EMS – Page 10

Online EMS Learning

Posted on March 24, 2016 Written by theambulancechaser

EMS social media, whether it’s a blog, podcast, or even a Facebook page, has greatly improved and democratized the access to advanced knowledge in EMS. The ability to hear about and learn from renowned clinicians and educators and to become rapidly informed on cutting edge research cannot help but improve the average EMS provider’s knowledge base and clinical abilities.

Having sung the praises of EMS social media, I’d share a few warnings, though.

There are a lot of people NOT to learn from. Namely, there are the pedants out there who know the minutiae of medicine. These people rarely put things into proper perspective. For the newer or less confident provider, the only thing they offer is self-doubt and a loss of confidence. We all have to walk before we can run and the social media pedants often forget that. A newer EMS provider may well not know subtle EKG changes or the minute details of pharmacodynamics of a medication. Overwhelming them with information may cause the newer provider to run away and retreat into a mindset where they believe themselves to be an inadequate provider as opposed to a provider who’s not necessarily been exposed to the concept(s) in question. The EMS pedants rarely account for the experience level of the provider or the relevance of the information to EMS practice. Rather, everyone who doesn’t master knowledge to the level of the EMS pedant is dangerous, incompetent, and quite possibly doesn’t even like kittens, puppies, and pizza.

You’re going to make mistakes. The truth is that in medicine, unlike the social sciences, there are answers that are wrong. It’s ok to make mistakes. The critical step is to learn from the mistake. Some of us on EMS social media, including me, engage in Socratic dialogues designed to educate and help you learn the fallacies and errors of your position. It’s rarely personal, but rather a way to educate.

On a similar note, expertise IS often a substitute for experience. Someone who’s a physician is going to have a much better understanding of medicine than a new EMT. Likewise, someone who’s an attorney with prehospital medical experience is likely to have a deeper understanding of the law than someone whose legal education consisted of having a PowerPoint presentation read to them. Just like there are wrong answers, there are also people whose expertise and education give them more credence.

In medicine, as in the rest of the professions, there are few absolutes. And the more education one acquires, the less definite the answers become. The absolute rules hammered during a 180 hour EMT course become increasingly nuanced with more education and experience. I’ve always said that, in law, the answer is “it depends,” primarily because of the facts of a case and the laws of the relevant jurisdiction. In emergency medicine, “it depends” is often true — unless you’re an entry-level student or provider who hasn’t acquired the education or experience to appreciate nuance. In those cases, the answers are always absolute and based on dogma.

So, my advice? Get involved in EMS social media. Get messy. Make mistakes. Engage in the dialogue. As the saying goes, good judgment comes from experience. And experience comes from making bad judgment calls. For me, I know I’ve made countless friends, acquired a few mentors, and learned lots. I hope it’s the same for you as well.

Filed Under: EMS, EMS 2.0, EMS Education

When We Are Called…

Posted on March 22, 2016 Written by theambulancechaser

I spend a lot of time griping about the things that I see wrong in the EMS world or things that we could improve upon. It’s probably part of my nature as an attorney to look for the negatives and the risks in life.

Today is not one of those days, though. I want to say something that we in the public safety world do right. Namely, when we’re called, we come.

Last night, I received a Facebook message from an old EMS friend who’s no longer in EMS. She has a three year old nephew who’s been admitted to Texas Children’s’ Hospital in Houston. He had a reaction to an antibiotic that continued to the point of needing more long-term care than just treatment for an allergic reaction. She also told me that he’s fascinated by firefighters and (hopefully also) paramedics. She asked if I knew anyone in the area who’d visit him while he was in the hospital. I said I’d post on Facebook and see if any of my Houston area contacts would help.

Not surprisingly, the post blew up. It’s been shared by multiple people. I’ve heard from fire and EMS professionals all over the Houston area, each of whom only wanted to know the child’s name and room number. Even despite multiple offers from me to repay expenses from the promised patches, t-shirts, and toys, I was rebuffed. (On a humorous note, I might need to retract some of my previous rants about people asking for free legal advice. I may need to be repaying it forward again…)

I’ve heard from all sorts of people at all levels of the fire and EMS world — flight medics, chiefs, firefighters, paramedics, EMTs, etc. Each of them did what we do best — when we hear about someone in need, we drop what we’re doing and we go help the best that we can.

