Wednesday, October 14, 2009
First of all, sorry about the lag between posts. As you know, most of my previous posts deal with broad issues affecting EMS or the healthcare system in general. I will now be changing that theme into something slightly more fun and gadget-oriented- namely, the toys and tools we take with us on the Band-Aid Box.
Many of us who get into EMS bring with us a love of gadgetry. I won't speak for everyone, because some folks are very sober and serious and don't get particularly jazzed about cool-looking uniforms, high-visibility ambulances, digital radios or the latest and greatest tools and analytics on their rig. I would like to say that none of this affects me; that the trappings of EMS are insignificant details in my broader love affair with the service.
But for multiple reasons. I like gizmos and gadgets. Not to the extent that I haul useless crap with me into a call, but I like finding things which aren't standard issue but enhance my ability to do my job. (I will state up front that none of these manufacturers are paying me, giving me free product samples, or giving me Disney On Ice tickets to say this stuff.) A couple of examples:
1) Ringers extrication gloves. Nobody hands you these when you graduate from EMT school, but when you have to root around the scene of a motor vehicle collision or a technical rescue, nothing beats them. They're reflective and cut-resistant, great around glass or metal shards. Only downside is that they're not too great around bloodborne pathogens, so you can't go wrong wearing a pair of exam gloves underneath them.
2) Sears LED safety goggles. The girl in my life thinks these are literally the lamest thing ever created, but they've been helpful on more than one occasion. They could be better with a more comfortable nose bridge, but especially at night or in close quarters, their surprisingly-bright LEDs have been pretty helpful.
Friday, September 18, 2009
It's absurd how easy this blogging stuff is when you have experienced and articulate people who are willing to voice their thoughts for public consumption. This comes from Andy, an old friend and a current emergency-medicine resident. He was good enough to put this together in spite of the fact that I remain openly and abidingly jealous of his current assignment doing air medical transports.
Thursday, September 17, 2009
I'm surprised and excited at the great responses I got to yesterday's post. I appreciate all of the posts that people shared, from EMS providers and civilians as well.
I wanted to share a post from Mary, an old friend and one of my mentors in EMS. She epitomizes the term "black cloud," and is well on her way to becoming one of America's leading emergency physicians, but she was still somehow incapable of managing Blogger's "comment" function. (Just kidding!)
In all seriousness, thank you Mary for sharing this. She brings up an important point- not about whether or not they should be allowed to watch, but about whether we can make it a worthwhile experience by allocating a rescuer to explain the process to the family. I'll also be reposting some of the other responses I got later on.
Wednesday, September 16, 2009
The majority of EMS providers have experience, in one role or another, in providing real-life CPR. Anyone who has knows the following five things:
1) CPR is chaotic and often confusing, even for trained professionals.
2) It is a violent and ugly spectacle replete with torn clothing, cracked ribs and vomit. The patient's body is battered by tubes, needles and electrical shocks.
3) It has nowhere near the success rate that TV leads our patient population to expect.
4) Successful resuscitation in the field doesn't mean they'll survive their time in the hospital, let alone be discharged with the same level of neurological and physical function.
5) EMS providers often begin CPR without the faintest glimmer of hope.
Aside from following protocol, it seems we are often motivated to perform CPR in order to be able to look the patient's family in the eyes and honestly tell them, "We did everything we could." This has led to a real question, both within EMS and in hospital environments- should family members be allowed to witness the chaotic, technical and often nauseating moments that constitute the end of their loved one's lives?
There has a been a lot of qualitative research (or subjective, if you want to be judgmental) done on this subject. There's no real agreement; some medical professionals think it aids in the healing process, others think it complicates the grieving process unnecessarily. The same thing goes for patient's families, although few ever think about it until they're faced with the decision.
I'd like to post a couple different points of view on this, both from EMS providers and the general public. So...what do you think? Leave a comment or drop me a line on Twitter @squirrel325. I'm interested to hear your thoughts.
Friday, September 4, 2009
The title is true. America's national security could depend on your patient assessment and transport decisions. Here's how.
A good percentage of the time- maybe 30%, but it all depends on the day or the territory you're working- we'll arrive on scene to find a patient who doesn't want to be transported, or in some cases, to even be evaluated or treated. We've all got different terms for the form or procedure for allowing a patient to decline care, but I'll use the commonly-recognizable "refusal."
Most of our patients (at least, the ones who aren't frequent flyers) hold the misconception that the decision about hospital transport is mostly up to us, the EMS providers. But unless they've passed out or are exhibiting obvious cognitive impairment (alcohol, severe mental illness, head trauma, etc) it's really up to them to make that decision. So we're left in an odd sort of limbo- a patient with a minor complaint that doesn't appear obviously life-threatening being told the decision to go to the hospital is up to them.
So our patient has all the decision-making power, but not as much of the expertise. We've got the expertise, but in the field, we may not have all the information. It makes for a gray area, especially with those patients with minor complaints. Add to that the fact that on our end of the stethoscope, we're privately weighing a couple of different factors on whether to recommend transport. These include-
1) Enlightened self-interest. We want what's best for the patient, because we'd rather not have to explain our lack of suspicion that Grandpa's indigestion would later blossom into a massive MI. This is the exception to the rule, however; the majority of these on-the-fence incidents turn out to be nothing, and we'll probably face down a baleful glare from an overworked charge nurse. But from a purely risk-management point of view, if they call, we should really haul.
2) On-scene time. If our patient gets into a lengthy discussion with a significant other, a child, a caregiver or a recently-departed relative who they're SURE they see over their shoulder, our judgment may be clouded by the fact that dispatch is going to get grumpy about how long we've been out of service. We may be pushing the patient one way or the other, even subconsciously, just to get the call resolved.
