Sunday, November 27

Internal Affairs

As part of my new role, I also wear the hat of Risk Management.  This means that all complaints and reports of medical errors come through my office.  It also means that I get all the "He said, she said" crap that comes with EMS not being accepted as part of the patient care team.

Surprisingly I have received more than one report of a crew "not giving notification via radio" from a hospital.  This often happens when the person who answered the radio was unhappy with the report, lost the triage slip and is in trouble or that the crew simply didn't make the call.  It happens.  Sometimes we're busy with a little thing called patient care and our partners driving should not be distracted by talking on the radio while driving if we're that busy.

 

Now for the best part: The investigation.

 

I go over to the computer and pull up the crew, date and time, review the chart and get a feel for what was going on during the call.  Most importantly I look through the timeline of interventions to see if there was time to make a call, and then I script what my report would have sounded like.

Then I go over to the fax machine and pull out a Request for Radio Traffic Form and pull the tape.

Much like politicians, I think some people forget that everything is recorded these days and simply saying "No they didn't" can be proven wrong in as little as 24 hours.

When that CD arrives and I listen to a pretty good radio report matching the patient I just read about, then hear a voice aknowlege it I feel great.  My guys did the right thing and I get to play that sound clip to the hospital.

Of course it's also a drag when I get an email from radio that states "No traffic exists for specified date/time, please check."  Then I can't confirm what really happened and have to be the bad guy.

When your CQI calls you on the phone or into the office, it's not because of some sadistic desire to torture you (despite how much that seems to be the purpose), but because we can no longer find evidence to support your version of events.  I have already been able to deal with most of the complaints that come in by reviewing your documentation, your previous documentation to ensure it wasn't a fluke, and everything else available to defend your care and demeanor.

Sometimes you just plain screwed up.

Make it easy for me:

Do what's right, write down what you did, tell the right person when you get there.

 

They'll still complain, but at least I'll have the ammo to defend you.

Thursday, November 24

Black Friday Ambulance Deals?

An Ambulance company in Fort Worth, Texas is taking advantage of the black Friday mentality and offering discounts in ambulance services early on Friday morning.

"It's a chance to break into a section of the population that might not normally think of us" said Bill Lockheart, Manager of Forth Worth's seventh largest ambulance service provider, Fort Worth Ambulance Group or FWAG. "If they need us, we're there. But if they need us between 4am and 10 am Friday morning, it's going to save them 25%."

Mr Lockheart is not alone in his thinking that savings on goods and services should not be limited to the big box stores and items manufactured in China.

"I call them every week for my asthma," says 33 year old mother of 8 Stephanie Johnson, "If I can get a discount on Friday morning, that means less Medicare I have to pay." Ms Johnson was unable to provide documentation to that effect.

Bryan Stevens, a 66 year old diabetic from Galveston was visiting Fort Worth when he heard of the discounts. "Well by golly, have they no shame.  It's a service for emergencies, not for profit.  I remember my early days as a lad in the..." We cut him off because we saw 40 year old Ted Remmit, an unemployed employment expert who called the Forth Worth Ambulance Group at 4:15 this morning with a sore thumb.

"I pay taxes, this is a service I 'm entitled to.  You can quote me on that."

Wednesday, November 16

Report from the Trenches

Only on the front lines can you tell where the bullets are coming from.

 

Everywhere.

 

To say I might be in over my head is an understatement.  To say I thought it would be worse is also an understatement.

This is an entirely different world.  My commute is twice as long as it was 6 months ago when I first tested it, or maybe since it's an everyday thing now it just seemed half the time before.

I wake at 5 to make the train by 6 so I can do research till 7 and make the office by 8.  Then I have to time my departure to make the train right before the tens of thousands of others exiting the City at closing time.  It's different than wandering into the fire house after an hour and 20 minute drive.

That's the only drawback so far.

 

I realized on my first morning of reviewing charts and advanced interventions that I am now responsible for more than my own patients.

To borrow from the meme, "I get ALL the patients!"

