Shake and Bake Disaster

I've made no bones about the fact that I think EMS is in trouble here in Massachusetts.

Until now, I've directed my opprobrium squarely at the people running the show here in the Commonwealth.

But sometimes we do it to ourselves.

An EMS "training" facility (and I use that term loooooooosely) is advertising a 20-day EMT-Basic course.

Let that sink in for a bit.

20 days.

Not even a month.

Not even 75 percent of a month.

How many other states in this country can you be, say, waiting tables at a Chili's today and in less than three weeks be listening to lung sounds?

Worse still, if the Powers That Be in Boston have their way, that same EMT graduate of almost 21 days of hard training will also insert an advanced, invasive airway device like the King LT.

It's a Shake and Bake disaster waiting to happen.

20 days....advanced airway devices.....some days it's enough to make me want to do something else for a living, and remove the numbers "9" and "1" from the phones of people I love.

Epi-cally Stupid

I'm going to make this short and sweet because I've got other things to do, and if I let myself go I'll rant for hours and hours.

Consider this an open letter to Massachusetts OEMS:

Dear Sirs/Madams:

I understand that Paramedics in Massachusetts are no longer allowed to draw up their own initial doses of Epi 1:1,000 nor administer them with traditional SQ/IM techniques, but instead must use EpiPens. I also understand that while we can still draw up our own follow-up doses, we must first contact Medical Control and get a Physician's permission.

From the scuttlebutt amongst us lowly providers, this is the result of a half-dozen to a dozen (depending on who's telling the story) instances where paramedics (who don't deserve capitalization in this case) have mistakenly administered said 1:1,000 through a peripheral IV, with adverse outcomes.

My question is two-fold:

1 -- why are you restricting the practice of all Paramedics, 99.9 percent of whom DID NOT make this error?

2 -- why are the 12 or so IDIOTS who did make this life-threatening mistake still allowed to work in Massachusetts?

Wouldn't it make more sense to re-educate or de-certify the offenders rather than dumb-down an entire profession?

Did anyone also consider what this means for our patients, who will now have to suffer the consequences of both paramedic blunder and bureaucratic overkill?

Having had injections by SQ/IM and autoinjector, I can tell you that a properly administered SQ/IM injection is FAR LESS painful than the spring-loaded delights we now must jam into our patients.

I implore you to undo this rule change and aim your sights instead on the knuckleheads who deserve it.

Thank you.

CMM

Primary Source

I post this item below for no particular reason other than it made me chuckle. A couple years ago a buddy of mine who works as a cath lab RN asked me what a typical night was like in The Big City.

While searching my email account for something else today I found my answer, archived for posterity by the fine folks at Yahoo Mail.

It gave me a chuckle. I left MegaHospital EMS not even a year ago but already I'd started becoming nostalgic for the job.

Not every shift involved so many inebriated or sad patients, but every shift involved at least a few of each.

This email was a nice reminder that it wasn't all wine and roses.

When you read this, keep in mind that there are guys and gals who've lived like this for 10, 15, even 20+ years, and yet are able to practice Paramedicine at a high level.

My hat's off to them. I can't think of many tougher ways to make a living!

"So it's almost 3 a.m., which is when my shift ends.

Here's what tonight was like for me at [MegaHospital EMS]:

Arrive at 5 pm, get narc keys, radio and perform quick check of truck.

Attempt to get dinner but am immediately sent out to pick up a drunk instead.

Try to get dinner three more times but am sent out for two drunks and a psych.

Eat cold, slimy slice of what I think is spinach and feta pizza at Worcester Med.

Listen as two other trucks get sent out on a code and pedi respiratory arrest.

I do LB instead, the world's most notorious drunk.

Watch four minutes of the Red Sox, go for the psych.

Then get sent to a code that turns out to be a long-dead drug dealer (complete with video camera monitoring system of his entire street) who sampled too many of his own wares.

