CENTRAL MASS MEDICS

Stop The Presses (Yet Again)

2011-09-02T09:48:00.000-07:00

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

2011-07-11T14:27:00.000-07:00

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

2011-04-30T14:38:00.000-07:00

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

2011-04-19T18:07:00.000-07:00

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?

2011-04-02T05:18:00.000-07:00

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

2011-03-11T07:19:00.001-08:00

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

2011-02-26T08:12:00.000-08:00

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

2011-02-22T18:47:00.000-08:00

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.

All Are Born Mad

2010-10-31T12:29:00.000-07:00

If you've read this blog for any length of time, you know I believe we c-spine waaaaaaaaay too many people.
The procedure is one of our Sacred Cows in EMS, and we do it with abandon.
5 mph fender-bender with no visible damage to either car? Board 'em!
Drunk college student trips and lands hard on their bum? Board 'em!
Nana Noodles farts? Board 'em!
Why do we do it so often?
Sometimes I think it's from an over-abundance of caution.
Rarely because it seems like it's in the patient's best interest.
But most often I think it's another example of the CYA-based medicine we are forced to practice in this state, because we all know how reluctant the Powers That Be would be to make any medic or EMT's life miserable if, from Boston and after the fact, it were deemed a mistake to not c-spine a particular patient.
(Note: and if you're wondering, the answer is "not at all reluctant." Plenty of good medics and EMTs have felt the wrath of the almighty bureaucracy here)
I wrote a post a few months ago that talked about a study that showed that placing c-collars on the few patients for whom they are actually made could contribute to their deaths.
You can read that post here.
In another study that highlights why working in EMS in Massachusetts is like being trapped in a perpetual production of "Waiting for Godot," ("All are born Mad, some remain so"), earlier this year The Journal of Trauma reported on some interesting -- and disturbing -- findings regarding penetrating trauma and c-spine immobilization.
Before we review the results of the study, let us think for the moment what hell would befall any medic or EMT in this state who showed up in the trauma bay with a patient with a gunshot wound to the chest without c-spine immobilization.
The folks in Boston would undoubtedly unleash an investigation for the ages, and certainly a suspension and lots of "re-training" would follow.
But what the Journal study points out is that those medics and EMTs probably deserve a medal for doing -- or not doing, actually -- what the evidence, rather than a protocol book, says is in the patient's best interests.
What the study found was pretty dramatic.
There are two main take-home points:
1 -- in patients with penetrating trauma, those who are c-spine immobilized die twice as often as those who aren't, and
2 -- it takes 1,032 c-spine applications in penetrating trauma to benefit 1 patient (defined in the study as patients with incomplete spinal injury who ended up needing spinal surgery for vertebral spine repair, spine fusion, laminectomy and/or halo placement). It takes just 66 c-spine immobilizations to contribute to a single patient death.
The study authors performed a restrospective analysis of 45,284 victims of penetrating trauma listed in the National Trauma Data Bank, and concludes simply: "Prehospital spine immobilization is associated with higher mortality in penetrating trauma and should not be routinely used in every patient with penetrating trauma."

A New Foe

2010-08-21T00:53:00.000-07:00

It's hard now to remember a time when the departure of the New England Patriots seemed like a possibility.
In the early 1990s it wasn't just a possibility, it seemed like a done deal.
And then a bunch of good things happened, beginning with the hiring of Bill Parcells and the drafting of Drew Bledsoe out of Washington State University.
But there were lots of other contributions on the road that turned the Patriots into a dynasty instead of a 25-year footnote in NFL/AFL history.
One of them was a catch by a fullback out of the University of Alabama named Kevin Turner.
On a cold Sunday in November 1994, Drew Bledsoe threw a game-winning touchdown to Turner, capping what was, at the time (pre-tuck-rule, pre-snow-bowl, pre-multiple Super Bowl wins), perhaps the greatest comeback in Patriots history, an improbable 26-20 OT win over the Vikings.
Probably not many people remember that catch, but for me it was an incredible moment, and although the Foxboro crowd cheered the team off the field chanting the name of its new strong-armed QB hero, it was Turner's heroics that I've always remembered.
Turner played just three seasons for the Pats, then six more in Philadelphia before calling it quits.
He was my kind of player -- blue collar, hard-nosed.
Now, Turner finds himself in the fight of his life, recently diagnosed with ALS, aka Lou Gehrig's Disease.
But Turner's fight may also provide some ammunition against a newly-discovered disease called Chronic Traumatic Encephalopathy (CTE) -- recently identified by researchers at Boston University -- in which patients subjected to repeated and significant head trauma seem to develop an ALS-like syndrome that is currently even more poorly understood than ALS itself.
You can read this excellent article from Boston.com about Turner's plight and this new disease.
I wish Turner nothing but the best.

North Brookfield EMS Ends ALS Run

2010-08-18T13:23:00.000-07:00

A quick update from a story I first wrote about two years ago.
It looks like North Brookfield EMS has lost its battle to stay in business.
According to reports in the local press, NBEMS has informed Selectmen that it intends to end 24/7 full-time service, drop its ALS activities, and return to service as a call and volunteer BLS system.
I don't know who will be offering ALS service to North Brookfield and New Braintree, but I'm sure they never would have made the decision to downgrade without ensuring there was a substitute in place.
This is a bummer, but times are tough all over and ALS is expensive to maintain, especially at low-volume rural providers.
One figure I heard was that it cost over $500,000 annually for NBEMS to staff three full-time Paramedics.
I don't know what their revenues were like, but I'm certain it was nowhere near half a million dollars.
I commend the NBEMS folks for realizing that they can't adequately pay for an ALS service and not entering into the charade certain other towns in our area have chosen to partake in, where they maintain "24/7" ALS coverage on paper, while the reality is something different altogether.

Primum Non Nocere, Mostly....

2010-08-12T15:03:00.000-07:00

It would be ironic if it weren't tragic.

Imagine a procedure we perform tens of thousands of times per year, knowing that 990 of every 1,000 occurrences are a complete waste of time.

But we rationalize it, deciding that the procedure is harmless for the 990 patients for whom it is unnecessary, and for the remaining 10 -- well, it can be positively life-saving.

Or so we think.

All such rationalization is moot anyway -- the bureaucrats who plague our profession have proven more than willing to suspend any medic or EMT who fails to do this procedure despite the indications, or lack thereof, and lots of tort lawyers (those are the guys with the bad hair, billboard ads and late night TV commercials) have paid for their summer houses on the Cape under the auspices of that old rule that says certain kinds of back pain are hard to disprove.

Now imagine that that procedure turns out to be not only useless for most patients, but potentially fatal to the 10 critical patients for whom such exacting adherence to the rules exists in the first place.

That's exactly the situation we face today, with our blind application of cervical collars and longboards to everyone who in any way suffers the effects of misguided kinetic energy, no matter how trivial or brief.

So it was with a mix of fascination (because it was fascinating) and frustration (because I doubt things will change) that I read an article this week challenging one of the most basic precepts of EMS.

The latest issue of the Journal of Special Operations Medicine includes an article by Dr. Peter Ben-Galim, of the Spine Research Laboratory at Baylor College of Medicine, where he is also an assistant professor of medicine.

In it, Dr. Ben-Galim comes to two interesting conclusions:

1 -- there is no evidence that a c-collar "can truly prevent abnormal motion of a severely injured spine in a trauma patient," and,

2 -- after experiments with fresh cadavers and examining other physical evidence, Dr. Ben-Galim found that for patients with unstable spine injuries, "the collars may be doing more harm than good," including all sorts of devastating sequelae, including death

In other words, there's no proof that what is perhaps the single-most common procedure in EMS (ie, aggressive c-spine immobilization as currently practiced) does even an iota of good, while there are some pretty significant indicators that it could be fatal to the statistically tiny fraction of patients for whom the whole megilla was concocted in the first place.

Like I said, it would be ironic if it weren't tragic.

Dr. Ben-Galim's conclusions were based on research he and his colleagues in Houston conducted on fresh human cadavers, on whom various c-spine immobilization devices were applied after a process in which the cadavers were frozen, then re-warmed to room temperature (there being a strong correlation between spinal movement in uninjured, asymptomatic living humans and room-temperature cadavers).

The research team surgically severed the ligaments holding high cervical vertebrae in place (C1 and C2), and fractured the odontoid, a small bone that extends from the beginning of the axis to the opening of the atlas, alongside the spinal cord.

Typically, these conditions result in instantaneous death, though Dr. Ben-Galim notes that there are almost two dozen instances in the literature of patients surviving this condition (aka internal decapitation).

The researchers then applied a properly-sized cervical collar and compared the resulting anatomical changes using flouroscopy and CT scans.

In EVERY SINGLE case, the "proper" application of cervical collars resulted in gross and potentially fatal separation between C1 and C2.

"The current presentation of our data supports several previous studies in suggesting that extrication collar designs can effectively push the head away from the shoulders, resulting in grossly abnormal displacements between the occiput and the spine," Dr. Ben-Galim writes. "Although these collars are applied to millions of trauma victims each year with the intent of protecting against secondary injuries in the RARE CASE of a serious cervical spine injury, IT IS IN THESE VERY UNSTABLE SPINE INJURIES THAT THE COLLARS MAY DO MORE HARM THAN GOOD." (Emphasis mine)

Dr. Ben-Galim applauds the move away from in-line "traction" to "stabilization" in EMS over the recent years, and encourages research into new ways of c-spine immobilization.

"These observations," he concludes with great understatement, "raise the question for a need of an entirely new concept of EMS and pre-operative cervical spine and head stabilization."

Of course, in EMS you can raise the question, it all just depends on who's going to provide the answer.

The Real Fraud and Freeing The Massachusetts 200

2010-07-01T15:37:00.000-07:00

Just over 200 Massachusetts EMTs and Paramedics began serving suspensions today of 9 months to two years, accused of signing rosters for bogus Refresher courses and lying to state officials.
Most of those suspended who worked for private ambulance companies are now also out of work, summarily fired the moment their names appeared on the state's list of the accused.
Certainly there is no defense for lying or, in the case of people who may have taken overtime money for classes they never went to, stealing.
But talk to enough people involved in the case and you realize pretty quickly that the guilt of many of the punished is far from certain.
In the ensuing brouhaha, a whole cabal of state officials, private ambulance company spokesmen and various fire department officials have gone to great lengths in the press to assure the public that they have reviewed every call completed by all 200+ EMTs and Paramedics in question and have found no instance of any kind of adverse patient outcome related to any of the medical treatment they provided.
IN OTHER WORDS, despite not completing refresher training so crucial to the safety of the Commonwealth that the state has seen fit to bankrupt and send to personal and professional ruin over 200 hardworking members of an already underpaid, underappreciated profession, NOT ONE CITIZEN was hurt or received subpar care.
I think we were meant to be placated by such good news, but I am merely perplexed.
If this training is SO important, why is it so clearly meaningless, and utterly unconnected to patient outcomes????
And if this is obvious to me, why don't I hear anyone other than other EMTs or Paramedics asking the question publicly?
Having completed numerous refreshers since 1995 both as an EMT and a Paramedic, I can say with complete confidence that the recertification process may sound good on paper, but in reality is a colossal waste of time and money.
Even the best refresher is not exempt from the law of diminishing returns, the courses steadily waning in utility and interest fairly quickly.
Isn't it time to re-think re-certification?
Isn't it, perhaps, time to re-think licensure, so that, like our RN counterparts, we can keep our jobs without enduring the mind-numbing burden every other year of a 48-hour re-hashing of things we already do every day?
I hope so.
And Free The Massachusetts 200!

Not A Purely Hypothetical Question

2010-05-24T07:45:00.001-07:00

Ok, so this is something of a poll question. I'd love to hear your responses.

Do you believe that there is such a thing as "driving too slow" when using lights and sirens?

AND,

Do you believe that, while using lights and sirens and patient loaded, it is your duty to "test the limits of the ambulance's performance?"

I sincerely want to hear your responses. This isn't a completely hypothetical question.

Medic In Need

2010-04-19T05:36:00.000-07:00

I know this isn't a "central Massachusetts" story, but I read this story about a Paramedic battling cancer in New Hampshire and I felt like it was something I needed to spread the word about.
Sarah Fox is a 38-year-old Paramedic who has 2 1/2-year-old twins and a 7-year-old daughter.
She also has terminal cancer and has been given a year to live.
Firefighters from the Portsmouth (NH) Fire Department are selling window and helmet stickers to help defray the cost of Sarah's treatment.
I know from firsthand experience how devastating the costs of caring for a loved-one with cancer can become, and I think it's a tremendous thing that the folks from Portsmouth FD are trying to do.
I hope and pray for Ms. Fox's recovery, but I also plan on buying a few stickers to help ensure that she can spend whatever time is left enjoying her family and not worrying about expenses.
Anyone interested in buying stickers can send a check payable to "Portsmouth Firefighters Charitable Association" to Portsmouth Fire Station 1, 170 Court St., Portsmouth, NH, 03801. Helmet stickers are $5 and vehicle stickers are $10.

