Stop The Presses (Yet Again)

Ok, remember how in cardiac arrests we used to do CPR until you had the pads on, and then we would stop to analyze the rhythm?

And then remember a few years ago we were told that we needed to do uninterrupted CPR for two minutes before we did ANYTHING?

Well, now it turns out that, at the least, the latter is no more beneficial than the former, and at worst, may be hurting our patients.

Evidence-based medicine is only as good as the evidence that begets it.

Now someone bring me MAST trousers and an amp of Bretylium....

http://www.jems.com/article/news/prolonging-cpr-doesnt-help?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+jems%2Fthelatest+%28JEMS.com%3A+The+Latest+EMS+News+%26+Features%29

EMS's Own Silent Epidemic

A simple question from the "Why Do We Do This?" File:

Why do 911 ambulances transport stable, uninjured psych patients who have no medical or toxicological complaints?

It's never made any sense, and recent injuries to good friends of mine in the field have only highlighted my disdain for the practice.

A friend of mine just learned today that he's out of work for another week, making four total, due to a back injury incurred lifting a stretcher on which was loaded an angry psych patient -- who had no medical complaint, other than being angry. This patient decided to lunge, without warning and at the exact perfect moment during my friend's lift, and now he's been off the job for a month. He has a mortgage and several small children to feed on a Paramedic's salary, so you can imagine what this is doing to his financial security.

And for what?

FOR NOTHING.

There was no compelling reason for this patient to go anywhere in an ambulance. Indeed, given the patient's state of mind, she would have been far safer in the back of a police cruiser, in handcuffs if need be, applied by a law enforcement officer with the authority and training to restrain this person.

For EMS personnel, psychs represent nothing but risk.

We aren't allowed by law to restrain them, but they turn violent so often that we are often left with no alternative.

There is no medical problem for us to attend to, and the minimal training we get in EMS for responding to psychiatric emergencies is laughably inadequate.

In my opinion, the number of EMS providers significantly injured on the job by psych patients is a silent epidemic that for some reason is talked about only on ambulance docks, or in crew quarters, or on the bus.

I have yet to work for an EMS agency that really addressed the issue, or even mentioned it in passing.

In the 17 years I've been in EMS, I've been injured exactly once -- by a psych patient who, for no reason and completely out of the blue, scissor kicked me in the chest as I was getting her settled on our ambulance stretcher.

I suffered an agonizing month with costochondritis, a painful injury that made attempts at sleep excrutiating and deep breaths impossible.

And because I couldn't afford to take the time off from work (due to my own mortgage and legion of mouths to feed), I kept the pain to myself and suffered in silence until the injury healed itself.

How many millions of dollars a year are wasted in EMS on time lost to injury due to violent psychiatric patients?

These patients rightly belong to the police.

They have the authority and the means to safely restrain these patients, and the backseat of a police cruiser is a far more secure environment -- with its cages, Lexan glass and doors without handles -- than the patient care compartment of an ambulance, with its myriad of options for escape and self-injury.

I understand completely that most police officers are going to be resistant to the idea.

And while I respect those folks and have many friends in law enforcement, I say it's time for that particular branch of public safety to step up and assume this role that so clearly belongs to them.

Suffer A Child

We decided she was about 8-months-old, and that seemed in line with the Broselow Tape, which put her weight at around 10 kg.
Her injuries weren't horrific, although the skull-deep laceration that ran from the top of her head to just between her eyes looked pretty dramatic.
But her loud wailing and vigorous movement led us to believe that our inability to find any other injuries was probably the right assessment.
Even if we could have found a broken bone or more cuts, it's most likely that the worst injuries are ones she won't know for a few years at least.
Because while my partner and I tended to this pretty little girl in the back of some random roadside ambulance, a couple hundred yards away her mother had died in an accident that left the first-arriving EMS crews so unnerved that their hands still shook.
I don't know what other family will be there for our patient -- hopefully a large and loving clan that will give her a chance at some semblance of a normal life.
When we got to our destination -- one which I'd love to name, but can't due to privacy laws -- I was impressed at the compassion of the trauma team.
They moved with the usual sense of purpose, but it seemed like each member who came into contact with the little girl took a moment to coo at her, or tell her how pretty she was, or cover her with a warm blanket, even if for just a moment.
And it gave me hope.
This job can make you cynical and hardened. It can take away your humanity, if you let it.
But at other times, you can see how it brings the best out in people, and give you hope even for the smallest and weakest among us.
I witnessed a tragedy today, and I witnessed sublime compassion.
I am going to go home after this shift, and I am going to thank God for what I am privileged to do for a living.

