound for in field pericardiocentesis, etc) on a supervisor's vehicle OR if that isn't possible then at minimum a mechanical compression device in its stead to ensure that either the specialized treatment comes to the patient or that transporting the patient to the specialized treatment does not compromise CPR--which holds precedence over all other treatments, save for defibrillation with which it is on par. Zmedic, while transporting a patient to the hospital to perform those diagnostic tests may be helpful in uncovering reversible causes of the cardiac arrest (though in my opinion not as good as bringing those tests to the patient), it's meaningless and useless knowledge to know what the cause (reversible or not) of the arrest was if by the time the patient reaches the hospital their heart and brain are shot from the inadequate CPR en route. You can reverse the arrest, but you'll only be bringing back a brain-dead body.

Ruff, that's a great idea, and one I wish we could implement. Unfortunately, with the current budget outlook, adding a position like that is probably not going to happen. But perhaps someone in our clinical department could take on the responsibilities of such a position. Tcripp, is the hospital diagnosis and treatment (and how similar your own diagnosis and treatment were compared to theirs) ever used as a clinical aid for improving patient care in the future? You said your assistant director follows up on all flights, but is the information being learned from these interactions being applied throughout the system to improve patient care? It sounds like you're pretty much in the same boat we are.

Hey, I could probably make it out to Texas. But, uh, northern Texas por favor?

I know, I know... I need to quit (but predictably won't, at least not for the foreseeable future, 'cause that's what smokers do). At least I'm not a coke fiend, I guess?

So, we often talk about data transmission in EMS. In fact, improving EMS information transmission has become its own dedicated field in the EMS realm with entire businesses dedicated to creating newer and better software for the sharing of EMS information with hospitals. What we don't talk about often, though, is reciprocity from local hospitals. I don't know about your guys' system, but in mine our ePCRs all get sent over to the receiving hospitals within 24 hours of the patient handoff. The medical providers in the hospital receive our full documentation; our assessment of the patient's home, their HPI as reported on scene, initial vitals and exam findings, and our impression. This information is used to paint a picture and aid in diagnosis and maintain the continuum of patient care. EMS, in return, gets... nothing. If we bug them, we can get a face sheet so we can input the patient's hospital ID number, along with any billing information we might not have been able to obtain on the call. If we call the ER and speak to the nurse who took the handoff, we can find out what the ER did for them. And if we really want to, we can bug our clinical coordinator to hunt down the eventual fate of the patient if they were admitted. Otherwise, once the patient handover occurs, they're gone. What becomes of them could be anyone's guess. Same for their eventual physician diagnosis and treatment. This presents a major problem for us in EMS. And one that has probably contributed to the massive amount of poor clinical practice in EMS for so long. We have absolutely no idea (much of the time) what becomes of our patients! Was our diagnosis right? Were our treatments continued or was a different treatment route taken? Was there something found at the hospital that we either didn't check for or which wasn't present at the time of our exam that was crucial to the correct diagnosis? We can't improve until we've identified the problem, and right now we have very little idea of where we really stand in EMS with regards to our efficacy, accuracy, and the soundness of our treatment decisions. Without that necessary feedback, we have no idea if our diagnosis and treatment is correct 80% of the time or 10% of the time. So! The solution to this problem is simple, though I have the feeling that the actual implementation of it will pose a much bigger challenge. We need feedback from the hospitals. We need to know what the eventual diagnosis of our patients is, and what treatments were administered in the hospital. What I want to talk about in this thread is this: what sort of system does your service have for QA/QI for routine and non-routine calls? How do you get feedback from the hospital on your patient care? Do you regularly get feedback from the hospital? Is your service trying to implement a system where you will get regular feedback on all (or the majority of) patient encounters? And if so, how do you take that information and utilize it to improve patient care service-wide or on the individual provider level? And finally, what are the challenges to implementing a system where EMS sends their patient report and gets another one back from the hospital? Thanks, -Bieber

Honestly, I eat like crap, I don't exercise on a regular basis, and I smoke cigarettes. I'm 5'10" and about 155 lbs, but I know I'm at major risk for a heart attack someday (only 25 right now). I can't seem to find the motivation to go to the gym on a regular basis, though I used to work out regularly.

There's three criteria to differentiating V-tach from other wide-complex arrhythmias. 1.) Is there extreme right axis deviation and upright V1? If so, V-tach. 2.) If V1 has an upright complex, is the morphology one of these three: a.) Taller left peak than right "big mountain, little mountain". b.) A single upright peak "steeple sign". c.) A single peak with a slur "fireman's hat". If so, V-tach. d.) If V1 has a negative deflection, is there a fat R wave (>40 ms) or slurring or notching in the initial downward stroke (q or s wave)? If so, V-tach. 3.) Is there any negative deflection or a fat Q wave in a biphasic complex in V6? If so, V-tach. Also, if they've ever had an MI before and if they've ever had tachycardia following the MI, the odds favor V-tach (86%). This is all information I learned from reading the handout of the Multilead EKG by Dr. Bob Page. Hope it helps!

