Licensed Texas attorney. Licensed Texas paramedic. Unlicensed BBQ critic.

Licensed Texas attorney. Licensed Texas paramedic. Unlicensed BBQ critic. And yes, I went to law school first. Got to learn how to chase the ambulance before you can drive it. Politically incorrect infidel who's very conservative. . Oh, and also a big fan of country music, firearms, and, as of late, cars.

Observations from Facebook Friday

Posted on April 4, 2014 Written by

Spent some time actually observing and digesting some EMS stuff on Facebook today.  Two random thoughts.

1) Less than a few moments ago, I watched my Facebook feed roll by with another NAEMT post shilling the “Field EMS Bill.” Tell me how making sure EMS ends up in the Federal HHS bureaucracy (ya know, the same people implementing ObamaCare) and creating a pool of grants for “innovative” EMS projects (read: politically connected EMS systems that already get plenty of national attention and funding) does a thing for the field EMS provider? I’d much rather the NAEMT powers-that-be working on true certification reciprocity.

2) I also observed a post about palliative care and DNRs that was shared from one of groups that I’d identify as catering to the so-called “low information voters” of EMS.   The ambulance drivers on that group (yep, if you act like Mongo the Gorilla, I’ll call you an ambulance driver) asked if a transfer patient had a DNR.  The nurse replied that the patient had “comfort measures only.”  The ambulance drivers said “full code then.”  I can’t understand some people in EMS.  They want a simple cookbook of recipes to follow, along the lines of “If A, then B.”   But when people call them ambulance drivers, they claim to be offended medical professionals.  Nope.  You’re an ambulance driver.  Professionals don’t define themselves by a skill set (witness the paramedic intubation debate) and exercise some freaking judgment.   Have a banana, Mongo.

Filed Under: EMS, EMS 2.0, Rants

Category 9

Posted on April 2, 2014 Written by

In many EMS systems, Category 9 or some code involving the number 9 is the code for cardiac arrest.  This number comes from the Medical Priority Dispatch System “determinant” codes.   And as we all know, the easiest, simplest, most low-hanging fruit of EMS metrics is some version of cardiac arrest survival.  Dead/Not Dead.  It doesn’t get easier than that.

But there’s a couple of rubs there.   Define “cardiac arrest.”  I think we all agree that there’s a wide spectrum of arrests.   An obvious dead-on-scene in a lot of systems gets classified as a “cardiac arrest” in others.

And then there’s the voodoo.  So many research physicians have convinced that they’ll be the next one to raise Lazarus from the dead if only they adopt XYZ protocol.   Some are dubious, some have potential, and some have raised more questions than they’ve answered.  Witness the debate over some supraglottic airways impeding carotid circulation or the current debate as to whether therapeutic hypothermia works.  What we do know works is good CPR and electricity.  But neither of those are “sexy” per se.

Here’s what bothers me, especially about certain services who constantly brag about a high percentage of “saves.”  Even in the best systems, a successful resuscitation is a 50-50 proposition.  And we know that cardiac arrests represent a very small percentage of EMS calls.   So, in short, you’re designing an EMS system based on a super small percentage of patients.

Let’s work towards a new metric based on what our patients seem to really want — symptom relief.  Did we make your breathing easier?  Did we take your nausea away?  And most importantly – did we take your pain away?

A system based on those metrics is the type of place where I’d be proud to practice medicine.   Because after all, paramedicine is practicing medicine, albeit under relatively defined limits.  And medicine is supposed to be about making people feel better.

Filed Under: EMS, EMS 2.0

Insta-medic

Posted on March 26, 2014 Written by

Recently, a good bit of publicity has been devoted to allowing EMTs to administer Narcan intranasally to patients who have overdosed on opiates.  speaking purely from a practical and clinical standpoint, these patients aren’t going to die from a lack of Narcan, but they are going to die from a lack of ventilation.   We should be reinforcing good BVM skills rather than adding ALS interventions piecemeal based on the media’s epidemic du jour.

This is nothing new.  Every few years, many BLS providers petition the powers that be for certain ALS skills.  In my EMS career, I’ve seen a few of these skills added or considered from nebulized albuterol to nitroglycerin to Epi-pens and now Narcan. In most of these cases, we limit the application of these (now formerly) ALS skills to specific patients in specific situations.   This is our attempt at managing and mitigating the risk of allowing an EMT with approximately 120 hours of training to perform a skill that was previously reserved for paramedics with over 1,000 hours of training.  (I’ll save the training versus education debate for another day.).  What we end up with is a cookbook, bastardized, piecemeal approach to the provision of advanced life support, based largely on public and political pressures as opposed to sound medical science.   What we don’t end up with are providers who understand the how, when, where, or why to apply these newly acquired skills.