Spend 45 minutes there, get to enjoy full metal familial meltdown when the dead guy's entire family shows up to profess their grief at 1,000 decibels, although judging from the pharmaceutical paraphernalia and stacks of cash being inventoried by the cops, this outcome can hardly have been a surprise.

Go out for two more drunks.

Try to get midnight snack, instead help an attractive, 18-year-old mildly drunk girl into her brother's car for a ride back to the 'burbs and the comfort of mommy and daddy's glorious McMansion.

She grabs my ass twice and pukes on my boots, so kind of a mixed blessing there.

We then take a well-known psych who's hearing voices that seem to sound EXACTLY like mine, then win the Double Jeopardy round by getting sent out for the person both drunk AND psych.

Top off the shift by breaking up a fight in the middle of Main Street between two drunk personages of Caribbean descent apparently angry with each other's driving habits.

Dinner never achieved.

Currently 42 hours with less than 4 hours sleep total.

Total caloric intake: One slimy piece of pizza, species unknown, believed to be vegetable. One Baby Ruth. One Snickers. Seven cans Diet Coke. One oatmeal creme cookie. Four Graham crackers and a jello stolen from the nourishment center at [MegaHosptal].

I come for the glory, I stay for the pampering........"

Slouching Toward Mediocrity

So we finally got Solu-Medrol on the ambulances here in Massachusetts.

It's a drug I used often in Connecticut once upon a time, to excellent effect on a variety of respiratory ailments. I don't care what the experts say, I've seen Solu-Medrol work its magic in under 10 minutes, and have always felt it was a missing piece in the Mass Paramedic armamentarium.

So now we have it.

This being Massachusetts, though, that sound you're hearing is the deafening shriek of someone standing on the brakes.

Why?

Here is the list of approved uses for Solu-Medrol, according to the most recent Statewide Treatment Protocols (Official Version # 8.03, Effective 3/1/2010) --

Anaphylaxis, asthma, spinal cord injury, croup, elevated intracranial pressure (prevention and treatment), as an adjunct to shock.

Pretty impressive, right?

Guess how many of those conditions Paramedics in Massachusetts will have the option of using Solu-Medrol to treat?

NONE. Nada. Zip.

Sadly, there is but one instance under which a Paramedic in the state of Massachusetts can call a physician and beg permission to administer Solu-Medrol: Known adrenal insufficiency.

True, Solu-Medrol can be a life-saving intervention for someone with adrenal insufficiency, where the namesake glands, located just behind the kidneys, fail to produce the cortisol and aldosterone which is critical to maintaining blood pressure, sugar and salt balance, and heart muscle tone.

Essentially the body loses its ability to handle stressors (in crisis, a normal person's adrenal glands can pump out up to 10 times their normal cortisol production; those with AI cannot), and the condition can be fatal.

Surely, for these people, having Solu-Medrol on the ambulances will be a life-saving development.

But the Office of Rare Diseases at the National Institutes of Health officially classifies adrenal insufficiency as a "rare" disease, meaning fewer than 200,000 people are affected by it.

That's 200,000 people out of a US population of about 300,000,000.

Locally, only about 3,800 people in Massachusetts have known adrenal insufficiency, or a little more than 10 people per town statewide on average.

Contrast that small patient population, for whom we have permission to treat (or, anyway, at least the permission to ask permission), to the vast population of respiratory patients who might also benefit from Solu-Medrol but who will not be afforded that opportunity.

It seems patently unfair, but I'm sure the experts have their reasons, and some day one of them may deign to enlighten the rest of us.

Until then, I'll keep scratching my head as I slouch toward the mediocrity that's being forced upon me, failing to understand the rationale behind carrying 375 mg of Solu-Medrol to treat a patient population I might see two, maybe three times in a decade, even though I see a dozen patients per week who might also benefit from the drug but to whom I must deny it.

Next Week: Epi-Pens, or, Why The State Is Punishing All Paramedics And Their Patients Instead of De-Certifying The Idiots Who Don't Know The Difference Between 1:1,000 And 1:10,000.........