Let it go, this too shall pass
Archives for ems-topics
Words that can get you fired. Others include,
She said she was fine;
His lead II was unremarkable and has had heartburn in the past;
Your anxiety can come from nowhere and leave you tachy, lady of 55 who’s mother died of an MI recently;
Damage like this happens all the time, that bruise is normal;
A little smoke inhalation won’t kill you, look at me;
Asthma is not going to kill you, go find your inhaler;
The Doc signed off on the AMA so I’m golden;
Babies sleep all the time;
The snow was too heavy;
It was too hot;
I was tired;
I read in a blog that doing that was alright;
Have you seen this funny youtube cartoon?
Point being that there are a lot of rumors, stories and opinions flying about what happens in our business and it can be very hard to find the truth in a situation with 3 correct versions, one wrong version and 15,000 who have parts right.
I have been known to join the fray when it comes to EMS and Fire Departments who do something I like (Tip of the Helmet) and things I don’t (Letter in the File) but drawing conclusions from a single source is a bad idea.
Have an issue with a story you read part of on facebook? Before you lay it on thick you may want to finish reading the story, then seek out at least 2 more sources to confirm the facts. If you can not get the facts, use the google to find out who to call to get the facts.
If they call you back, great. If not, then you have to go with what you have, but the impulse to post something you may regret will have passed.
If you are the one facing termination for doing something you knew in the moment was wrong, see ya. If you find yourself on job 21 in 24 hours and know that not writing a chart will get you home sooner, keep in mind that not writing the chart could get you home a lot. As in unemployed.
If just yelling at the guy to wake up instead of checking his blood sugar and other vital signs to confirm it’s just Reuben again after another $3 bottle of wine, you yourself could be the one budgeting for the cheap stuff while on unemployment.
Backed the ambulance into another car near end of shift and drove away? Might as well keep driving into the sunset.
We all make mistakes. I make them all the time, but I make sure I’m doing what I’m supposed to be doing for my patients based on the information I have and how that information fits within the laws, protocols and policies I have sworn to uphold. Have I not charted patients? Of course, when it is not indicated. Have I omitted vital signs on my charts? Yes, it happens when you get back and can’t recall the BP, so instead of lying I write nothing.
Being able to defend your actions or inactions with cited policy and protocols in front of you goes a long way to easing stress and the impact on your employment status.
In the end we all need to take a deep breath and find the facts about stories we read, especially in the internet age, when opinion can be mistaken as fact on a regular basis.
“Mr Happy Medic is there a reason you did not awaken the man lying in the street who was later found to be in cardiac arrest?”
“He looked OK to me…”
I’d be fired for sure, and for good reason.
In a number of emails I have been asked for an outline or “thesis” about what EMS 2.0 is. There was talk awhile back about a national EMS 2.0 organization to begin lobbying for the changes we all want to see. Others asked me for my suggested education requirements and how I expected a volunteer Paramedic already working two jobs to go back to school to keep doing what they want to do.
I have no answers to those questions.
Sometimes when asked I reply that I have all the answers, I just haven’t sorted out what questions they go to yet.
I used the phrase EMS 2.0, and I think Mr Chris Kaiser did as well, because it brings up the image of a reboot, or upgrade.
Many of the Windows 7 features I got are neat, but most of it is based on the same things I liked about Windows 3.1, sure it is full of random errors and can be frustrating, but the system is slowly updating itself.
A few years ago I had had it with my operating system and all the limitations I saw in it and jumped into Linux.
I was under the impression I was savvy enough to make code changes to effect the entire operating capacity of the system. And since I had only a basic understanding of the features I so desperately wanted, I was unable to have the comfortable computing experience I expected. The adventure ended months later with a partitioned hard drive and having to choose an operating system each time it started. Drove me nuts. But those who know how to make it work love it and it works fine.
So when I speak of EMS 2.0, I am indeed aware of the pros and cons of an “upgrade.”
Another list of questions I get is about the comparison to Web 2.0, the movement that led to the communities and user submitted content we call the internet today. I recall the early days of FTP file searching by tree late into the night in college, having the entire internet text based as a few html sites began to sprout up. I compare searching roots and file trees then and the “Web 2.0″ experience we have now and realize that it is the inter-activity of the internet that has made it a community rather than just a marketplace.
There is an element there I can identify with when it comes to EMS. One of the Medical Directors who came by the booth in Baltimore asked me how he could use blogs to get his Paramedics to accept changing their protocols. I told him he should listen to what the patients his Paramedics encounter need and let that guide protocol changes. Then I asked if his medics had any way of approaching him about changes and he looked as if no one had ever suggested a medic could ever suggest a policy change, let alone present evidence in support.
“An open door and an honest opinion goes a long way in folks feeling like you care about what they’re doing,” I told him.
“No, I need them to do what I say.” he replied and I couldn’t speak against that because I am not an MD, nor in his system, understanding his troubles and challenges.
So where does this all fit into the EMS 2.0 landscape?
I dunno.
We need change, we need a new re-thinking of EMS, what it is, what we’re doing and why, how, where, everything needs to be re-examined and reformed based on new research, response models, patient presentations and care taker abilities.
How that can happen on a National level all at once is something I would love to see happen, but we all know here are far too many feifdoms, unions, politicians, companies and providers who will fight tooth and nail to maintain the status quo, regardless of the benefits.
There are those who will not move forward no matter what they are shown or told. And not all of them are the old salt medics. Some of the new kids on the EMS block feel they have made it and will just sleep through their refresher every two years and keep drawing the pay check.
Departments will fight to keep licensing requirements low so as not to have to pay their people to seek out education, possibly because the higher educated can draw a premium at the next service over.
From my lofty perch here with my education and high paying EMS job you may think me a dreamer with all this CoEMS and EMS 2.0 talk and you’d be right.
But the Chronicles was a dream a year ago and now we’re set to travel the world doing exactly what we want to do, explore what EMS means.
So I’m going to keep dreaming about EMS 2.0 and hope one day I can meet a crew from a department somewhere who both have an advanced education and operate under protocols or guidelines that give them the flexibility to treat, transport or transfer citizens, clients and patients based on what they need, not what they or some future lawsuit want.
I think we can all agree on that.
But how do we get there? We all get there in different ways at different times, hence the trouble in explaining EMS 2.0 to people at different levels of different systems.
There can’t really be an EMS 2.0 “thesis” or guide, but more of a mission statement, and that I am thinking about.
So far three main principles come to mind and how to expand on them will be up to you. They will certainly mean different things to different people, and that is one of the things I love about it.
My EMS 2.0 is based on three main concepts.
Technology
Teaching
Trust
Using technology to improve our ability to assess and treat,
Advancing our educational levels to not only learn more about our patients and communities, but teach them what we can and can’t do.
We have to earn the trust of those who give us the power to do what we do in order to do more.
In short I need some expensive gear, a pricey college education and then let me go do what I’ve learned and proven competent to do. Exactly what that is will depend on your community.
The future is coming and we as a Profession have a chance to not only make ourselves a respected part of the health care system, but excel in providing care in an innovative manner that can release the burdens the current system is collapsing under.
It is a dream. But it had to start somewhere and if that is all it is for now, I’ll take it, but something is happening out there and I want to be ready if my Chief asks my, “What do you think we should do?”
What are the three concepts your EMS 2.0 platform would fight for? Let me know.
I have finally had the opportunity to become one of the folks I mentioned in the trailer of Chronicles of EMS. I am now one of the lucky ones who can travel across the country to visit other providers at a trade show.
As I’ve been reminding you, Zoll invited Mark and I out to EMSToday in Baltimore, Maryland.
And oh boy did we almost not make it on time.
When I was growing up we always got to the airport early. Always. Sometimes by hours. So that just became my normal plan. Get there early.
With two little ones and a just over one hour commute home from work, then turning around and racing to the airport I got there 1 hour ahead of the flight, a nail biter in my world.
Mr Setla was relaxing after a calm lunch and I was frazzled to find our flight not only delayed, but now not even arriving at our destination.
The airline, for whatever reason, saw fit to take the same plane we were on before and reroute it. Not through a different connection, since the same plane continued on to Baltimore, but to send us an hour out of the way to DC.
Despite multiple questions as to the reasoning we were no longer able to land at our purchased airport, we were assured the two airports were not far away from one another at all.
I should have known better.