Demons From The Imperial City

2010-04-14T18:43:00.000-07:00

There were moments when my patient was gone, just....gone.
At first I couldn't figure out why this 60-year-old man, apparently in terrific health, who bragged that he still pounded out the mileage every day, would from time to time squeeze his eyes tight, begin sweating profusely and whimper.
There was no connecting with him in that state.
It was as if his body was here but his spirit had traveled elsewhere.
And as fast as he left, he returned, opening his eyes as if seeing his surroundings for the first time.
I was baffled.
And then I noticed a familiar tattoo on his left biceps.
"Were you in the Marines?" I asked.
"I was."
"Me, too. Semper Fi."
We shook hands.
"I was with 2/5, in 1968," he said.
And suddenly it all made sense.
2nd Battalion, 5th Marine Regiment.
A storied unit that has done three deployments to Iraq in this latest war, 2/5 had its origins in the early days of World War I, the unit's motto -- "Retreat, Hell!" -- derived from a perhaps apocryphal quote by a Marine 2/5 officer who, when ordered to retreat during a battle in The Great War, is said to have exclaimed "Retreat? Hell, we just got here!"
Forty-one years ago, my patient's regiment greeted the new year by undergoing the onslaught of the Tet Offensive in the Vietnam War, followed in February by the door-to-door carnage of some of the war's most violent combat, the battle to take the Imperial City of Hue, fighting immortalized in the movie "Full Metal Jacket."
It was clear that when my patient's spirit left our ambulance he was returning to those bloodied streets, where he was a rifleman in one of three battalions of Marines who fought 10,000 enemy soldiers in some of the most brutal close quarter fighting of the war.
A little math gave me my patient's age at the time of the battle -- 18-years-old.
My patient wasn't particularly sick, at least not in a physical sense.
I started an IV anyway, drew some labs for the ED, placed the man on our heart monitor.
Mostly I just rested a hand on his shoulder during the worst moments, letting him know that even though I was in the Corps 20 years later and on the opposite coast, that he wasn't alone, that he had a buddy with him nonetheless.
It was one of those calls where afterwards you thank God for what you do for a living, for the rare and brief chances we get to touch, even for a moment, the sublime.
I can't imagine what it would be like to be chased by nightmares for 40 years.
I wish I had the power to bring him some peace.

Shake and Bake Disaster

2010-03-29T12:47:00.001-07:00

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

2010-03-15T09:59:00.000-07:00

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

2010-03-11T08:47:00.000-08:00

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

2010-03-09T18:51:00.000-08:00

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.........

19 Years.....

2010-02-19T13:33:00.000-08:00

I wanted to take a moment to congratulate a friend of mine, Rod Witkos, for reaching a remarkable milestone -- 19 years of superior Paramedic service in one of the busiest EMS systems in the country.

To mark the occasion Rod has written on his blog, Wormtown Medic, one of the best posts I've ever read describing the state of EMS in central Massaschusetts today.

It's an unflinching look, but Rod has never been one to flinch in the face of some unpleasant realities.

Congratulations Rod. Here's to 19 more great years.....

RIP Emerson ALS-1

2010-02-14T12:03:00.000-08:00

One of the state's premier EMS services closed this morning, replaced by a for-profit ambulance company.

Emerson Hospital ALS-1 is no more.

As of 7 a.m. Pro EMS of Cambridge, previously most famous for carrying Cambridge FD's luggage, is now responsible for the 14-town district once served by a cadre of Paramedics who lived and worked in the area, for whom local EMS was a calling, not a revenue stream.

I'm mad.

I'm mad at the CEO of Emerson Hospital, Christine Schuster, for turning her back on a service that was for decades the hospital's best ambassador to the communities it served, and for joining the ranks of other hospital executives for whom quality prehospital care is not worth caring about enough to actually spend money on.

I'm mad that my worst fears have been confirmed -- quality care, professionalism and integrity matter not a bit in this industry. All those years of thinking that all we had to do was provide the best prehospital care we could and the rest would take care of itself, well, it turns out I wasn't completely wrong. "The rest" did in fact take care of itself, though not in the way I would have wanted.

And I'm mad at what I'm sure is a whole series of events of which I am completely unaware but which conspired to end ALS-1's run.

Thank you to all the people who made my time there such a rewarding experience, and best of luck in the future. You will be missed.

The Cost of Dying

2010-01-18T18:47:00.000-08:00

My friend Burt sent along this clip of a recent "60 Minutes" story detailing the incredible costs of end-of-life care.

It's a compelling and provocative story, although I don't share the pessimistic view of ICU care that the piece espouses.

Still, great food for thought.

Watch CBS News Videos Online

Uncomfortable Arithmetic — Whom to Cover versus What to Cover

2010-01-14T19:19:00.001-08:00

New in the latest issue of the New England Journal of Medicine, a couple PhDs with Harvard credentials admit that no matter what health care reform looks like, the money isn't unlimited.

The government won't be able to cover everyone for everything.

"[E]ventually, we will have to engage in the difficult discussionsrequired to choose whom and what our public insurance programsshould cover," the authors admit near the end of the article. "Some might call this rationing, but the realityis that millions of Americans now have no access to lifesavingmedical technologies at the same time that public resourcesare being devoted to covering less-effective therapies for less-seriousconditions. We find that sort of rationing hard to justify."

Interesting article, if only for its honesty.

Read it here:

Uncomfortable Arithmetic — Whom to Cover versus What to Cover

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America

2010-01-12T19:13:00.001-08:00

Still obsessed with health care reform, still feel like a babe lost in the woods when it comes to the details.

The New England Journal of Medicine has been a great source of many interesting articles on the subject, and I've linked to one of the more recent, excellent examples below.

There's a grim case study in the article about Atlanta's Grady Hospital that had to shut down its dialysis unit after losing upwards of $50,000 per uninsured patient per year.

I think more frontline providers in EMS need to pay attention. Ultimately we're the ones that will bear the burdens of whatever chaos the bureaucrats and politicians wreak.

America’s Safety Net and Health Care Reform — What Lies Ahead?

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Cleveland Rocks!

2010-01-12T08:07:00.000-08:00

Maybe it's a sign of things to come.

Maybe Cleveland is just the first EMS system to admit officially that 911 has become a farce.

Either way, I agree with this post on the Happy Medic blog lauding a report in the Cleveland Plain Dealer regarding Cleveland EMS's decision to refuse priority service on nonsense.

The plan instead seems to be to hold toe pains and VNA referrals for patients with UTIs until enough units are in service so that a cardiac arrest doesn't get a delayed response while everyone else is tied up driving sad people all over Kingdom Come.

Like everything else in our industry, it may be a laudable plan but it's mainly been chosen because a lack of money dictates it.

Maybe someday EMS decision-makers will make the right calls based solely on their rightness.

For now, money will have to do.

A Gap In The Thin Blue Line

2010-01-03T11:56:00.000-08:00

When I was hired as a medic in The Big City, one of the first things the veterans told you was that we had an incredibly close relationship with the WPD.
Solidified over decades working side-by-side with Worcester's thin blue line, one of the biggest responsibilities we new guys had, outside of patient care, was to NOT screw that relationship up.
WPD officers were to be treated as our own, and if, God forbid, one of them were to be hurt on our watch, we were expected to move Heaven and Earth to care for them.
It didn't take long on those city streets to understand why.
Simply put, the men and women of the WPD are the best cops around.
They watched our backs and were a big reason working in The Big City was once one of the best paramedic jobs anywhere.
Officer Mark Bisnette was among the best officers on a department full of great officers.
A brother Marine, Biz was one of those officers who always seemed to have a smile on his face and a little time to shoot the breeze with the ambulance crews.
In a city chock full of people who get off on antagonizing the police, I never saw Biz have a bad word for anybody.
I've always been amazed by the way WPD officers defuse potentially violent situations on a daily basis without resorting to violence.
To me, that's got to be on the list of things that differentiates great cops from average ones.
WPD officers always know the players on their routes, always seem to have a great feel for street-level human psychology and motivations, and clearly know how to put this knowledge to use keeping the city safe.
I think this combination of attributes explains why officer-involved shootings in Worcester are incredibly rare.
People who possess this ability are equally rare, and Biz definitely had it in spades.
It's just one of the many reasons he will be missed.
Worcester Police Officer Mark Bisnette, 38, was off-duty early Saturday morning when he was killed in a single-car accident in a nearby suburb.
He leaves a wife and four children.
RIP Biz. You are one of the best.

Going, going, going.........

2009-12-28T07:51:00.001-08:00

This is the infamous MAHOPS patch I wrote about earlier.
Let's review, counter-clockwise from top left:
Emerson -- gone
Holyoke Hospital -- gone
Lawrence General Hospital -- Active
Greater Lowell (aka Saints) -- Active
Milford 2181 -- gone
Caritas Norwood -- gone
Southshore Hospital -- gone
UMassMemorial -- Active

That's five out of eight hospital-based ALS units out of business since 2005, when this patch was created.

I could have included the Natick-based MetroWest Medical Center unit that was shut down just prior to this patch's conception, or UMass's ALS-2 out of Marlboro Hospital, which closed in 2000 or 2001 (I forget). If we REALLY wanted to round out the roster of shuttered non-transport, hospital-based services we could include the likes of St. Lukes in New Bedford and NSP-1 out of Lahey Clinic in Burlington.

I'm tempted to include the paramedic unit out of the Jordan Hospital in Plymouth, but I think that would just be piling on as, from my understanding, that was a partnership between the hospital and AMR.

Is EMS A Failed Experiment?

2009-12-22T13:19:00.000-08:00

I got the word last night.

Another nail has been driven into the coffin carrying the remains of what were once some of the best EMS systems in the country.

Emerson Hospital will discard its non-transporting ALS service next month, ending over three decades of service to its 14-town region spread along Route 2 and centered on the town of Concord.

A private ambulance company will buy the service from Emerson and has pledged to keep things the way they are, right down to the uniforms and offering employment to the service’s current paramedics. Though it will no longer run the service, Emerson Hospital will still provide the district’s medical oversight.

Of course, such employment will come at a significant pay cut for Emerson’s soon-to-be-former paramedic staff, especially considering this private has a lousy pay scale for the area ($16 per hour base, with 25 cents per year of experience) and doesn’t appear to offer differentials for working nights and weekends.

I also think the pledges to maintain the status quo were a means to placate nervous customers (ie, the towns once served by Emerson, the hospital itself) and won’t last.

And so another hospital-based paramedic service bites the dust, this time the oldest in Massachusetts.

Where once there were over a dozen in the late-1990s, there now stand just three – Lawrence General Hospital in Lawrence, Saints Memorial Medical Center in Lowell, and UMassMemorial in Worcester.

Three hospitals in the entire state committed to caring for the people in their catchment areas but outside the walls of the building. Before I say anything else, I think I need to laud in the highest way possible these three hospitals for keeping faith with the idea that prehospital medicine is important, and has a rightful place at the table of the medical professions. There is going to be some criticism in these paragraphs of hospital commitment to prehospital medicine. Saints, Lawrence and UMass have proven themselves the stalwart exceptions, and I wish them all decades of continued success and service.

Some of the hospital-based services that shut down previously have since re-started as transfer-only services, but these bear little resemblance to the non-transporting regional 911 paramedic units they replaced.

Throughout the years the argument has raged over whether EMS should fall under public health or public safety.

Those supporting EMS under the umbrella of the fire service champion it as another facet of the “all-hazards” approach to public safety, where the local fire brigade does everything from putting out the fire in your kitchen to inspecting your new boiler to treating your chest pain.

Advocates of the public health model say that the “M” in EMS stands for “Medical,” and that the proper delivery method for EMS should rightly fall under the auspices of the medical experts.

Which sounds good in theory, but in practice most public health entities from whom paramedics have sought employment – ie, the hospitals – have ultimately decided the cost far outweighed the benefit of providing Emergency Medical Services via a single-role, medically-oriented delivery model.

In other words, hospitals have proven they only have an appetite for running paramedic services if someone else pays for dessert.

Critics point out, correctly in a lot of cases, I believe, that fire departments often only want EMS as a way to bolster their numbers, a backdoor means to securing employment for the most firefighters possible and reinforcing personnel rosters in an era of declining fires, an imploding world economy and an exponentially increasing utilization of EMS.

Deep Throat told Woodward and Bernstein to “follow the money,” and I think anyone who follows the money in public safety realizes that EMS, unlike Police or Fire services, generates revenue.

Whether it generates revenue in excess of expenses is another conversation altogether and depends mainly on your customer base. Decaying former mill cities will have fewer customers with high-end private insurance or HMO coverage than the ‘burbs, plain and simple. It might be math, but it ain’t rocket science.

But these critics unjustly let hospitals off the hook.

Some in EMS pillory as morally bankrupt fire departments who want EMS as a way to keep their people gainfully employed, and yet don’t bat an eyelash at hospitals who unceremoniously drop their ALS programs as a way to slash the payroll and balance the budget by breaking the backs of some of their lowest paid employees, employees who, it needs to be said, also bear patient-care responsibilities that much higher-paid health workers, like nurses, could only dream of in their worst nightmares.

In the end the closures of the hospital-based paramedic programs at Emerson, Milford, Holyoke hospitals and MetroWest Medical Center in Natick, as but a few examples, served no higher purpose than the saving of a few bucks.

Even UMassMemorial in Worcester, which is to be commended for its commitment to providing 911 to Worcester and Shrewsbury, had its limits. Earlier this decade UMass shut down its non-transporting ALS unit out of Marlboro Hospital for cost concerns.

The claim, often touted in these hospital-based service closings, that a declining call volume due to fire department upgrade to the ALS level is responsible for hospitals shutting down their paramedic units has clearly proven over time to be a red herring, meant to distract us from the fact that hospitals in Massachusetts do not believe in EMS as a core public health mission vital enough to be supported in the one way support is registered in 21st century America – money.

Were it otherwise my MAHOPS patch (a wonderfully and pitiably anachronistic acronym for the Massachusetts Association of Hospital Operated Paramedic Services – it is worn on the right shoulder of my soon-to-be defunct Emerson Hospital Paramedics uniform and was designed by a former longtime Emerson medic who had to quit and become a municipal bus driver in order to get the same benefits and retirement plan as local police, fire and DPW workers) would not be adorned with the names of a half-dozen hospital-based paramedic services shut down over the last decade even while recording robust call volumes.

