EMS 2.0

#CoEMS: CPR Effectiveness

08/11/2010 by Adam Thompson, EMT-P Leave a Comment

Chronicles of EMS, A Seat at the Table takes on CPR effectiveness. The Las Vegas video that they mention can be found below as well. Keep up the good work Justin and Mark!

Side note – ILCOR, The International Liaison Committee On Resuscitation has not found any supporting evidence for the Autopulse. They are the ones whom do the research for AHA. Also, transporting patients without a pulse should be re-looked at by any agency performing this practice. The initial treatment at the ER will not differ from the treatment we provide at the scene per ACLS guidelines. Why not give the patient the best chance possible. If they don’t get a pulse back on scene, it is probably never going to come back–that’s just the facts.

Man vs. Machine

Filed Under: Cardiac Arrest, Cardiocerebral resuscitation, CoEMS, Education, EMS 2.0

Empathetic vs. Pathetic

05/28/2010 by Adam Thompson, EMT-P Leave a Comment

Empathetic vs. Pathetic

Listen up EMS

By Adam Thompson, EMT-P

I know I have pretty much kept this blog purely aimed towards education, fact, and evidence. It is time for a rant though.

Please read the following links before continuing:

So what do we do? How do we change the attitude of our fellow EMSers? Do we need to make the change, or do they?

This is something I have been cognizant of for some time. Being an overachiever in EMS gains you no friends. The more successful you are, the bigger your blip is on the radar of ridicule. But who cares, right? They aren’t talking about you for being a cretin medic that screws up on calls.

Example. I am a young, but experienced medic. I have achieved a lot in my career. I am a published author. My training captain recently sent out one of my articles with a thumbs up message to my entire agency. The response was as good as it was bad. The ongoing joke is with every conversation I bring up I hear “why don’t you go write an article about it”. Some of this may be just a joke, but I can feel the animosity from many. Why?

The Problem

I think, from my experience I have pinned down one problem. We are our own bosses.

I know we all have bosses, chiefs, supervisors, what have you. What I mean is, most of us don’t have those people on our trucks with us. If you work in a system like mine, you may be the lone medic working with an EMT, or maybe you are the EMT. I think that the systems that have multiple medics per ambulance suffer less from these issues–and here’s why.

If you are use to making your own decisions with little repercussion and the ignorant feeling of correct-fulness, you will not likely be inclined to take advice from your fellow medics. I dread the response of a peer that I attempt to assist with a smidgen of education. Because there is a naive belief that they know EVERYTHING.

Why are we so damn sensitive?

If you haven’t read my letter to the new guy, go read it. It is time we toughen up. If a salesman isn’t making a company any money, are the bosses going to be fearful to approach him?

I was speaking with one of the white shirts (officer) from the training department the other day and made some proposals. I said we should have a real QI/QA committee that picks ten calls at random every month. Some ran good, some not so good. Then, the medics on each of those calls would have to present each case in front of their peers. There would be questions and answers.

My thought was that we hear about the bad calls through hearsay all the time, but do those medics get to defend themselves on a normal basis–no! A lot gets lost in translation. Sometimes you have to be on a call to understand, right? Well here is the chance to remedy that while implementing a QI/QA process that physicians use and grow from.

His response: The union will never allow it.

What the hell are we doing to ourselves? While unions might be established to protect the best employees, why do they work so hard to keep the worst? We can learn so much from each other, but you can’t learn if you keep thinking there is nothing left to learn.

We all mess up. Get over it!

I consider myself a pretty educated paramedic. I have made many mistakes.

Now think about that. When do you learn most? I’m not saying that there is a cemetery somewhere, filled with all my mess-ups. I’m talking about simple, little mistakes. Mistakes that if unmade, would have lead to more information and a faster diagnosis or better treatment modality.

If you think you are invincible, go ahead and continue living on your beachfront desert property. You make mistakes too.

If you can learn so much from your mistakes, and I can learn so much from mine, why can’t we BOTH learn from EACH OTHER’S mistakes? This of coarse requires a deflation of bulbous craniums.

When did this stop being about the patients?

Empathy is a virtue that is quickly finding itself on the endangered attributes list.

Please read Professionalism: What we say by me.

No matter what you read here, or believe. No matter how long you have been doing this. No matter how bitter you are. You have to agree that at some point of your career you wanted to help people. You wanted to make a difference, and do some good. So I ask you this… Are you?

