Tuesday, July 10

Dues

I was told recently that I have paid my dues in EMS and have the right to speak my mind.

Funny, my check never cleared.

I've been:

  • puked on,

  • peed on,

  • gotten ROSC

  • called a code on scene

  • carried limbs

  • carried dead limbs

  • extricated patients

  • extricated bodies

  • carried those who can not walk

  • carried those who could

  • been hurt in a fire

  • helped those hurt in a fire

  • laughed at jokes that are not funny

  • told those that are worse

  • run 23 jobs in 24 hours

  • been an entire paycheck without a call


And yet I don't feel that I have paid my dues.

I talk a lot.

I write a bit.

Haven't done much.  Really.

AD says some medics have 1 year of experience repeated 20 times, I wonder if I am falling into that category.

I'm going to be taking one of those famous blogger breaks, where I try to ignore the interwebs machine and get my own house in order.

See you on the other side, Ray.

Saturday, July 7

Just because it's right...

...doesn't mean you can do it.

We've had some confusion around the yard as to just what we're supposed to be doing when it comes to assessing the car rather than the patient.
We all know to assess the patient, not the car, the patient, not the monitor etc etc.

At a recent training evidence was presented that contradicts our current protocols as set forth by our regulators.
It seems a number of folks took that training to heart and are trying to apply it to the patients they encounter in the field.

Problem is, the treatment, or omission of treatment in this case, is causing trouble for me in the CQI office since I now have to talk to folks about doing the right thing and breaking the rules.

First a note on one of our favorite terms: mechanism.

Motor vehicles today are designed to crumple, absorb energy and disperse it around the passenger compartment. This design allows for a great deal of damage to be incurred prior to the passenger, if properly restrained, is injured. This is the reason that recent CDC wording of field trauma triage criteria specifically mentions intrusion into the passenger compartment. Your protocols and policies likely have a similar clause.
The problem is when the protocols and policies start making assumptions about the possible damage to the car and how it relates to possible damage on the patient, then prescribes treatment based on the car, not the patient.

Rollovers used to be a big deal. If everyone is belted chances are they're self extricating before you get there and strap their curved spine to a flat board. You know...just in case.

Even more frustrating is when you finally convince the patient that the hospital will take careful care of them in case they have a back and neck injury only to arrive to a triage nurse removing the collar, performing the same assessment you did, then removing the board if your treatment was based only on mechanism.

Even worse is when you convince them to be seen at the trauma center based on damage to their car, only to see them moved to the hallway prior to your chart being completed...no board, no collar.

I asked a few of my crews to think of the worst Paramedic they had ever seen and if they would want that person "clearing" C-spine injury in the field on them. The point set in that most of us can barely get our noses out of the cookbook long enough to do a complete assessment now. Those folks have no future in EMS if I have anything to say about it.

So what to do?

Attend the meetings of the groups that make the rules. Get on the agenda and speak. Bring research, evidence, examples from other systems already doing what you want to do.
You get a lot more attention when you bring in a multiple page presentation on Community Paramedics rather than complaining in the yard that we need more training to be able to do more.

Follow the policies. If they aren't what your patient needs, lobby to change them. Don't ignore them in the field or your next patient may suffer when you're on suspension and that medic you despise has to treat them.

Which is worse?

Monday, July 2

Summertime in the City - Why does hypothermia have to be therapeutic?

brrrrrrr...

"Coldest winter I ever spent was a summer in San Francisco" - Mark Twain

"Don't believe everything you read on the internet" - Abraham Lincoln

"Quotes are stupid" - Some idiot

 

Summertime is here and I for one am glad.  Glad that I get into my car in the high 70s and get out in the City somewhere in the high 50s.

At home it's shorts and flip flops, at work it's jackets and glad we wear wool pants.  When I return home, however, to temps in the 90s we rethink the wool.

In a recent conversation with a respected hospital administrator the term "therapeutic hypothermia" was tossed around rather freely, as if saying it for the 500th time would win them a set of steak knives.  It seems the powers that be are interested in bringing some active cooling measures to the only recently mostly dead.  This was the result of a series of meetings I somehow never made it to.  Laziness one possibility, apathy another, or I could have been reading charts and yelling at people.

In our discussion of the merits of the term "therapeutic" we wondered if having to mention a treatment is good in the title is a red flag we'll look back on in the future.

"Try this therapeutic oxygen, it's amazing, but avoid that passive oxygen, it's no good."

Making people cold can apparently help them recover from a cardiac arrest.  I guess some papers have been written and some friends looked at it and agreed so it became the thing to do.  Trouble I have is the recommended window of initiation of treatment.  It seems that if we can get their heart beating on it's own again, then make them slightly cold within 4 hours and keep them there for 12-24, we can improve their chances of survival.

4 hours.

Our average transport time hovers in the teens and tack on a few minutes to get pulses back...let's call it 1 hour.

One full hour, 60 minutes from when the heart stops to when we hit the doors of the ED with pulses and a BP.  That leaves 3 hours to initiate CONTROLLED cooling in a CONTROLLED environment.

My conversation with the hospital rep then turned to the process that will be used to monitor the cooling efforts.  Thermometers perhaps?  Maybe, we'll see.

On a side note, we also have a problem with a little something called passive hypothermia wherein Erma Fishbuscuit drops a few tenths of a degree just by sitting in her drafty bay window, then we carry her out to the rig on a cold chair with a single wool (wool again!) blanket.  Then we have to get her all tucked in and cozy warm.  Makes sense.

But for her the hypothermia is not therapeutic, had she suffered cardiac arrest, then yes, but late for her dialysis, then no.

So what to do?  Hypothermia seems to be the next big thing, but I'm not sure the effects it will have in my system.  Could we get more people leaving the hospital without deficits from cardiac arrest if we focus on the weakest links of the chain of survival?  Bystander CPR, Public Access Defib and ED CPR quality? (See how I threw that in there?)

 

The conversation ended with a desire to see all policies and protocols require footnotes showing the research that supports the contents.  Then we realized half the manual would need to be discarded and laughed.  It wasn't a triumphant laugh, but more the kind of laugh when you realize your car was stolen.

As Clinical Supervisor I am tasked with ensuring my crews follow established policy and protocol while acting in the best interests of their patients.

But Justin isn't sure what kind of an impact making the recently deceased shiver will have.  On a cold summer's day in the City we could probably just leave the blanket off and get good results.