6 hours later we gather our luggage in DC’s Reagan Airport and ask the locals the best route to Baltimore. Their suggested Super Shuttle was a moderately priced hassle, requiring us to sign in, buy a ticket and wait 20 minutes before getting in one of the half dozen waiting vans.
We were 2 hours later than expected and now an hour away from our hotel. It’s 1130 PM and we’re tired and hungry.
A taxi trip will run us almost $100, but get us there quickly.
Knowing a trip from Baltimore airport to the hotel runs about $40 (Thanks FireDaily for the heads up) our chosen method of transport made perfect sense.
Jay’s Sedan Service is a family run business in the NY/DC/VA/MD area operating just a handful of cars driven by the owners and the care and attention to detail shows. We’ve all been in a leased car vs an owned car and the difference was clear.
Our driver, Jay, made us a deal over the phone and was curbside in less than 5 minutes. En route we started with idle chit chat until we learned Jay is on Facebook and Twitter (@jayssedansvc) with his business and we had to have fun with it.
Next thing you know Ted is ustreaming live video from the back of the Lincoln Town Car while Jay is laughing along with us.
After a touch of traffic we finally arrived at my hotel just after 1 AM local time. I say mine because Ted had been booked by a different group at a different hotel nearby.
Thank goodness for free late night food delivery.
So skip ahead to what my body thinks is 430 AM when my alarm goes off and I open the window to the beautiful brownstone Baltimore clock tower.
I can’t wait to dive in to everything this weekend could create for me, my friends and EMS in general.
I can only assume everyone played this game as a kid, but as rescuers, we play it everyday.
For those not familiar, you and your friends sit in a circle and one person whispers a sentence to the person to their right and so on and so on. The gist of the game is to see how much the sentence changes from person to person either by forgetting the exact words, or rewording it for whatever reason.
Funny thing is, I get to see each step of the game as it goes. This was brought to mind one morning when I got another one of my blog starting runs when I asked, “You called 911…for this?”
The game started when the client (See Glossary of Terms) had a sore throat and went to the doctor yesterday. Our story should end there, but this is managed care, so of course there is more.
This morning, 10 hours after starting the course of antibiotics, our citizen phones the expensive private health care nursing advice line. According to her, she told the nurse, “My throat still hurts, can I use a throat spray to eat? It hurts to swallow.”
The nurse told her to “…hang up, call 911 and tell them you need an ambulance.”
Our client calls 911 and, in clear words, tells the call taker she needs an ambulance for a sore throat.
Call taker follows instructions coding the call as a 26A25, Non-emergent sore throat. It worries me the 911 system even recognizes this, but…
The dispatcher changed the call to a 11D2, choking with difficulty breathing.
The notes on the MDT state she is unable to swallow.
As we arrive code 3 as instructed, we are met by a young woman with a diagnosed and medicated case of strep throat.
“Did you call your doctor today?” I ask after checking all vitals without disturbing findings.
“No, the office said he was too busy, they had me call the nurse line.” She hands me the card.
“What did the nurse say?” I can’t wait to hear this.
“To call 911 for an ambulance.” She says with a small laugh.
After a small conversation I discovered she didn’t feel different, just wanted advice on a throat spray so she could have breakfast. Her throat hurt, but no more than yesterday.
We went full circle in the telephone game this time, where the sentence was the same at the beginning and end, but it was all the junk in the middle that got messed up.
Maybe folks should be able to call us directly in the ambulance for advice since the dial-a-nurse seems to default to us most of the time anyways.
Got a message from my Paramedic mentor a little while back about the title of this post. He was asking what makes a call critical?
The definitions include “at or of a point at which a property or phenomenon suffers an abrupt change especially having enough mass to sustain a chain reaction; characterized by careful evaluation and judgment; urgently needed; absolutely necessary; forming or having the nature of a turning point or crisis; being in or verging on a state of crisis or emergency;”
But what does it mean to an EMT or Medic in the street he wonders.
Is it the presentation?
The required interventions?
Is it a feeling we get either before or after?
Well?
What makes a “critical call” in our book?
It’s being billed as
The Largest Fire/EMS Blog meet up of all time
and it is in Baltimore March 5th, 8pm.
Bloggers from the FireEMSBlogs network will be there and not just Mark and myself.
If you are a blogger and will be there, leave your info in the comments and I’ll add you to my list.
All are welcome, bloggers, readers, fans, stalkers, ex-wives (only odd numbered ones), industry reps (if you’re buying), Chiefs in uniform (so we can drink in front of you), small woodland creatures (so cute), #TeamHappy, anyone from the 1996 Eden Prarie Varsity Lacrosse Team, Firefighters, Paramedics, EMTs, conference goers, Instructors, Destructors (OK, not really destructors), my Mom (Hi MA!), retired members, volunteers, paid, paid/call…
…if I left you out you’re invited.
Uno Pizzeria Harborplace- Pratt Street Pavilion, 2nd Floor
201 East Pratt Street
Harborplace
Baltimore, MD 21202
410-625-5900
Sponsored by George Washington University, JEMS and FireEMSBlogs.com
Special thanks to Chris Kaiser
I had no idea that walking patients to the ambulance was such a risque thing to do.
Since the debut of Chronicles of EMS I have been seeing posts and getting emails about how folks are glad they saw me walking patients to the ambulance because it proves I’m willing to show the cameras what’s really happening.
Well, news flash – I walk patients to the ambulance all the time.
When their condition permits, of course.
But when Bubba Fishbiscuit calls because he is out of “brain pills” again, or sprains his wrist guess what folks, he walks if he wants to.
I have even been known to walk patients INTO the ER! AAAAAAAHHHHHHHHH!
My question to you is, why aren’t you?
If your patient doesn’t need the cot, or want it, why are you “required” to use it? And the stair chair too?
I dug through my County Guidelines, Department Protocols and even Department rules and regulations and found nothign about folks not being able to use their good legs when they want to.
Forcing people to make you carry them is insulting.
“No Ma’am, we have to for liability reasons” is the exact opposite of what you’re doing. By letting them walk they are responsible for their actions. When you carry and drop them, well, that was your call.
So why is it that so many Paramedics and EMTs were taken aback when I allowed people who were walking around when they called me and walking still when I arrived to walk into the ambulance?
Is it billing?
Is it?
Is the ability to be reimbursed for the transport more important than the patient? If you are required to carry or cot everyone no matter what, then yes.
Ask your Medical Director about walking patients to the rig who have non life threatening injuries or who are stable per their history and protocols and request to walk on their own, watch what they say.
Now go ask your billing department how hard it is to get Medicare to reimburse when you start your narrative with “Pt ambulated without assistance to Medic99.” Watch their eyes catch fire.
Your protocols should outweigh your policies because your policies cover you and your protocols your patients and we’ve covered more than once in this forum that this thing isn’t about us, it’s about them.
If Bubba’s had a few too many, he gets carried. If he’s going to reach out on the stairwell and twist in the chair causing my knee to go out, who’s fault is that? Bubba’s for reaching out or mine for not helping him down the stairs in the first place.
Have a serious talk with your system administrators if you are not permitted to let your patients walk to the ambulance. Show them the Chronicles episode and show them that I do it all the time and, gasp, no one dies.
But, and I hate that I have to add this, follow your established policies and protocols until otherwise advised by those who have the power to change things.
What a weekend indeed. As our regular readers are aware, it appears those 26 exhausting days back in November were worth it after all. Even though only the first half of our Project was turned into the Chronicles of EMS, the entire experience has changed the way I view my system.
This screen shot will take you where you can watch the show.
This past Friday saw the World Premiere of the Chronicles of EMS Reality Series in San Francisco. Mark and I arrived a bit early at the request of Producer/Director Thaddeus Setla and were quickly aware of the extensive set up on site. Multiple large TVs are linked to laptops and cameras, all relying on a tiny ethernet cable to stream it all live around the world.
The chat room got a bit colorful at times but we did notice those of you out there reminding visitors to keep things clean, even if they refused.
Before we knew what was happening, Mark and I were at a table talking with magazine reporters, investors, friends and readers, all excited to see the first episode.
Although we had a really nifty schedule of events, technical troubles and the wave of people in the Hotel Frank made that schedule difficult to keep.
Keep in mind this is all being put together by Paramedics, not professional live streaming folks. We can’t afford them yet.
But when the show went live, the room got quiet and I went to the back of the crowd to gauge reactions. And the were 100% positive.
Thank you all so much for taking your own time and money to help us show the world what we did and what we learned.