A Challenge Bigger Than A Marathon

Marathon Monday was yesterday.
That's the Monday each May where more than 30,000 aspirants gather on Hopkinton's town common hoping to join the hundreds of thousands of runners through history who have earned the title of "Finisher" of the Boston Marathon, the world's greatest road race.
Yesterday my buddy Pat Purcell, of Westborough Fire Department and Worcester EMS, once again successfully navigated the 26.2 miles from Hopkinton to Boston.
I've run Boston with Pat five times, although I took this year off.
Before that, the last year I didn't run was 2005.
Pat finished that year, though.
After trekking from Hopkinton to Boston in a sun that beat down with an ungodly heat that turned the final 1/4-mile slog to the finish line into a concrete oven, Pat received his medal and continued running to Children's Hospital, where he visited me and my son Brendan in Brendan's room on the hospital's 9th floor.
Pat had run the marathon that day in honor of Brendan, and presented him with a Dana-Farber Marathon Challenge medal in his hospital bed.
Brendan was suffering from a malignant brain tumor known as medulloblastoma, and at the time was in the middle of a grueling run of chemotherapy treatments. In the preceding days he had done little more than lay in bed and struggle to breathe.
But when Pat arrived to visit, Brendan stirred and accepted the gift with the closest thing to excitement his broken and battered body could muster. If you didn't know Brendan, you wouldn't realize how much Pat's gift meant to him, but my wife and I did, and we've never forgotten.
I don't know how many years now in a row Pat Purcell has labored to complete the 26.2 mile Boston Marathon on behalf of the Dana-Farber Cancer Institute, or how much money he has raised ($50,000? $100,000?)
I DO know that because of the money raised each year by Pat and hundreds of people like him, the scientists and clinicians at Dana-Farber are making incredible gains in the fight against cancer.
And I know that those gains are the reason I was able to play catch with Brendan and his brother Kevan today, and why Brendan is a happy, healthy 8-year-old 3rd-grader.
I also know that there are still far too many kids who won't have success against cancer, and that the battle goes on.
So while I didn't raise money this year, I figured I'd take an opportunity to appeal to readers of this blog to perhaps consider a donation to Pat Purcell's Dana-Farber fundraising page.
Simply follow the link, and click on "Support A Runner" on the right hand side of the page. Enter "Pat Purcell" for the name, and it will bring you to his page.
I thank from the bottom of my heart anyone who is able to donate. The battle is a long way from over, but every dollar brings us a little closer to victory.

Is CPR As Effective As We Thought?

Dr. Bryan Bledsoe has made a career of challenging assumptions with the pesky tag team of facts and the scientific method. I found this article about another Sacred Cow -- in this case, the foundational belief that it is CPR alone that saves lives in cardiac arrest -- very interesting reading.