So the question I find myself asking, in light of the fact that the medical profession here in Massachusetts has by and large turned its back on prehospital medicine, is this:

Is EMS a failed experiment?

What does it mean if the only people who truly want you do so mainly because it helps them fight fires, and that the medical professionals who should want you don’t think you’re worth the money?

If so few doctors, the high priests of medicine themselves, have railed against the closing of the hospital-based paramedic services (although it should be noted that the doctors who have tried to stop the madness have fought with great passion and conviction – and to them I would say that we know who you are, and we are proud to have worked for you), what does that say about our place in the medical cosmos?

Not much, I’m afraid.

Part of that, of course, might have something to do with the relative age of our profession. The first cops were probably the biggest guys in the prehistoric post-Ice Age caves, who tens of thousands of years ago used clubs to keep order. The first recorded firefighters were loosely organized under Emperor Trajan during the Roman Empire. I, however, am 40-years-old, yet still older than my profession.

We’re new to everyone.

But are some people in the medical profession beginning to have doubts about EMS, or even the necessity of paramedics?

I think so. It doesn’t take a Burmese scout to track the scent.

Numerous studies have appeared in journals in recent years documenting paramedic shortcomings in everything from intubation to STEMI recognition to the overall morbidity and mortality of every living human over the last 30 years. There are too many of us, the studies say, we’re not particularly good at what we do, and the evidence doesn’t seem to suggest we make much of a difference.

Adding insult to injury, the powers-that-be in Massachusetts want to give EMT-Basics the ability to place invasive, advanced airways in patients despite the fact that the curriculum for EMT certification is so watered down that we can’t get them to bring Stair Chairs or do blood pressures on calls on their own initiative.

Such suggestions smack of the low regard paramedics have garnered in some corners of the medical establishment, that someone with 110 hours of training is pretty much interchangeable with someone who’s had 2,000.

It reminds me of the stand taken by the Massachusetts Board of Registration in Nursing several years ago in a white paper that said, in its view, paramedics were no more capable than a certified nurse’s aide and had no place working in hospitals at all.

Of course, those of us who actually do this job for a living and are not sitting in a university office somewhere with a graphing program and an Excel spreadsheet, know that these conclusions are ludicrous, because our eyes and ears tell us so every day in the real world, with actual patients who have more substance than mere data points on some PhD's graph.

There are people walking this Earth who would be dead had my various partners and I not arrived in our ambulance and done a few things correctly, things that took experienced paramedics working in concert with the committed physicians who trained and watched over us. There aren’t as many of these former patients as I’d like, but they’re out there, and I know their loved ones would have an opinion or two about whether paramedics make a difference, and what price competent ALS is worth to the general public.

The truth is that many of these studies (and, perhaps predictably, most often the most damning examples), though given the veneer of hard science, are really just sociological ruminations, promulgated under the guise of science, made at the behest of certain “investigators” who simply want the imprimatur of publication in a scientific journal to advance their own agendas, even when those agendas are often in direct contradiction to the reality on the streets.

I find it laughable to read these serious-minded “studies” that come to such broad conclusions based on a heterogeneous mess of self-reported data and guesswork, assigning cause-and-effect via intuitive leaps in reasoning so confounded by flaws in logic that they would never pass muster in a laboratory, where real science using objective data to come to repeatable conclusions is performed.

But the state of "scientific" research in EMS leads me to the conclusion that EMS itself, at least here, where I live and ply my trade, is verging on a failed experiment:

Hospitals don’t want to pay for us. Most doctors don’t want to work with us. Most nurses don’t respect us.

But I have hope, and it’s that word “most” that gives me hope.

I know there are physicians out there who have given immense chunks of their professional and personal lives trying to advance prehospital medicine, often working even harder than my paramedic colleagues and probably to the detriment of their own careers. I often wonder how much different this field would be if some of my paramedic friends gave as much of themselves to advance our profession as some of the physicians we’re privileged enough to work with and for?

And I know plenty of nurses who give paramedics their due, who realize we’re an important part of that chain of care that begins by the bedside and continues in the hospital. And to be fair, paramedics don’t always do themselves any favors by the way we interact with nurses. Some of my best mentors have been, and continue to be, nurses. But we’re not going to get any where with the nursing profession as a whole until we hold ourselves to their standards, which is why I think the minimum entry to being a paramedic should be at least a two-year Associate’s Degree program. Again, a conversation for another time.

So for the time being I personally don’t think EMS is a failed experiment, but we’re in trouble.
I think the model is changing, and I think we need to embrace the change. That’s the only way we’ll have a voice in whatever’s coming down the pike to replace what’s already been done.

For EMS, we’re at the end of the beginning. The question is, now what?

Hospitals don’t want us. Fire departments, private ambulance companies and third-services do. I think we need to find a way to keep the “M” in EMS, even if the medical establishment couldn’t care less, and practice the best MEDICINE possible, no matter what the patch on our shoulder says.

The First But Not The Last

2009-12-06T13:14:00.000-08:00

There are some things on this job that will never become routine.
Or, more specifically, there are things about this job that, should they become routine, ought to signal to you that it's time for a career change.
You can't check your humanity at the door the day you get your EMT ticket in the mail.
It's Ok for certain things to get to you. Hell, it's probably necessary. After all, what would it mean if there was nothing on this job that could tap into those parts of ourselves that contain empathy, sympathy and compassion?
What if we no longer had a well inside us that contained those things?
It would mean we had become less than human, automatons able to recite drug doses and perform various medical procedures but without that spark -- divine or otherwise -- that differentiates us from monkeys, who are also able to perform simple procedures.
In short, it's Ok to admit that some things bother us. It is in fact necessary to admit this.
That was the point I tried to make to the distraught EMT in the charting room.
We'd just worked together on what was her first cardiac arrest, a sentinel event for anyone new to EMS but made especially so because our patient was 2-months-old.
After we dropped our patient off with the code team I restocked the truck and went to the charting room looking for my partner, ostensibly to see if he needed help writing up the call, but really just to spend a minute or two with a medic I respect tremendously, commisserating about the sadness of it all before shaking it off and getting ready for the next call.
This is a strategy I've used to great success throughout my career.
The room was empty except for the EMT, who stood in the corner weeping. She was a little embarrassed to be discovered, but didn't stop.
I asked her if it was her first pedi code, and she told me it was her first code, period.
I assured her that she had performed admirably and professionally, and that there was nothing she or any of us could have done to bring that baby back; that we all acted as aggressively as we could, but that the baby had been down long before we got there.
I know the "research" about debriefing after rough calls is sketchy, and that there is a school of thought out there that says critical incident stress debriefing -- an automatic process that kicks in in many EMS systems after intense calls -- actually causes more harm than good by continuously re-opening psychic wounds among responders and not allowing time for healing.
I'm not sure what I think.
I've never taken part in a CISD session.
I don't say that as a critique of people who have, but I've never had a problem admitting to a partner after a bad call that there were aspects of the call that bothered me.
More often than not my partner has felt the same way.
And having those feelings out in the open, I so far have always been able to move on.
There are many former partners of mine out there who deserve thanks for the fact that I am not burdened by the occasionally horrific and often sad things to which I've been a witness.
I don't know if my little conversation with the EMT in the hospital charting room helped or not.
I know her partner, who I didn't speak to, ended up going home after the call, while this EMT did not.
I saw her again on a call, later that night.
A 35-year-old woman had walked into traffic on a busy street and been hit by a car.
The street lights were out and the woman lay in a crumpled heap in the middle of the road, her left leg mangled.
We worked by the reflected glow of emergency strobe lights off the wet pavement and the weak light of a half-dozen Mag Lights held by a surrounding phalanx of police and fire personnel.
I completed my assessment and was working on securing the patient to a long board when I noticed that EMT again in the circle of people caring for the woman, this time holding traction on the patient's head.
We completed c-spining the patient, loaded her into the ambulance and took off for the hospital.
I was in the back with the EMT but we didn't really speak, occupied as we were with caring for our injured patient.
But I couldn't help but think that the fact that she was even here with me in the back, doing her job, taking care of the sick and injured, was a good sign.
Her empathy didn't die with that poor baby.
It lived on, in the simple belief that she still had work to do and there was a worthwhile reason to be here, working in the back of a cramped ambulance roaming the streets of this beleagured mill city.
There is a name for such a thing.
We call it "hope."

Congrats Mistah Mayor!

2009-11-04T16:44:00.000-08:00

Lost amid all the media hubbub over Joe O'Brien's election as Mayor of Worcester this week is the fact that before he was a rising star in the Massachusetts political firmament, he was (and remains) a gifted and universally liked and respected Paramedic.
I've had the pleasure of knowing Joe since 1994, when I got my first job in local EMS as an EMT at the Worcester division of MedTrans, where Joe was working as a Paramedic.
(As a side note, MedTrans is a now-defunct service that found itself without a chair when the music stopped in its parent company's attempts to buy AMR; it was finally folded into the latter's brand when corporate overseer Laidlaw decided AMR carried more weight nationally).
From the very beginning you knew there was something different about Joe.
While all Paramedics are convinced we have the answers to any problem in society, few of us actually become active participants in things like local politics.
Joe was one of the exceptions, probably THE most exceptional of the exceptions.
He didn't simply have an opinion, he was involved and he knew the issues inside and out, far beyond the surface knowledge the rest of us gleaned from the newspapers.
Joe was the first one I ever heard -- in the media or anywhere -- mention the name Deval Patrick as a legitimate candidate for higher office, telling me over breakfast one morning during a shift together that he thought Patrick stood a real chance at winning the race for Massachusetts governor should he decide to run.
Anyone who's ever met Joe knows what I mean when I say that he received a triple-helping of that quintessentially Irish ability to make everyone he meets feel like a long-lost friend, and is especially well-known in local EMS circles for bestowing nicknames.
Joe probably called a hundred people "Superdude" or "Super Salad Shooter" in the course of a day, but when he called YOU that name you felt like he really only meant it for you.
He's a phenomenal clinician, as good as any medic I've ever seen in a jam. He is on that very short list of medics I would trust without question to care for my children.
As much as I've always liked Joe, my admiration for him increased exponentially when he and his wife bought a house in Main South, back at a time when that really meant taking a gamble with your own personal safety AND despite the fact that he could have lived just about anywhere.
But Joe always loved Worcester, and truly believed in the goodness of its residents no matter the neighborhood.
I'd be lying if I said I always agreed with Joe politically.
But as I get older I realize more and more that we've made a huge mistake as a nation by picking our leaders dogmatically, when what really matters is character.
So maybe I don't agree with Joe on every issue, in the end it matters not.
The thing I know about Joe O'Brien is that he is a man of incredible integrity and character and intelligence, and Worcester residents couldn't have chosen a better person to lead their city.
Congrats Mistah Mayor.

Flying Frequently

2009-10-31T18:28:00.000-07:00

I'm sitting in the kitchen of a Frequent Flier and wondering what to say.
My main job is for a suburban service now. We're slower, but the patients tend to be sicker because they take their medicine, visit their doctors, take better care of themselves and thus, when they finally need 911, it tends to be because they are very sick.
This patient is the exception.
There is nothing remotely sick about him, at least not physically.
In my last job at a busy urban 911 system, Frequent Fliers were as common as streetlights.
They were an accepted part of the landscape. Only when they decompensated and became real players -- say, calling once or twice a day, every day, for a month or more at a time -- did they warrant comment.
But when they do get under your skin, well, there's NOTHING worse in EMS.
Some guys can handle taking the same Frequent Fliers shift after shift without a problem.
For others, it's sometimes enough to make them contemplate leaving the field entirely.
I'm usually in the former camp, but often in the latter -- much more so lately.
So now I'm in the kitchen of a guy who's called for nine nights in a row, each time complaining that his uclers are bleeding.
But he always has a twist to his main hemorrhagical complaint -- the ulcers are acting up AND a local gang has caused a rash on his forearm, or the ulcers are acting up AND the federal government has him under surveillance.
He's been rotating among the three nearest hospitals because each has identified him for what he is almost immediately.
Typically he's discharged and on his way home within a couple hours, depending on how much time and personnel the overworked EDs have to devote to a patient who darkens their door daily with a slew of bogus and bizarre complaints.
Tonight he is asking to go to a hospital 20 miles away. On a rainy Friday night. In a town with a single ambulance.
I have to measure my words.
These are not good times for telling it like is in EMS.
It's best if you don't think too much, don't worry about the system or allocation of limited resources or wasting public money on public nuisances.
The best thing for my career is to just forget the abuse this particular patient is heaping on the system, forget the tens of thousands of taxpayer dollars wasted on the meaningless carousel of transports, ED evaluations and ambulance rides back home this patient has created in order to exorcise his personal demons, and ESPECIALLY to not consider for a moment the possible patients we won't get to help while we are performing yet another fruitless transport -- the father of four who suddenly goes into cardiac arrest, or the 72-year-old CHFer woken from sleep by the suffocating presence of lungs filling with fluid.
Thankfully this nightmare scenario hasn't happened. But it's only a matter of time, I think.
But telling him so won't do any good and may in fact cause me significant grief.
So as much as I'd like to tell this patient exactly what I think of what he's doing, instead I smile.
We can't go to that hospital 20-miles away, I say. We are, though, more than happy to bring to the hospital of your choice in The Big City, about 5-miles away.
He is appeased, and within minutes we're on our way to the hospital once again, both of us certain in the knowledge that this won't be the last time this particular patient will make this particular trip in this particular ambulance.