The following morning Ted loaded up the cameras, Mark and got a few folks from out of town we usually talk to over skype or email to sit down and talk with us. We fired up the cameras and filmed a sister show, A Seat at the Table.
It was more fun to film than I expected and we talked about a lot of issues. You can watch the show link for information on future table discussions and how you can join them live, each show has a laptop open to the chat room which has it’s own place at the table.
Whenever we travel with the Chronicles team, we hope to gather folks around the table and open the dialogue even more.
Thank you again for all your positive comments about the show, we hope to live up to your high standards in the future.
The pre-Chronicles retrospect of favorite posts continues with part 2 of the 3 part posts about a patient who didn’t exactly behave himself. My partner on this job recently went light duty and pulled strings to let me keep her spot warm while she’s gone.
Originally Published June 25th, 2009
Round 1 seemed normal enough, at least as normal as things get in the big scary City some nights.
Round 2 begins as I’m assisting Bubba down the stairs and he decides an elbow to my face would make his night better.
Luckily, I watch a lot of movies. Not fighting movies or martial arts movies, Happy is a lover, not a fighter, but I enjoy a good strategy and tactics film when I can.
I had 3 options as Bubba took his first of many swings.
Option 1 – Let him hit me. Um, no.
Option 2 – Try to duck or dodge out of the way. I’m not one for choosing the direction of an assault and I figured I had a 1 in 3 chance of moving the correct way.
Option 3 – Close the range to target.
What came to my mind in a flash was the Hunt for Red October. When he turns into the path of the torpedo before it can arm itself. My reasoning after the fact seems perfect, in the moment I just needed him to chill.
The bottom of the stairs had along it’s side a large wrought iron ornamental security gate, the kind we have to force open most days.
As Bubba moved with the elbow, I forced my shoulder into his, jamming him into the gate. My right leg got up under him to throw him off balance while my left hand dropped the computer and squeezed Bubba against that gate. I knew if he got me off balance and I went to the ground I was going to get hurt.
My partner was already on the radio screaming for police assistance. She had to scream to be heard over the screaming of, in ascending order of volume, Me, Bubba, the girlfriend…and mom, who’s voice had found new heights.
Bubba was my height and had at least 20 pounds on me. I was tired and sober, he was drunk and rested. My only hope was to keep him against that gate until the cavalry arrived. All I wanted to hear was the screaming of the police sirens.
I was able to get his right hand into mine and forced behind his back, now near my waist. His left arm, the one that swung the first time was pinned between him and the gate, not moving for now.
The scene from Pulp Fiction when Julius is telling Honey Bunny to be cool was playing over and over in my head and I’m sure lines from the scene were coming out of my mouth. All I remember is wanting to keep his 230 pound frame off balance and against the gate which was almost more than my one leg could do.
After what seemed like hours of holding him he began to calm and still no sirens filling the night air, only screaming. He promised he was “OK,” and I reminded him that I had no problem keeping him there all night if I had to, a thought my leg would most certainly disagree with.
I decided, possibly foolishly, to let him back down to the ground, partly for a rest and partly because he had indeed calmed. I kept his right hand behind him and made a reach for the left wrist, controlling both rather well considering the circumstances, I thought, and we slowly made the drunken, angry stumble towards the ambulance, feeling him squirming and trying to get free the whole time.
There in the middle of the street, mother still screaming and us now screaming at her to go back inside, Bubba sees an opportunity to try knocking me down again. He’s got one leg up on the rear step of the ambulance and one hand on the rail to climb in when, I’m told later by my partner, Bubba takes a swing. All I recall was seeing him shift his weight and losing my cheerful disposition.
He quickly found himself flat on the cot as I tackled him into the ambulance, landing one leg on his hip and one arm on his chest. I’m not entirely sure it was one maneuver but I would have loved to see the video.
As we’re struggling now in the ambulance, as if by stealth, a sea of blue rushes the back and there are no less than 3 boys in blue saying and doing things that I can not. They have him four pointed and are able to clearly shout over the rest of the commotion outside where I can make out at lest 2 more officers dealing with mom and the girlfriend.
I look at my partner and share a look of, “Holy s*it, did that just happen?”
I took off my duty jacket and took a deep breath throwing it to the bench seat in frustration, suddenly feeling the strain in my shoulders and legs from holding him for what turned out to be 4 minutes against that gate.
The officer looked to me and told me he was impressed I didn’t fight back. What I had taken as staggering towards the ambulance, they had seen from afar as him struggling and swinging elbows, all while I’m walking behind him.
The final part of our tale, Round 3, will be covered tomorrow morning, Friday as a perfect You Make the Call.
Another co-worker recently reminded me of when she and I met Bubba one night, leg wrapped in a towel, tied with twine and an attitude.
Originally published June 25th, 2009
The next 3 posts will cover 3 distinct parts of a rather interesting job.
Round 1 – The Dispatch
1:15 AM and the MDT tells me you’ve cut your hand. It also tells me you’re in your twenties. It doesn’t tell me if you’re seriously calling 911 for this. I assume you know more than I do about who needs an ambulance and away we go.
THE EMERGENCY
A man has accidentally cut his hand.
THE ACTION
This was a perfect storm of mystery, intrigue, alcohol and lies. The building is older and has a large partial S staircase leading from the street level to the first floor door. So when we start our trek up the dark staircase, the front door is out of our sight above us and to the right. I stood there at the bottom of the stairs, tired already from the first 16 hours of the shift, waving my arms at the motion sensor light that, apparently, has yet to be installed. Warning flag #1.
The door is open and I hear high pitched voices speaking, nay shouting, in a language I do not understand. As is habit I scanned the floor for blood. I see none. In the next room is Bubba. (See Glossary of Terms)
Bubba has his pants half way down and has a towel tied to his thigh with twine.
“Hi there.” I say, hesitant to put anything down quite yet.
He mumbles in response. Even just this slight mumble sends a waft of alcohol breath my way that would have caused me to fail the brethalyzer right then and there.
He’s telling a story about opening a can of oysters and missing, hitting his leg. Then, after a few questions he tells a different story about how he got cut. All the while I’m telling him I know he is lying. And all the while the mother and the girlfriend are shouting and won’t leave the room until my associate for the day finally convinces them to give us peace and quiet.
His leg is cut, not his hand…warning flag #2.
Using my Happy Medic skills we’ve convinced Bubba to come to the hospital to have the 5cm wide 2-3 cm deep wound from the chef’s knife examined.
Oh, did I skip that part? After arguing with the landlord Bubba thought it would be a good idea to get wasted drunk, grab a couple of knives from the kitchen and wave them around like a child demanding more dinner. Darn it if those things are sharp when you get a little too animated.
His mother and his girlfriend, who hovered over my discussion with Bubba in the room are still shrieking in their native tongue and Bubba is trying to shout back at them as I’m guiding him towards the front door and down the stairs.
Quick aside, the wound is wrapped, not bleeding and he flat out got angry when we tried the chair. Warning flag #3.
Halfway down the dark stairs I have my hand under his arm to help him balance, as I offer to everyone I treat. I have Bubba in my right hand, one step ahead of him and the electronic PCR in my left. I looked away to check the bottom steps. When I looked back up…warning flag #4, a swinging elbow coming my way.
Coming soon – Round 2 – the Struggle
Buried within all the excitement of the premiere of the Chronicles of EMS Reality Series is another premiere I’m proud to be a part of.
Over the years EMS has been serving their communities we seem to be finding ourselves out in the cold when budgets are doled out or reimbursement tables adjusted. The practitioners on the street, in the patient’s bathroom, bedroom, living room, deepest darkest days are largely ignored when industry heads meet to discuss where the trade may go.
They’ve talked of minimizing standards to maintain a constant flow of low paying jobs and EMTs eager to step on the gas and run the lights and sirens. Study after study showing one way is wrong so another can get a bigger market share. All the while our pagers are going off and alarm bells are ringing.
If we’re lucky enough to have a voice in the discussion, we are looked at as an afterthought. A nod and a smile greets our suggestions for improvement, often with a “we tried that before, it didn’t work” which is the EMS version of a pat on the head.
Various committees and organizations sprung up with a spot for us, among dozens of others, making sure we had no chance to be heard. EMTs and Paramedics were never given a seat at the table.
So we made our own.
Social media has us sharing ideas and concepts in a way they never saw coming. Research can be done from home instead of at a far off conference of owners and Chiefs all striving to prove themselves as having the best system. We can now call their bluffs, and they can call ours.