The response, while not surprising, has made me incredibly proud to have previously worn the uniform of the fire service and to still be wearing an EMS uniform. There are not a finer group of people than the men and women of public safety in Texas. Firefighters, medics of all certifications, and our peace officers. Today, I’m just a little prouder of who we are and what we do.

I’m far from religious and Christianity isn’t my faith tradition, but a verse from the Book of Matthew seems appropriate here. “I was sick and ye visited me.” Thanks to each of you for visiting this sick child; visiting the sick and injured on every shift; and reminding me again of why what we do each and every shift is a special gift from the deity of your choice. Thank you all. I truly believe I’m a better person for having earned my Texas paramedic patch — largely because I get to spend a few days a month with each of you.

And if I haven’t said it enough here: I’m proud of our Texas firefighters and medics. (And yes, the cops too.)

Filed Under: EMS

Part of Being a Professional

Posted on March 15, 2016 Written by theambulancechaser

There’s a lot of debate on what EMS is, including whether it’s a profession. Some would say that we are; some would say that we aren’t. Personally, I think that we have the potential to become a profession, depending on some decisions that EMS collectively makes, especially regarding education and entry into EMS.

But there’s one thing that I’ve found is a hallmark of some of the traditionally accepted professions, such as law and medicine. Namely, we recognize that our patients/clients have autonomy — in other words, the right to accept or reject our advice in most cases.

In our Anglo-American legal system, people have a legal right to make bad decisions. It’s very rare that we, in any field, can substitute our own decisions and force someone else to do what we think is “the right thing.” It’s a hallmark of the liberties that our country and legal system are based upon. It’s a quick, slippery slope and a short, dangerous trip to allowing the power of the government to intrude on any decision that anyone makes at any time.

So, the next time you think you “know best” when you want to force a patient to accept transport or put them on that backboard because you can, ask yourself what a professional does. You’ll find the answer rarely involves substituting your personal judgment for your patient’s free will.

Respecting your patients, including respecting their free will go a long way toward enhancing professionalism — as well as avoiding meeting legal professionals.

Filed Under: EMS, EMS Legal, Law

It’s an EMT (or Paramedic) Card, Not a Hero Card

Posted on March 7, 2016 Written by theambulancechaser

Recently, the Internet has “blown up” over the two firefighters who, instead of waiting for an ambulance, put a seizing infant in their engine company and transported to a local hospital. Of course, I wasn’t there and as such, it’s virtually impossible to know everything about the call in question. However, that’s never stopped the attorney (or medic) in me from applying the 20/20 hindsight spectacles.

First things first. Pediatric calls scare all of us in EMS. We rarely have either much training or experience in pediatrics. Combine that with the all-too-natural instincts to panic when there’s a sick child and it’s a recipe for making some rash decisions. Not necessarily a wrong decision, but a rash decision. Most pediatric seizures resolve on their own and those that don’t require ALS medications. Also, the cab of most fire trucks aren’t set up for patient transport and/or treatment. Much like the National Registry exam, much of EMS (and medicine in general) is about choosing the “best” answer to your problem. I can think of very few cases in which transporting a patient in the back of a fire apparatus is the best answer. The legalities of using a vehicle not licensed for patient transport aside, it’s a potential legal quagmire in the event of a bad outcome. The back cab of a fire truck is NOT set up to safely transport a patient, especially a child, much less provide working space (or even equipment access) for a medic to treat a patient. For the overwhelming majority of medical patients, “scoop and run” or “load and go” went out with the Cadillac high-top ambulance. We’re medical professionals. We need to be taking care of business, making good decisions for our patients, not panicking, and then playing the “hero card” when we are held accountable for our decisions.

Of course, like anything in law or medicine, the more you know, the less absolute your answers become. But that’s another topic for another post….

Filed Under: EMS, EMS Legal

It’s Registry Renewal Season

Posted on February 25, 2016 Written by theambulancechaser

And that means everyone is scrambling to get their continuing education hours in. (For the record, mine are done, paperwork is in, and Registry is renewed for another two year cycle.)