In The Land of the Blind, The One-Eyed Man Is King

2009-10-26T05:39:00.001-07:00

Think the health care reform debate is complicated?
Think the people making the policy that will result most likely in a government takeover of about 20 percent of the US economy give a flying fart about EMS?
I understand when laymen have trouble figuring out all the ramifications.
What does it mean when the "experts," people with PhDs who do nothing but ruminate daily on the health care reform debate, admit that they haven't thought even for a moment about health care reform's potential impacts on EMS?
And yet, this is exactly the case.
Last week I read a 10-page supplement to the Columbia Journalism Review written by a think-tank that philosophically stands squarely behind President Obama on health care reform.
The think tank advertises itself as "A private foundation working toward a high-performance health system."
When I read this group's piece I thought maybe I had found that touchstone, a group that made it's argument lucidly, plainly and convincingly.
Maybe, finally, I had found a way into the debate that made sense, could give me a reason to get behind reform.
But one nagging thought remained.
Nowhere in this 10-pager was there mention of EMS.
Nothing about how ambulance services would be re-paid for services rendered to Medicare/Medicaid patients despite the fact that almost every proposal for health care reform calls for Draconian cuts to the costs of Medicare/Medicaid.
How, I wondered, would EMS survive deep cuts to Medicare/Medicaid reimbursements if services to those folks were already burdensome financially at the current level of funding?
So I emailed the director of the think tank that wrote the piece and asked if she had any information on the subject.
She wrote back rapidly with the candid admission that she had no idea.
To her credit, this director spent part of her Friday night tracking down the contact information of people who might be able to answer my question, even though it was clear that I'm not a person of any particular importance and was asking the question mainly out of personal curiosity.
But it also points to the fact that EMS is NOT a part of this debate, and my fear is that when the entire US health system is overhauled and re-done, the EMS system could find itself with more demands and no way to meet them.

2009-09-20T17:01:00.000-07:00

My son's G-tube fell out this week.

He was at soccer practice.

I was at work, but my wife said he nonchalantly handed her the "tubie," as we called it, its anchor balloon deflated by a lengthwise tear.

"Here," he said. "This fell out."

One of the other players' grandmother is an ICU RN, and she was kind enough to clean and dress the site.

The whole event wasn't the emergency it might otherwise have been.

The g-tube had outlasted its usefulness, Brendan hadn't had a feeding from the tube in months and we were planning this week to ask for its removal.

Fate took care of things, and after a brief inspection by a doctor revealed no problems, the GI clinic at Children's Hospital in Boston signed off on our request to get on with life and close this particular chapter.

We're happy for practical reasons.

The tubie, as far as I'm concerned, was just another route of infection.

It was a constant source of worry, and caused my son a good amount of pain when hit by soccer balls, baseballs and errant limbs while wrestling with his brother.

But it was more than that.

Now 7, Brendan was starting to feel self-conscious about the device.

Most importantly, though, it's another in a progression of mileposts that puts some distance between the now and the then, not that long ago, when Brendan was fighting for his life against medulloblastoma, a highly malignant brain tumor.

And it was a good week to create some more of that space.

September, after all, is National Childhood Cancer Awareness Month.

You can read more about it here, at the Web site Curesearch.org, a wonderful resource, and here, on the Web site of the Dana-Farber Cancer Institute, home of the Jimmy Fund and the Stop & Shop Pediatric Brain Tumor Clinic, the people who directed the care that saved his life.

The Disaster Is The Planning

2009-09-08T09:39:00.000-07:00

I've railed on this site before about the ridiculous amounts of money poured down the drain since 9/11 in the quest for "preparedness."
A whole industry has sprung up over the last 8 years dedicated to something, although what that something is I'm not completely sure.
Across my own little corner of the public safety universe legions of trailers, stacks of portable radios, pallets of tents, spacesuits, PAPRs, AV-2000s, and enough Tyvek material to encircle the Earth stand ready to protect central Massachusetts from the forces of evil who are conspiring to destroy us.
But meanwhile the people who would presumably use that equipment to keep us safe are being laid off due to budget cuts.
As disaster preparedness money has appeared in such abundance that no one really knows what to spend it on anymore, real-world public health experts are being discarded because the cash to pay for THEM has dried up.
But I have to wonder, in the end, what's going to protect me and my family -- a comprehensive vaccination program and a robust public health department to ensure the population is protected, or a bunch of bureaucratic hacks in color-coordinated polo shirts and khaki trousers "working" from grant to grant without producing anything that will actually save a single life?
I did some work briefly for a local Medical Reserve Corps who's biggest concern was purchasing an ID system for its volunteers, and what color duffle bag to hand out to its workers.
We got Polo shirts AND a fleece vest.
I didn't last long.
It's all very worrisome to me, and now it appears that an MIT doctoral student has published a paper that supports my concern.
In it, MIT PhD candidate Peter Doshi suggests that so-called "pandemic flu" planning has actually made us less ready for a real breakout of a flu epidemic like that one in 1918 that killed 50 to 100 million people worldwide, depending on who's estimate you believe.
It's an interesting read.
I think it's time for a little common sense when it comes to preparing for disasters.
You can't just throw money at the problem -- the people who catch the most cash are rarely the ones who can do a darn thing to help us.

Helping a Helper

2009-08-16T13:58:00.000-07:00

I really like this.

Michael Morse, author of my favorite blog, Rescuing Providence, linked to this site.

Besides just being a nice thing to do for someone who clearly deserves it (I can't even begin to describe the respect I have for working Moms and Dads who manage to complete something as daunting as Paramedic school), I think the writer is addressing a real need.

With the world's credit markets still frozen like the Siberian Tundra, school loans are becoming harder and harder to come by.

A friend of mine who runs a Paramedic program told me that the company that once financed the considerable cost of an education at his school notified six members of his last class at the last minute that the money they had counted on would not be coming.

Those six are having to instead wait a few more years to attend school.

I love what's being done here, and I hope some Central Mass Medics readers might be able to help out even a little.

To steal a little more from Morse's last post, here's a link that might explain why this is worth it.

Adios, redux...

2009-08-12T01:33:00.001-07:00

I've quit EMS in The Big City.
For real this time.
I've left before, once to go to work as a flight paramedic, the other a firefighter.
Both times I remained per diem.
But not this time.
The heart can't serve two masters, or something like that, so this time I made a complete break, and barring unforseen events I will never again wear the brown uniform that has meant so much to most people who've worn it, myself included.
I am very proud to have worked here.
I think I did a good job.
I think I was a good partner, and a good clinician, but ultimately those judgments are left to the people I worked with.
I only hope they enjoyed working with me as much as I enjoyed working with them.
It wasn't an easy decision to leave, but in the end not as hard as I would have thought.
It wasn't the 20-call shifts, or the every other weekend schedule, or the banged up trucks.
Truth be told, while we complain about those things, the reality is that we wear the craptastic nature of some of our equipment like badges of honor.
Miracles have occurred in the back of beasts of burden like 611, or 68, or even in the crop of ambulances that were on their way out when I arrived, the ones with cabs so small that Gomesy drove with his knees pinned behind his ears and roofs so thin that the metal flapped like tinfoil at highway speeds.
And while five new ambulances are planned for shipment soon, there's a grim pride in tapping numbers like "264,500" into the "mileage" field of our newly-installed Mobile Data Terminals at the start of every shift.
It's kind of like when I was in the Marines and you would meet Huey pilots proud of their ships and the way they could get so much from aircraft abandoned so long ago by larger, more pampered services.
Kind of like that.
Though I'll remain forever pissed off that 2667 doesn't have arm rests...
I didn't leave because of the continuous influx of new technology, some of it balky and overly-delicate and maybe released into the wild a little before being ready for prime time.
Nor did I leave because of that new EMD dispatching system -- designed for a completely different model of EMS delivery than the one we use in The Big City -- that sends first responders careening through the city for urinary tract infections because some card tells the dispatchers to make it so, or that sends us and a fire engine and some police officers, Priority 1, EVERY NIGHT, for the same guy who calls at the same time from the same steet corner complaining of "assmar," when all he really wants is a sandwich and some sleep in a comfy hospital bed.
It was none of those things.
Technology improves.
No EMS system is perfect.
Frequent fliers are a bane everywhere.
It wasn't the lousy press we've gotten lately, notably from Tom Caywood at the Telegram, who's more stenographer than reporter, and who has seen fit to ruin the reputations of six medics since April without ever contacting any of the targets of his "investigations," even once, for comment.
Tom, I don't think you can ethically accuse six people of the horrible things you accused them of, name them publically and prominently on Page 1 of the most-read edition of New England's largest metro daily newspaper outside of Boston, and not have the decency to EVEN ATTEMPT to contact ANY of them.
Not once.
Nothing.
Complete...radio...(and telephone)....silence.....
The medics you've maligned didn't deserve any of what you've brought upon them.
The press is becoming something we all need to fear, I think.
I was once a newspaper reporter.
I still have friends in the business, and the business is dying.
One of the consequences is that newspapers are too busy trying to stay afloat to pay much attention to the stories their reporters are turning in.
And if those reporters decide to forgo fully reporting their stories in order to make a quick hit before splitting town for, say, a weekend blues festival, then that flies in today's media, the innocent be damned.
This is a dangerous time for journalism, and I had a front-row seat to just how bad things are.
But bad press had nothing to do with it, either.
No, the main reason I'm leaving is to spend more time with my family.
It's that simple.
But I find that the simplest things in life are the most important.
I wish the best for my now-former colleagues, and I hope if you're reading this you'll take a moment some day in The Big City, when you see those folks in brown working yet another shift on some of the busiest ambulances in America, to let them know they're appreciated.
Almost no one ever does, but I bet it would go a long way.

As for this blog, I intend to get it going again.
I had refrained from posting over the last few months during the furor of which I spoke earlier.
It just seemed best to keep on the sidelines.
Also, though, a colleague of mine who writes one of the most entertaining area blogs -- Wormtown Medic -- had gotten some grief from management for his unabashedly honest analysis of various local EMS issues.
It was the first period in my life where I caved in to what amounts to prior censorship.
I'm not proud of that fact.
It won't happen again.

And you thought "Rescue 77" was bad...

2009-05-11T13:17:00.000-07:00

I'm going to check it out -- I mean, hey, how many shows about EMS are on TV?

Hopefully it won't be as crap-tastic as the last few (remember "Saved?")

No Second Chance At Second Chances

2009-01-24T19:05:00.001-08:00

We found him upstairs.
He was wedged in the far corner of the largest room of a huge home at the end of a circuitous driveway in a secluded, wooded neighborhood where million dollar homes dot the rolling hills by the dozen.
If happiness were merely the product of our trappings, than this man should have been delirious with joy.
But in today's economy, happiness is a commodity that can no longer be bought. The market has re-set its value, and some are unprepared for the change.
Our patient was one of those.
In his late 50s and obviously a man who'd enjoyed significant professional success, his wife reported that he'd come home despondent over the loss of his job earlier that day.
After dinner he'd said he was tired and wanted to go to bed early.
Four hours later, when the wife had gone to bed herself, she found him, here in the corner, his mouth full of vomit, his heart not beating, his lungs sitting idle, and several bottles of empty antidepressants lying nearby.
We tried desperately to bring him back, to give him another chance to see a different way out, but nothing worked. He'd been down too long, taken too many of the wrong drugs, and ultimately he was pronounced dead in the emergency department.
I'm hoping that this call was just part of the normal ebb and flow of life that we see on the ambulance, that his death, while tragic, statistically fits what we expect to see from time to time.
People commit suicide in the best of times as well as the worst. Our patient was taking medicine for depression, and for all I know this was not the first time he'd attempted to take his own life.
It's hard, though, not to see him as a casualty of a war on whose front lines we unknowingly sit every day.
No matter where you work, ambulances -- and by extension, emergency departments -- are always dealing with a particular population of people for whom daily life is itself a task.
Think about the chronic drunks and junkies for whom life is one endless chase for the next bottle or the next fix, and who take residence in the backs of our buses so often that we know their names and dates of birth by heart, whose medication list is as known to us as our own, and who can be identified by the time of day and location of the pay phone from which the 911 call is made.
But I worry that my patient represents the early stages of a new wave of casualties who are having to cope with an economy in the worst condition since World War II.
Does my patient represent the start of a wave of people overmatched by the conditions of early 21st century America, or is his death simply a normal part of the process of life for the rest of us?
Time will tell.
I'm an optimist by nature, which of course means I'm conflicted because I don't know that either possibility leaves much about which to be optimistic.
I do know that I wish my patient had been able to see beyond whatever it was that led him to take his own life.
I wish he'd been able to see that tomorrow is always a new day.
Mostly I just wish we'd been better able to give him that second chance ourselves.

Neurosurgeons are people, too.

2009-01-14T19:17:00.001-08:00

Anyone looking for a good book would do well to consider "Another Day in the Frontal Lobe" by Katrina Firlik.
Dr. Firlik is a Connecticut-based neurosurgeon with a spare, compelling writing style who gives her readers entre into one of the most challenging and probably least understood (at least amongst the lay public) fields of medicine around.
The book mostly covers the period of Firlik's seven year neurosurgery residency in Pennsylvania, and while there are some war stories, they are brief and always in the service of the deeper introspection and naked honesty she brings to her examination of her chosen profession.
It's this last point, in fact, that I find to be the most interesting facet of the book, that Firlik would admit to some indecision about whether becoming a neurosurgeon was even the right choice in the first place.
It's clear that she has made an uneasy peace with her decision. As compelling as she finds the work, it's obvious that Firlik has interests and passions that extend far beyond medicine, and it seems that she's not entirely happy to, say, defer her wanderlust and love of travel in exchange for frequent call nights and the tyrannical power of the pager.
Firlik is at her best when wrestling with such issues, and she manages to bring flesh and blood to the neurosurgeons, those ethereal creatures most of us are lucky enough never to need.
It's a great book and a relatively short read at 270 pages.
Check it out, you won't be disappointed.