Repeal AR 2-260

Why do bureaucrats need to be watched?
Here's a great example:
MDPH/OEMS AR 2-260.
What's that, you ask?
Well, besides being some state bureaucrat's desperate attempt to justify their job (a job which otherwise could go away tomorrow without the slightest effect on prehospital care whatsoever), it is also the latest burden on EMS providers and taxpayers foisted upon us in last fall's sneak attack on EMS.
What AR 2-260 does, besides evoke the Orwellian nature of our state OEMS, is to require that all EMTs and Paramedics -- most of whom are already working 50 to 80 hours a week at multiple jobs in order to put food on the table -- take 4 hours out of their lives to attend a lecture to learn things they A) already learned in school, B) already do on a daily basis, and C) also re-learn in the respective ALS and BLS refreshers that they are forced to take every 2 years in order to keep their certifications.
The regulation requires ALL EMTs and Paramedics take an initial 4-hour course on how to work together, THEN repeat a 2-hour version of said course every other year.
If you're an EMS provider in Massachusetts, it's another 4-hours the state wants you to waste jumping through pointless hoops.
If you're a Massachusetts taxpayer, it's just a few more hundred thousand dollars that will be wasted every year, since, believe me, any EMT or Paramedic working for a municipality or the state isn't going to attend this course for free.
I know I'm not.
AR 2-260 is a response to the debacle that was quietly adopted last November (when everyone was thinking about Thanksgiving dinner and Christmas shopping) in which ALS ambulance services are no longer required to seek permission to staff their ALS ambulances with a single ALS provider.
Prior to the change, ALS ambulances in Massachusetts were required to have two Paramedics in order to work at the ALS level, although with a state-approved waiver they could staff ALS ambulances with a single Paramedic and an EMT partner.
In reactionary, knee-jerk fashion possible only in Massachusetts or some similarly dysfunctional banana republic, someone in Boston decided that this new regulation -- which goes into effect literally decades since Paramedics and EMTs began working together -- will result in a knowledge gap.
Apparently, these same people don't realize (or forgot) that there ALREADY exists a 4-hour Paramedic Assistant class for EMTs to cover the things with which they can legally assist a Paramedic.
Now, thanks to AR 2-260, Paramedics ALSO have to take a 4-hour class to learn how to work with EMTs, which I COMPLETELY don't understand because you can't work as a Paramedic without ever having been an EMT, so what exactly am I expected to learn?
Other than 6 hours of pay for drooling my way through a 4 hour class, what am I supposed to get from this?
Of course, I'm asking the wrong question, because this has nothing to do with how Paramedics or EMTs or the patients and taxpayers we serve will benefit from this, it's all about a bunch of hacks sitting in a room hunt-and-pecking their way through another Microsoft Word document of meaningless bureaucratspeak in a transparent attempt to justify their employment.
Ok, still doubtful? Think I'm just ranting again?
Here is the course outline.
If you're an EMT or a Paramedic and need help with any of the below, please raise your hand and I'll send someone around to hit you in the head with a tack hammer.
Students (because that's how OEMS refers to participants in this class, not "professionals") will:
- demonstrate use of a BVM, OPA/NPA, nasal cannula, non-rebreather (NB: does anyone really, seriously need any help with this?)
- identify intubation equipment
- appy cricoid pressure
- ventilate with a BVM
- identify an Easy-Cap ETCO2 detecting device
- identify a Combi-tube, King LT, LMA, CPAP device, Bougie ETT introducer
- identify signs/symptoms of hypoxia (NB: well, I worry about whoever came up with AR 2-260; they seem a little oxygen-deprived)
- state causes of false readings on SpO2 and CO monitoring devices
- turn on cardiac monitor, place leads properly (NB: my God, they've discovered my personal shame; all these years and I don't know how to push a button or where those sticky things go)
- access the monitor's archives function
- spike an IV bag
- prepare tape for securing an IV (NB: seriously, I'm not making this up. You're going to be evaluated on this. Ok, let's cover this whole section now -- folks, the sticky side goes against the patient)
- identify an IO device
- state meds allowed to assist/administer, include indications/contraindications
- demonstrate ability to properly administer BLS medications
- identify indications/contraindications for albuterol use
- put a neb together
- properly use a glucometer (NB: Yup, YOU need to take a class to learn how to use a device that my Nana uses, and which is currently on-sale for $9.99 at CVS)

Folks, if you need a 4-hour class to learn this stuff, and have failed to demonstrate said knowledge during your initial training, your state-mandated testing, your biannual state-mandated refresher training, or to the satisfaction of your daily employers, then you don't need to be working in EMS.
There is NO RATIONALE whatsoever that justifies forcing yet another redundant class down the throats of this state's already overworked, under-paid and under-appreciated EMS workers, and there's NO JUSTIFICATION for extracting another few hundred thousand dollars from the pockets of taxpayers (who will have to pay overtime for municipal employees forced to undergo this training) already straining under the burden of the worst economic conditions since the Great Depression.
I'm calling for no less than the complete repeal of AR 2-260.
Of course, OEMS isn't going to listen to us, so we need to take this to their bosses.
I urge everyone who is against wasting time and money on nonsense to write their state Representatives and Senators and complain about AR 2-260.
I would start with the Joint Committee on Public Health at the state legislature.
Email state Sen. Susan Fargo at susan.fargo@masenate.gov, and state Rep. Jeffrey Sanchez at jeffrey.sanchez@mahouse.gov and register your complaint.
Sen. Fargo and Rep. Sanchez are the co-chairs of the committee.
In addition, I would contact your local state Representatives and Senators, as well as your local city managers or Boards of Selectmen, and let them know about this new financial burden on their communities.

Forget Wisconsin, The Real Threat Is In Rutland

UPDATE: FF Newcomb's case is scheduled to be heard before the Rutland Board of Selectmen this coming Mon., March 7, at 5 p.m. at Rutland Town Hall, 240 Main St. The Professional Fire Fighters of Massachusetts is planning a significant presence there as are firefighters from many local departments, but this issue could have implications for anyone who works for a town or city.