A Seat at the Table takes one element we discovered while filming the Chronicles of EMS Reality series and expands it into a format rare in our industry: Video. This element was the civil discussion of differences by street level EMS personnel who took the time to comment about what Mark and I were learning from one another.
There are plenty of EMS videos available for viewing online and by purchase, but never before has a filmmaker with a vision and a background in EMS taken up the challenge to document what we’re talking about.
Take a look at this snippet Ted Setla and I shot to explain to investors the power of Chronicles of EMS:
Chronicles of EMS – The purpose from Thaddeus Setla on Vimeo.
The Chronicles of EMS:A Seat at the Table is a table top discussion program filmed in the round and is scheduled to include as many people involved in the future of EMS as we can find.
Each time the Chronicles team travels, A Seat at the Table will be close behind to take advantage of the unique people we might meet and want to hear from.
Not only will we be sharing ideas, but getting answers to questions from those in charge of where we’re all going. Mark Glencorse and I will be there but you will be as well, following each episode as it is filmed HERE in the ustream chat room (scroll to the bottom). When you listen live to the filming, Mark and I will be monitoring your comments and questions for the panel and including them in where the show goes.
That chair you’re sitting in will now be at the table, a voice in where our young profession leads.
Watch the Chronicles page for updates about filming in your area and if you want to be in studio with us, let me know. thehappymedic@gmail.com.
Bookmark the link to the Seat at the Table page as upcoming episodes, topics and guest lists could change suddenly as we’re sent all over the world exploring how EMS systems operate.
See you there.
With the Chronicles of EMS premiere racing towards me I find myself distracted in my writings of late, so I wanted to share some of my favorite posts with some of you newer readers.
This one comes from the very early days of my writings and still is a bit edgy, but I see the partner I had on this run a lot now and we still laugh about it.
Originally published August 3rd, 2008
You called 911…for the heart attack…?
Another run in the middle of the night to a local residence hotel. You know the kind of place. Seedy part of town, lobby looks like a garbage sorting station, complete with dirty employees. We rarely carry equipment without a plan on never putting it down and cringe about having to clean our boots afterwords. We’re met in the lobby by a rather clean gentleman wearing headphones who waves us over like he knew we were coming. I can tell by his almost new shoes he is not a resident, nor has he been in town long.
THE EMERGENCY
“My heart is just beating away.” Usually a comment from a citizen like this elicits my compassionate response of, “Can you be more specific?” but on this morning at 3:30 and on our 20th run of the 24 hour shift, I had lost my cheerful disposition. In response to the comment, “My heart is beating away” I responded, “Mine too. Do you have an emergency?” “I can’t sleep,” he responded after a slight pause.”Me neither,” I shoot back getting annoyed. Not annoyed so much at the fellow who called us, but that this conversation is occurring in the lobby of the garbage station like residence hotel. But be careful, if you get these folks outside, they think they automatically get a ride, so keep them on defense. After his, “I can’t sleep” complaint crashed on take-off, he asked why I was so mean. I explained that there could be a baby choking or someone being shot who needs us but if he can tell me what the emergency is I can let him know how I can help. “I need some food, man, I’m broke.” “I have a job,” I reply, “You need to come up with something better. Maybe this line works where you’re from but not here.” “How did you know I’m not from here?” He wondered out loud while I moved towards the door. “Wait, can you give me a ride to the bus station or a shelter or something?” I moved towards the heavily fortified Manager’s window in the lobby of the residence hotel we were in and knocked on the window. A sleepy man who may have been speaking a form of English I’m not aware of became visible.”This guy needs a room, how much?” I ask. “Him stay 1 hour? or more to day? $10.” I look over to the fellow who called us and motion towards the window. “You can get a room for the rest of the morning or keep that money in your pocket and call whoever you left behind wherever it is you’re from and beg forgiveness and go home.”
THE ACTION
The gentleman considered my words, put his headphones back on and stopped talking to us, just standing amongst the trash, waiting for something to happen. I asked if he wanted an ambulance to take him to the hospital and he gave me the universal one finger signal for “Go away.”
My EMS adventures in Newcastle upon Tyne had come to an end and I had but one full day left in England. Swalwell Station Manager Peter Mudie has arranged for me and Mark to take a bit of a tour of the capabilities of the Tyne and Wear Fire and Rescue Service, so we’re up early and he’s taken us for a road safety class.
Not for me, thank goodness, but for a group of young drivers to impress upon them the importance of not drinking and driving.
Many of us have been to these presentations before. A middle aged expert prepares what to them appears to be a hip multi-media presentation and the attendees seem less than interested. I was the same way at 16, we all were.
Enter the Happy Medic and UKMedic999 and the class is now wondering what just happened.
The presentation was actually one of the best I’ve seen including some racy videos that in the end have a message about driving safely. The kids were really paying attention then. Mark and I had a chance to impress upon the gathered youth the importance of seat belts and driving safely. I think my “accent” kept their attention more than my content.
Even the locals were cold. Mrs HM knit me two hats, so I shared.
Then it was off to the yard behind the station for an extrication drill to show the new drivers what happens when cars collide.
Set up down the hill were two cars and two students were chosen to be the victims.
To say it was “balls cold”, as one student put it, would be an understatement. I’m a 6th generation Californian, 50 is cold for me. This yard was cold. Wind blowing, snow falling and me with no gloves.
The kids watched as their friends shivered in the cold while the fire appliances pulled up and began their task. I mentioned in passing to the instructor that I would have let the kids go back inside and he suddenly had a point to make to the youth suddenly more interested in each other than the hydraulic tools freeing their friends.
“AYE!” He shouted to the huddled, hooded forms, “You’re here wearing your coats and gloves, hats and whatnot, but what if you were heading back from your mate’s place and were wearing only a shirt and crashed?” He was moving around in front of them, almost pacing like a drill sergeant, “Laying in the snow, cold, tired and hurt? You wouldn’t last very long would you?”
He had their attention the rest of the morning.
The extrication was straight forward with the only difference being the use of the smaller ladders to brace the car on it’s side.
After a lunch cooked by the station’s french chef (Yes, the chef is not a firefighter) it was off to Tyne and Wear Fire Headquarters.
What an impressive building and training ground they have!
A grand foyer greets the visitor and many small groups of men are sitting in plain clothes discussing this and that. One of them, the only one wearing a shirt and tie sees my SFFD Firefighter/Paramedic jacket and does a double take.
As I surveyed the enormous complex I would assume candidates are intimidated when they enter to get their employment packets. Peter led Mark and I on a brief tour of the lower level and the man in the tie wandered over and said hello. Just a casual greeting, he seemed like a regular guy in a sea of white embroidered uniforms and street clothes.
Chief Bathgate, Yours Truly, Peter Mudie
The man in the tie wandering the lobby is none other than Iain Bathgate – Chief Fire Officer for Tyne and Wear.
blink. blink.
He offered a hand and I shook it. There I was in my uniform shirt, but buried under a sweatshirt and a jacket. Had I known I was going to meet the Chief I would have at least donned my cap and tie to show respect.
Turns out he was more interested in the back of my jacket than what wasn’t around my neck.
“You do both then?” he asked me.
“Not often at once, but yes, I am proficient in both skills” I replied, wondering if I should go into further explanation. As we spoke the other men were taking interest in the fellow with two titles on his jacket their Chief was talking to. He immediately suggested a tour of the training grounds, something his face glowed about, he was proud of it.
Through the main lobby and out another set of large glass doors was their training facility, easily 5 acres and including a wide variety of props.
There was a standard training tower that, since once at the top one could peer over to the automobile manufacturer test track next door, was rotated and modified to keep wandering eyes away.
Next to that was a high voltage power line tower prop for high angle rope drills. Under construction nearby was a large two story collapse house that can be dropped and rebuilt quickly to simulate rescues.
A number of burn buildings stood ready for recruits and in service crews alike, one of which was in service when we visited.
But the piece of equipment that caught my eye as special was their train rig. Over behind the airplane prop and the piles of wood was a full size train car half in a man made tunnel. 
I wish we had one.
Half way through my tour, Mr Bathgate dismissed himself and went back to running what appeared to be a well funded and well respected organization.
Mark, Peter and I finished the tour and the Department had a photographer come down and snap a few pictures of us in front of some of the appliances. then a few minutes later she rushed out with a stack of nice photos for me and Mark to remember our visit.