Filed Under: EMS 2.0, EMT, General Discussion, paramedics

Prehospital 12-Lead ECG Efficiency

05/13/2010 by Adam Thompson, EMT-P 14 Comments

Recently I have taken part in a very interesting discussion on the NAEMSP dialog page. This discussion is based on the paper Early Cardiac Cath Lab Activation by Paramedics for Patients with STEMI on Prehospital 12 Lead ECGs. Tom B from The Prehospital 12-Lead blog, and contributing author to Paramedicine 101 is one of the active participants in the discussion.

Some of the problems discussed:

- Poor quality ECG captures

- Deficiency in knowing when to capture a 12-lead ECG (43% of paramedics in one study did not perform a 12-lead on an active STEMI)

- Deficiency with STEMI recognition (False positives are still far to frequent)

- Poor STEMI alert and transport guidelines

One of the solutions which has a lot of supporting evidence is the transmission of 12-lead ECGs from the field to the receiving PCI facility.

Some research:

THE POSITIVE PREDICTIVE VALUE OF PARAMEDIC VERSUS EMERGENCY PHYSICIAN INTERPRETATION OF THE PREHOSPITAL 12-LEAD ELECTROCARDIOGRAM

Background. Obtaining a prehospital 12-lead ECG may improve triage and expedite care of patients with acute myocardial infarction (AMI). Whether the ECG should undergo physician review prior to activation of a percutaneous intervention (PCI) team is unclear. Objective. To document the positive predictive value (PPV) of the prehospital 12- lead ECG when interpreted by paramedics versus emergency physicians. Methods. This was a prospective, observational study. In November 2003, our local health care and emergency medical services (EMS) systems implemented a prehospital “cardiac alert” program in which patients suspected of having ST-elevation myocardial infarction (STEMI) based on the prehospital 12-lead ECG were diverted away from receiving facilities without emergent PCI capability and the PCI team was mobilized. For the first year, a cardiac alert was activated by paramedics (Phase I). After the first year, the ECG was transmitted to the ED, with the emergency physician (EP) responsible for activation (Phase II). The PPV for cardiac alerts in Phases I and II were compared by using three different “gold standards”: cardiologist interpretation of the prehospital 12-lead ECG, disposition to emergent PCI, and coronary lesions on angiography or arrest prior to emergent PCI. Results. A total of 110 patients were enrolled (54 in Phase I, 56 in Phase II). Cardiologist confirmation of a STEMI on the prehospital 12-leadEKGwas 42/54 (78%) in Phase I and 54/56 (96%) in Phase II. Disposition to emergent PCI occurred in 38/54 (70%) Phase I patients and 51/56 (91%) Phase II patients. Lesions at catheterization or arrest prior to emergent PCI were observed in 41/54 (69%) of Phase I patients and 50/56 (89%) of Phase II patients. All of these comparisons achieved statistical significance (p less than 0.01) Conclusions. Transmission to the ED for EP interpretation improves the PPV of the prehospital 12-lead ECG for triage and therapeutic decision-making.

-PREHOSPITAL EMERGENCY CARE 2007;11:399–402

Okay so a solution I would like to provide, and please provide comments here and/or on the dialog page linked to above.

My solution is to provide an adjunct course. Much like ACLS, CPR, PALS or BTLS, this course could be taught in conjunction with the paramedic curriculum but will expire and renewals would be required. The current paramedic curriculum does not include enough instruction on prehospital 12-lead ECG interpretation. My proposed course would include a whole lot more information as well as STE-Mimic recognition. Why not? In my experience, I have noticed that the biggest deficiencies that paramedics present are airway, medication administration, and cardiac rhythm interpretation–especially 12-lead ECG interpretation.

So what do you think?

Provide your thoughts or your solutions to narrowing the EMS to repurfusion times.

Filed Under: Cardiology, Education, EMS 2.0, General Discussion, Research

Chronicles of EMS – A double edged sword?

04/26/2010 by Adam Thompson, EMT-P 2 Comments

I’ve been struggling lately.

Struggling with all of the information I am absorbing from all of the professionals I get to communicate with on a daily basis these days.

I am suddenly exposed to a wealth of EMS knowledge and experience which would, I assume, be seen as a gold mine of information to many people. Indeed, that is how I see it also, and I have gained so much from that, that sometimes my head hurts from the combined thoughts of hundreds of people’s experience.

The Chronicles of EMS has given me so much more than I would have ever thought possible, but there is a flip side to it also, and this is what is affecting my day to day work life.

I have had a post in the back of my mind for a number of months, one which constantly sits there and sometimes raises its head asking to take up its place in the archives of this blog.

It was going to question whether EMS 2.0 is a purely American thing. Does the UK need EMS 2.0 or are we already there?