Prehospital Cardiology Blog

2008-12-25T18:35:00.001-08:00

Just wanted to include a link to an awesome prehospital cardiology blog.

Comprehensive, well-written, immediately useful.

I can't ask for much more.

Just Another Day

2008-12-25T16:20:00.000-08:00

To those of you who.......

...are far from your families in order that my family might be safe

...ate cold ham and fixings today provided by people with warm hearts in an ambulance garage or day room or nurse's station

...drove across cities and towns and back country roads to calamities great and small today under flashing lights while the rest of us watched our kids vroom Tonka ambulances and fire trucks across the living room floor

...know what it's like to deal with frequent fliers who also didn't take the day off

...get the job done day in and day out, but especially on days like today....

Merry Christmas, and THANK YOU.

...and I'll Tell You No Lies.

2008-12-22T13:58:00.000-08:00

4 a.m., the home stretch of one of the busiest shifts I've ever done in a normally quiet suburban town we cover.
The dispatcher tells us the guy who called complaining of shortness of breath seemed anxious, and when we get there I realize anxious is an understatement.
He meets us at the door, and the moment we open it a crack he jogs into a living room down the hall and drops into a couch.
He can't or won't sit still.
"I've been having trouble breathing since midnight," he says."I had some chest pain earlier but it's gone now."
His history is textbook train wreck: mid-50s, lifelong smoker, diabetic/hypertensive with coronary artery disease and a stupendous case of the high-lows: everything that should be high is low and everything that should be low is high.
The more we talk to him the more agitated he gets.
We try putting a nonrebreather on him but he tears it off every time, maybe from hypoxia, maybe from claustrophobia. He accepts a nasal cannula, but barely.
He looks sick, and my partner and I move a step faster than normal, believing we may be headed to the cath lab.
So here's where I need to take a moment to debunk an EMS myth of my own.
The myth goes like this: any time a patient tells you they're going to die, believe them.
Well, that makes for a nice truism, but I've found that the ratio is something like 1 in 100 people who tell me they're about to die that actually go ahead and give it a shot.
Mostly, patients who tell me they're going to die are responding to a mix of anxiety and dyspnea, and almost all the time we're able to deliver them to the hospital without a problem.
But there are exceptions.
Back to the living room:
In the midst of the usual hurly-burly that goes into treating a patient like this, I was finishing up applying electrodes to the patient's chest for a 12-lead EKG when he became eerily calm and grabbed my arm.
He looked right into my eyes and said, with all the stress of placing an order for a medium regular at Dunkin' Donuts:
"I'm going to die."
I tried to be reassuring while still managing to get the EKG done.
"No, I'm going to die," he said again.
The 12-lead showed that the patient was suffering from an anteroseptal STEMI, but his vitals were good and he had a strong radial pulse at 80, matched by a similar rate on the monitor, so my partner and I figured we were in good shape to get him to the cath lab less than 5 miles away.
Then, in an instant, the patient died.
He went from 80 and normal sinus on the monitor to pulseless and asystolic in the space of about 10 seconds: do not stop, do not pass VTach or VFib, go straight to nothing.
It was like turning off a light switch.
We fought as hard as we could for the patient, but nothing we did had any effect, and he was pronounced dead not long after we got to the hospital.
There was no one to tell. The man lived alone and left no list of contacts or next-of-kin for anyone to locate.
I know the police were trying to track down rumors of a sister elsewhere in the state.
Sometimes patients will do what they say they're going to do, no matter how hard you work to fix them.
A lot of our patients lie to us, try to convince us they're not sick when they are, or that they're sick when clearly they are not.
And sometimes, there are patients who tell you no lies, and you remember them probably forever, and at the very least for a long time.

Questioning the Sacred Cow

2008-12-17T18:40:00.000-08:00

Anyone who follows the writing of emergency physician and author Dr. Bryan Bledsoe knows that he's not afraid to challenge many of the things we take for granted in EMS.
Among other things, he has in the past been critical of what he sees as the overuse of air medical transports, has wondered not only about the usefulness of CISD, but also questioned whether the process actually increases the psychological trauma of high-stress incidents.
He has a really interesting article on JEMS.com right now outlining a series of studies that jibe with Dr. Bledsoe's distrust of the sacred cow.
His thought-provoking column is a round up of studies, some of which have been inexplicably ignored in the US for over a decade, like the one comparing neurological outcomes in trauma patients between Albequerque, where aggressive c-spine immobilization is the norm, and Malaysia, where c-spine immobilization is unheard of.
Interestingly, the study found that the neurological outcomes in Malaysia were better.
This study was published in 1998, and yet we continue to strap thousands of people a year to hard plastic boards without a second thought.
Other studies Dr. Bledsoe highlights include one that suggests IV epi is of little use in cardiac arrests and another that proposes using D10 for acute hypoglycemics versus D50.
Check out the column, I don't think you'll be disappointed.

EMS Longevity

2008-11-12T14:59:00.000-08:00

Work EMS for any length of time and you're bound to eventually question whether you've got the stamina to make a career of it.
We all know the challenges.
It was refreshing, therefore, to read this article by a guy who's been doing EMS for 24 years in North Carolina.
I hope when I've been doing it that long that I'll be half as optimistic as the column's author, Robert Powers.
I don't see why not.
I look at the ways EMS has improved since I worked my first shift as a Basic at MedTrans in 1995.
The field is dramatically better in almost every respect, and I have no reason to expect that this won't continue.
Like I tell myself whenever I respond to the wet shelter in The Big City for the fourth or fifth time in a shift -- this job may be hard, but it still beats working for a living...

An Easy Change

2008-11-05T10:56:00.000-08:00

Change is hard.

I had an official from the Boston headquarters of the DCR tell me that once when I complained about a parking lot he was putting in my front yard.

This official was the worst kind of government hack, and I hope they move the PIP to his backyard.

But he had a good point.

Change is hard or, rather, can be hard, if you're not prepared for it.

I've written here before about the changes at Spencer Rescue, which under the guidance of its leadership has transformed itself almost overnight (at least in glacial EMS terms) into one of central Massachusetts' best EMS agencies and a place where good medics want to work.

Most of that change took place under the watchful eye of Keith Ventimiglia, the service's former clinical supervisor.

Keith has since moved on to tackle a very interesting project that I look forward to writing about here in the future.

Hired to continue the progress made under Ventimiglia's watch is Dominic Singh, who recently took over Keith's position at Spencer Rescue.

Dom, 31, is an immensely likable and talented paramedic, and in the interest of full disclosure I should admit that Dom and I worked together for several years in The Big City and he is a friend of mine, so objectivity is out the window on this one. Personal feelings aside, Dom has earned his reputation the way all good medics do it -- one shift at a time, year in and year out.

A native of the Merrimack Valley, Dom graduated from Andover High School in 1995 and received a B.A. in Chemistry from The College of the Holy Cross in Worcester. It was during his studies there in 1997 that Dom got his EMT card and went to work for both Patriot Ambulance and the Stow Fire Department. After graduating Dom attended the Quinsigamond Community College Paramedic Program.

In addition to Spencer Rescue, Dom is a career Firefighter/Paramedic with the Amherst (Mass.) Fire Department and was until recently a Paramedic for UMassMemorial/Worcester EMS.

Dom lives in Amherst with his wife and three kids: Matthew, 4; Eden, 2; Ezekiel, 1.

In an email exchange with CMM, Dom was kind enough to talk a little about his new position, Spencer Rescue, and EMS in general.

CMM: EMS is a challenging field, particularly for those working to improve the product, so to speak. What do you see as the main challenge facing QA/QI programs in general, and at Spencer Rescue specifically?

DS: The main challenge that any QA/QI program faces is learning to cater the feedback to your crews, so as to promote growth, learning and better patient care without creating a feeling of alienation or condemnation.
A lot of places start out with the best of intentions, but end up creating an adversarial relationship with the crews, or review so infrequently that too much is missed.
The challenge in Spencer is to cater the program to the wide range of experience and certification levels.
The personnel here range from 20-year medics to basics just out of school. The initiation of the new employe during his or her formative years is just as important as making sure a senior member is current on the latest advanced modalities.
As long as the employee can be encouraged to buy into the program and the administrator keeps the reviews honest and level, it should succeed.

CMM: Spencer Rescue has undergone a remarkable transformation in a relatively short period of time. What has allowed the service to make such strides, and do you think such progress is sustainable?

DS: Spencer EMS has undergone some rather radical advancement over the last several years which were primarily the result of Keith Ventimiglia's leadership. He had a vision of where the agency should be headed, and facilitated that by bringing in a few reliable and reputable providers, as well as updating equipment, policies, and introducing some leading-edge therapies (e.g., CPAP).
I believe this type of change is sustainable as long as each small step on the way is planned, carefully executed, and has the buy-in of the crew members. While administration can choose a course, it will never be properly received without the backing of the providers.

CMM: Spencer Rescue is a third-service, non-profit agency that serves the Town of Spencer. What advantages do you see to this model, particularly in the western part of central Mass, where there aren't necessarily the resources in money and personnel you might find closer to Boston? Any disadvantages?

DS: Unlike some other third-services or fire-based EMS, we don't receive any funding from the town. All the monies collected from transports go entirely back into the agency.
I believe it does truly change the attitude of the crews if they think that their skills and hard work are being used to line the pockets of a distant owner, or all the money is being thrown into a town budget and distributed to other agencies.
Each dollar we make is in some way being used to assist people. I personally find this motivating, and it was a major in my decision to accept this current position. I'm truly working to heolp people and maintain a healthy environment for providers of a like mind.
We even allow the citizens of our service area the opportunity to buy-in to the agency with our subscription drive. It pays for itself in one transport, and offers a little bit of ownership in our end goal. [Residents] know that those dollars are going directly to this specific agency, unlike your taxes.
Our only disadvantage with this system comes from some people's view that, because we are not a "town department," we don't have their best interests in mind. Nothing could be further from the truth.

CMM: What's on the horizon for Spencer Rescue? Any new initiatives or changes you can talk about?

DS: We're currently accepting sketches for a new patch design, possibly a couple changes to the uniform.
We're also investing in new outerwear and PPE for all department members.
My plan is to invest in our crews as much as they invest in us. There are definitely other plans in the works, but nothing I want to roll out in this forum. Sorry!

CMM: What was it about Spencer Rescue that first appealed to you, and what advice would you have to leaders of similar services about setting and achieving clinical goals?

DS: Spencer actually came to me. Keith contacted me to come in and fill some shifts. After checking it out for a while, I saw the unique model Spencer operates under and how this is truly the core structure I had been searching for. I also saw the potential this place had and wanted to be a part of its rise to that potential.
The only advice that I hve is to keep your crews involved.
If the crews don't buy-in then you're doomed to fail.

Another podcast

2008-11-01T17:55:00.000-07:00

Just wanted a quick note to plug SurgeryICUrounds.com.
It's another site with a collection of awesome lectures, most less than an hour long, touching on some current topics in critical care medicine.
The site has some great information that is applicable to all venues of EMS, not just critical care.
Recent topics have included lectures on crush injuries and rhabdomyolysis, a two-part overview of MIs and their management (particularly thrombolytics and PCI centers), abdominal compartment syndrome (that one's for you Dr. Restuccia; I'll never forget sweating my way through the compartment sydrome question on your infamous written exam), and the philosophy and methodology of pain control.
The lectures can be downloaded to an mp3 device, or simply audio-streamed directly from the Web site.

Urban Inspiration

2008-11-01T09:13:00.000-07:00

As you all know, one of my favorite blogs out there is Rescuing Providence, written by Mike Morse, a lieutenant on the Providence (RI) Fire Department, where he works on one of the country's busiest ambulances.

I especially liked his latest post, which I've linked here.

It made me think of all the times where an extra moment to take a closer look at my patient as a person has reaped amazing rewards.

I've been blessed to serve Holocaust survivors and war heroes, Gold Glove boxers and a novelist or two, General Patton's driver from WWII, long-forgotten celebrities and, once, a woman who was raised in the Philippines practically as a member of General Douglas "I Shall Return" MacArthur's family, and who went to elementary school with the children of Dwight Eisenhower, one of the most important figures in U.S. history.

These were interesting people and I am a better person for having met them.

They are proof positive that beneath the surface of some of these silly EMS calls we go on there occasionally lies gold.

Silent Night, Random Night

2008-10-30T16:42:00.000-07:00

It wasn't something that happens in The Big City often.
I think the last time I pulled it off was almost three years ago.
We pulled a no-hitter on an eight-hour overnight.
Nada-for-eight.
Eight up, eight down.
If last night were a soccer match, the score would be 0-0.
I'm back in tonight, and I'm expecting a loooonnngggg night.
That's the way it goes, right?
Last night was bliss, tonight should be bedlam.
Which got me to thinking about the idea of randomness.
Personally, I don't think it exists.
Theoretically, EMS shifts should follow a uniform distribution, where the chances of a call or no call during a given time period (in my case, an eight hour shift) is drawn from a single pool of chances, all of which are equally probable.
Or something like that.
Seems some guys way smarter than me agree.
True randomness is hard to generate, even when you want to, and even when you've designed a computer to achieve it.
The folks at Random.org bemoan this lack of true randomnity (is that even a word?).
"Surprising as it may seem, it is difficult to get a computer to do something by chance," says the Web site. "A computer follows its instructions blindly and is therefore completely predictable. A computer that doesn't follow its instructions in this manner is broken."
Of course, those of us who've spent any time having meals and sleep interrupted by the machinations of the EMS Gods could tell you that there's nothing random about our profession.
For me it all comes down to the statistical concept of frequency distribution.
Frequency distribution is used to illuminate data by providing a visual representation of particular occurrences and how often they occur.
Usually this data is presented in tabular form.
EMS could best be summarized by what's known as a "continuous" frequency distribution, which is used to present data on a theoretically infinite number of possible values.
It seems fitting because there are, for now, an infinite number of EMS calls yet to be.
Tonight, I expect one of those nights that feels like there are an infinite number of EMS calls yet to be.
Hopefully I'm wrong.
The answer might be in the stars, but personally I think it's in a few thousand Capes, triple deckers, nightclubs, homeless shelters and apartment complexes.
I'll let you know how it went.

