Saturday, March 30

Thank God Captain Smart didn't post his rant on Facebook

In a follow up to the Angry Captain in Miami-Dade I got to wondering why Captain Smart had not already been fired.  Millions of people have now seen this video of Captain Smart wrongly trying to bully a citizen into not filming a helicopter operation.

He was wrong in intention, in the law, in Operations...I'll even go so far as to say the polo shirts they wear leave a lot to be desired, but, it was at least clean and tucked in.  He raised his voice, yelled, threatened to call the police, called the police, all the while the patient was not being transferred.  But they run 3 man rigs 2 plus the helo crew likely means the patient was being well looked out for.

So let's get to the giant pink double standard in the room.

Let's say this video was posted onto a local Miami-Dade Facebook page in a universe where Captain Smart stays in that odd looking ambulance and transfers the patient without confronting the person filming.  All goes fine and they later drive away.

Now Captain Smart gets home and sees the video.

He types his interaction with the person filming into the comments section.  Word. For. Word.

I think we can all agree Captain Smart would have already been suspended and a blanket no social media policy would be in place in Miami-Dade.

So why the double standard?

I think it is because Departments have yet to realize that social media is just the tool bad employees use to do bad things.  Captain Smart didn't need social media to make his agency look the fool, he did that on his own.  He just had the unfortunate experience of doing it in front of 2 cameras.

Facebook is not your enemy Mr and Mrs Fire Department, your bad eggs are.

Captain Smart may be an accomplished firefighter/Paramedic/Company Officer but will forever be remembered for losing his cool with a kid with a camera that one day the helicopter landed.

Folks, we are being filmed everywhere we go.  Generation Y seems to understand that, the boomers are having a little more trouble with it I think.  Having even more trouble with it are the folks in the gap, those in their late 40s and early 50s.  For whatever reason it's this population that seems to adopt a black out mentality when it comes to social media and sharing membership in the fire service.  There are exceptions to every rule, I've met quite a few right here within the walls of social media.  Trouble is, most of the administration of the fire and EMS services today are in this socialphobic bubble where anyone who posts a pic of themselves in an FD T-shirt on facebook is out to ruin the good image of the Department.


Just look at Captain Smart.  He didn't need social media to screw up, he did that all on his own, but will likely not even get a day on the beach judging by his Department's initial response hiding behind scene safety.

Your crews wear polo shirts...scene safety?  Nice try, shake the magic 8 ball again Miami-Dade.

Just remember that had he done it anywhere else but in the face of a citizen, at an emergency scene with patient care still happening and captured on camera for the world to see, it's a bad thing.  Seriously?



Friday, March 22

The Real Problem with the Miami Dade Angry Captain Video

Surely you've all seen Statter911 and FireLaw's take on the Miami Dade Angry Captain for shouting at the public for...well...I can't figure out why.  Dude wants to shoot video in public, dude can.  Dude isn't covered by HIPAA.  Curt mentions a safety zone, dude is across the street.  My young daughters and I were closer than this when REACH landed at a firehouse on open house day.  No shouting was involved.  This is Risk Management in reverse, placing so much fear into providers about cameras that they snap thinking they're going to get fined for a violation.  Only to make them look a fool the world over.

Let's take a few IF pills, shall we?

IF, somehow, the video catches some kind of PHI (Protected Health Information) there is no HIPAA violation.  If the crew inadvertantly loses a PCR sheet in the prop wash and the guy on the camera picks it up...maybe, just maybe that could be considered...MAYBE...and incidental disclosure of PHI.

The fine?


So long as the agency can prove they did as much as they could to prevent the paper from flying away, no harm no foul.


There, isn't that easy?

So why all the fear around the privacy legislation?  Because it's changing?  Have you read the changes?  Still won't include dude on the sidewalk, still won't fine you for letting dude film and still won't require personal liability insurance in the event of an incidental disclosure no matter what the insurance salesman tells you.