I mean look at what I can do? I can tell people that they don’t need to go to hospital, I can organise for alternative care providers to come and see the patient at home instead of transporting them to the hospital. I can make autonomous decisions about what is best for my patients and have them agree with that treatment plan. Surely that is already EMS 2.0, right?

Well yes, I would say that that part of my role is definitely part and parcel of whatJustin, Chris Kaiser and I hope to see develop from the Chronicles of EMS and EMS 2.0. However, what I am learning and what I am finding more and more difficult to accept is the fact that in other ways, the UK ambulance services are far behind our brothers and sisters in EMS across the great pond.

Before all of this crazy show started, I lived and practiced in my own little bubble. I used to naively think that we were the best at what we can do. If a patient needed emergency care, then they would get the best the world has to offer. In some cases I still believe that, but not in all.

Now, I can say this because I am not criticising my service here, I am looking at the NHS ambulance service as a whole and recognising that what has happened for years and years still happens now and will continue to happen. That is that we follow US developments in the field of medicine, usually anywhere from 2-5 years after the new development has been tried and tested in the USA.

That’s never been a problems for me before because I have never had the awareness that I have now from spending so much time in the US and talking so much to operational staff, managers, Chiefs and industry professionals.

Now, it is becoming a huge frustration for me because I can see what I should be doing and I can see what will be coming, but until that happens I feel angry that we are lagging behind.

Let’s take one example.

Out of hospital cardiac arrest.

I used to think that we were as good as this as anyone else. But now I know that there is so much more that could be done, like:

More hands on scene – that has always been a role I would like to see our colleagues in the UK fire service take on. If not, then even getting more ambulance responses on scene would be a benefit. One crew, 2 members of staff, no matter how well trained cannot perform continuous compression CPR on a patient from arrival on scene until handover at hospital, it is impossibility. As much as I can see flaws in a Fire Based EMS model at times, the one thing I saw which has obvious benefits is the amount of hands on a patient when necessary. There is no point in me looking for someone to swap in for some compressions when I am in the back of an ambulance alone, and if we can’t have extra hands then why not look at equipment that can help us.

Compression assist devices such as the Zoll Autopulse and the Physio-Control Lucas device could take the place of the extra pair of hands needed for a UK paramedic crew on scene. This will come, without doubt, but it will be a couple of years down the line.

What about the apparent holy Grail of prehospital induced therapeutic hypothermia? How long before that hits the UK shore.

Please don’t get me wrong, I’m not saying that all of these things will bring real benefit to patient care (well, actually I guess I am), but why does it take so long for them to make their way over here?

Why should I have to go to some of my patients knowing that there may be better ways of caring for them, which I may well not have access to for a number of years?

Uk pre-hospital care isn’t the yard stick for all other EMS systems to be judged against, far from it, but maybe this just goes to show the value that The Chronicles of EMS and the EMS 2.0 movement can have…..bringing new thoughts and ideas to services which feel that they may be doing things the best way they can already.

I have had my eyes opened and I can see the future of prehospital care, and it includes every bit of knowledge and experience that I can gather, and more importantly share, with services throughout the world.

Until that day comes though, I will remain hopeful and proud to work in my system, but also frustrated waiting for best practices to make their way over here as well as some of ours making their way over the the States.

To finish off, just read this article from the Richmond Ambulance Service in Virginia. This is what I want to be doing for my patients!

Richmond Ambulance Authority nearly doubled prehospital ROSC rate because of the ARCTIC program

Filed Under: CoEMS, EMS 2.0

When is a refusal really a refusal?

04/06/2010 by Adam Thompson, EMT-P 1 Comment

One of my fellow EMS Bloggers, MedicSK from `EMS in the new Decade’ recently put a post up which has initially struck my ‘getting on a soap box’ bone, then has made the grey matter work a little over the last day. I initially commented on his post, but decided that the follow up was going to be too long and deserved a post all to itself.

In his post, MedicSK asked questions about patients refusing treatment and looked at two things in particular.

The need for the ability to deal with non transport decisions
The fact that determining that someone being conscious, alert and orientated is the be all and end all of ‘accepting’ a patient’s refusal of treatment.

Go and read his post first, then come back and let’s talk about this further.

All done?

Great, right then off we go.

In my first comment, I questioned the statistics that he stated. Specifically:

“Nationally, on average, approximately 20-25% of all 911 Ambulance calls result in a non-transport, so refusal scenarios are encountered frequently”

I stated that the true amount of refusals are significantly less, probably somewhere in the region of <5%.

In general people phone 999 or 911 because they want our help. The refusals are usually from people who did not make the call themselves but instead it came from a ‘3rd party caller’ who thought they were doing the right thing.