A Friend of Ours...

2008-10-16T13:16:00.001-07:00

Depending on the day I'm having, I either thank my grandmother or blame her for my career.
Either way, she's a big reason I do what I do for a living.
When I was 4-years-old, Nana brought me to a firehouse in Concord, New Hampshire.
I don't remember which one, but I still have the photo she took of me standing on the tailboard of an engine, proudly wearing a firefighter's helmet, with the number "9" on the shield.
I remember watching episodes of Emergency! on her family room floor, and the time she bought me a headlamp from LL Bean that you wore on your head because I thought it was something Paramedics Gage and DeSoto would wear.
I also remember going out with her on her little skiff into Maine's Casco Bay near Bailey Island, where she had "retired," if you could call it that.
She was the least retired retired person I ever met.
She was always running exercise classes on the islands or at the nearby Naval Air Station in Brunswick, or SCUBA diving in the Caribbean with her best friend, all of which she did until she was well into her 80s.
For fun, she launched and hauled a 20-pot string of lobster traps every year, guaranteeing we always had some of the freshest Maine lobsters around whenever we visited.
Most of all, Nana taught me to appreciate the people who help us.
She was incredibly proud of what I do for a living -- incredibly proud of what WE do for a living.
Nana understood sacrifice and hard work and doing something with your life that serves a higher good, and she always had a special place in her heart for paramedics and firefighters and cops and teachers and nurses and all those people who serve our families and communities every day with little or no fanfare.
Whenever I'm fortunate enough on the job to help someone in some small way, I know that I'm pleasing my grandmother to no end.
So it saddens me to say that those of us in public safety lost a true friend this week.
Arlene Hanchett, my Nana, of Brunswick, Maine, died Monday at the age of 94.
She was a friend of ours, and will always be.

Stairchair surprise, Pusware.com

2008-09-28T17:28:00.000-07:00

It was the kind of call that can get under your skin if you let it.
5:30 a.m.
The end of a busy shift.
Every prior patient obese or beyond.
Many of them actually sick.
Dinner was a couple Big Cups and an orange soda several hours earlier.
We had flung more stairchairs that night than an assembler at the Ferno factory.
My partner and I were exhausted, and now we were standing in the living room of an elderly woman who didn't seem to like us at all.
"I don't want to go to the hospital," she said. "They make me sit and wait too long."
"Ok," I said, "but you must have wanted to go to the hospital when you called 911."
"Damn right I did! I'm in pain! My hand hurts, and I can't walk! Can't you just give me something here so I don't have to go?"
We'd had this same conversation three times by now, and it was getting a little tiresome, but this patient was of a kind that we've all had once in a while.
No matter what you suggest, the patient wants to do the opposite.
I began by offering a trip to the hospital, to which the patient responded in the negative, exasperated that we'd even brought up the idea of an ambulance ride.
So when I asked if she would then prefer to wait until Monday and follow up with her family physician, since, after all, she'd had this particular pain for a decade and it was no worse currently than normal, she became truly offended and demanded transport to the hospital.
Finally, after about 20 minutes of negotiation in the cramped back bedroom of the musty triple decker, the patient relented.
And for the umpteenth time that night, my partner and I strapped our overweight patient into a stairchair and began the long descent down three floors of twisty, dark and steep steps.
We paused at the bottom just before heading out onto the sidewalk.
I had the bottom of the chair and as I bent down to grab the handles for one last time, I felt something on the top of my head.
I looked up and noticed that the patient was sitting back in the stairchair.
"That was a kiss for you," she said. "For working so hard."
It was the kind of gesture my patients surprise me with from time to time, and another example of why this is the best job in the world.

Persiflager's Infectious Disease podcast is a great site to keep up with the latest and greatest developments in the world of infectious disease.
The link also connects you to PACID, aka Persiflagers Annotated Compendium of Infections Disease Facts, Opinion and Dogma.
It's kind of a meta-site, full of links to other pages concerning antibiotics, pathogens and diseases.

Get This Book

2008-09-23T11:02:00.001-07:00

In reading his book, Rescuing Providence, the thing that stands out most to me is Mike Morse's refusal to complain.
Not that I would blame him if he did.
A Lieutenant on the Providence (RI) Fire Department and assigned to the EMS division, the book follows Morse on a 38-hour shift in a busy urban 911 system.
The litany of calls is familiar.
The patient names may be different, but Morse could have just as easily been writing about Worcester, or Lawrence, or Lowell or a dozen other New England cities still trying to recover in the 21st century from the erosion of the 19th century manufacturing economies that were once their foundations.
What's different is that Morse obviously loves his job, and has genuine compassion for those particular patients, like the frequent fliers and drunks we all deal with, who would be much easier to hate.
He occasionally questions why he continues to work in such a busy system when relief is just a simple transfer request away.
In his book, Morse comes back with the simplest of answers -- he loves working on the ambulance.
I know Mike reads this site, so I hope he won't mind if I give his book a huge plug.
I started Rescuing Providence at 9 a.m. on a recent morning and read it in one sitting, not because it's short but because I couldn't put it down.
Along with Peter Canning's two books (Paramedic and Rescue 471), Morse's is the best I've read about EMS and I highly recommend it.
Check it out at the Paladin Press Web site , or follow the link on my blog to Morse's Rescuing Providence blog to order.
It'll be the best 22 bucks you'll spend this month.

Better Living Through Thin-Slicing

2008-09-16T15:35:00.000-07:00

"What does it take to be good at something in which failure is so easy, so effortless?"
The man asking the question is Atul Gawande, a surgeon at the Brigham and Women's Hospital in Boston who also happens to be a bestselling author.
The question comes from Better: A Surgeon's Notes on Performance, Gawande's 2007 rumination about what constitutes success in healthcare, especially in the face of what he describes as "daunting expectations."
Although Gawande is a surgeon, I think his book offers profound insights for anyone in healthcare in general, and EMS in particular.
According to Gawande, the hurdles between doing a job and doing it well begin with the simplest of premises.
"For one, lives are on the line. Our decisions and omissions are therefore moral in nature...In medicine, our task is to cope with illness and to enable every human being to lead a life as long and free of frailty as science will allow. These steps are often uncertain. The knowledge to be mastered is both vast and incomplete. Yet we are expected to act with swiftness and consistency...It's not only the stakes but also the complexity of performance in medicine that makes it so interesting and, at the same time, so unsettling."
I thought of Gawande's book over the weekend while I watched a trauma team work on a severely injured patient brought in by one of our other ambulances.
The patient had taken a huge fall and was in cardiac arrest when found by the ambulance crew.
As most people know, there are few events so certain to result in death as a heart stopped by some kind of blunt force trauma, like, for example, the sudden stop awaiting you at the end of a long drop.
The number of people who survive this kind of event is minuscule, yet my co-workers delivered this patient to the trauma team with a pulse and blood pressure, not to mention some grievous musculoskeletal injuries.
The trauma team did a similarly professional job, and the patient made it alive to an operating room that he never should have seen, if one were only to consider actuarial tables.
I thought of the innumerable opportunities for failure with this patient, beginning with the bystanders who heard his last moans and called 911, extending to the first responders who did their jobs with aplomb, and then, of course, my co-workers who got the patient's heart pumping again despite the odds and effects of gravity.
Gawande whittles down the challenge of medical success and performance to three core requirements -- diligence, doing right and ingenuity.
Diligence, he writes, "is the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles."
On the surface of things, this should be "an easy and minor virtue," Gawande writes. "You just pay attention, right? But it is neither. Diligence is both central to performance and fiendishly hard."
I think I know what Gawande is driving at here.
In Sunday School we called these things "sins of omission," those things that we do wrong by not doing.
But Gawande doesn't judge.
"Medicine is a fundamentally human profession. It is therefore forever troubled by human failings, failings like avarice, arrogance, insecurity, misunderstanding."
Perhaps the Gawande tenet most applicable to those of us who wander the streets daily in ambulances is ingenuity.
He considers it not a matter of intelligence, but of character.
"It demands more than anything a willingness to recognize failure, to not paper over the cracks, and to change," Gawande writes. "It arises from deliberate, even obsessive, reflection on failure and a constant searching for new solutions."
Gawande admits these are difficult traits to engender, and who in EMS wouldn't agree?
We are a self-reporting profession, which means not only that the inmates occasionally run the asylum, but that only the machinations of the asylum that we allow to be seen or accidentally reveal come to light.
My favorite partners are those folks who ask themselves daily how they could do the job better.
What would EMS look like if that was a question the entire profession asked itself in earnest every day?
But then I think of the work of Malcolm Gladwell, a staff writer for The New Yorker and another bestselling author, and I think maybe it's a question we're answering all the time, even when we don't realize it.
If taken to its logical conclusion, Gladwell's book Blink:The Power of Thinking Without Thinking suggests that those of us in EMS and healthcare are constantly adding to an internal data bank of experience that we draw upon every shift.
Most busy urban systems share one common trait -- a particular pride in being able to walk into a room and know without even speaking with a patient whether they're "sick or not sick."
In observing various partners over the years in these busy systems, I'm amazed at the accuracy of their split-second assessments.
Gladwell wouldn't be.
A relatively new field of study in psychology, Gladwell says it's the brain's "adaptive unconscious" that allows for these uncannily accurate predictions based on the slimmest of evidence.
Ever wondered how that medic you work with was able to take a look at a patient and know it's a head bleed or CHF or STEMI before you've even put the first-in bag on the kitchen table?
Gladwell calls it "thin-slicing," which is "the ability of our unconscious to find patterns in situations and behavior based on very narrow slices of experience."
People who work for long periods of time in high-pressure, time-sensitive professions hone their thin-slicing skills to a razor's edge.
According to Gladwell, they have to in order to succeed.
"Thin-slicing is part of what makes the unconscious so dazzling," he writes. "But it's also what we find most problematic about rapid cognition. How is it possible to gather the necessary information for a sophisticated judgment in such a short time?"
Gladwell opines that an "automated, accelerated unconscious" processing takes over, and more often than not -- and more often, at times, than people who hashed out the same decision with lots more time and lots more data -- leads us to the right conclusion.

Lancaster Departments to Remain Separate

2008-09-09T06:15:00.001-07:00

It was interesting watching how leaders in Lancaster handled a proposal to merge the fire and EMS departments.
The T&G is reporting today that the merger is off, at least for now.

Charge of the Popup Brigade

2008-09-08T08:00:00.000-07:00

I should have invested in tents. Or maybe RVs. Definitely Tyvek.
I'd be a multimillionaire by now.
It's THE hottest growth industry of the post-9/11 economy, "it" of course being the sea of baubles and toys on which billions of your tax dollars have been spent in the quest to save us from the legion of Biblical plagues that terrorists are certainly preparing to unleash on us any day now.
But I worry about more than smallpox or anthrax or panflu (and that last, technically, wouldn't be the terrorists' doing, but the money to combat it all comes from the same place).
Thumb through any magazine dedicated to fire, EMS, police or "homeland security" and you can't avoid one obvious truth:
To counter Al-Qaeda's next attack on American soil, hundreds of intrepid security and safety corporations plan to send not troops but a sea of canvas tents, rubber huts and microwave-emitting RVs driven by Tyvek-suited first responders.
These companies have amassed a dazzling array of tents, pop-up trailers, tagalongs, pullalongs, tents with shower heads, red tents, blue tents, yellow tents, tents color-coded to the type of chemical agent used, Winnebagos jammed with more electronic equipment than the Space Shuttle, and of course, my personal favorite and an example of corporate synergy so refined as to make the bean counters at DynCorp or Halliburton break down and cry, one company has come out with a radio-infested combo popup trailer AND tent, whose purpose is as unclear as the entire device itself but the ads pitching it are pretty nifty.
Hopefully, if the day ever comes that we need this stuff, it will all work as planned.
Until then, I'm buying me some shares of Camping World.

FOLLOW UP: Get ready for lots and lots of new tent designs, once this report gets out there. I believe in preparedness, but sometimes I wonder how many hospitals could be built, how many ED beds opened, how many Paramedics and EMTs put on the streets, how many ventilators bought, how many doses of flu vaccine given out, how many uninsured could be covered, how many public health ills eliminated, all by redirecting even a portion of the billions and billions of dollars the federal government has spent ensuring that we have more RVs than a Utah salt flat, more tyvek suits than a field of McMansions, and that every first responder who goes to a convention is wearing the appropriate golf shirt?
A lot, I'd bet....

Soccer

2008-09-06T17:58:00.000-07:00

My twin 6-year-old boys had soccer practice this morning.
It was the first of the new season and we squeaked it in between rain showers, although we couldn't escape the oppressive humidity.
Watching them run, particularly the Redhead with the slight hitch in his step and who looks so much like his Mother, the last four years became like a decade, or maybe two, or three.
Hard to tell, really.

