Monday, March 30

An Unexpected Compliment

While walking through the kitchen to the comm room to talk to a co-worker, I walked past, and wished a good afternoon to, one of my co-workers.

She stopped me and said, "I have never seen you move without purpose.  You always have someplace to be and you're going there like it matters."


Possibly the best compliment I've gotten in a long time.

Wednesday, March 25

Cash on Delivery - American Healthcare from the Outside

Those of you following along know where I work and why I can no longer mention them.  For you new people, I work at one of the busiest airports in the Nation and the world.  I meet all types of people, from the college kid traveling home on the puddle jumper to the executive boarding early for champagne on the A380.

I meet them all at one time or another because of a tight travel schedule that didn't leave time for lunch, a few too many $12 mugs of beer at the terminal, a bag falls from the bin or, on the rare occasion, their pilot isn't able to bring the aircraft in for a controlled stop.

Most times we encounter a person dehydrated, intoxicated or suffering from a minor traumatic injury.  Like any other EMS service we respond, assess and offer treatments and transport options as appropriate.

It was the summer of 2009 when my discussions with Mark Glencorse, then a Paramedic in England, turned towards the American and NHS systems of care.  In the US we were being told the British were being turned away at over crowded emergency rooms and old women were laying in the street to die.  Mark was being told that in America if you didn't have cash money the ambulance would not take you.  This opinion was confirmed on multiple ride alongs with Mark in England and, most recently, at my current job.


A pilot has contacted the tower declaring a medical emergency, person unconscious and they are on final descent.  ETA to terminal, 5 minutes.


My crews are at the jetway as it lurches to life to approach the aircraft that appears to be pulling into the gate rather quicker than most.  Sometimes the pilot will call in CPR, other times you are met with a door opening and the sound of "three and four and five..."

Meeting us at the door the crew informs us that the patient merely fainted at the rear of the aircraft after getting up from their seat after the final descent began.  She's in good spirits, embarrassed, but in need of further physician evaluation and she agrees to it.

As the local ambulance company arrives she is digging through her purse rather intently.

"We have your passport if that's what you're looking for," I mention to her, softly toughing her arm to distract her from the task.

"Oh, I know, but I need to pay for the ambulance."

The looks that flashed around the room were of disbelief on all faces but one.  Mine.

I crouched down into her line of sight and held her hand.

"You don't have to pay right now.  I wouldn't be surprised if NHS picks up the tab, but they'll take you in and get you well for no fee up front."

Her face was considering my words when I realized some background was in order.

"I had the chance to serve a week in Newcastle Upon Tyne with the Northeast Ambulance Service and heard folks from that region concerned about American medical access.  Rest assured, you can get care without cash in hand."

She sighed heavily as the cot finally reaches her side.  As she was covered with a blanket and my business card tucked neatly behind that of the airline supervisor in her purse I heard her tell the ambulance Paramedic very softly "He told me not to give you any money now."

To his credit, the medic quickly whispered back "I'll make sure the hospital knows to contact the NHS for you."

Her smile likely reversed the condition she was suffering from while the rest of us packed up and headed back to get ready for the next call.

Preconceptions can cause trouble.


Saturday, March 21

When Does Intoxication become an Emergency?

[caption id="attachment_3579" align="alignleft" width="240"]Drunk Girl - Crossfirecw Drunk Girl - Crossfirecw[/caption]

I've been having a number of jabs on Facebook (2 or 3 comments in 2 or more places) about the all too common intoxicated patient.

There are those in our ranks who believe they have the ability to determine when a person is "just drunk" implying that no assessment is required.

We need to make a clear delineation on our terminology before moving forward.  First, notice in this post title that I do not use the term "drunk" but instead intoxication.

Drunk is the extreme form of intoxication.  Drunk refers to one affected by alcohol to the extent of losing control of one's faculties or behavior.

While certainly not an emergency, a person who meets the definition of drunk is in no way, shape or form able to assist in an assessment for other mimics to intoxication such as stroke, hypoglycemia and sepsis, just to name a few.

A drunk person is likely to be semi-conscious or unconscious.  These folks are horrible at maintaining a clear airway and can get into trouble fast if not properly taken care of.  That may not always mean a hospital, however.  More on that in a moment.

How many times have you been called out by PD for the "alcohol poisoning" only to find someone alert, ambulatory and smelling of alcoholic beverages?  Is this person drunk?  Only after a complete assessment will we be able to determine if their level of intoxication meets the definition of drunk.