3) Personal priorities. It's a lot easier to clear a call with a refusal than it is to transport to the hospital, fill out a patient care report, wait for a bed, give report and clean up the unit before returning to service. We may be hungry. We may be exhausted. Shift change may be right around the corner. It may be hot or cold and we just want to get back somewhere comfortable. We may not admit it, but we're thinking about it.
4) Hospital status. No one wants to take a patient with a sprained ankle or chronic constipation across the county because all the local hospitals are on bypass, or to wait on a nearby ED for two hours because they haven't got any beds available for your Priority 3. Patients don't like long hospital waits either, so if we say "You'll wait a long time to be seen," we're prejudicing them against transport.
Are any of these considerations bad things? Of course not. We're humans. But it helps to take an honest look at the factors we consider in the field beyond simply patient interest.
I would propose one other factor to consider. (Hauls out his soapbox.) Good patient assessment by EMS in the field will help our healthcare system. If we as EMS providers, ALS and BLS, bust our backsides to do a comprehensive, quality assessment of our patients, and document the hell out of it too, then we'll have a lot more support in making our decisions. That charge nurse may not be quite as displeased when we arrive, and if our patient refuses care for something that ultimately requires hospitalization, we have facts to back us up.
So why does this help the healthcare system? If we cut loose a truly non-emergent patient to seek help from their primary care physician or to simple recover without hospitalization, that reduces the strain on hospital emergency department beds and keeps costs down. If we transport a patient who doesn't look THAT sick, but manages to avoid complications due to early hospital care, we alleviate the strain on the healthcare network those complications would have imposed. EDs across America are swamped with nonemergent cases. If you can responsibly steer your patient to alternative therapy, you help- in a small way- to alleviate that strain.
In short, don't just transport because it's safest for your career and risk-free for your patient. A high-quality patient assessment is the best factor in your transport decisions, and it helps keep the emergency department prepared for true emergencies, like floods, disasters and terrorist attacks. And that's a homeland security issue. So get that second set of vitals- your country is depending on you.
Tuesday, September 1, 2009
Monday, August 31, 2009
Many of us EMS providers, career and volunteer, work in suburban areas or have to go through them en route to a hospital or a call. These places tend to be a little more sensitive about noise- any kind of noise, from airplanes to highway traffic to construction, all the way down to the occasional piercing wail of our beloved Band-Aid boxes. We rarely get complaints about siren usage in broad daylight, or especially at rush hour, when we need every loud and/or flashing tool at our disposal to alert the public and clear a roadway or an intersection. But at night, we often find ourselves switching off the sirens, if not the lights, to avoid subjecting quiet residential areas to the noise.
Leaving aside the debate about whether the risk of using lights and sirens is validated by the savings in out-of-hospital time for our patients, as well as whether late-night noise increases the risk of health problems, we have a basic question. Is it appropriate in the later-evening hours, with little traffic on the road and most of the public at home and resting, to turn off your sirens and only use your ambo's lights as you respond to an emergency?
Those who say yes- kill the siren at night unless it's completely necessary- have a couple good points, the primary one being the maintenance of public goodwill. People are more likely to view us in a positive light (and to value our presence in their neighborhood) if we don't constantly wake them up in the middle of the night with loud sirens. Public goodwill can translate into contributions to a volunteer rescue squad, support for a career fire department tax increase, or willingness to back ambulance billing- not to mention a general positive relationship with the community.
Others argue that, wider community concerns aside, it's simply not necessary. Why blare the siren on an empty road, when the only people who will hear you are probably in bed? The only savings (I've heard this argued) are in the wildlife community; you'll probably scare nocturnal critters off the highway and create less roadkill for the local highway department. If you blare your siren on an empty road and there are no drivers to hear you, are you making a sound? And if so, why?
And we all know that prolonged exposure to siren noise (as with any other high-decibel activity) is correlated with hearing loss. Yet another reason to just turn the damn thing off if you don't need it.
Yet the pro-siren crowd has some valid points. First, in many states (including mine,) you don't qualify as an emergency vehicle unless your emergency lights and siren are activated and functioning properly. That means, if you get into a crash, you lose a lot of liability protection- you may have been speeding and responding to an emergency, but you can be found negligent if you weren't giving other motorists the full benefit of your warning equipment.
Outside of the liability argument, some EMS providers just put it in terms of safety. We all know that drunk, distracted and just plain dumb drivers haunt our roads and highways. We never know when someone is going to pull out of a blind driveway, off a highway shoulder, or blow a red light that puts them directly in our path. EMS providers die in on-duty collisions every year. Regardless of community concerns, why wouldn't we protect ourselves with every tool that we're authorized to deploy?
Some agencies have nonemergency dispatch procedures, which are widely acknowledged to cut down on the number of collisions and to help curb unnecessary lights-and-siren use. The implication being, if you're running your sirens late at night, it's for a good reason. Other communities have designated "quiet zones" applying to emergency sirens as well as train and truck horns- but these often correlate with an increase in grade crossing and highway accidents.
So personally, I come down on the "pro-siren" side of the fence. Doesn't matter when the call goes out; if we're expected to respond to an emergency, our ambulance ought to demonstrate it, and to warn the rest of the public that we're coming. I'm not psychic; I don't know what's around the next bend or waiting in that driveway. But whatever it is, I want it to hear me coming, because I want to go home the next morning.
But what do you think? Do you spare your local citizenry the full blast of the siren when they're in Dreamland? Have you got policies that govern siren use? Let's hear your thoughts...