I involuntarily make the connection backwards to an ambulance call in a town 40 miles and five years away.
It was a September day, perfectly blue and sunny, and I was working at my part-time job at a non-transport ALS service when we got a call for a child with a pitchfork in his head in a nearby town.
We intercepted with the fire department BLS crew downtown.
The EMT in the back jumped out as we approached the ambulance's side door and didn't say a word.
In fact, I never saw him again on the call.
He knew how sick his patient was and so he went right to our truck to drive.
He also knew there wasn't much he could add to the scene we were about to encounter.
When my partner and I got into the ambulance we found a 4-year-old boy in c-spine immobilization with a non-rebreather oxygen mask strapped to his face.
He had a bandage over the top part of his head, and you could see a half-dollar sized patch of blood through the gauze.
A small three-pronged gardening pitchfork sat on the tech bench.
I'll never forget how two of the prongs were encrusted in mud, while the third gleamed as brightly as the day it was taken down from the hardware store rack.
Somehow we discovered that the boy had been playing with a friend, and for some reason the friend had plunged the pitchfork into our patient's head.
While waiting for the ambulance, the patient's mom had removed the pitchfork and the EMTs had had the foresight to bring it with them.
The boy was seizing violently, or "to beat the band," in the EMS vernacular.
We didn't waste any time in starting transport to the hospital.
En route we got a couple IVs going, administered one drug to stop the seizures and a few others to sedate and paralyze the little boy so we could put a tube into his trachea and breath for him.
A helicopter met us at the hospital and took him to the major children's hospital about 30 miles away.
I was convinced the patient was going to die.
I couldn't imagine the infection potential of the dirt and mud that had found its way deep into his brain; I could definitely imagine the trauma the pitchfork prong caused as it made its way into the most valuable real estate in the human body, into places where our true selves are secured.
While I'm convinced there is such a thing, I don't know where the soul resides, but I know that this poor little guy had just had a sharp pointed object rammed through the machine that gives motion and action to the soul's desires.
I wasn't optimistic.
But children are wonderful, confounding creatures, and they never cease to amaze me with their ability to do the unexpected.
This little boy survived first, and then thrived.
The neurosurgeons at the hospital performed miracles; the nurses on the neuro floor made sure those miracles stuck, and had a chance to cement themselves.
A year later, I was met at the ED entrance by this little boy, who now walked with a slight hitch in his step, which I barely noticed as he came forward to give me a hug.

I remembered the names of those surgeons, not because I ever thought I'd need them, but because I thought their work was amazing, worthy of the kind of fame we reserve for rock stars and actors.
I thought my admiration would remain academic, third-hand.
Then my little redhead starting getting dizzy.

Medulloblastoma is a malignant brain tumor of the posterior fossa.
That's the part of the brain, kind of near the brain stem, that controls balance, among other things.
We learned this on Nov. 8, 2004, when a CT -- in the same ED where the little boy with the pitchfork injury had thanked us for helping him out -- ordered by an ophthalmologist investigating the source of my son's swollen optic nerves revealed a large mass in the back of my son's brain.
My little redhead, 2-years-old at the time, ended up in the same children's hospital, on the neuro floor no less, and was promptly readied for surgery on Nov. 10.
I liked the date.
Nov. 1o is the Marine Corps' birthday, and as a former Marine I couldn't imagine a better day to start a fight against brain tumors.
The day before the surgery my wife and I met with the woman who would be operating.
I knew from my follow up on our little pitchfork patient that this woman had also been on the team that had saved his life.
As the ICU nurse who cared for my son put it in the hours after that Nov. 10 operation, this woman is a miracle worker.

I won't bore you with the details of the next two years of treatments.
Suffice it to say there was lots of chemo, radiation treatments, a stem cell transplant, more than a few brushes with death.
He lost his red hair and his appetite. More than a few other kids we met in the same fight lost their lives.
My little redhead is currently tumor-free, although we know there are no guarantees.
But today I watched my little boy play soccer with a slight hitch in his step, racing around a small grass field against opponents who will sit next to him in his first grade class on Monday and joke about how much fun they had on Saturday, and I couldn't help thinking that some miracles don't always end.
Sometimes they go on and on, even playing soccer with a slight hitch in their step.

Follow-ups

2008-09-03T05:40:00.000-07:00

Just a couple quick items to follow-up on things CMM has blogged on earlier:

It seems North Brookfield EMS has gotten its contract with the town. According to the Telegram, the deal is for a year and provides the service access to $25,000 that town voters approved earlier this year.
Ominously, though, it sounds like the deal would allow the town to put up its own ambulance with town employees (I assume they mean the Fire Department) and break the contract with just a month's notice.

In Gardner, the City Council has decided against signing-on with a company that would collect money from at-fault drivers to recoup the costs of fire and police responses to the accidents they cause.
Rather than defeating the proposal by official vote, the city council simply removed it from their calendar, achieving the same goal.
Cost Recovery Systems, of Dayton, Ohio, is a company that promises to recoup the cost of sending fire and police vehicles to accident scenes by targetting the drivers deemed at-fault in the accident and sending them a bill.
I'm sure a good chunk of the money ends up in Cost Recovery's pockets.
A couple other communities in the state have or are nearing deals with this outfit.
I applaud the Gardner City Council for steering clear of this whole mess.
Money is good, but at what cost?
To me, it's a pretty thinly veiled attempt at allowing police and fire departments to start billing for services that have traditionally generated no revenue.
I couldn't agree more with City Councilor Kim Dembrosky, who said after the move was defeated that “sometimes people say that government goes a little too far. I think this would have been one of those cases.”
Amen.

Planting The Left Foot

2008-08-29T10:01:00.001-07:00

I was thinking today, as I looked at the flattened toes on my patient's left foot, about the powerlessness of words at certain times.
Fortunately, there's a unique vocabulary that goes along with the art and science of caring for the sick and injured.
Heart attack patients "circle the drain."
When the drain is empty, they "code."
Congestive heart failure patients who are in acute distress are "full to the gills," while an equally troubled asthmatic or COPD patient is "tight as a drum."
The ambulance is a "bus,"a significantly hypoglycemic patient is "gorked," and a car rammed high-speed into a tree, trapping its occupants, is a "pin job."
And, of course, limbs that get run over by heavy industrial equipment are "pancaked."
Today's patient is a middle-aged guy who has worked in a factory for 30 years.
"Without an injury," he proudly notes.
Pause.
"Until today!" we say in unison.
It gets the patient laughing, enough that he cheerfully says that he thinks the injury might help his golf game by forcing him to plant that left foot more.
His toes are flattened into gelatinous stubs.
There is not even the slightest suggestion of boney formations left. It's as if the four toes have become the necks from those steamed clams everyone eats on the Cape each summer, with only the big toe miraculously escaping serious harm.
We splint the limb and give him fentanyl for analgesia, and since we're about 40 minutes by ground from the surgeons who have the only shot at saving what's left of the patient's left foot, we send him by helicopter to save time.
Throughout the whole ordeal our patient stayed calm and kept his sense of humor, no small task for someone who, in an instant, is now forced to perhaps say goodbye to an important piece of anatomy.
This is the second time in a couple of weeks that I've really been impressed with a patient.
In the urban systems in which I work, I've had patients call 911 to get a prescription refilled, or because they're convinced that an ambulance ride means faster service in the ED.
Earlier this year I had one of our frequent fliers call 911 demanding to be brought to the hospital for a pregnancy test.
But patients like today's prove that one piece of vocabulary to describe our patients needs no improvement.
It's quite enough to name it for what it was.
Courage.

Podcast Education; How Much For That Speedy Dry In The Window?; Blog Loss; ECG ABCs Course

2008-08-23T15:20:00.001-07:00

Looking for ways to keep up with some of the current research in EMS and related topics?
The Web offers plenty of opportunities and from time-to-time I'll try to spotlight ones I like.
For today's installment let me direct you to phtlspodcast.com
The site allows you to listen to talks by physicians and national leaders in trauma research via audio streaming on several dozen trauma-related topics, everything from shock and spinal cord injuries to the current state of research into fluid resuscitation.
You can also download the lectures to your mp3 player for listening later (Apple iTunes actually has a pretty remarkable selection of mp3 medical lectures available for free on its site -- but more on that another time).
The interface is easy to use, the audio is excellent quality, and you would be hard-pressed to find a better source of cutting edge information on trauma care, current practices and future developments.

I don't know how I feel about this idea making the rounds in Winchendon.
I can see the rationale for charging at-fault drivers for the cost of the emergency response to the accidents they cause, but something about it doesn't sit well with me.
I mean, why not start charging anyone who calls 911 and sends an ambulance, police car and fire engine out the door?
Should we start charging patients who call 911 then refuse to go to the hospital? How about hypoglycemics who refuse to go to the hospital once EMS corrects their low-blood sugar with an IV and amp of D50?
I don't know if I like the sound of any of that.
My feeling is that we're a public service, and the public shouldn't have to worry about how much it might cost them to call us.
This will bear some watching.
FOLLOW UP: Here's the Web site for the Dayton, Ohio-based company that is mentioned in the Telegram story. It sounds suspiciously like a way for police departments to finally bill for some of their services, and for fire departments to bill for something other than inspections and ambulance runs.

I'm sorry to say that one of my favorite blogs may be no more. The Boston EMS paramedic who wrote Other People's Emergencies announced this week that he was suspending his blog for the time being due to his activation in the armed forces, and that in all likelihood the blog is done permanently.
That would be a huge loss to his readers, but the blog remains up for now, and I highly recommend following the link above to read his archive. Let's hope this is just a temporary interruption.

This course comes highly recommended by a friend of mine whose acumen at choosing excellent courses is legendary.
"The ABCs of ECGs: Essentials for Frontline Clinicians" is being held on Nov. 1 at the InterContinental Hotel in Boston, and is a continuing medical education event sponsored by Harvard Medical School.
The course announcement claims that there will be something of interest to every level of provider here, and some of the topics covered during the day are definitely relevant to EMS, for example:
"Basic Principles: How to Read an ECG"
"Artifacts, Lead Misplacements and Normal Variants"
"Avoiding ECG Fumbles and Errors"
"Bradycardia: Causes of Pauses"
"Metabolic Abnormalities and Drug Effects/Toxicities"
The course costs $170 for everyone except docs, who get to pay $350.

WEMS Names New Deputy Chief

2008-08-23T09:30:00.000-07:00

UMassMemorial/Worcester EMS officially named Monday Night Group Shift Captain Michael Hunter as the service's new Deputy Chief.
DC Hunter was named to the post late last month and replaces former DC Ed Ramstrom, who has decided to go back on the road as a street medic after nearly six years as deputy.
With an EMS career that has spanned 26 years, the last 16 at WEMS, DC Hunter brings to the table a strong commitment to professionalism and patient care.
A North Brookfield native and current Holden resident, where he lives with his wife, April, a nurse practitioner, DC Hunter first became an EMT in 1982 and volunteered for the former North Brookfield Rescue Squad (now North Brookfield EMS) and the town fire department for a dozen years.
He completed paramedic training in Brattleboro, Vt., in 1983, and by 1984 was a nationally registered paramedic working at a non-transport service covering 10 towns out of Marlboro Hospital.
That service shut down in 1989 and DC Hunter went on to serve as the ALS coordinator for the original Marlboro-Hudson Ambulance and its successor after a merger with Ruggerio.
In 1992, DC Hunter was among the first group of medics hired by WEMS after it became part of UMassMemorial.
DC Hunter is a strong proponent of the Prehospital Trauma Life Support program and a member of its Executive Council, teaching at numerous conferences here and abroad, including his recent trip as part of the first PHTLS course taught in Muscat, Oman.
In an email exchange with Central Mass Medics, DC Hunter elaborated on the personal philosophy he intends to bring to his new position, and the future challenges he sees facing EMS as a whole.

CMM: What principles guide you, both as a medic and now as Deputy Chief?

MH: I always try to remember a few key phrases at work and in my personal life. One, loyalty above all else, except honor. Two, lead from the front and, finally, three, actions speak louder than words.

CMM: It might be a bit cliche to say it, but EMS seems to be at a crossroads today. It seems like the industry -- for years in the shadow of more-established brethren like the police and fire services -- is on the cusp of something, but it's hard to tell whether that something is a leap forward or backward. What do you see as some of the challenges facing our profession?

MH: At a national level -- and locally -- recognition is a huge problem. With recognition comes respect. We need to continually build positive relationships with the media, political leaders and the medical community. We need to become involved in committee work at the local, state and national levels. We are the experts in our field, and our opinions and thoughts need to be heard by the ones making global healthcare decisions. We also have a duty to educate the public and we need to advocate for public health. There are many places where our voices will lend credibility and depth to healthcare issues. Seatbelt use, car seat compliance, bicycle helmets, stroke and cardiac disease awareness, elder care and referral to services are just a few examples of worthwhile causes. Through our involvement in these issues will come recognition and respect.
We are also a young profession and our leaders are still developing. We all need to remind ourselves to look backward and help bring the new group of providers along. The newest members of our profession should not have to make the same mistakes we did. It's not a rite of passage. I think we all should also remember that involvement in medicine, especially in a young profession like EMS, is a dynamic process. We must all be "life-long learners." Too often we find ourselves basing decisions and actions solely on tradition. We must all be willing and eager to learn new technologies, theories and ways of working smarter. If we don't, we're doomed to make the same mistakes of those before us. Tradition and folklore have a place in the EMS society, but must be kept in perspective and we must not be rigid in our resistance to change.

CMM: Deputy Chief is a demanding position, especially at a service as busy as WEMS. How will you approach your new duties?