I’d favor EMTs being allowed to perform these ALS skills in two situations. First, where the skills are being performed under the direction and supervision of an ALS provider in an effort to provide a true “extra set of hands.”  Second, and subject to strict clinical oversight, in rural systems without ALS access.

In my opinion, if you want to be able to perform ALS skills, you need the knowledge of an ALS provider.   That means if you want to do the “cool” paramedic stuff, go to paramedic school.   Otherwise, this trend to add ALS skills to the EMT protocols is yet an another example of the instant gratification model that continues to hamper EMS and EMS education in particular.

Yep, I think I’ve finally turned the corner and become one of those crusty (at least relatively speaking) and cynical older medics.

Filed Under: EMS, EMS Education

What medical types don’t understand

Posted on March 20, 2014 Written by

I’m fortunate enough to practice both law and paramedicine regularly.  As a result, I see a lot of ignorance where lawyers don’t understand medicine.  Namely, that lawyers continue to mislead the lay public that a bad outcome equals malpractice.

But I find healthcare types regularly blaming lawyers for so-called “defensive medicine.”  The latest one of these came from the respected (well, as respected as a blog can be) physician blog KevinMD.  The blog posted an opinion piece about a Boston jury awarding over $4 million in a malpractice verdict for an emergency department physician misdiagnosing a patient who later died of viral myocarditis.

Let me tell you again (because I’ve blogged about this before) what a jury verdict or a settlement should mean to the average healthcare provider, whether a CNA, paramedic, or attending physician at a world renowned medical school — NOTHING. Zero. Zip. Nada. Zilch. Nil.  You get the message.  A jury verdict, settlement, or even a plaintiffs’ firm’s press release have no binding legal authority.   They are meaningless except, perhaps, maybe to the specific case at hand.

So, then, what law should a healthcare provider pay attention to?  Quite simply — federal and state statutes in your jurisdiction, including the administrative regulations adopted by your jurisdiction’s licensing/regulatory authorities.  Also, you should pay attention to reported case law from appellate courts in your federal and state jurisdictions.  These are the laws and interpretations of law that you’re under.   Nothing else. Not even on odd-numbered Thursdays.

So, in short, to my fellow healthcare providers — learn the law.  Learn to recognize the phobias of law.  Learn to recognize and avoid panic and hysteria over any jury verdict you hear in the news. And learn when to call BS.  And just like you get mad when someone consults Uncle Ernie instead of a doctor, learn to consult someone schooled in the law when you have a legal question.

Obligatory final caveats and disclaimers.  This isn’t legal advice.  I’m not your lawyer.  I don’t want to be your lawyer.  This is just my personal opinion expressed through my blog.  My opinions are my own and don’t reflect the opinion of any employer, past, present, or future.  Objects in mirror may be closer than they appear.  Press hard, three copies.

AND FOR CRYING OUT LOUD — QUIT READING MEDICAL BLOGS AND WEBSITES FOR LEGAL GUIDANCE!

 

Filed Under: EMS, EMS Legal, Law

Toxic exposure

Posted on March 13, 2014 Written by

Some of my EMS friends refer to the less enlightened of us in EMS as LIV, shorthand for Low Information Voters.  I’m the first to admit that I like the term and use it.  Sadly, I have occasion to use it regularly, especially seeing what some providers post publicly on Facebook.

After some thinking this morning about a couple of discussions I’ve been watching, some LIV providers scare me more than others.  The youthful, overly eager provider who has maxed out their credit line at Galls by buying every piece of equipment known to mankind has the potential to be a diamond in the rough. Those of us who consider prehospital care to be part of medicine owe it to ourselves and our patients to channel said youthful enthusiasm into the art and science of patient care.

Then there’s the other form of LIV.   The so-called “experienced” provider whose only contributions are mindless repetitions of bad information, usually associated with withholding pain medications to those they deem unworthy of their skills.  These older LIVs are also usually the first to scream about the good old days and shame anyone who doesn’t conform to their limited understanding of medicine and operations.  To quote Spiro T. Agnew, these people are the “nattering nabobs of negativism” of EMS.  Their pessimism is toxic, both to other providers and to the advancement of prehospital medicine.