The only comments Mr Bathgate made regarding the wording on my jacket was, “Oh, we’ll not be doing that here” which is something I’m not unused to hearing from the Big Red Machine.
Same System, Different Country.
I’ve got a few more posts worth of observations and anecdotes that I’ll be saving until after the Chronicles of EMS premiere on February 12th.
Thanks to the Chronicles of EMS, both Mark Glencorse and I will be attending the JEMS EMS Today Conference in Baltimore, Maryland, March 5th and 6th.
It’s a big deal for us to be able to spread our message to as many people as we can and there is no better way to share ideas than face to face. Even though we can communicate here in the internets machine, Mark and I didn’t really see what each other meant until we stood shoulder to shoulder in each other’s systems.
Since it will be a little while until we can get to everyone’s systems and learn from everyone how best to deliver EMS, heck even what EMS means anymore, we’ll travel as much as we can to meet you and keep the dialogue open.
That’s where our sponsor ZOLL Medical comes in.
SFFD Zoll Rep Roy Kniveton was kind enough to give the Chronicles of EMS team a run down of things coming from Zoll and let us put the new E Series through some quick tests. Not any of that scientific lab type stuff, but medics dragging it around a room type tests. Roy even offered to let the 100′ aerial ladder truck run over it to show it’s durability.
The truck officer declined the request.
But aside from coming in and letting us see what was new, Roy actually listened when we told him about our growing following. He was genuinely interested in the EMS 2.0 movement and did some quick searching to see what we were interested in getting from our equipment in the future.
We must have done something right because our near future included a generous sponsorship in our pilot episode and flying Mark and me to Baltimore for EMS Today. We will be Zoll’s guests at their booth and we’re looking forward to meeting all of you and answering questions about the Chronicles show, new concepts coming in social media TV and anything else you want to talk about.
I’ve never had anyone fly me anywhere before.
And to EMS Today no less. Check out the web page HERE and look for JEMS Editor in Chief AJ Heightman to wander in to give you the details on all the exciting things happening around me and Mark. Yes, there will be more than us ruggedly handsome frumpydumple fellows.
If you get a chance to make the premiere of the Chronicles of EMS in San Francisco on Feb 12th, we’d love to have you, sign up to let us know you’re coming HERE. And a special thanks to EMS1.com and AAM Consulting (Randy Africano) for sponsoring the premiere event at the Hotel Frank. More about them soon.
See you in SF.
See you in Baltimore.
My name is John and I am 63.
In just over 3 years time I’m going to be driving through your jurisdiction just as you are sitting down to your first meal in 12 hours. As your order hits the counter I will experience an odd tightness in my chest and dismiss it as gas.
When you take your first bite my wife of 35 years will watch me clutch my chest and stop the car on the side of the road.
Just as you begin to think your bad day is finally slowing down, the worst day of my life, and possibly the last, has just begun.
I’ve slumped over in the car, releasing the brake pedal and the car drifts into a signpost, discharging the airbags.
My wife is hit by the passenger side airbag as she is leaning over to help me, noticing my unconsciousness just prior to her own.
A passerby has stopped and is now describing a motor vehicle accident to your dispatcher.
Lunch is still warm in your hands when your radio alerts to the accident.
You are tired.
You are hungry.
The kids have been keeping you up late.
The rent is past due.
Big deal. I’m about to die. While you’re cursing me walking to your rig, my MI is moving and my wife’s head injury is complicating what is already going to be a difficult airway judging by the amount of teeth on the floorboards.
As your rig negotiates traffic, my respirations are rapid and shallow, my wife’s now non-existent.
When you pull up to the scene I need your A game. I need you trained to the point where what you are about to do comes as naturally as breathing, because we’re having a bit of trouble in that department.
This is not about you. It’s about me. It’s about us.
So back to your studies, we’ll meet again before you know it.
It all comes down to this meeting doesn’t it. The entire project, everything I hoped to learn comes down to sitting with Mark’s supervisors and policy makers in the UK and making a solid impression that American EMS is not awash in profit driven patient care.
But then again, we kind of are.
I started the meeting starving hungry from my hours in the dispatch center downstairs and was told this would be a kind of working lunch meeting.
Sandwiches and various appetizer type dishes were brought in and my personal favorite, fresh coffee. The conference room at the NEAS appeared to have been recently remodeled or redecorated as there were literally dozens of legal sized computer generated signs reminding those reading not to place cups directly on the table.
So what do I do?
Yes, and luckily I had Peter right behind me to place a saucer beneath the cup and shoot me a “Hey stupid” look. It was in this framework that the rest of the administrative team made their way in and began a presentation on the stats of the NEAS. Population, call volume, etc.
It was made clear to me ahead of time that Fiona, the Chief Executive’s aide, had prepared the presentation and Simon Featherstone gave credit where credit is due.
Mr Featherstone, the aforementioned Chief Executive of the NEAS, seemed like any other person I had met on my travels so far and that made it very easy to listen to him discuss his system.
A few slides in he turned to the dozen or so folks in the room and suggested we do more interacting. This was, after all, common knowledge to all but one person in the room, me, and they wanted to hear from me, not their Chief Executive.
I went into a brief overview of my system in the SFFD and also explained other systems around the country. Much time was spent, and not surprisingly, with their fascination with the idea of for profit ambulance services.
Each member present asked a number of questions about billing and a person’s ability to pay and I had to remind them many a time that that doesn’t come into play until well after the call, but does drive policy decisions in the end, therefore changing our field care decisions.
Each time I snuck a bite to eat another question would have me or Mark discussing his observations of the system as well as his tales of life in a San Francisco Firehouse.
When it came to Mr Featherstone asking what differences we have observed patient care wise, I brought up CPAP and cardioversion and that those are widely used skills in the US. Pacing and cardioversion along with adenosine surely more common than CPAP, but it is such a wonderful tool more services should invest in it.
In true executive fashion Mr Featherstone turned to his clinical care person and said, “How soon can we look into doing these things?”
Bang.
Right then and there, slightly leaned back in his chair, the Chief Executive might be moving forward on something that can directly benefit the patients Mark encounters as well as giving him tools to help more people.
The meeting ended with handshakes and wishes of luck, but very little was said regarding the lack of Ted Setla and the Chronicles of EMS team in the room to record all of this fantastic learning and sharing of best practices.
But I understand that. England is a far less litigious society than the US, but they still have to concern themselves with the appearance of the service and those who function in it.
Everyone reading this post knows Mark and his blog are a source of incredible knowledge and a commitment to improving himself through new pathways. If Mark wrote a book about EMS I would buy it. If he had a radio show I would listen to it, but until those things happen (If he had a TV show I’d watch it) I will follow the media he uses to become a better Paramedic. Right now that is his blog http://999medic.com, twitter @ukmedic999 and on facebook. All media that is growing not only in popularity but usability and relevance to what we’re trying to do in the pre-hospital care fields.
I don’t expect every service in the world to be open to bloggers sharing patient care and contact stories, regardless of permissions, and the few that value the following some EMS bloggers have are doing so very carefully.
One of the things Mark and I hope to work on in the years to come is acceptance of new media and new ways to share information that still respects a patient’s privacy while allowing those doing the care to share insight and best practices in real time.
A unique airway solution is discovered in Australia, blogged about, read by an ECSW in England who passes it along to their Paramedic who posts a link to twitter where I read it. Suddenly a technique that 5 years ago would wait months to get considered for a trade journal has been seen by thousands of caregivers who are about to share it with their friends and co-workers, and all in minutes, not months.
After a morning of listening to the Pathways system work in the dispatch center, then seeing the openness of the Executives to concepts and treatments, I think Mark is in a good place with the North East Ambulance Service.
In Conclusion-
The NEAS provides a high quality service in a straightforward manner to a well informed population. Powers rest with the Paramedic at the scene to determine transport, not the patient ahead of time like in my system. Front loading and getting eyes on a patient is a reliable way to handle system resources and gauge response.
The service is not reliant on insurance companies reimbursing for the services rendered nor are their paramedics passing perfectly capable ERs to reach a certain carrier’s preferred spot.
Mark Glencorse was a gracious host and everyone I met from A&E tech to Chief Executive was welcoming and asked great questions about American systems and I did my best to represent all of us in a professional and knowledgeable fashion.
The food was great, the coffee we can work on in future visits.
Will the NEAS model work in San Francisco? I won’t know until tomorrow when I get a tour of the Tyne and Wear Fire and Rescue Service by Station Manager Peter Mudie. Fire readers, this is the post you’ve been waiting for. But like most of what we do, EMS comes first and accounts for 80-90% of what we do. Why should my UK story be any different?