You respond to the airport at around 9 o'clock in the morning for a report of a sick patient on board a plane returning to the eastern American coast coming from Greece. En route to the call dispatch tells you that the patient is a 9 year old male complaining of abdominal pain, vomiting and diarrhea that began shortly after the plane departed and has progressively gotten worse and worse. The airline crew has given the patient treatment within their capabilities (I know they have quite a bit, but I'm not sure on the specifics, someone help me out?) however the patient's condition has progressively worsened. The patient's younger brother, a 6 year old male, also came down with similar symptoms during the flight and coded en route and was triaged black after attempts to resuscitate him were made. No one else on the plane is sick or injured at this time. Go.

As a service we run about 56,000 calls per year across 14-18 trucks (we staff additional trucks during the day). Each crew is assigned to 2 or 3 posts that they rotate through, switching every month. One of my posts is the busiest in the county and we run an average of 6-14 calls per 12 hours working downtown in the major county city, and at my other post we average around 1-4 calls per 12 hours working in one of the small rural towns in the county.

I didn't get into this job to be thanked, or thinking that I would be thanked very frequently, and while I appreciate it when it comes, I don't expect it. The thanks I get comes in the form of a paycheck, and from being able to make a difference. Oftentimes, the difference I make is something that the patient may not even realize has changed their condition or their outcome (giving aspirin or calling a STEMI/stroke alert so the hospital can be ready to get the patient to the right care as soon as they get there; getting an IV so the hospital can draw blood or have immediate access for fluids or medications in the future even if they don't need them right this minute; etc). It's enough that I know that I've made a difference in their outcome, even if they don't. I'll contend what one person said about police, fire and EMS being thankless jobs. I think that there are two thankless jobs there, not three. Sorry to all the firefighters out there, because I know there's times when you're not appreciated the way you should be, but compared to police and EMS, you're way ahead of the curve. Firefighters ARE "America's Heroes", plain and simple. And while EMS and police are appreciated by some, I don't think that it's anywhere near the same degree and--at least in EMS--it's really all our own fault. We eat our own, fight amongst ourselves when we should be banding together against EMS's common enemy and biggest threat: pro-fire, anti-progressive EMS fire departments and fire organizations. We don't market ourselves and we pay the price for it when we show up on medical calls with fire first response and our patients thank the fire department and ignore us or when the fire department gets additional funding and EMS is asked to "make due" with what we've got, regardless of the actual needs of the departments. Anyway, sorry to get off on that anti-fire tangent. I love the fire department for what they do (fight fires), but I disagree with how the majority of them view and run EMS. All the same, they've managed to turn themselves into America's Heroes and become THE folks people want to love and thank. If we in EMS want to be appreciated, it's not going to come from continuing with "business as usual", but from marketing ourselves (because EMS IS a business, like it or not), and from making ourselves known and visible to the public. It IS important that we are appreciated, because as we can see with the fire service, the monetary and political benefits of being appreciated and liked by the public are tremendous and those are benefits that I think most EMS agencies could benefit from. But it's gonna take a lot of work for us to reach that level of appreciation, and even longer if we don't start taking a proactive approach to it.

Hey man, I know System and Dwayne already pretty much nailed this one, but if I can I'll share a few words with you too. I haven't been in this profession for long, and though I have my own woes with the job I haven't yet experienced the kind of hopelessness you're finding yourself in, and I can't even imagine the things you've seen over the span of your career, but I hope at least some of what I say might help. Like I said, I haven't been in this job for long, but I can see in the eyes of my colleagues and in the stories like yours that this job takes it out of you. Mentally, physically, emotionally. I wish there was a better way for man to cope with this sort of trauma, but the truth is we were never designed to face it head on but to run away from it, and going against our natural instincts strains us. There's nothing weak about it, it would happen to anyone without the right coping mechanisms; and unfortunately we haven't yet embraced proactive implementation of healthy coping mechanisms and continue to hold onto the "sack up" philosophy. The coke and the alcohol, you've got to get away from that stuff. You already know this, but the temporary relief it gives you from your stress is outweighed by the long-term strain it adds to the stress you've already got from the job. And like Dwayne said, ultimately, it may just be your time to move on. Nothing weak about it, nothing anything about it. People change. The things we once loved fade on us, and things we used to hate we embrace. Either way, I think you've got to get yourself healthy first and foremost. Maybe you just need a break from EMS, or like Dwayne said to change your perspective if you can, but you don't have to fight this battle alone and you shouldn't. Get psychiatric aid if it helps, get drug and alcohol abuse counseling, continue to talk to people who understand what you're going through; folks who've been in this job forever (there's plenty of them on this forum!) I think, and tell me if I'm wrong, that the foggy lens of the world that we see through EMS has made it difficult for you to see why you got into this to begin with. The world goes from vibrant colors and excitement to this shadowy, black and grey hue when you only see it through the back of an ambulance. Take some time away from work, go experience the world and people when they're at their best as opposed to what we see at work: when they're at their worse. Above all else, you have to get your mind clear so you can see what's right for you. In this case, being the strongest is making the right decision for YOU. If that's finding new life in EMS, then that's the courageous decision; and if it's recognizing that this chapter of your life is over, and that it's time for you to move onto the next part of your life, then that's the courageous decision too. You don't have to stay in EMS if it's not right for you anymore, and you don't have to leave it either if the right thing is to get yourself clean, physically, mentally, and emotionally, and return to the "next" chapter of your EMS career. Find what you love about your life and the world, and mold your life around the concept of making your life and world your love.