After dozens of pages determining if your agency must comply with the legislation, HIPAA says this: (paraphrasing)

"Don't be a dick. Don't tell stories about people or take pictures or use their personal information, OK?"

It does not mention violating the freedom of the press in the name of a law you never read and clearly do not understand.  GRANTED the Angery Captain never mentions HIPAA in his request for code 3 PD (I can hear Motorcop's eyes rolling), my guess is that was the reason for his outburst.


More importantly...WHAT IS THAT TRANSPORT UNIT?!?!

That thing is a BEAST!  I cringe looking at the front overhang and thinking of some of the hills in San Francisco.  Sure we have Engines, Trucks and Squads with overhangs, but they are much higher centered.  And a crew cab?  I like it for the future of EMS being more centered on getting patients places without having to recline them, but dang, that's a lot of space.  Can anyone speak to the history of this design in Miama Dade?  I like the idea of something new, but it still looks like a box on a frame.  It appears to be a Spartan RT.

Is the Captain in the video Angry about these rigs perhaps?

Tuesday, March 19

A comment on the post that never was "Poor Risk Management + 'nurse' = Death"

Reader ryan chimed in on a topic more or less already covered to death, the Bakersfield "nurse" that said she couldn't do CPR on a person who collapsed.

We learned after the initial uproar that the patient had expressed a desire NOT to have CPR performed, but did not do so through the usual channels.

We have also learned that the facility stands by their policy to, well, stand by if you collapse.


ryan commented:

"im still confused on this, isnt there a duty to act the same as an emt who is at work?"


Nurses do not have a duty to act under their licensing.  It is true that if the facility hired an EMT to wander the halls they would be required to administer CPR regardless of company policy (and in the absence of a valid DNR of course) but this "nurse" had no such requirement.


I use the term "nurse" carefully here.  I'm not discussing Nurses or Nursing but instead the gray area of "nurse."

I've been on more calls than I can count where someone presents themselves as a "nurse" then makes it painfully obvious they are not any such Nurse I've ever heard of.  Then after the patient begins to recover because of our interventions expresses that they are a nursing assistant, student nurse or any variety of care giver, but nowhere close to an RN.

More concerning to me than the lack of a duty to act was the almost complacency by the 911 caller to identify herself as a nurse, then refuse to give care.  In this economy I can understand wanting to keep a sweet gig like that one.  Imagine getting called a nurse and not being allowed to help people.


Multiple sources list her qualifications differently, so much so that determining her level of accreditation, experience and licensing can't be relied on so I have to go with "little to none."

It's frustrating to think this facility sells this product, promising to call 911 instead of intervening or, better yet, educating their clients to seek out proper advanced care directive documents instead of a "we promise not to do CPR on you."

Imagine if she wandered off site for lunch and this "nurse" was also at lunch off site and the same thing happened.  Now ask yourself if it's just as absurd.


Thanks for reading ryan.

Saturday, March 16

CKEMTP's toilet needs your vote

Now that I have your attention...

EMS 2.0 co-creator and noted ginger Chris Kaiser (CKEMTP) from Life Under the Lights is having a bit of trouble with his toilet.  Well, washroom, well...oh dear Lord, let me just show you the picture.

Damn, Kaiser, that sink alone makes me question our friendship.  And is that duct tape in the shower?  My God man...

Thing is folks, Kaiser has a chance to make things better.  He has been entered in an online contest to win a bathroom remodel that will take the abomination in that photo and turn it into something he can be proud

Many of us have been voting for him but he needs your help.  One of the competitors may be trying to buy votes from voting farms (No, I didn't make that up) in Korea or parts unknown.  Since I'm the closest thing EMS has to a Kim Jong Un I am blegging you to help one of our own before I call in Dennis Rodman.


Follow THIS LINK and vote.  Then come back to HMHQ tomorrow and click the link to vote again.  You can vote once per day.  Yes you have to log in to the site, but only the first time.