Seriously. I am able to act in the best interests of each and every patient this system comes into contact with.  Sometimes that will mean counseling a provider or defending them from an MD unclear on the concepts of EMS.  Other times it will be discovering where we're not doing enough and finding the evidence to show it, then provide solutions to the command staff.

Some they will embrace, others they will reject.

I am not here to change the world for myself or even EMS, but for each and every person in my City who calls for help.  That is my new goal.  Not a 20 minute intervention, but a 20 week analysis of their experience and outcome.

 

Bring it.

Sunday, November 13

Overheard on vacation - the Barber

A cop walks into a barber shop looking for a haircut.  As they discuss the news of the day and the weather, the topic turns to his line of work.

"What do you do?" the barber asks.

"I'm a cop."

"I admire what you men do, I'd like to give you this haircut for free." the barber says and the cop reluctantly agrees.

 

The next morning the barber can't get into his shop because there is a large box of donuts and a card from the cop.

 

As he walks in another man takes a seat for a haircut.  As they discuss the news of the day the topic once again turns to his line of work.

"I'm a paramedic." the man replies.

"I admire the work you do and I'd like to give you a free haircut as a thank you." the barber says and the Paramedic agrees after the barber refuses his money a third time.

The next morning the barber can't get inot his shop because there is a box of bandages and pamphlets about staying healthy.

Soon after another man walk in and takes a seat.

As the topic turns once again to his work the man replies, "I'm a fireman."

"I admire the work you do, I'd like to give you a free haircut."  And just like the others he reluctantly agrees.

The next morning the barber can't get into his shop because there is a line of fireman around the block.

 

 

Told to me by a retired fireman who served not 30 miles from me growing up.  Met him on a cruise ship in Canada.  Go figure.

Thursday, November 10

A Whole New World

On a summer day back in 1996 I walked into the trailer at the Isleta EMS and Fire Station and began my paid career helping people.  I have worked a variation of a 24 hour schedule ever since and it has become second nature to be away from my family for long stretches in exchange for a few days in between.

 

That will make Monday all that much more interesting.

 

On Monday I hang up my turnouts and late nights without sleep in exchange for a promotion and a reassignment downtown.  That also means giving up that ever so comfortable and vacation friendly schedule.

 

I was bummed at first until I realized that now the HMjrs are in school and we can't just pick up and go somewhere whenever we feel like it anymore.  When this job at headquarters opened up it seemed too perfect a fit.

 

Monday I will take over the vacant CQI position that has been retooled ever so slightly to now officially include research.  Talk about a perfect chance to mine the data to see what is really going on out there.  I have lofty goals for my service, but it's going to be a long while of playing catch up and learning the new job before I can start going forward with new ideas.  I also have a new political landscape to consider and will be in direct contact and communication with the regulatory agencies, budget writers and vendors that all have a stake in patient care in my jurisdiction.

 

It's an amazing opportunity for me both professionally and personally and I am beyond excited to get started.

 

About the blog...

There will be a slow tapering off of 911 stories, I've got quite a few more half written and half anonymized just waiting in the wings, but there will likely be a shift in what I share.  My EMS 2.0 rants may well turn into updates about what I'm dealing with in that little office downtown.  I won't be changing the name of the blog to Happy Captain (or Happy Cappy as MC suggested) since this is about my therapy, not necessarily an accurate mirror to my own life.

I now join the ranks of Sparrow, Morgan, Crunch and Stubing, to name a few.

 

Thanks for all your supportive messages on FB and Twitter.

 

-Captain HM  ;)

Monday, November 7

MOI oh MOI!

Rogue Medic is in a great mood as of late and this article about the complete joke that is Mechanism of Injury (MOI) hits the nail on the head.  I recently had to triage a car over a patient because of strict trauma guidelines, luckily finding the always available "Paramedic Judgement" to wiggle my way out of it.

 

The simple point is this: Mechanism needs to be a symbol on a map, not the destination.  With cars designed to crumple around our patients, what if it does take 30 minutes to get them out but they are unharmed?  And the pedestrian clipped by the mirror on the arm by a passing car at 40MPH?  Why are they on a board and in a collar?

