Saturday, October 24

The Crossover talks arrogance vs confidence

MC and HM con­fi­dently present episode 26 of The Crossover Show. They arro­gantly feel it is the internet’s best, first, and only Police/Fire/EMS pod­cast fea­tur­ing con­fi­dence vs arro­gance you’ll lis­ten to today.

In the world of Police, Fire, and EMS there is no short­age of con­fi­dent men and women. Often, how­ever, there are accu­sa­tions of “arrogance”.

The guys take a shot at crack­ing the code of when one can morph into the other, who decides, and they even break open the Google machine to get some actual, real-life definitions.

Also, there’s beer.

If you haven’t rated the show, please visit iTunes and rate the show six stars! If you have sug­ges­tions for improve­ment, please send the guys an email and let them know what they can do to bet­ter the show!


Wednesday, October 21

October 21st, 2015

We've been having some technical difficulties here at pertaining to the ability to schedule posts.  Believe it or not gentle reader, when a post goes up at 6 AM, chances are I'm not hitting publish right that minute.

We have (had) the ability to schedule things out so that my 10 posts I write when fired up don't all come tumbling out at the same time.

So to test a few ideas on how to trick the system into doing what it is supposed to do, you may see this post from time to time go up, then come back down.

I have chosen to schedule this post for October 21st, 2015, the day in the future Doc Brown takes Marty in back to the Future.

So if it not October 21st, 2015, just ignore this post, it'll be gone soon enough.

Thursday, October 15

An Inconvenient Truth - The Chicago Study is Right

EMS has our collective panties in a wad about yet another study showing that BLS has a better survival rate than ALS.  This time some researchers from the University of Chicago, including Prachi Sanghavi PhD a medical policy researcher from Harvard, looked back at patient outcomes at 90 days and how they arrived at the ED.

Fair enough.  More data that we caregivers ever get.

They then went through and controlled for all sorts of variables that can impact care and found what we all already know:  Patients who arrive BLS do better than patients who arrive by ALS.

You can not dispute this data.

You also can not dispute Prachi Sanghavi PhD's comment in a related video that "Our ambulance system is in serious trouble."

Just not for any of the reasons she wants to put forward.  Have a look:

Put down your pitchforks and let's wander through a few comments she pulls from the larger data set.  The first one I'll take issue with/agree on is when she alludes to EMS's inability to properly perform an endotracheal intubation.  Data on this skill ranges from incomplete to confusing.  For example, am I a success if I have a 100% first pass rate but do so on patients who did not need the procedure?  What if I have zero attempts, but a higher ROSC and discharge in tact  rate?  What if my last 3 misses were on the same crashing CHF patient?

"Delivery quality problems with intubation" as mentioned in the video is a stab while the ref isn't looking.  The research may not differentiate ALS or BLS placement of esophogeal airways.


In addition, let's start addressing all the post ROSC care required by many systems.  I'm talking about cooling, serial 12 lead ECG, fluid management...all things that take time to establish in the field to meet a pre-determined level of care the local regulatory agency thinks will work.


We have all known that the ambulance system is broken far longer than Prachi Sanghavi PhD has been studying it.  We also know that placing blame for a patient's death solely on the time between the scene and the hospital is foolish to say the least.

Response times generally don't impact patient outcomes.  Most cardiac arrest survivors had interventions prior to EMS arrival.  Many patients who die in hospital are still dying from hospital acquired infection.  If a patient dies of a GSW to the chest, that's one thing.  No amount of BLS or ALS can save them and I'd argue that a thoracic surgeon gowned up and standing in the street as it happened won't make a difference either, but let's not let that get in the way of the true drive behind this research:

Hospitals save lives, not Paramedics.

Can't argue that.  It is hard to argue that a person alive in a hospital for 56 days following cardiac arrest, then dies, is the fault of 14 of the first 21 minutes of that person's insult.

We can control for variables and I don't doubt that the researchers did just that, but we must also remember that focusing on the blood and guts and CPR alone will not give an accurate picture of an EMS system.

ALS exists to assess and treat at a level far above what the Chicago folks want you to understand.  "Scoop and Run" and "Stay and Play" haven't been uttered since the early 90's as far as I can tell and we've learned our lesson about pausing compressions for intubation and pulse checks (In the middle of this research no less).  ALS exists to intervene in respiratory cases, allergic reactions, tachycardias, bradycardias, mental disorders, minor infections and illnesses and a whole host of other cases that are treated and redirected away from an ED when appropriate.

If the researchers follow their conclusions to a logical end, their data will support only BLS ambulances and a universal "Scoop and Run" policy for each and every 911 call.

Did they miss where we only transport about 60% of our patient contacts?  Think the EDs are overcrowded now?  Wait until each and every patient hits the doors lights and sirens (shortening arrival to ED time) with an incomplete assessment, no interventions prehospital and an increase in volume of nearly 50%.


The numbers are nothing new.  Don't get upset because this data contradicts your 3 years observations on an ALS truck.  This is a wake up call for EMS.

The data say ALS isn't helping, heck it is hurting.  Methodology aside, would you rather address this study or make sure the next one has different results?