Wisconsin's evil genius, Gov. Scott Walker, and his attempts to fulfill the dream of a couple of Texas billionaire brothers bent on setting the middle class in America back by about five decades is getting lots of press right now.
But in a quiet corner of central Massachusetts, equally sinister moves are afoot.
The Rutland Board of Selectmen is waging war on public safety employees statewide by attempting to deny justly-earned benefits to a dedicated town employee who suffered a career-ending injury serving a town resident in time of need.
By extension, the Rutland selectmen are threatening the livelihoods of tens of thousands of Massachusetts public safety workers who may find their towns and cities, like Rutland, ready and willing to turn their backs to employees injured in the line of duty.
Rutland selectmen are splitting linguistic hairs so finely that Bill Clinton would blush, and targetting a hardworking Firefighter/Paramedic who made the mistake, apparently, of giving his employers an honest effort in the misguided belief that Rutland officials would A) obey the law, and B) uphold their end of the bargain.
Anyone who works for a municipality needs to pay attention to what's going on down Route 122A, because in the end, if what Rutland selectmen are trying to do is allowed to stand, precedent may be set and no firefighter in Massachusetts who goes on medical calls will be protected if injured.
First, a little background:
Paul Newcomb is a 43-year-old Firefighter/Paramedic for the Rutland Fire Department.
I've known Paul for a long time, and can vouch that in addition to being a really good guy, Paul is also a hard-working man that any taxpayer would be proud to have on their town's payroll.
A little over a year ago, Paul was lifting a patient on an ambulance call and ruptured a disc in his back, an injury so devastating that surgeons removed the disc, placed titanium rods in his back and implanted a electrical nerve stimulating device in the hopes he might regain some nerve function in his legs.
Worst of all for Paul -- doctors told him his days as a Firefighter/Paramedic were over.
This was not someone who was looking forward to ending his career. From my own personal conversations with Paul over the years before his injury, this was a guy who enjoyed being a firefighter and a paramedic.
After brooding about the end of his career, Paul eventually submitted paperwork for a medical retirement.
Massachusetts firefighters who are injured on the job are covered under a state law commonly referred to simply as "111F," in reference to its location in Chapter 41 of the Massachusetts General Laws.
Under the law, Paul has been able to collect his regular town salary while awaiting news about his medical retirement.
Once approved for a medical retirement, Paul would be able to collect 72 percent of his most recent salary, as per state law.
But an interesting thing happened on the way to Paul Newcomb's well-deserved medical retirement.
Someone on the Rutland Board of Selectmen had an idea:
How about we defy common sense, ignore the laws we're bound to uphold, screw our employee out of 40 % of his annual income while waiting for the formal medical retirement, and in the process hang every cop and firefighter out in the wind?
Well, maybe that's not exactly a quote, but that's what they're trying to do in Rutland.
See, some esteemed Rutland Selectman, echoing President Clinton's famous question ("That depends on what the definition of 'is' is"), stretched the English language to the limits of credulity, reasoning that since Newcomb was on a medical call and not fighting a fire, and since paramedics aren't covered under a firefighter's medical disability law, Newcomb might not be eligible for a firefighter's 111F benefits as he awaits his medical retirement, allowing the town in the meantime to pay him under its workers' compensation policy, which is a cheaper alternative for the town.
It doesn't matter that Paul was working as a Firefighter/Paramedic when injured. It doesn't matter that he was working on an ambulance run by the Rutland Fire Department. It doesn't matter that 95 % of the work of a fire department in a community like Rutland is ambulance work.
Selectmen figured that if they could make that claim, run it up a flagpole and see if anyone saluted, then they could pay Paul under the town's workers' compensation insurance, saving Rutland some money, but resulting in a 40 % reduction in pay to to a man who'd already sacrificed his health permanently serving a town whose leaders couldn't care less.
This is so ludicrous that the mind barely knows where to begin.
For one thing, Paul's job title was clearly "Firefighter/Paramedic."
Secondly, as part of his job Paul was REQUIRED to perform ambulance duties as part of the ambulance service provided by the Rutland Fire Department.
Firefighter disability retirements aren't reserved only for firefighters injured fighting fires. There's actually a separate chapter of state law for that.
Of course, even a cursory review of medical retirement records (they're not hard to find) shows that few firefighters medically retired due to injuries on the job got those injuries at fires.
I wonder if, even in cities like say, Worcester, which doesn't run an ambulance but does provide first responder duties, would the Rutland Board of Selectmen suggest that a Worcester firefighter who suffered a permanent, career-ending injury while on a medical call is also not eligible for 111F while awaiting a traditional medical disability retirement?
What's going on in Rutland is as much a threat to the livelihoods of firefighters and police officers as anything going on in Wisconsin or elsewhere.
Fortunately, other boards of selectmen have tried to pull similar stunts and have failed miserably. Let's hope this one does, too.
The Rutland Board of Selectmen has scheduled a meeting for March 7 to debate the matter further.
If you want to express your displeasure to them directly by letter or
telephone, here is the address for the Rutland Board of Selectmen:

Rutland Board of Selectmen
Attention: Sheila Dibb, Chairman
246 Main St.
Rutland, MA 01543


(508) 886-4100


http://www.townofrutland.org/

Jumping the Shark

I think we've finally jumped the shark here in Massachusetts EMS.
A committee has recently been formed to tackle a pressing and completely new and unforseen problem here in Emergencyland: The Bay State Edition.
That idea:
We need to make sure we get two paramedics on the scene of some ALS calls in Massachusetts.
("Some," apparently being synonymous with "all," but more on that later)
Those of you NOT currently hitting yourselves in the heads with tackhammers probably don't work in Mass EMS, and thus need a little history.
See, until recently, the state required that all ALS units be staffed by two paramedics.
Ergo, all ALS calls were serviced by two paramedics.
Then at the behest of people looking to either minimize expense, maximize profits, or both, those regulations were watered down so that, with the state's blessing, some services could operate an ALS unit with only one paramedic on-board, partnered by either an intermediate or basic EMT.
Not a great set-up, but the system had adapted, made peace with the arrangement.
THEN, this past Thanksgiving season, quietly and under the cover of darkness -- WHAM! That regulation was thrown out the door competely by the state legislature under the guise of planning for the next flu epidemic (you know, like the one we DIDN'T have last year) so now, in Massachusetts, all you need to have an official ALS unit is a single paramedic on-board.
So next time you call 911, try not to think about the fact that you're relying on the emergency planning accumen of a bunch of state reps and senators who can't balance the state budget, keep promises to roll back the income tax, or build a tunnel without going 15 times over budget.
As the various boards and committees left picking through the wreckage wrought by our elected overseers begin their work, one of their missions is to figure out A) do we need two medics on ALS calls?, and B) if so, which calls, and C) how the heck do we do THAT?
Now, I'm in favor of dual paramedic staffing, but not for the typical reasons.
I concur with the forces calling for single-medic ALS units who point out that there is very little evidence in the medical literature that dual medic units produce concrete improvements in patient outcomes.
There has even been some conjecture that state data indicates patients treated by dual medic units have fared worse, if the number of complaints generated by dual medic units vs. other configurations are an indication (which I don't think they are).
I also concur that the calls two paramedics are legitimately needed for are few and far between.
But I support the dual medic configuration for two reasons:
1 -- although it is a consideration that I am sure that those in charge of our profession could care less about, I think dual medic is a better configuration for the two paramedics themselves. Like my Nana always said, many hands make light work. Two medics on an ALS unit allows for perfect distribution of labor, and, I would argue, happier employees. Anyone who's ever worked P-B as the medic knows the joy of a shift consisting of three chest pains, a shortness of breath, a hypoglycemic and one sad person. Good shift for the basic, bad shift for the medic. With a two medic system there's no debate or worry over who does what, you just split the calls down the middle
2 -- I think skills dilution is less of a problem with dual medic ALS units. If every ALS unit were forced to consist of two medics, that would by necessity cut down on the total number of ALS units even while the total number of calls stays constant, meaning more medics would see more sick patients.
Of course, this being Massachusetts, we're working diligently on applying a $1,000 solution to a $10 problem that we created in the first place.
The current proposal, as I understand it, would call for a second ambulance to be dispatched to certain ALS-level calls, although from my early perusal of the list of qualifying chief complaints, pretty much ANY ALS call would get a second ambulance dispatched to it.
This might not be much of a problem in urban systems with ambulances to spare (all you city guys try not to spit coffee out of your noses when you read that -- that stuff'll burn...), but what happens in my neck of the woods, in the suburban-rural interface?
As I understand it, any ALS call would have to involve multiple communities, leaving two towns unable to adequately provide ambulance service, instead of one.
And who's going to pay for the increased cost of call-backs at local ambulance and fire services to cover while the primary ambulance crew is chasing down yet another chest pain in a neighboring town?
My guess is that certain folks think amending the new law with these regs might in some way aid the wet dream that is regionalization.
I think regionalization is by far the best model for EMS delivery, but I am a lifelong Massachusetts resident, and thus know better than to believe in Santa Claus, the Easter Bunny, and statewide regional cooperation.
This is a horrible idea on so many levels, unless of course you think that what the EMS system in Massachusetts needs is additional complexity.
Just stop the madness and put two medics back on the bus.
Jumping sharks is dangerous.