CK is a brave man to even post that picture.  Now imagine the shame if he doesn't win and we all know his bathroom still looks like that.


Get voting!

Monday, March 11

"You should read this blog..." said the Medical School Professor

Our local teaching hospital / trauma center / STEMI center / stroke center is putting on a new lecture series which focuses on STEMI and ROSC patients.  It is very similar to the trauma seminar I've mentioned before and has a wealth of information.

It starts with our pre-hospital radio report and continues through the balance of care for the patients.


My favorite part was when the MD leading the presentation suggested everyone in the hall go to a blog for ECG knowledge.

Mine?  Of course not, not until the seminar on fart jokes and grammar mistakes.

No, he directed us all to "Tom Boot-hill-aye" and his excellent work at EMS 12 Lead .com.

I will admit I sat a little taller in my chair when someone I know was mentioned as an expert in his field...and uses a blog to disseminate it.

Sure Tom Buothillet speaks nationwide about the importance of pre-hospital 12 lead ECGs, among other things, but also uses social media and video to make his message more powerful.

Tom recently debuted the London Ambulance Service episode of CODE:STEMI where he travels the world talking about EMS systems and their reaction to sudden cardiac chest pain and arrest.


Good work Tom, keep it up!  I think you'll get a few more hits from today's session!

Thursday, March 7

Poor Risk Management + "nurse" = Death

This post was a good example of venting.


You write down your thoughts, purging them from your head, then come back in the morning to see if you still feel that way.


The only drawback being that if you forget to change the publishing date, it finds it's way live.


I should listen to my own advice.


If you saw my opinion on the Bakersfield event, that's what it is, my opinion.

Sunday, March 3

Our Caridac Arrest Survival Rate is 100%

You read that right.  San Francisco has a cardiac arrest survival rate of 100%.

Does that mean that everyone who suffered a sudden cardiac arrest survived?

Of course not.

But our survival rate is still 100%.

That's because today my numbers for witnessed Asystole with ROSC and cooling measures look really good.  So, our rate is officially 100%.

Hogwash you say?  How is that any different than some communities who bend their inclusion criteria to give the impression that they have an amazing rate of survival when their overall numbers are a complete unknown.

I rub my temples when editing our CARES registry, not because the data fields seem unending, but because there is one that I'm not sure we should be editing until long after the event:

"Suspected Cardiac."

This term sits in a line with others such as drowning, respiratory, trauma etc.  Since our cardiac arrest patients seldom tell us what led to their arrest, we have to make a HUGE assumption and hope the hospitals update the information accurately.  That is also assuming that the hospital was able to discover the cause of the arrest.

It would be refreshing to be able to determine the cause of cardiac arrest and only count the patients we were going to be able to help at all, but that should not be taken into account when reporting survivability.

Imagine it this way: Our major trauma survival rate is 99% because we don't include patients who had a BP of less than 50/P in the field since our efforts are unlikely to impact them.

Insanity, right?  If trauma care and survivability from injuries is our population, why exclude those who are less likely to make it?

Because it makes us look bad.

We can argue the semantics of statistics, reporting and the like for decades, we have and we will, but make sure when someone reports 60% survivability from a condition that kills more than 90% of those who suffer it, ask what they mean by "survival" "cardiac arrest" and "witnessed."

It's all in who you place in the denominator that decides your final answer.

So when I neglect to tell you our survivability only includes tourists with witnessed arrest who received bystander CPR and an ALS intervention within 4 minutes, am I really telling you the chance of you surviving cardiac arrest in my community?

Nope, but it sure is fun to say.

What is our actual rate?

We don't know, some of our 2012 patients are still in the hospital.  Some communities might count them as survivors and move on, but we're looking for total survivability, not simply a target some time after admission.  It will also help us guide future interventions if we can wait to learn exactly what happened to cause the arrest in the first place.