I’ve been busy preparing for the premiere of the Chronicles of EMS and haven’t been sleeping well. When I do sleep, it is shallow, poor sleep, at least at work. At home Mrs HM tells me I sleep like a baby rock log.
But a few days ago at the table after a long night at work I had to ask the firefighter on the engine, “Did I get in trouble last night?”
As I remember it, we were running back and forth on our usual compliment of folks unclear on the concept of an emergency. The engine was dispatched to a reported motor vehicle versus pedestrian. At 4 AM it could be bad, so we were ready to work when we arrived at the intersection to find a man laying on his back between 2 parked cars.
A quick approach shows no damage to the vehicles around him and no fluid on the ground. As we approach we see his feet crossed and he wipes his chin with a dirty hand.
“Sir!” I call out as we arrive at his side.
“Ah, you made it. Man, I need a place to sleep, this is killing me.” He replies as he rises looking past me to the engine. “Where’s the ambulance? I asked for an ambulance.” No distress, no problems.
I assessed his clean clothes and unstained shoelaces, a clear sign he has not been on the streets long. He told us all about how he was a local and grew up in the neighborhood, but couldn’t name the school he went to or what street he lived on.
We get a lot of folks coming to town thinking it’s all wine and roses on the streets of the big City. Many other cities appear to be using us as their dropping point for folks they choose not to help.
This guy clearly expects an ambulance to take him in. As we confirm he is not injured, I spot a $20 in his pocket.
“You have cab fare, just call a cab if you want shelter.” I tell him as the boss code 2s the ambulance.
“You can’t tell me what to do, now call me an ambulance and go away.” He said laying back down between the cars.
I lost control for the briefest of moments and threw the BP cuff at him from a short distance. I was fuming, rage kept deep for so long bubbling up to the surface and I know I have to leave. Across the street I walk and sit down.
“What the hell are you doing?” The boss calls out to me.
“I’m done with him. Call the EMS Supervisor and the BC, I’m not coming back over there, I might do something more stupid than I just did.”
Hours later I’m sitting at the kitchen table, sipping coffee, still angry. The firefighter is pondering my earlier question, clearly thinking about it.
“No, I don’t think so. Did you kill someone while I wasn’t looking?” He answers, looking back to the metro section.
“Did I throw a BP cuff at that guy in the street?”
His head looks up and he smiles. “Threw a WHAT? Are you feeling alright? Have you thrown anything, like, ever? No you didn’t get in trouble last night. We didn’t run a guy in the street.”
The boss has heard the tail end of the conversation and chimes in, “Bad dreams huh?” and he offers to fill my coffee.
Bad dreams indeed.
RTB means Return to Base. A cuppa is slang for a cup of tea. Allocating is something I very much wanted to see first hand.
On this morning in Newcastle, my second to last, Mark has arranged for me to meet with the executive staff of the NEAS at their headquarters.
Before meeting with them, however, I’m downstairs in the bullpens. I’ve got 2 hours to sit in the dispatch center and do a “Sit-along.”
When you tell a guy who loves talking theory on systems allocation he gets to see the system work from the nerve center, he gets a touch giddy.
My first chair was at a call taker’s desk and I got plugged in.
BANG, less than 10 seconds, not even a chance to introduce myself to the call taker I’m with the first tone is in my right ear.
Before she can answer the call a timer has popped up on her screen 8:00, 7:59… the clock is running.
“Ambulance Service” she answers and begins reading from the screen the pre-ordained triage system called Pathways. As I’ve mentioned before, this dispatch system makes no attempt to diagnose the problem, but the physician designed questions can dial up or down the response in real time as the call taker asks the questions.
While she is asking and answering, a small red circle has appeared on the screen, then, a bit away, a purple one. Later I would learn that one is the location of the caller and the other the closest vehicle assigned to the call. When that vehicle arrives on scene, the timer now passing 6:15 will stop. This is their target and they take it very seriously. As I’m listening to the call, it is a very straight forward sick call and the caller is honest about it. It is then I see the benefits of the flexible front loaded system. The rapid response car, the closest resource to the caller, has been stood down since there is not an emergency at the caller’s location.
The vehicle, or cot transport capable ambulance, is continuing, however, and the target is no longer 8 minutes, but now 16 from the time the call was answered.
As more questions are answered and the system confirms the lack of life threats, a simple screen gives instructions for the caller until the crew arrives. The call taker then scrolls around her GPS monitor and finds the vehicle, then advises the caller about how far out they are. The caller thanked her and the call was terminated. Less than 3 minutes passed from the answering of the call to the triaging and confirmation of appropriate response.
At no time did a supervisor step in to augment the call taker’s classification, nor did the system err on the side of caution by upgrading the response, putting rescuers’ lives at risk, “Just in case.”
In the hour we were together I learned more about the desk I was at and the number of calls she answers in an average shift. We took mostly non-emergent calls, details of which would obviously violate privacy, but I can share with you the CALLERS.
When I explained how folks abuse our service by calling from a cell phone miles away about a person they think might have been either unconscious or sleeping, she smiled. Then, I went on, our criteria based dispatch system considers the caller’s inability to confirm consciousness to be unconscious and their inability to confirm breathing to be apnea, and 7 people are now responding code 3 for nothing.
It was just when the call taker was explaining some of the loop holes used that a care facility called to request an ambulance.
They were not with the patient so unable to observe their mental status, efficiency of breathing or if there was any bleeding. The system took this information and kept the RRC responding. Each time the call taker asked a question, the caller was already answering, knowing exactly which question comes next.
She later explained that folks have learned that if they take a cordless phone around the corner and call an ambulance, the crew arrives faster than if they honestly answer the triage questions.
“Same callers, different country.”
It was later in the morning across the room with the allocators that I saw the strength and weakness of the NEAS.
Mark and I spoke at great length about being honest but respectful when offering our observations and suggestions to improve each other’s systems. Mark was an example of this when he met with SFFD Chief of EMS Pete Howes for a kind of exit interview before leaving. I hope I can meet that example with the following paragraphs, but each time I write it it comes off preachy, so here goes.
Sitting between the allocators I watched them constantly on the radio with numerous vehicles and cars in various states of service. Each color on their screens meant something different, from enroute, on scene, RRC, vehicle, on post etc, but it was the clipboard they were passing back and forth that caused them the most frustration and, more than once, delayed allocation.
Not by a definitive amount, we’re talking 3-5 seconds, but it was the constant flipping of pages and radio traffic related to the one thing that I think the NEAS needs to change for the betterment of the system.
No more breaks.
I can hear the UK medics now “Hell no.”
Let me elaborate for my work straight through the shift American friends.
The NEAS, as a portion of their labor agreement, provides their crews with certain breaks depending on their daily activities. When they have been on post for an hour away from station, they get rotated back to the station. This was commonly referred to on the radio as “Return for a cuppa.” The basic premise is simple enough, really. People need clean bathrooms and a chance to eat since eating is not allowed in the cars or vehicles, nor are they allowed to sit down and eat in an establishment while on duty. This was evident when Mark was nervous enjoying some Pho in San Francisco.
In the car and vehicle this didn’t seem to be a big deal, we’d get a message to return to base, or that we were clear for meal break. The meal break can be interrupted, should the allocators need the resources, but they avoid it since the crew interrupted gets paid quite a bit for it and the allocators, although they wouldn’t elaborate, appear to be held accountable.
Sitting between the two allocators on the desk that morning, 50%-75% of their time was arranging rotation station breaks or ensuring crews got their meal breaks. These variables also added more color codes to the dispatch screen. This car is on dinner, this vehicle is on base rotation…etc, etc.
When a call came in they shot a quick look to the clipboard showing who gets a break when and dispatch decisions are based off of that. I did not witness it make a difference in response times, since that information is streaming in real time on giant monitors overhead, but these folks are scrambling to keep everything running smoothly.
With my limited dispatch experience it seemed like a simple change, since on the days I was on rotation in Newcastle we never had a point in the day where we were unable to reach a bathroom or food.
My head was trying to process all the information these women were basing their allocations on and one of them turned to ask me, inbetween moving a car back to base “for a cuppa,” “How do your dispatchers handle your breaks?”
When I explained we (listen to me, like I’m still in a rig), THEY are gone for 10 hours, no breaks, they froze.