Here's a quick tip: Your local protocols probably don't have a section for this.  There's an altered mental status section, but no, "He doesn't need to go to jail but we can't let him drive home, so take him to the hospital" section.

PD is adorable on these calls, often telling a patient they can either go to jail or to the hospital.  I often cal their bluff, when appropriate, and tell the patient they can still refuse transport (After my assessment finds them able to do so under local policy).

Intoxication is, technically, a poisoning.  All levels of alcohol ingestion constitute alcohol poisoning if you want to get down to the nitty gritty.  The key is going to be determining to what extent the intoxication is impacting your patient's ability to make sound decisions regarding their care.  Plain and simple.

My local policy states that, among other elements, the patient does not appear to be under the influence of drugs or alcohol in order to be able to refuse care.  That's a big gray area.  They may be intoxicated, but able to comprehend my questions, weigh their options and have a plan for decreasing the level of intoxication in the near future.

These folks should have a sober adult with them and not operate a motor vehicle, but they seldom need an ambulance ride to an ED.  Think about it.  What will the treatments be?  Fluids?  If they are able to sit in triage long enough they could drink more water than any IV could run in in the same amount of time.

Now, before you go running off to your next drunk call and leave someone lying in the street because of something I wrote, let me ask you this:

How do you know they are merely intoxicated and not drunk?

Remember the definition?  Losing control of one's faculties or behavior.  We all have that one friend that overindulges and becomes an idiot, but are they drunk or intoxicated?

Stop looking for zebras.  Sometimes drunk is just drunk but you won't know until you assess.

Unconscious people are unable to make sound decisions.  Semi-conscious people are the same.  Ambulatory people who have been drinking may still be able to understand their situation.  Only after a complete assessment will you know for sure.


Thursday, March 19

Response Times Discussion Continues

While I expected Scott and I to get into the ALS vs BLS first response debate a lot faster, we seem to have trouble moving on from the response times discussion.  Or, I keep getting distracted by great questions and comments.

Reader Florian commented on my original post regarding a large American City struggling to meet response times with a question about unit deployment and availability:

"WHY there are not enough units available? Cost, ageing fleet, retired staff etc were touched upon, but what are all the available transport units up to when they are unavailable for other calls? Are they on actual emergency calls? Or calls that could have, and should have been dealt by other services, e.g. community nurses, GPs etc? Should that unit have been dispatched at all, or could they have been given home help advice over the phone?"

Excellent points all Florian and you were right later in your comment that your views are skewed to the UK version of healthcare: Actually getting people the care they need.

When I visited Mark Glencorse in the UK my eyes were opened wide to a new model of delivering care - Respond Not Convey.  This simple program allowed medics to divert reclined cot 2 person transport units away from ambulatory patients and those who did not need transport via a reclined cot.

The system allowed for single paramedic resources to relocate patients to their GP, local clinic or even local A&E (ED) depending on severity of condition.

Because of the American system of health insurance those options are almost impossible.  While many communities are adopting Community Paramedicine with great success they may also still be locked into a rigid transport model that does not allow single practitioners to transport.

And all because of billing.

You can take someone to the hospital in a horse drawn wagon if you wanted to.  Perfectly legal.  Just don't label it "Ambulance" and don't try to bill for it.

But back to Florian's comment in regards to the American City noted in the news story.

It is likely that those reclined cot 2 person transport units are busy taking folks to the ED who neither need the cot or the ED.  Most 911 calls require only BLS intervention following an ALS assessment.  So why keep those practitioners, equipment and units committed?

Billing and a warped definition of liability.

I can't speak to the municipality mentioned in the story but it is likely that any system seeing an increase in call volume without an increase in patients who require intervention needs to address their patient population with alternate services.

Homeless outreach, community prevention programs, asthma programs and community paramedicine can all do a fair job at decreasing the calls to 911, but offer no help when a crew is on the scene of the cut finger who demands an ALS 2 person reclined cot van ride to an ED while the choking down the street gets no ambulance.

Florian, I would bet that this system could benefit from diverting appropriate patients to single unit resources for transport to clinics, urgent cares and EDs but the lawyers would never go for it.

After all, they would want to try to bill for it and you can't bill unless you meet the requirements.

Is an ALS front loaded system with those options more efficient than throwing BLS fire engines at every call?  Most definitely, no question about it.

But what would we do with all the BLS resources in the community?


Great question, Florian.

Tuesday, March 10

Doctor on Board - Professional Courtesy

"Units responding to the unconscious, be advised a Doctor is on scene."