If all we do is reclined cot transport to the ED, I'm 100% behind the Chicago study.  Load'em all up, staff the ambulance with a driver and EMT-Basic and haul ass to the ED.

If we want to make a positive impact in the community, agree that ALS patients are more often sicker, more complicated and require more assessment and intervention skills to be delivered viable to the ED.

Agree that the ED CAN NOT be the only destination for all patients.

Agree that BLS and ALS CAN NOT be the only services provided in your community.

Agree that regardless of response times and scene times, good care sometimes takes time to get right.

Agree that endotracheal intubation is not the gold standard in airway management.

Agree that most of what we do is based on anecdotal observation, past practice and, in some cases, voodoo (LSB, epi, Bicarb).

Agree that the American ambulance system is broken and that all the bells and whistles we want to add to the prehospital area need to be researched and proven successful before being widely implemented.


Only then can you challenge the research.  Only then can you try to stand up to defend what you do, what I do, what we do.



Sunday, October 11

You Make the Call - Chef in Distress

ymtkIt happens.  Sometimes dinner at the firehouse is delayed by calls for service, drills, details you name it.  However, sometimes a newer member of the company, who's turn it is to cook, is having trouble with a new recipe.

I've already told you all about the dangers of trying a new recipe at the firehouse (try it at home first), but this member never got that advice.

As folks mingled into the kitchen to help, the member confidently told them that everything was prepped, he was just waiting to get started.  Lettuce had been cut, washed and is in the fridge, dressing made and chilling. "Just timing the chicken," he told everyone.

So we all wandered off.

At 15 minutes before 1900 hours, dinner time, I enter the kitchen to see the cook browning some chicken in a pot.  "What do you need?" is the question I ask.  The answer and how you respond to it will define what kind of Firefighter you are.

His answer was "I need to brown this chicken, then it goes in the oven for an hour."

There were half a dozen other firefighters at a nearby table commenting on how dinner would be late.

What would you do?


You Make the Call.

Friday, October 2

The Crossover Podcast - Is the Grass Really Greener?

Your first, best and only Police Fire and EMS pod­cast returns to talk about what it would take for our experts to leave their cur­rent ser­vices for another.

Is it pay?  Could it be oppor­tu­nity?  Do you feel a sense of loy­alty to your cur­rent organization?

All ques­tions that come up when a Fire­man and a Cop sit down for a beer (or 3) and talk about why it seems like every­one is always look­ing for another job.



Thursday, October 1

That's Why We're Here, But That's Not What We Do

I got in a spirited discussion with a co-worker recently about the need for Paramedics in the modern Fire Service.  They railed on and on about how there is no EMS in the Fire Service, that we are here to put out fires, make rescues and do other fire related tasks and that EMS should be left to someone else.  When pressed for who exactly that should be they had no solutions, only a request that they personally not have to do "all that medic type stuff."

Bad news folks, EMS is going to be in the Fire Service for a long time, regardless of how much that third service idea gains traction.  The reason is because not every community can afford to pay 2 people to do 2 jobs when often 1 person can do both.

Simple math.

The key to recognizing the mission of the modern Fire Service is first coming to terms with the title of this post.  We are here to fight fires, but that is not what we do.  Increasingly the fire service has had to absorb other duties in the community for a number of reasons from shrinking budgets in other agencies to decreasing fire calls and a need to justify staffing.

Trouble is, when the reason a fire engine is in the community arises, we need it staffed by enough trained professionals to handle the problem.  Try telling Mrs Jones that the reason her house is now a parking lot is because budget cuts didn't allow a third person on the engine.  Sorry, that isn't going to cut it.

In between fires we need to be seeking out other ways to have a positive impact on the community.  For many that means running EMS calls.  Some will complain that those resources are needed on the EMS side and we should just move those jobs from the engine to the ambulance and solve all the problems.

Math is hard for these people.

Imagine the roles reversed for a moment.  Fire Engines are slow to respond because there are too few, but a large group of Ambulances seem to respond to fires and make a difference in the early stages.  Why not move those employees to the engines so you don't have to do that anymore?


We can do both from a single platform and that doesn't mean making every big red truck ALS or putting airpacks on every big box patient mover.  What it does mean is that those in the fire service need to recognize that the engine is there for a specific purpose and when not in use needs to be used for something else whenever possible.

EMS is not why the Fire Department is here.

BLS is not why the ambulances are here.

But that is what we do.

Day in and day out our preconceptions become misconceptions and your desire to get off the ambulance and onto the engine has simply changed when you arrive.  Same patient, same problems.

Too many today speak of the ambulance as if it is a disease that makes them less of a firefighter.  I've heard it here and many other places.  "I'm not on the box today, I was on it yesterday.  Today is my engine day."  So?

Why are you here?  What are you going to do today?  How many fires will you catch?  How many medical aids?

We spend so much time touting "Expect Fire" and throwing ladders that in the rare instances those actions apply they are second nature.  In the same shift we will make an arguably equal impact on far more people because of what we do in between fires.


Ask yourself, "What am I here for?"