It was passing the clipboard back and forth that I saw the only 2 seconds they both held still: glaring at me. It was clear I was not to repeat that statement for the rest of my time with them.
“That would make, ‘Go ahead 405′ this so much ‘thanks and to base if you please’ easier.”
Yeah, 2 conversations at once. I have trouble typing and listening to music or TV at the same time.
Mark had some family business to attend to while I was meeting the voice on the other end of the radio and he returned just before dinner time to collect me. It was an eye and ear opening experience to see the chaos that a simple concept like breaks caused the folks moving units around.
Something I completely neglected to mention over lunch with the executive team.
Told you I couldn’t screw that up. My conversation with the folks hopefully getting Mark cardioversion and CPAP, and where to put your coffee when the table is literally covered in signs that say “DO NOT PUT CUPS ON TABLE, USE SAUCER” soon.
Yeah I did.
All right all you twitter folk, I heard your call for the contest and I’m stepping up.
We’re having ourselves a little caption contest.
Mr Setla, my producer, and ninja trainer, over at the Chronicles of EMS posted some teaser photos of a brand new series in the works called Chronicles of EMS: A Seat at the Table. This new web series is an exciting project we’re working on to open up the dialogue in our profession in a way that’s never been done before.
As a result, we’ve been testing and experimenting with topics, light and film and this photo is a screen shot of one of those tests.
So you’re wondering what I’m saying? Let’s hear it. Caption this photo.
CONTEST RULES
- You can comment as many times as you like and offer as many entries as you like.
- All entries must be here at the Happy Medic blog in the comments of this post.
- I am the judge and will choose the one that makes me the happiest.
- Entries must be made before 10 PM pacific time February 11th
- The winning caption will be announced immediately after the premiere of the Chronicles of EMS pilot episode which airs at 5 PM Pacific on February 12th.
- The winner will receive a Chronicles of EMS T-shirt to be supplied by me.
- You MUST be present at the premiere or in the chat room during the premiere to claim your prize.
- This contest is void where prohibited by law or llama, whichever comes first.
- Foul language will not get you eliminated, but may be difficult to explain to your mother when the shirt arrives in the mail.
- There is no cost to enter, but if you must, donate to the CoEMS cause.
- The winner will also be invited to be a special guest on the new Chronicles of EMS:A Seat at the Table series in Northern California. I’ll invite you, you just have to get here.
This hose monkey has some questions for you. Please answer honestly, anonymously if you like, but some things have been bothering Happy as of late.
Question #1
Does your employer discourage you from being honest with your patients when it comes to transport decisions?
Question #2
Has your employer asked you to omit information on your reports that would prevent billing a patient a certain way?
Question #3
If a patient asked your opinion, you told the truth and they refused care, would you be in fear for your job?
Question #4
Does your service encourage starting an IV or EKG monitoring for BLS patients to upgrade the billing?
Question #5
Are you aware that the above situations could constitute fraud?
If you are trying to decide whether to do what is right by your patient or keep your job, email me. Your employer, municipal or private, paid or volunteer, is wrong and we need help changing their practices.
If you are comfortable and supported by your service when being honest with your patients about their conditions and transport options, please list your service in the comments section, they deserve praise.
HM
Subtitle for this post: Can you reach that for me?
Coming off a superb time on the Rapid Response Car, nappy time aside, we’re on the vehicle today. The vehicle is what you and I would call an ambulance, but since anything that can take people to the hospital is an ambulance, it needs to be narrowed down a bit.
The car is certified as an ambulance since it can take people.
The vehicle can, as that is the main purpose of it.
But hiding around town, and just out of camera range as we drove by were swarms of non emergency ambulances, almost buses in their capacity. When asked their function, Mark and our ECSW Becky (more on her later) informed me they take folks to their appointments, get tests and from one facility to another.
Collecting my jaw from the floor I explained to them and reminded Mark how many times we activated 6 people to do just that. Becky shot me a look from the driver’s seat of the vehicle and asked a great question I still can’t answer.
“Why not just give them a ride in a van or bus? Why send the ambulance?’
Why indeed Becky, why indeed.
I could try to explain to her how, in America, people have become so expectant of lights and sirens whenever they want them that they’re willing to sue if they don’t get them. Regardless of the condition, reason or outcome, folks will threaten a lawsuit and managers will blink and change protocol. Why inconvenience the few when we can just take them and inconvenience the many, right?
That was the start of my shift on the vehicle. I’d love to tell you that life on a UK ambulance is so much different than in the US. But when it finally gets to comparing apples to apples in these systems, having someone in the back is it.
Previous posts have covered my impressions of the ambulance layout and ways I think they can be improved to benefit patient care and provider comfort and safety.
Mark had difficulty accessing most of his equipment from the cabinets. Everything he needed he got to, but not without ducking around the patient, around the family member, then leaning over. The trash was also oddly placed, lying directly behind the family member so that to dispose of bloody mess you have to ask them to lean aside.
But that being said, with the current layout based on “safety” there is no other place to put these things.
Mark described to me the regulations in place to protect the persons traveling in the back of the vehicles and it makes perfect sense. Until we have to actually do patient care.
After my description of the ambulances in a previous post I was contacted by an ambulance manufacturer who wishes to remain anonymous, I’ll call them Box inc. Box inc wanted my thoughts on what makes the perfect ambulance and I told them I have yet to see it. But, Box inc had some new ideas about making your ambulance more versatile when on post, more on that another day. But Box inc will still take a van or pickup truck, rip off the back, slap on a place for a cot and make it flash, there really isn’t another option at this point.
But back to Newcastle and the McDonald’s parking lot.
Yes, we’ve found our way to the parking lot at the McDonald’s, on post if you can believe that, so I snuck in for a coffee. It’s an addiction, I know. We had a chance to talk on camera about Becky’s role in the NHS and what an ECSW is. But as we talk about it, a few points to look for first.
I am sitting on the cot and Mark in the chair for family members. The pass through to the cab behind him has a small door on the top that leads to the trash bin behind that seat he’s in.
The cabinets behind us and between as as we talk contain all of Mark’s equipment. Just from the layout you can see how challenging it could be to access them with a poorly patient in the back.
When I said that Becky was above an EMT, the comments section at youtube went insane. What I meant was that she can give pain relief without medical direction. She can do something I can’t do, mainly because I’m told I need more education and training to deliver pain gas to those in need. Becky is proof I do not. So when I said she is above an EMT, I was referring to her ability to medicate them in that manner. An EMT can transport, Becky can not. Apples and Oranges folks.
Our jobs on the vehicle were similar to what Mark and I saw on Medic 99 in the City, moving folks with this complaint over there and that complaint over here.
It was on the vehicle that we encountered the only person, out of dozens, who demanded transport.
As you all plainly know, my clients demand transport 90% of the time and need it 5% of the time. Newcastle respects their Paramedic’s opinions, likely because they can get in and get seen outside the A&E in a reasonable amount of time compared to here in the US.
This person activated 999 to report an assault and we entered the house cautiously. It was quite a bit reassuring knowing that the occupant was most likely not carrying a weapon that could mow us down from 40 feet away. I’m no ninja but I’ll take a clipboard to a knife fight over a knife to a gun fight any day.
The local police were close on our heels, again, without firearms (hard to get used to) and the scene was more than secure. Very secure the police confirmed, poking holes in our patient’s story. Then there was the recounting and description of the event given and none of that matched what we were looking at.
Clearly there were behavioral issues in play and the decision was made to transport based on the inability to confirm normal mental status. We’ve all been there and trying to communicate with eye movements and physical gestures must have appeared as though Becky and I were flirting.
My eyes said “Look at the door, the things piled in front of it, it opens inward, no one broke in there.”
Her eyes said “What?”
My body, arms crossed, said ‘Over there, look, the door!”
Her body, arms raised to the side and shoulders up said, “Huh?”
Mark’s eyes said “Stop it!”
Mark does not ring down, or pre-alert, the hospital himself, but relays it through his control center. When I saw what the control center did the next day, I decided that was unnecessary. If your service relays patient reports trough a third person you are introducing another player in the telephone game and just another chance for pertinent information to get lost. I would love to be able to forward my report to that point to the hospital and they can move that information to a bed and await our arrival.
Oh, did I nod off?
Right now my service gives audio radio reports to whichever nurse lost the coin toss that day and has to answer the radio. I tell them what I have and why, vitals and hang up.
Many Americans may shudder at the idea of waiting 2 hours for an ambulance but I met a woman who disagrees.