These old-timers run off enthusiastic providers, stagnate development, and generally make work a crappy place.  Their toxicity runs off others and infects the workplace as surely as an outbreak of norovirus.  Heck, at least norovirus runs its course and leaves.  Yet for some reason, these cranky ones are only happy when they can actively discourage others.

Please, if you actively embrace terms like toasted or burnt out, step away from patient care, whether for a sabbatical or permanently.  You owe it to your coworkers and your patients.

 

 

 

 

 

 

 

 

Filed Under: EMS, Rants

If you see something, say something.

Posted on March 9, 2014 Written by

The Homeland Security folks have plastered the saying, “If you see something, say something” all over the place.  EMS needs to adopt this saying as well for what we do.

First of all, when you’re part of a team providing care to a patient: “If you see something, say something.”  If you see something that the other members of the team don’t see, say something.  If the other team members aren’t treating the patient right, say something.  Of course, there might be a good reason for why the team is going in a specific direction, but part of being a team means that you’re supposed to ask, especially if something doesn’t seem right to you.

What really inspired this post tonight was a story from a friend and mentor of mine.  He’s also an attorney and has been in EMS so long that he has the original recipe for D50.  He showed up at a neighbor’s house when her friend fell and struck her head.  The local fire department and EMS showed up and immediately stood the patient up and tried to talk the patient into refusing transport.  My friend pulled the medic aside, explained that he was also a paramedic, an attorney, and had previously been an expert witness against this EMS system.  Oddly enough, the lead medic then told his partner to go get the stretcher.

I’ve been in a similar situation when a family member was cared for by the local EMS system.  That first call was, in my opinion, handled poorly.  (No need to rehash what I’ve already blogged about.)  However, I had a responsibility to speak up.  When the crew started going down all of the wrong pathways, I should’ve spoken up.  I probably should’ve even asked for a supervisor to make the scene.

The takeaway from all of this is that patient advocacy is part of being a medical professional, regardless of whether you’re the lead provider, whether you’re off duty, or regardless of your certification level.  Patient advocacy isn’t about popularity, but it is sure as heck is the right thing to do.

So, if you see something, say something.

Filed Under: EMS

What’s our paradigm?

Posted on February 28, 2014 Written by

Fair warning.  I’m going to offend a lot of you.  Hell, I’m expecting a nasty snarky reply or two.

I love the public safety aspects of being a paramedic.  I admit it, I’m enough of a sparky type that I like having a utility belt. I love my duty boots, my radio (which, yes, I leave on “scan”), the 5.11 pants, and the really cool windbreaker with my department patch and my Texas paramedic patch.

Here’s what I don’t love about the public safety paradigm.  The paranoia. The “us versus them” mentality. The culture of fear.  The constant “street survival” mentality.  The belief that every call may be our last.

Now what about medicine?   That model has some flaws too.  So many of us idolize Dr. House and his approach.  You know the mindset.  Nevermind being nice so long as you nail the obscure diagnosis. And it’s never lupus.

Minions, we’re EMS. We adapt.  We adopt the best from every discipline.  It’s time to start living that.  Yes, the public safety mindset protects us,  but it shouldn’t make us paranoid wannabe state troopers.  Yes, we practice medicine (and even diagnose), but it’s not a substitute for warmth.

Whether or not we like it, we are an amalgamation of several different professional disciplines.  I like to say that we practice operational medicine — we deliver acute and urgent care medicine at a mid-level scope using aspects of the public safety professions to help us deliver that care.

In summation, never let being either a clinician or a public safety provider detract you from the main mission — being a caregiver to all of our patients. And yes, the family, friends, and bystanders are part of the care continuum, y’all.

Have a great Friday and an even better weekend.

 

 

Filed Under: EMS, EMS 2.0, Rants

The future is here…

Posted on February 24, 2014 Written by

We just don’t realize it.  There’s a lot of discussion about community paramedicine and what that entails. For a while now, there has been additional training and education available for EMS providers in the tactical and critical care arenas.  Our care methods are changing.  In many EMS systems, we are gradually moving from blindly following the recipe in a cookbook to standing orders where we are actively encouraged to exercise and apply our clinical judgment. Selective spinal motion restriction and pain management are but the first steps.   I truly believe that point-of-care labs are coming soon to an ambulance near you.

We may not “officially” recognize it, but we’ve grown.  At this point, with all of these additional areas of EMS growth, we are becoming de facto mid-level providers, specializing in delivering unscheduled care in out-of-clinical settings.