 

Because 30 years ago when this Profession was still trying to figure itself out we bought into some crazy ideas, that's why.  Now that we're actually starting to study some of these ideas and finding them hurting more patients than they are supposed to help, we need to start revamping a number of our "standards of care" which actually should read "That's what everyone else does..."

Whenever I have to document damage to a vehicle (mainly for my recollection of the run later on, just in case) I try to use some basic terms that at least remain consistent in my own description of vehicles.  Those are:

Light truck, truck, large truck, coupe, sedan, wagon, van and commercial vehicle.

Then I go and describe the damage using 3 terms, light, moderate and considerable.

Those are mine and can be widely interpreted.  Maybe I'll get Motorcop to jump in on this but...A coupe hitting a brick wall at 40MPH will look differently than a van that hits another van at 25MPH.  One is a trauma, the other not by protocol, even though one may indeed have carried far more force.

And even if I do mention light damage to the front of the vehicle, what does that mean? What kind of car? What kind of impact? Against what? Did the vehicle's protection systems discharge properly?  If the driver was able to self extricate and has no chief complaint, why am I chasing him down with a C-Collar? Because the folks who wrote the policy are in a committee long ago and far away.

MOI is important as far as it gives us an idea of POSSIBLE injuries to consider.  I consider it as a part of the Past Medical History and weigh it just as heavily.  If it does not apply to the patient's presentation it will be considered, but not relied upon.

One rollover will have a 17 year old girl sitting on the curb completely unharmed while a minor damage collision could yield significant injuries to the passengers.  We won't know until we assess them.

I remember long ago in far off new Mexico, some medics would launch the helicopter just based on dispatch information of the reported damage.  And we're back to the telephone game of one person's "Oh my God! They're trapped!" and another's "She's just not getting out, but looks fine."

Assess.  Use MOI as a tool, not a guide.  We always look inside the passenger compartment for deformity, blood, marks, bent steering column etc, but we should not be basing a transport on the vehicle.

 

Then again, try documenting that you let a driver refuse transport who had moderate damage after a head on collision into a guardrail, deploying front airbags with a non-complete recollection of events.

Now if I tell you they hit the guardrail head on after sideswiping another vehicle at 40MPH and spinning around, coming to rest in the slow lane and is avoiding telling the police they cut across 6 lanes of traffic to make an exit...now can I let them go home?  Or should I be chasing him down with a collar?  We all know the answer to that one.

 

Looking forward to more, Rogue!

Sunday, November 6

Man Up NFL - Ditch the helmets

FOOTBALL!

I'm talking American Football.  The game where almost 50 men complete against one another 11 at a time with plenty of breaks in the action to catch their breath.  They are strong, large men, many of them obese and wear enormous pads and helmets to protect them not from the other men, but from the other men's pads and helmets.  Why do I care? Well, I always have, but watching a college game yesterday made me want to comment on it.

Chris Owusu, a wide receiver for the Stanford college team was removed from the field Saturday after being struck in the helmet by...another helmet.  This was his fourth concussion and reports have him being taken off the field unconscious.

This phenomenon is nothing new in the world of American Football and has been studied for decades.  A simple google search returns studies that talk about ensuring the players hit each other less, or not head to head.  Good luck.

 

The entire motivating factor in American Football is to hit the other guy hard, yet there is no stat for hits.  So if the culture of the sport is encouraging dangerous play, shouldn't we protect the players?  Surely stronger pads and helmets will protect them right?  Sadly no, it just adds a harder hit from the other guy.  It's a lot like arguing that car accidents will be safer if we all had bigger heavier cars.  Foolish, yet that is what the NFL, NCAA and youth programs are doing.  They add more pads and stronger helmets, all the while seeing more injuries and more serious injuries to boot.

 

I'm not a huge fan of American Football and have a number of ways to make it more interesting to watch, but none of them is "HIT HIM HARDER!"