Note to go with my post, when I say "report" I mean verbalizing the error to the patient during patient care. NOBODY should be falsifying or omitting errors in their PCRs or during their report to the hospital, and if the patient requests the file it should be disclosed to them in its full entirety. Ultimately, I think there are very few errors that shouldn't be verbally disclosed to the patient or their family during patient contact, but there's ARE those which I think should be disclosed in a more appropriate setting (i.e. the code blue example) which may not be during patient/family contact (i.e. telling them that the line was infiltrated and none of the medications reached the systemic circulation; while it's true that the family has a right to know, will they be able to understand that a patient with an already extremely poor chance of survival would probably be no better off even if the line had been good when they're already so emotionally distraught? Or will their emotional distress cloud their judgment and result in even more distress, distrust of the medical system, and a lingering feeling that "if only they'd gotten that IV, they'd be alive right now!" mentality?)

Talking about medical error, I think that one of the most important things we've realized is that more often than not it's not a provider error but a system failure. Does the system promote the reporting of mistakes for the purpose of non-punitive correction of aberrant or potentially dangerous behaviors, or is perfection (unrealistically) expected and failure to achieve that met with harsh, unhelpful punitive responses by administrative personnel? At my service, we've recently changed the way we approach provider error. Mistakes are classified as either unavoidable human error ("I meant to push X drug but pushed Y drug instead, unintentionally and accidentally"), mistakes from at-risk behavior ("I meant to push X drug, even though Y drug was the correct choice"), and dangerous behavior ("I know that Y drug is the correct one to push, but I pushed Y drug nonetheless"). Our new system includes non-punitive coaching for at-risk behavior, along with remediation if necessary so that the mistake will not be repeated ("let's find out why you thought X drug was correct, even though Y drug was") which includes trying to understand WHY the provider thought that their actions were correct in that situation WITH the knowledge that they had at the time. For dangerous behavior, punitive actions will remain in place, but the primary goal of our current system is to REDUCE medical error, not just PUNISH medical error, taking the principles and learnings of the airline industry and applying them to our own system. With regards to reporting medical error, I think that there isn't a straight answer to it. First, what was the cause of the medical error? Was it due to unavoidable human error? At-risk behavior? Dangerous behavior? What were the damages resulting from the mistake? Was there a change in the patient's prognosis following the error? If I mistake an anxiety attack for an allergic reaction in a pediatric patient and give the patient IM epinephrine (true story, not mine), was a mistake made? Yes. Was it due to dangerous behavior, at-risk behavior, or human error? In this case, it's safe to say that it wasn't due to dangerous behavior; most likely it was due to at-risk behavior (failure to identify the correct condition). And finally, what is the patient's prognosis? I think that in the absence of additional risk factors or unforeseen complications, it's safe to say that while the patient may experience some discomfort for a while, their prognosis remains good. Does this need to be reported? I think so, but it must be done with extreme care to make sure that the parent understands why the mistake was made, and above all else that the patient is unlikely to suffer permanent or long-term damage as a result of the error. But what about the code blue asystolic patient who's obviously been down for a while and has a massive history of heart problems, COPD, hypertension, diabetes, etc, who's line infiltrated after placement and, as it turns out, none of the drugs pushed made it into the systemic circulation? The provider failed to notice it until after they had retriaged code black and were covering the patient with a sheet. Was a mistake made? Yes. Was it a dangerous mistake? No. Did the mistake likely change the patient's prognosis? Probably not. Will the family benefit from learning about this mistake? No. Anyway, like I said, like so much in medicine, I think that this is a dynamic, not a static issue, and that it's very much situational. There are times when we absolutely have to report the mistake to the family, but I don't think that reporting every single mistake would benefit either the families or the providers either. -Bieber