But this got me to thinking about continuing education. There seems to be a real conflict between continuing education and refresher. Refresher, at least to me, means a review of previously obtained knowledge. Continuing education, at least in the professional world, implies education designed to expand on previously obtained knowledge. In other words, you’re supposed to be learning about what’s changed in your profession.

And there’s the conflict. Too many of us in EMS see maintaining our certification as merely maintaining our current knowledge base. And it’s so easy to do with a recertification process that makes it easy to take the same card courses and even the same continuing education courses year after year. In fact, if anything, the current process means its actually less of a headache to take card courses than to find the exact courses you need to cover the relevant topics for the refresher requirement. And for most of us, present company included, that’s often a headache we don’t want to deal with.

My solution? Simple. Let’s have a short refresher course on high-acuity, low-volume skills coupled with an update on core topics in EMS care and mandate actual continuing education that expands on, rather than repeats, initial EMS education. There should also be a requirement that continuing education hours not be repeated in multiple renewal cycles. Further, I believe that certain infrequently practiced skills (e.g.: intubation) should be refreshed in a skills lab or clinical environment. (Speaking of which, wouldn’t it be incredible if we had a process for currently certified EMS professionals to go back into a clinical setting to get additional exposure to certain skills to maintain mastery?) And as convenient as it is to have all of the continuing education done in house, it also creates an environment where the education and the presenters become stale. Take the time to truly expand your knowledge base by expanding where you get your continuing education, whether it be from another EMS organization or an EMS conference. While you may not get extra hours of credit, the expanded networking and differing views are guaranteed to make you a better provider.

It’s time for medics renewing their certification to be learning about current medicine rather than rehashing dated medicine — or worse yet, dogma.

Filed Under: EMS, EMS Education

What We Really Are

Posted on January 29, 2016 Written by theambulancechaser

I see a lot of people in EMS who want to be heroes. I see a lot of people in EMS who consider us part of the public safety family. Occasionally, there’s some heroism in EMS. And yes, in many places, EMTs and paramedics are part of the public safety team. I also hear the term life-saving bounced around. I can count on one hand the number of EMS calls where a life was immediately saved by EMS interventions. Lives prolonged? Yes. Lives made better? Yes. Lives saved immediately? It’s a rare occasion.

I have a real concern, though. None of those reflect the day-to-day reality of EMS. In my opinion, after a few years in this field in a variety of settings, we rarely get to be heroes. In fact, if we’re at the point of heroism, something’s likely to have gone really wrong in the course of the call. What we really do is deliver unscheduled out-of-hospital medicine. Our definition of “emergency” often varies from the patient’s definition, but the God’s honest truth is that we’re here for our patients. Period.

Over the last couple of days, I’ve been pretty dismayed by some posts I’ve seen in EMS social media groups, whether by new EMS students or experienced providers. I’ve seen posts advocating “punitive medicine” like ammonia caps and dropping the patient’s hand on their face to determine if the patient is “faking” a seizure. I’ve seen other posts asking how to identify “drug seeking” patients so that a provider can hold back pain relief. I’ve seen posts advocating that EMS providers be allowed to decide who gets to go to the emergency department. And I’ve seen posts by supposedly experienced paramedics advocating “just taking the patient to the hospital” rather than performing a complete assessment and providing treatment all because the hospital is close.

I get all of these complaints. I really do. We’ve all been on the shift where the calls keep coming and it seems like no one really has a supposedly legitimate emergency. I’ve complained. I’ve griped to my colleagues. And I try not to let it impact what I’m doing as a medic.

The reality is that we may be public safety heroes who save lives — occasionally. But what we truly always are is professional caregivers. Part of the obligation that you have is to suspend your judgment of the patient in order to CARE for them. Even the most malevolent, challenging psychiatric “frequent flyer” has issues that we’re not going to be able to understand, much less fix as EMS providers. Our duty is to assess the patient, provide care as we’re educated to, and get them to an appropriate destination to address their concerns. When we start embracing the care aspect of the job more, we’re going to have less burnout, better outcomes, and probably some happier EMS professionals. Until that point occurs, I’m concerned — because I’m seeing what people think is acceptable. Ask yourself if that’s how you’d want your family treated or if you’d be proud for the local news media to showcase your last call.

It’s time for all of us in EMS to take a look in the mirror and see what we’re becoming. I, for one, am not sure that this what any of us should accept or condone. We can do better. I know because I’ve seen us do better.