My first order of business is to remove the helmets in use now and replace them with nothing.  Yes, nothing.  It'll take a little while for the game to adapt but far less people will be getting concussions if they have to go skull to skull against the other guy.  It might actually require them to learn how to tackle, not just hit.  Look at rugby and Australian Rules Football, both requiring more strategy, fitness and contact to tackle a person as opposed to simply hitting him so hard he passes out.  Imagine an NFL lineman who can run farther than 40 yards...all.game.long.

But American Football fans don't want to watch men who can play an entire game.  They live for the hard hit across the middle, knocking the player who caught the ball on his face in some form of ancient battle.

Removing the helmets, the radio transmitters and making the players actually play the whole game with limited substitutions (imagine that!) will greatly increase the pace of the game as well as the entertainment factor for those of us interested in a competition, not a battle.  Not to mention, less career ending injuries.

 

Lose the helmets NFL, what do you think you are? Hockey?  As far as I can see the only hazard on the field is the other team and the only reason is because they're heavily fortified as well.

Saturday, November 5

A Tip of the Helmet - San Francisco Police

You may have seen in recent updates that your pal HM had a rough call not long ago.  While I can't discuss the particulars, possibly ever, I did want to give some credit to a few folks who made it so much easier to focus on patient care: the police.

 

Not only did they deal with family and nosy neighbors as we worked, but they did a lot of the behind the scenes stuff.  For example, one officer retrieved additional O2 bottles without being prompted, calling out to us that they were in the hallway if we needed them, and we did.

 

When we were ready for a backboard they grabbed it and handed it through into the room, AFTER asking which end needed to be handed in first.

As we moved through the small hallways, I noticed a Sergeant moving items off the cluttered stairway and calling out how many steps there were.

Down on the street they had taped off the sidewalk giving us a clear path to the ambulance.

At the hospital they managed family and served as a story teller when the hospital asked questions we had no answers for.

 

It may seem like simple things or something that should have come naturally, but they have different priorities at the scene than we do.  It is possible that it was simply the nature of this call that got them involved to this extent, but judging by their ability to anticipate our needs, they've done it before.

 

A tip of the helmet to our boys in blue on this one.  Thank you.

Wednesday, November 2

I'm no expert...

...oh wait, um, I am.

 

THE EMERGENCY

Automatic alarm activation. Smoke detector, first floor hallway.

 

THE ACTION

Even though it's dinner time and our own dinner will be pushed back at least an hour now we're loaded on the engine and out the door in less than a minute.  The first due engine is out of service so our response time will give a small fire more chance to grow.

 

More often than not the alarm company calls to advise a resident on site reports a faulty alarm and we often cancel the truck company and Battalion Chief also assigned to the alarm.  As the engine, we always continue until we get eyes on the detector.  We get no such advisement.

On scene to the 3 story type 5 residential we have nothing showing and a person on the front steps, phone to her ear waving us down.  Airpack on, axe in belt, lamp on shoulder and a pump can in hand I'm met by the person who tells us she can't understand why the alarm won't stop going off.  We aren't hearing a fire alarm, but a smoke detector shrieking it's triple beeps from the building behind her.  Some may take a deep breath and pack down, but I love a good chance for free exercise so I head for the sound.

And that's when I see it.

Smoke.

From behind me I hear the occupant telling the officer, who suddenly sees my pace change, that "I'm no expert but that thing is broken..."

 

The house is charged with the light to moderate smoke of burnt food, the smoke detector faithfully discharging it's duty and working perfectly.

The pan on the stove is...wait for it...still on and we turn it off and remove it from the house, now surrounded by curious neighbors coming out to see what is going on.

A quick side note, I love going into a building without hearing sirens, only to return a minute later to the truck on scene and the stick coming out of the bed.  Those guys are fast.

 

As we open windows we note the occupants clear confusion with how a smoke detector functions almost as if she was never taught in school.  Oh...

"But it wasn't a fire, just oil...it's only supposed to go off when there's a fire" To say the Chief did a face palm would be great, but being the professional he is he took her under his arm and slowly walked back into the building.  The last thing I heard him saying was:

"These things happen to people sometimes.  Some more than others..."