Mary, I’ll call her, fell down on a friday afternoon and injured her hip. Being of a stoic generation, she didn’t want to bother anyone with her trouble, so she hobbles through the weekend until her doctor’s office opened monday morning. She called the office and spoke to her doctor who advised her to go into the A&E to be evaluated since his office had no x-ray capabilities.
The doctor called the ambulance and the call was classified as an “urgent” meaning there was no life threat, but still a need for a transport. This call is then put in hold in the system with a maximum wait time and an ambulance is assigned as soon as the system has the available resources.
Mary met us at the front door and walked us in with a slight limp, dressed and ready for her trip to the A&E like many of my lights and sirens patients. We took our time making sure her medications were gathered and the stove turned off, then into the chair and down to the ambulance.
Because this trip was arranged her medical records were waiting at the hospital, as was a bed reserved for her and she was seen as soon as she arrived. I asked her if the 2 hour wait was too long and she looked at me as if I asked her what color the sky was.
“I waited all weekend to call, another few hours wasn’t going to kill me, son.”
I wanted to hug Mary right then and there.
After a day of back and forths on the vehicle and torturing Becky with the American and the camera duties, we were close to finishing our shift when that dreaded job came in.
The late job.
We were planning on meeting some of the rank and file for a social evening and this job would put us over our shift and we’d be late.
We screamed through the streets of Newcastle, pushing old women off the road and opposing traffic wherever we could. OK, not really, we were sent on a common case that would later bring out our common response “Same patient, different country.”
With the patient on board and her friend safely secured we made our way through the evening traffic to St Farthest, all the while talking and keeping our patient in good spirits.
The day went fast in retrospect. Traffic still doesn’t get out of the way when you’re rolling lights and sirens, you still have to go hunting for the extra blanket at the hospital and the nursing staff is still often glad to see you when it counts.
The evening was a night out with some of Mark and Sandra’s co-workers, we were fashionably late after some creative dropping off and ride sharing. I got to talk to them about Mark without him listening and their opinions were high and genuine. Mark is a respected and admired Team Leader in his station and his system.
Well, Ma’am, a great deal more than you. Especially when it comes to emergency response protocols, anatomy and physiology, the effects of alcohol on the clotting factor of blood and what my job is.
THE EMERGENCY
A woman in a wheel chair has rolled herself into a hotel lobby, bleeding from the nose, asking for an ambulance.
THE ACTION
The engine has advised us to slow to a code 2 response and we are happy to do so. As we arrive on scene I see the engine crew on the sidewalk having an animated discussion with a very alert and oriented woman with cotton balls stuffed up her nose.
As the door to the ambulance opens I now have the audio to match the pointing and head shaking.
Engine Medic: “Have you called your doctor, any doctor, about your nose bleed?”
Hell on Wheels (Could have been Helen, I can’t recall): “I’m not saying anything to you. You are not a doctor.”
HM: “He sure isn’t. Anything remarkable?” Is my question and the head shake my answer.
HM: “Then thank you Sir, we can take it from here.”
I introduce myself to our client and ask her to define a chief complaint. Most times the person who called us has a singular issue they wish our assistance with. My dad can’t breathe, for example, or I cut off my foot. But this client goes into a laundry list of complaints ranging from before I was alive finally ending with what got us involved today.
“My nose is bleedin’.”
And it was. At least it had been. Hard to tell with her constantly moving around telling me to get her to St Farthest before she dies from it.
HM: “How long has it been like this?’
HOW: “Since 1 AM, I haven’t slept! Why all the stupid questions, let’s just go.”
A quick glance at the time, 6 PM.
HM: “Have you made any attempt to seek an evaluation without calling 911? A clinic or an urgent care?”
HOW: “Honey I just got here and don’t have time for all your 20 questions. I need a doctor, I need my pills.”
As my partner is confirming the vitals we got from the engine, I begin my social worker intake interview.
HM: “You mean you need a pharmacy. The doctors don’t dispense medicine, they write prescriptions. Is your prescription empty?”
She shoots me a look I get often wen I bring reality into these conversations. The head snaps around on the thick neck to me while leaning back slightly, eyes wide and a look of anger around the mouth. Then it comes out.
HOW: “What do you know? The paramedics where I’m from never disrespect me like this.”
HM: “What do you mean disrespect you? I’m trying to establish if an ambulance ride to the hospital is the best option for you right now.”
I feel my tired arms leaning onto my knees as I stand bent over trying to stay in her line of sight as she realizes I’m not the pushover medics she left behind in whatever town she sailed in from. A quick stretch and I ask her the magic question.
HM: “Do you want to do the right thing or would you like an ambulance ride to the hospital?”
HOW: “Do your job and take me to the hospital. But somewhere where I can get seen fast, and get something to eat.”
My hands are back on my knees and I’m as in her face as I can be without losing my cheerful disposition.
HM: “Are you looking for a ride to food? Because if you are we actually have that resource here. You’ll have to wait a little while, but I can get you a free ride to a shelter and a warm meal.”
HOW: “I don’t have time for that, I need my pills now. I have chest pain.”
Had I been a TV detective, this is the part where I bang on the interview table and go into a well prepared speech about the abuses of 911 and how the best thing she can do for everyone is go back where she came from. Where she came from easily has a lower cost of living, but that has not entered into her equation.
But I am not a TV detective so she steered the power wheel chair over to the ambulance and told us how she has so many leg problems she is on disability. Then she stands, climbs in the ambulance and sits on the cot with a familiarity some folks on the job don’t show.
We sigh.
HM: “Chest pain you say?”
HOW Now with arms and legs crossed: “Yup, let’s go.”
HM: “That means an IV, and I’m not all that good at them.”
HOW: “Oh no you don’t, you ain’t touchin’ me with no needles.” Her head is shaking almost to a point I think she’s going to hit it on the cabinet doors and then need an ambulance.
HM: “Yup, let’s go.”
On our short trip to St Closest she wanted to discuss the finer points of how I don’t know what I’m talking about and only Doctors understand what she is going through. My lips were sealed, only asking my billing and pertinent negative questions and completing my report. She refused a line, a trace and everything else except another BP.
When we made it inside she commented that the ER had an odd odor to it and she wanted to know the name of the hospital.
HM: “St Closest, why?”
HOW: “Tomorrow they’ll take me somewhere better.”
Report finished I left, smile on my face, almost wanting to work the next day just to see if she does it.
Some of you may have known the age of the child in this post from experience, others may have had no clue.
In the comments there was a wide range of values, and it is indeed difficult to guess the weight of a child if you aren’t with them. But the point of the post was to get us thinking about why we base our peds doses on weight and how we arrive at that weight. There were comments about carrying a backup broselow tape (I spelled it right this time), but is that really the answer?
I understand the usefulness of a field guide and having a broselow tape in my peds bag is one of the first things I look for in that kit.
But I am also confident in knowing that if it is lost, stolen, damaged or suddenly switched for a BeeGees Best of Compilation that I can take a deep breath and do my job without it.
I am not better than anyone else because I feel comfortable with peds calls. I can’t handle dislocated fingers. That’s my Achilles heel, or finger, if you prefer.
Again, the goal of this You Make the Call game was to get you to remember what you are trained to do when all the fancy tools, bells and whistles are gone. Anyone claiming “BLS before ALS” needs to start with the simple deduction of size, age and weight of the patient.
We do it for Dopamine on adults, but don’t carry large cheat sheets to lay next to them. Why do we rely on one for kids?
The young lady in the photo was 4 weeks old and weighed 9 pounds.
If you were way off, no big deal, keep that tape handy. But next time you have a peds patient ASK the parents how much they weigh and remember it for reference. We also learned a quick reference rhyme in P school, hopefully you did too. It’s the 1-5-10, 10-20-30 ratio. Meaning a 1 year old should weigh in around 10 kilos. A 5 year old at 20, and a 10 year old at 30. These are guidelines to establish if a suspected weight is within reason. Don’t grab a one year old and start dosing at 10 kilos without a proper assessment. Also keep in mind that a child’s diet, heredity and, believe it or not, race could be a factor as well.
A wonderfully designed system being adopted by hospitals can be found here, along with photos of children to represent their sizes and color coded dosages of medications. But keep in mind your concentrations of those medications may be different and if you don’t know what the value should be, there is no way the guide can help you.
Take a few minutes to wander the Color Coding Kids site, a lot of common sense stuff there.
See you next week when our patients get bigger. Much bigger.