Filed Under: EMS, EMS 2.0, Rants

You Don’t Understand What We Do

Posted on January 26, 2016 Written by theambulancechaser

One of the recurring things I see with EMS memes and t-shirts is the theme that “you don’t understand what we do.” This sentiment is usually expressed along with some gory or chaotic EMS scene intended to show just how hard and heroic it is to be an EMT or a paramedic. Funny how these scenes never show the more mundane dialysis transfer or posting the ambulance at an intersection. But I digress. Being a medic, I understand the realities of EMS, especially the unpredictability, the inability to know what will happen next, and yes, even the occasional chaos.

Last night, a good friend of mine who’s been around EMS for a while told me about an encounter they had with an older medic they occasionally work with. My friend was explaining and sharing an article about the Folstein Mini-Mental Status Exam, its applicability to EMS, and how the standard chart notation of “A&OX4” for alert and oriented times four is rather insufficient, especially in the legal setting as it is conclusory and often lacks further context or explanation in the medic’s chart. The other medic, let’s call him T-Rex, because he approaches dinosaur level knowledge, argues that he’s been to court multiple times and no attorney has ever challenged him.

Let’s stop right there. Putting my lawyer hat back on, I can, with a pretty high degree of certainty, tell you why no attorney has challenged T-Rex on his documentation. The documentation of “A&OX4” is not relevant to what the attorney is asking about. I’ll further surmise that, fortunately for him, he wasn’t the defendant a lawsuit in which the patient’s present mental capacity was a key part of the plaintiff’s claim. In such a case, I can assure you that the questioning from opposing counsel would have taken a much different tone. Additionally, the questions that the lawyer asked would have most likely been guided by an expert witness or two with knowledge of EMS. The experience of being examined or deposed by opposing counsel is rarely a fun experience, even when the lawyer comes across as being friendly. Nay, especially when the lawyer comes across being friendly. The probing nature of the methodical examination and questioning of each and every aspect of everything you did on that call is the mental version of a simultaneous colonoscopy and root canal, both of which are occurring without the benefit of pain management or sedation.

So, my dear EMS friends, I ask you this. Don’t presume to understand what a lawyer does, why they do it, or how they do it. Having had the benefit of law school, I can assure you it’s as foreign of an experience to an EMS provider as the work of an EMS provider is to an attorney. We just don’t have “cool” t-shirts or memes to tell you how awesome it is to be an attorney or how you don’t understand what an attorney does. Maybe I should get some t-shirts printed up with Tom Cruise saying, “I want the truth!”

Until the t-shirts get printed, here’s hoping that each of you never have to find out exactly what it is that a lawyer does or how we think.

Filed Under: EMS, EMS Legal, Law

Opining on Protocols

Posted on January 22, 2016 Written by theambulancechaser

As Bill O’Reilly says, if you must opine, keep it pithy. I may not be pithy, but I must opine. Lately, I’ve noticed a recurring trend on EMS social media when discussing protocols. Namely, people are convinced that deviating from protocol makes you immediate prey and fodder for attorneys. Well, that’s simply not true.

Here’s some good news. First, most attorneys aren’t that interested or knowledgeable about EMS and what we do. Second, while deviating from your protocols may well get you in trouble with your medical director and/or your bosses, it’s not going to make you automatically subject to a lawsuit.

Let’s discuss that a bit further. Most claims against EMS for a bad outcome are going to be based on negligence. I’ve discussed negligence before, but as a reminder, the four elements are a duty to the patient, a breach of that duty, causation of harm, and damages. So, in order to prove a negligence claim based on a breach of protocol, one must first prove that deviating from protocol breached the duty to the patient. In other words, the plaintiff is going to have to prove that the protocols represent the current standard of care. In many cases, many EMS systems have outdated protocols that do not represent the standard of care. For example, look how many EMS systems still backboard the majority of trauma patients or require high-flow oxygen for all patients. In the case of high-flow oxygen for cardiac and stroke patients, the current science in fact reflects that high-flow oxygen actually harms patients. Next, the plaintiff will have to prove that the deviation from protocol caused harm to the patient and that the harm caused damages. That’s a high burden to overcome. In other words, the plaintiff is going to have to prove that what you did or didn’t do was the reason there’s a bad outcome. Especially in critical or high acuity patients who had a bad outcome (IE, death), there’s often an argument to be made that, no matter what EMS or other medical providers did, the patient might have died regardless. The reality is that we just aren’t going to get every patient back.