Sub point being that putting all your efforts into community CPR may seem like a fantastic idea, but if none of your survivors received it, will it make a difference in your community?

None of your survivors received cooling measures...does it still have an impact in your community?

No one who had a transport time of less than 5 minutes survived...should we slow our response?


Asking questions like this comes from looking at the data with too fine a comb.

1/2 of 1% (.5%) of the patients seen by my system are in cardiac arrest.  Of that group upwards of 90% do not survive, many of them being beyond our help before we arrive.  So now look at the subset of the population we're observing. 10% of .5% means .05%.

That's 50 cents out of a $100 bill.

Are you willing to change your system, your community, your children's graduation requirements... for .05% of your patients?

While I'm a big fan of community CPR, I'm also a big fan of community asthma programs, community hypertension screenings and community programs to reduce unnecessary 911 calls.

Those programs impact a far greater population and while there are not immediate results, like in ROSC, we are preventing far more cardiac arrests 30-50 years from now.

Which is better: Preventing an arrest, or classifying one so as to show success?

Hard to prove a negative.


EDIT - I was contacted by someone I respect very highly who informed me my stance has been misinterpreted (ie I didn't get my thoughts out the way I thought I had.  Not the first time either, go figure).  I am not calling for the muddying of the waters when it comes to Cardiac Arrest Survival rates, simply that agencies know what they are reporting and, more importantly, WHY!  I'm aware I come off as a non-believer in this post, implying that all the new fangled stuff doesn't work, I just want to make absolutely sure we don't all focus on one outcome at the possible expense of others.  My views may be confrontative, ill-advised and downright wrong, I've never claimed to have the answers, but in my current position of gathering and interpreting data I see how easy it is to steer the results in my favor.  It's tempting when someone survives cardiac arrest and goes home mere days later...yet doesn't fit the Utstein numbers, so doesn't "count."  It's also frustrating when we have an Utstein case arrest in the ambulance and not survive.  The one person we think we have the best shot with and there's little we can do or learn from it.  Agencies like Medic One and Hilton Head Island, with impressive Ustein results should be admired. They're using their data, learning from it and applying it.  Good for their patients (and good for them) but if you are not part of the CAREs registry make damn sure you know your metrics and are reporting apples to apples, otherwise you're not only fooling yourselves, but doing your patients a disservice.



Saturday, March 2

Code 3 for the Headache - Sudden

...and it's contagious.



A headache!  Won't someone think of the children?!



I'm cooking tonight and the chicken enchilada casserole will be OK cold I guess.  The bells ring and we're out the door code 3 for a headache, sudden, worsening.  It suddenly occurs to me that the sensation that develops behind my eyes between the kitchen and the engine is likely worse than what we'll find on scene.

She's in her mid 50s and is quick to mention her disability status (we noted the handicap placard in the BMW in the driveway) and her husband confirms it.  The disability status that is, not the headache.

Not one to take a patient at their word we do a full work up including 12 lead ECG which aquires a normal tracing just as the ambulance I downgraded arrives.

The patient's headache seems to have subsided.  The pain that was an 11 is now a "tolerable" 7 although we all know that means nothing without knowing her 10/10, which she refuses to share...none of my business and all.

Turns out she had a bad tooth and got some medicine for it.  I know what you're thinking, but no, she actually filed the prescription.

It was when the pain remained 30 minutes later that 911 was called.  And the call made it through the call center because of the words "dizzy" and "can't think straight."


Thanks MPDS, you win again.


Back at the house the casserole was cold and I lost the dinner shake, meaning I had to cover the cost of everyone's meal.  That was a sudden headache.  I did not call 911.



Friday, March 1

the Crossover Episode 22 - Hanging Out

The boys are back!

What do you mean from where and who cares?

We're doing the show LIVE from now on using Google Hang out, a part of Google+

Thursday nights 8pm Pacific, fire up the computer and come have a chat with us!