Possibly the most feared words in EMS.  Not because we're heading to a scene where a Doctor might be needed, but because finding a physician in the wild is unusual.

No, the most common "Doctor" to encounter on scene is a PhD or specialized MD.

Not unlike the scene in Mother Jugs and Speed when the Doctor on scene happens "to be the best dermatologist in all of Los Angeles."

"Well, if acne breaks out, we'll let you know."

While all MDs have received more training than the average Paramedic, most of it was not geared towards the situation they encounter in the wild.

On a recent job we were told a doctor was tending the patient.  As the plane landed and the door opened the look on the Purser's face told us all we needed to know.

Sure enough, a Psychologist a few drinks into the trip decided to help when a man was feeling dizzy.  No assessment was done and according to the crew he never even questioned the patient, but wanted to speak to the Captain about the need to land immediately.

Luckily the airlines have a beefed up dial a nurse resource who advised to continue to destination based on the assessment completed by the flight crew.

When we tried to begin our assessment he insisted we listen to his report prior to contacting the patient.  Luckily for the patient these folks are my specialty.  I gathered him to the side and took his rambling report, thanked him and sent him on his way while my crew made contact.  Then I leaned over to the flight crew who knew the patient's name, vitals, history and everything else I needed.

Professional Courtesy dictates that I listen to your concerns and address them as appropriate.  I would only ask that if you have had a few drinks on the plane, haven't practiced medicine in awhile or have a PhD in something other than medicine, maybe hang back and just make sure the flight crew does what they do.

Oh, and we'll let you know if his dizziness makes him depressed.


I speak from experience on this topic from both sides, remember?

Thursday, March 5

Should Response Times Matter? A discussion with Medic SBK

I've been discussing THIS story with good friend and fellow EMS 2.0 believer Scott Kier on the book of faces.

Since I can not mention the Department name here, just read the story and come back.

Disclosure:  I am a trained Firefighter/Paramedic.  I am a second generation Firefighter.  I am a card carrying member of the IAFF and my Local.

That being said, let's move on to the meat of Scott and my discussion.

The story references a municipality struggling to meet increasing demand for ambulance responses under a state mandated market share of 80% responses shared with 2 local private providers.  To reach that target the municipality made funding available to replace an aging fleet (some stories reported over 200,000 city miles on some ambulances) and hire new EMS staff.

The Municipality operates an EMS transport tier within its Fire Department, a decision made in 1997 when the municipality's public health ambulance group was folded into the fire department.  If you've been awake for more than an hour you know that never goes over well.

Skip ahead to about 2006 when single function EMS crews are sent back out from 24 hour assignments in the firehouses on a "1 and 1" deployment model.  That means one EMT and one Paramedic per unit.  AKA the norm.

The 24 hour medics were reassigned to the municipality's fire engines to increase the capability of ALS first response.

The local EMS Agency sets response times for all ambulances in the system and has magically chosen 10 minutes for code 3 calls and 20 minutes for code 2 calls.  The determination of code 2 or code 3 is made by the call taken and caller discussing the patient's condition, weather and who knows what else.

The times are averaged using an approved statistical model and reported to the EMSA and State.

Now that that's out of the way, let's talk about response times.

Response times are solely to determine if a contracted agency is meeting contract parameters.

See, wasn't that easy?

It would be a challenge to hold ABC Ambulance Company or Random Municipality to actually treating illness and injury to a certain level.  Imagine if the contract to earn a service area required an agency to treat all asthma patients with a bronchodialator or ensure that all patients with a revised trauma score less than 5 are being transported to a level 1 facility.

EMS needs to be held accountable for the assessments and treatments they provide not how swiftly they can arrive or how many people they can haul away in a day.

Trouble is we've spent the better part of 40 years telling people that "seconds count" when in fact they only count in groups of about 200.  Add to that that reimbursement is tied to transport, not treatment and the service simply looks to turn over calls as fast as possible.  Armed with the belief that a 10 minute response time is required for chest pain, ankle injuries, drownings and sleeping street people, the entire system must be built for the smallest community of patients: the critically ill.

EMS 2.0 is about stopping the band aid fixes and overhauling the EMS system in each community to meet the needs of that community.  For some that means EMS based EMS or a third service while others will need to lean on fire and PD to take up the slack when staffing levels can't be filled.

Scott and I agree that a tiered approach is necessary, however, based on discussions we've had online and in person we are on opposite sides of that discussion.

Perhaps Scott can pick it up here over at EMS in the New Decade?