And let’s consider one other thing about protocols. Sometimes protocols are blatantly wrong and following them is just as wrong. Let’s pretend that your protocols suggest you administer a clearly incorrect dose of medicine. Blindly following them does not shield you from liability. As a trained medical professional (which is what we’re all striving to be), you have an obligation to clarify and/or refuse to follow a clearly wrong order. The “just following orders” defense went out with the Nuremberg trials at the end of World War II and remains just as legally and morally invalid as it was then. If EMS providers want to be considered as the professionals we should be, then we can’t hide behind the doctors’ lab coats when we’re practicing medicine that is clearly wrong and/or harmful.

Of course, nothing here constitutes legal advice. I’m just trying to clarify and educate here. If you’re that worried about the attorney boogeyman, your time and money would be better spent on buying EMS professional liability insurance and/or consulting with a lawyer admitted to practice in your state. Sadly, I’m afraid that some of the people most worried about the legal boogeyman would rather spend their time repeating legal myths and dogma they heard third or fourth hand in a war story during their initial EMT class’s medical legal lecture.

In conclusion, the law is a complex and nuanced topic that is dependent on the statutes and case law of the particular jurisdiction as well as the facts of the case. That’s why those who’ve attended their one mandatory medical legal class have absolute certainty in their wrong answer and why attorneys with three years of law school after four years of undergraduate education say, “It depends.”

Filed Under: EMS, EMS Education, EMS Legal, Law

About Nightwatch

Posted on January 17, 2016 Written by theambulancechaser

Earlier today, I was reading a post on Facebook from Titus Tero, one of the paramedics featured on A&E’s reality show Nightwatch. I’ve watched the show several times. The paramedic in me occasionally winces at some of the clinical and operational aspects of the show. Of course, like a color commentator on a football game being telecast, I’m always happy to critique the events play-by-play. That’s just human nature and doubly so for an attorney and paramedic.

However, there’s one thing I can’t fault about Nightwatch and the crews they follow around with a camera. Namely, they treat every patient with dignity, respect, and dare I even say, a bit of love. I’ve always believed and often say that the overwhelming majority of our patients don’t know how good our care is (or isn’t). However, every patient is perfectly capable of figuring out if their medic(s) gave a darn about them. I’d say the same is true of the overwhelming majority of viewers of Nightwatch. They don’t know whether New Orleans EMS is a great system or not. They don’t know the current science on spinal motion restriction nor the current use of CPAP devices. What they have most likely figured out from watching Nightwatch is that if you call 911, you’ll most likely get caring medical professionals. That’s the legacy that Johnny and Roy left with my generation from Emergency and EMS and the fire service have reaped the benefits ever since.

So, to the ladies and gentlemen of Nightwatch, I thank you for faithfully representing the EMS profession with the care and passion that we all strive to deliver daily. The truth be told, I’m not 100% sure I could always live up to those standards every day, every time, especially with a TV camera following me. You’ve done our profession a great service.

Filed Under: EMS

At the very least.

Posted on January 5, 2016 Written by theambulancechaser

I was talking with a local college EMS faculty member about determining the right hospital choice for the right patients. She rightly pointed out that emergency physicians routinely deal with patients who are brought to the hospital by themselves, family, or friends.

Here’s my premise about what we do as EMS professionals, especially as it relates to taking the right patient to the right hospitals for the right conditions: We need to be doing a better job for our patients than transport via private vehicle.

Whether it’s assessment, destination determination, treatment, patient advocacy, or patient comfort, our goal needs to be that we’ve done a better job, each and every time, than the patient would have from getting a ride from family or a friend.

It’s arguably a low standard, but I’d argue that we aren’t hitting that standard all of the time. And until we do, it’s hard to justify the existence of EMS. Whether it’s the bean counters who balk at the price, the “policy experts” who balk at the outcomes, or the customer satisfaction gurus who do the patient surveys, EMS is doomed until we can prove, consistently, that patients do better with EMS than without.