MH: I feel that four principals are paramount for my new position, and I try to adhere to them with every decision and action.
One, leadership. Leaders choose to lead. They must understand the consequences of their decisions and accept the responsibility of their failures, and successes. Leaders also lead from the front.
Two, respect. We should treat everyone as we would expect them to treat us. This holds true at many levels -- patients, peers, supervisors, subordinates and the general public. Putting on a uniform implies a position of authority, and with that comes the responsibility to act accordingly.
Three, communication. It is much easier to lead if everyone knows the direction we're going. The goals and expectations of a project or action need to be understood by everyone involved. Communication involves at least two parties, and the best ideas don't always come from the top down. It is important to remember that you cannot listen if you're constantly speaking.
Four, evaluate. We should always step back and evaluate every decision we make or action we take. This goes to life-long learning. Is there a better or smarter way or doing what I just did? Was my action in the best interest of my patient, partner and service? It goes to what Einstein said about insanity -- that doing the same thing twice but expecting a different result is a sign of insanity. Older medical professionals embrace mortality and morbidity rounds as learning experiences. EMS tends to embrace defending our own actions, even when they are proven to be less than correct -- or even deleterious -- to ourselves, patients and reputations as healthcare providers.
The medics, physicians and communication specialists of WEMS are a great and diverse group of individuals. They each bring unique strengths, backgrounds and experiences to the table. One of the strongest bonds the members of WEMS share is the desire to be the best and provide the highest possible level of care and service to the population we serve.
It is an honor to have been chosen as Deputy Chief and I'm looking forward to learning and growing into this position. WEMS is a great place. I'm very happy to be here and will do the best I can to keep it a great place.

Courage Under Fire

2008-08-22T18:00:00.000-07:00

The patient was a teenager, but he looked like he was 12-years-old.
In the 45-minutes I was with or near him, he passed out four or five times.
His normally-beating heart was betraying him, his atria quivering when they should have been contracting in synchrony.
It's not the sort of thing a young man's heart typically does.
We started two IVs on him; the ED added a third.
His heart rate never dropped below 130 beats per minute, and twice -- once when we moved him over to the ED bed and another time for no good reason -- accelerated to 280 plus.
Eventually, the ED threw the drug box at him -- Amio, Mag, Versed.
Before the cardioversions began they even gave him some Etomidate.
Anesthesia came down with their bag of tricks as the docs considered intubating him, but this kid was tough.
He maintained his own airway and defied our system's plans to take away his ability to breath unaided by machines or people, probably the most basic proof we have that we're alive.
The docs shocked him 5 times. A helicopter was called, and by the time they took him to the city he was doing much better.
As they wheeled him out the door I tapped him on the shoulder and told him to hang in there.
He nodded, but it seemed like he was already dealing with his condition better than any of us.
Today was a bad day, but not the worst for this young man in his brief life.
Diagnosed with a form of bone marrow failure and chronic anemia when he was just a few months old, the patient's disease has left him with an alcoholic's liver and a 90-year-old's heart, and he bears a 12-inch half-moon scar down his abdomen from where they'd removed his spleen at one point.
And despite all this, despite having a million and one reasons to complain, to feel sorry for himself, to do any one of the legion of things I might do if faced with a similar path, our patient was calm, almost stoic.
He answered questions and described his condition with the maturity of someone three times his age.
I don't know that I've been more impressed with a patient.
We hear a lot about courage and heroism.
Most of it is crap.
This kid was the real deal. He knew how sick he was, better than us -- better than ANY of us there that day, and he was the calmest one in the room.

The patient has what's known as Diamond-Blackfan anemia.
If you haven't heard of it, don't sweat it.
There are only 500 cases in America.
The condition is a member of the family of inherited bone marrow failure syndromes (IBMFS), and according to imedicine.com it's incidence in the U.S. is somewhere between 2 and 6 cases per million people.
It usually appears first in early infancy and is marked by a pure red blood cell aplasia, which means that the patient's bone marrow lacks any red blood cell precursors.
About a quarter of those cases result from gene mutation; the other 75 percent, apparently, appear mysteriously.
The treatment generally includes lots and lots of transfusions, which can lead to cardiac arrythmias, congestive heart failure, iron overload, stunted growth and infections.

For my partner and I, the acute dilemma was twofold.
The patient presented with a rapid AF in the 150s, but also threw pretty frequent runs of Vtach.
It was a unique ECG strip, to say the least.
His pressure was Ok, 124/70 bilaterally, but he was able to tell us that he has had episodes of acute hypotension with Dilt.
So we worried about dropping his pressure.
The Vtach was problematic, too, because we worried about giving Amio due to the hepatic issues, what with Amio being excreted mainly by the liver.
We ended up contacting med control.
The online doc, having already spoken to the city specialist who treats this young man, told us to give a little fluid but, as long as he continued with a stable hemo status, otherwise just observe.
Given how complex his treatment course in the ED became, I'm glad this is the course we took.
Sometimes less is definitely more.

Even as I write this, I wonder how this patient is doing.
Unless we return to his house, I doubt I'll find out.
And if we have to return to his house, it can only mean that things aren't going well.

North Brookfield On The Ropes?

2008-08-20T08:00:00.001-07:00

From the Things Are Tough Everywhere file, this story about the financial woes of North Brookfield EMS.
I hate to see these third-service non-profits have such tough times. My first job as a Paramedic was with New Britain EMS in New Britain, Conn., a third-service non-profit with loose ties to the former New Britain General Hospital (it now has some new convoluted name that I can't even begin to remember).
I loved every minute I worked there.
There are numerous examples of such services thriving here in Massachusetts -- Spencer Rescue and Webster EMS come immediately to mind -- but obviously the financials can seem insurmountable.
On an editorial note, and although all I know of the proposed contract with the town is from what I read in the paper, I'd have to agree that it would be cost-prohibitive for a town with a call volume as low as North Brookfield's to insist on TWO 24/7 dual medic trucks dedicated solely to 911 calls.
Frankly, I don't know how they'd pay for it.
I wish North Brookfield EMS all the best.

Some Blogs I Like

2008-08-18T17:47:00.000-07:00

I like blogs.

Actually, I LOVE them. It's like they exist in real-time, and speak directly to their readers, unlike what most Web sites have become these days -- marketing tools meant to tease you into buying something; hopelessly out-of-date, at least by 2008 standards. I mean, who wants to linger at a Web site that was last updated 8 months ago?

So here are a few of my favorites. One of the best things about each of these blogs are that they link to dozens of others, each of which links to dozens of others, and so on, until suddenly you realize there are tens of thousands of people writing blogs just about ambulances and EMS, which is pretty cool.

Wormtown Medic. Written by a co-worker, it's a new blog that focuses on Worcester EMS in Worcester, Mass. Anyone who knows its author, Rod Witkos, knows it will be opinionated, insightful, definitely funny and a must-read worthy of a Bookmark. For those of you wondering about the title, "Wormtown" is a city nickname that has stuck around for a few decades despite some opposition among more sensitive residents. I always liked the name.

Rescuing Providence is a blog written by Lt. Michael Morse of the Providence Fire Department.
This is a great blog written by a guy who chooses to work on one of the busiest ambulances in America despite having the option not to. Inspiring to those of us who don't feel the need to apologize for being passionate about EMS. Another must-read.

Other People's Emergencies focuses on Boston and is written by a veteran Boston EMS medic.
This blog captures the experience of urban EMS in all its facets like few others I've come across. No war stories, just clear-eyed observation underscored by keen analysis of the day-t0-day life of an urban Paramedic.

Random Acts of Reality is a blog written by an EMT for the London Ambulance Service. Well-written and funny, it also goes to show that a 3,000 mile gap doesn't mean much when it comes to EMS. The things that make the job great and galling are universal, it seems.

Brick City Blues covers the daily (and nightly) grind of working for University EMS in Newark, New Jersey. This is definitely an intense place to work, on all fronts, and the medic who writes it pulls no punches. Although in the news recently for all the wrong reasons, this is one of the nation's best EMS services and the blog is a joy to read.

Not Just For Firefighters; Down With The Stairchair

2008-08-18T16:59:00.000-07:00

Thanks to Rod from Worcester EMS for pointing out this link.
While sponsored by a group attempting to tackle health problems amongst firefighters, I think they could easily have been describing anyone who makes a living responding to emergencies with lights and sirens.
We work so hard to help those around us that it's so easy to forget about ourselves.
Although there have been some EMS initiatives, the fire service is really striving to address those things that make heart disease the most prolific killer of public safety personnel.

In perhaps a more EMS-centric vein, JEMS.com recently posted an article about back injury prevention.
This is where I find the state's declaration that we stair-chair EVERY patient to be not just ridiculous, but downright career-threatening.
Can someone please tell me why I should risk a career-ending back injury stair-chairing a Section 12 patient with no physical issues whatsoever?
With all the talk about selective c-spine immobilization and the recent research questioning the wisdom of backboarding everyone who calls 911, I think we need to look at stairchairs the same way we look at surgical airway kits -- something only to be used when needed and appropriate.
I want to do this job until I retire, and I need all my discs and vertebrae in their proper location and functional.

Here's an interesting .pdf file about expanded scope Paramedics, an idea that was in vogue for a brief period a couple of years ago. I'm always intrigued by ideas like these, but we work in Massachusetts. I'm not holding my breath...

Flophouses, Foyers and Lobster Trap Hearts; Plus, Does Your Doc Throw Stuff?

2008-08-17T20:42:00.000-07:00

I worked a shift today at one of my part-time jobs, a non-transporting gig based in one of Massachusetts's most economically depressed cities.
This job is usually a good jolt to the system because in addition to this city, the service provides ALS to a couple of the state's nicest -- that is, wealthiest -- towns.
The juxtaposition can be jarring.
One call you're intubating a cardiac arrest in the fetid bathroom of a flop house and trying not to think about what the gooey stuff is that you're lying in, and the next you're evaluating the chest pain of an elderly matriarch -- whose relatives skippered the Mayflower -- in the foyer of a brick mansion that itself is bigger than your own home.
I make no judgments here about either of these patients. They both get the best I have to offer.
That's the great thing about being a Paramedic.
We don't have to worry about who these people are -- the sick and injured who call 911 or have it dialed for them.
No matter whether you're the alcoholic homeless guy at the local wet shelter who had his nose broken in a fight with another alcoholic homeless guy from the local wet shelter, or the CFO of a Fortune 500 company in flash pulmonary edema, all we have to do is treat you.
Throw in a little humanity and you're on to something...

Doctors take the hit in this article, but none of us in the field are blameless.
For me, the dangerous hour is 3 a.m.
Certain decisions that seem completely justified or rational in the middle of the night -- like throwing discarded pizza and Chinese food containers against an EMS charting room wall instead of actually asking the ED nursing staff to stop using the only table in the room as a trash bin -- will almost always be revealed during the daylight to be really, really stupid.
I've noticed that some people in healthcare seem to equate personal competency with a license to treat the rest of the field like fools or little children.
I don't know where this comes from.
Mostly I think it's a form of amnesia.
When you forget where you came from it becomes even easier to forget where you are -- a small part of a big team trying to alleviate suffering and cure illness.

For those of you who might have missed it, there's a bit of a Rennaissance happening at Spencer Rescue over the last year or so. This article in the Telegram makes reference to Spencer Rescue's pact with Paxton, and is a great example of how a little cooperation and innovative thinking can bring good things to all sides.

I don't know much about how EMS operates in Upton, but it seems changes are afoot. Although maybe unrelated to anything going on in nearby Upton, EMS in the Milford area has undergone a sea change lately, what with the sad demise of the 2181 non-transport service out of Milford Regional Medical Center. I'm not sure who's stepped in to make up for the loss of ALS coverage, other than AMR now owning the entire operation in Milford itself. Uxbridge Fire Department has been making strides to get its ALS program running, while Events and Alert Ambulance are still in the area. I'd love to hear from people who can explain where everything stands down there.

Does it seem like we respond A LOT in the course of a week for patients complaining of possible reactions to antibiotics?
It seems we're not imagining things.
A recent study found that nearly 20 percent of all hospital evaluations for adverse drug reactions involved antibiotics, affecting nearly 150,000 people.

Here's something for the Medical Oddity of the Month Club, courtesy of George, a partner of mine at the part-time job I wrote about earlier who works full-time as an RN in a cath lab.
George is one of my favorite partners of all-time, mostly because despite having over two decades on the streets as a Paramedic, George still approaches the job with a sense of wonder and a desire to learn.
I hope I have half his intellectual curiosity when I've been a medic that long.
So anyway, George had to give a little mini-lecture at a meeting of the cath lab staff on the subject of takotsubo.
Also known as Transient Left Ventricular Apical Ballooning, it's basically a deformation of the left ventricle resulting from extreme psychological or physical stress.
The name is derived from the shape of traditional Japanese lobster traps, which the stricken heart resembles.
It's kind of rare, but not unheard of. George has himself seen two of these cases in the cath lab, where he's been for less than a year.
I don't know how knowledge of this will help you directly in the field, since it's not something we'd be able to discover and even if we could, there's nothing to be done about it prehospitally.
But I'm not adverse to knowing stuff just for the sake of knowing it, and takotsubo is pretty interesting, so if you feel the same way, then bon appetit.

For those of you willing to send it along, one of my main goals for this blog is to be a resource for EMS and related news for central Massachusetts.
I'm not looking for gossip and I have no agenda other than spreading the word about goings-on in our part of the prehospital world.
If you have anything of a newsworthy nature -- and my list of things that might be considered newsworthy is pretty broad, everything from new vehicle purchases, contracts, hirings, open positions and whatnot to attaboys and award announcements -- please feel free to email it to me and I'll be sure to get it in the blog.
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