If we can change the reimbursement model for EMS to focus on care delivered rather than transportation and we can continue enhancing our education requirements, who knows what might happen?

Deep enough thoughts for you on a Monday?

Filed Under: EMS, EMS 2.0

Legal Learning

Posted on February 14, 2014 Written by

Over the past few years in EMS, we’ve heard a lot about “standardizing” EMS across all fifty states in the US, whether it’s the Institute of Medicine’s report or the recently adopted National EMS Education Standards and Instructional Guidelines.   Fair enough.  The proverbial Mrs. Smith’s COPD probably won’t be too different between Peoria, Illinois and Peoria, Arizona.  Oxygen, breathing treatments, and medications work the same across state lines.

From my perspective as an attorney, paramedic, and occasional EMS educator, one thing that shouldn’t be part of a standardized curriculum is the dreaded medical-legal section.  Besides my ongoing pet peeve that medical-legal is the one EMS topic we continue to allow to be taught by the uninformed, we continue to assume that a one-size-fits all approach to medical legal education suffices.  Aside from a few Federal law issues (HIPAA, EMTALA, and CLIA most notably), the overwhelming majority of EMS law, particularly the regulatory framework and tort law, is decided by the individual states.  Other issues, such as advanced directives and medical direction/protocols are equally dependent on state law.

For aspiring medics to be truly informed on their respective legal issues, the best thing that we could do is to take the following steps.  1) Remove the legal curriculum from being part of a national curriculum. 2) Ensure that the legal principles taught in initial EMS education programs are taught by experts and/or developed by the appropriate state regulatory body. 3) Ensure that any testing on EMS legal principles is done at the state level.

But hey, what do I know?  It’s not like I’m a lawyer or anything.

Filed Under: EMS, EMS Education, EMS Legal

Big Mac or Porterhouse

Posted on January 27, 2014 Written by

I’ve noticed two interesting discussions going on simultaneously on EMS social media.  One discussion, which started on the National EMS Management Association list on Google Groups initially started out as a medical director trying to update his protocols.  It has since evolved (or perhaps, devolved) into a discussion about keeping endotracheal intubation as a paramedic skill.   The usual positions are being hashed out.  Again.  In short — one position is that EMS, as a whole, doesn’t do a good job at intubation — either in initial education and skills mastery or in skills retention.  The other side is the argument of “That may well be true, but things are different at the XYZ EMS System where we absolutely excel at intubation.  Here’s why and take a look at our numbers.”

Another discussion has been brought up by friend and fellow blogger Chris Kaiser.  He’s raised some very good concerns about the current American Heart Association Advanced Cardiac Life Support program sinking to the level of a merit badge course that every advanced life support EMS provider has and that most hospital staff have.

I see both of these discussions as a symptom of what I call the McDonald-ization of EMS.  In other words, we want to ensure a similar experience wherever you get EMS, regardless of previous excellence (or incompetence).  Face it, when we travel, we stop at Mickey D’s because we know what we’re getting, not because it’s the best burger anywhere.

EMS seems to be trending towards this as well.  The statistical gurus and the usual crowd of professional committee members and buzzword repeaters all bloviate (sorry for the Bill O’Reilly word there) about the need to have a common standard.  Two problems there.  First, the common standard doesn’t take into account the variations throughout the entire United States.  To me, it’s unreasonable and illogical to presume that Cut Bank, Montana and Boston, Massachusetts have the same needs for EMS, much less the same populations and sources of funding.  Second, like McDonald’s, when your chief concern is consistency, your product or service easily becomes the lowest common denominator.  What you end up with is a consensus model where pit crew CPR, good airway management (both including and excluding intubation), and even more cutting edge advances like dual defibrillation and transporting certain cardiac arrest patients straight to the cath lab end up sacrificed because “we all need to be delivering the same care everywhere.”

As for me, I’ll take the occasionally singed porterhouse in recognition that even that is better than the uniformly average Big Mac, which for the record, isn’t even prepared the way I like my burgers to begin with.  It’s time that we quit punishing the EMS services that try to deliver excellent patient care just so that everyone receives the same, consistent, AVERAGE care.

Of course, the statistician will tell me that there’s always going to be an average.  We just need to keep IMPROVING what we do so that the average keeps advancing too.

Filed Under: EMS, EMS 2.0, EMS Education, EMS Politics
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