MedicSK clarified his point by stating that:

“That also includes cancelations, unfounded calls, lift assists etc”

That’s all fine and good, but my soap box moment comes with the proportion of ‘refusals’ that are actually nothing of the sort.

These can be split into two sorts.

The first is one that MedicSK gives an example of:

The transport offer is always said to be there, and many Medics are taught to make three attempts to get someone to go to the hospital. It will usually go like this:

Medic: “Do you want to go to the hospital?”

Patient: “No, I do not.”

Medic: “That’s some pretty good damage to the front end of your car there. You could be hurt a lot worse than you realize. Are you sure?”

Patient: “Yes, I’m sure I do not want to go to the hospital.”

Medic: “Okay, well if you aren’t going to go I need you to sign this piece of paper. Before I leave, are you sure you don’t want to go?”

Patient: “No, I don’t want to go.” *Signs Paper*

There is some room for a Medic to give advice to a patient, but that door does not open up until after the PATIENT decides that they do not want to go to the hospital.

Is this a refusal of treatment?

I would argue that it is not. This is a conversation that will be repeated all around the world, numerous times a day and it is usually in relation to a minor injury or illness. I know this because if you were truly worried about someone’s health, the discussion would not start with “Do you want to go to hospital”

For someone to consent to treatment, there needs to be an informed decision. Likewise, if someone is refusing treatment, there needs to be an informed refusal. They need to be made aware of the risks of refusal in no uncertain terms, and in many cases this can be done fairly bluntly if you really want someone to go to hospital.

I have been heard to say to certain patients:

“You have a significant swelling to your head and there is a chance that with this type of injury you may develop a bleed into the brain. I am strongly advising you to come with me in the ambulance to hospital and get assessed fully by the doctors there. If you still choose to not come with me then you will have to sign a form stating that if you die tonight whilst you are asleep, it is all down to you, and has nothing to do with me as I am telling you that you need to go to hospital”

Now obviously, the language used depends on the person you are talking too. I wouldn’t dream of speaking like this to a sweet elderly lady who is afraid of going to hospital In case she doesn’t get back home; but as you all know, there are times that you need to speak to patients in a manner that they will understand and respond too.

Unfortunately, if we cannot prove that someone has lost the capacity to make an informed decision then we cannot do anything about it.

We can only act in the best interests of the patient if we can show that they do not have capacity anymore. This brings its very own moral and ethical dilemma which I will discuss at another time. Suffice to say though, just because we disagree with a patients choice doesn’t mean that we can force them into going to hospital.

If however, we can show a lack of capacity, then there are options open to ‘force’ them into receiving medical help.

But, for example, where does this leave us with a patient who has not taken any alcohol. Is alert and orientated and her partner is concerned that she has taken an overdose (and she admits it) but she absolutely refuses to go to hospital?

Between a rock and a hard place, that’s where.

If she is in her own house, we cannot get the police to remove her to a place of safety, as she has to be in a public area for that, and we have no authority to remove her either. The only option is for her to sign the refusal form and for us to leave and inform the GP that she has refused and we remain concerned for her. It is then down to the GP to try and persuade her to go, or go down the route of sectioning her under the Mental Health Act.

I have been in this situation a number of times and as frustrating as it is, sometimes we just have to go.

The second kind of ‘refusal’ that isn’t a refusal, is one that goes like this

Crew: “You know, we can take to you to hospital to get you seen, but it’s going to be really busy and you may have to wait hours to be seen, and the likelihood is that they will just send you home anyway”

Patient: “Oh, Ok then, I think I will just stay at home then”

Crew: “That’s fine, I just need you to sign this form for me, and then we can be on our way”

The patient then signs the form, not knowing what they are signing and thinking that they are just signing something to say that they aren’t going to hospital.

Is this a refusal of treatment?

Absolutely not, and these are the ones that open medics up to complaints and litigation.

I have issues with medics doing this, but I can understand why they do it. They do it because they can see that there is no real need for the patient to go to the hospital but they do not have any system in place or any support that will allow them to make that decision and advise the patient of what is the correct form of treatment for them to seek.

If you only have two options, either transport or refusal, then there is no pathway open for the medic to do legitimately what they want to do i.e. the best for their patient.

And here is the link to the ever present EMS 2.0 argument. As I have been speaking to my American colleagues, they all say how they would love to be able to tell patients that they don’t need to go to the ER or that there complaint or concern did not require an ambulance or any emergency response. However, they have been doing this for years already, only it has been just like I used to do before we were trained to ‘Respond not Convey’. I too used to use the old gem of telling the patient how long they would have to wait if they went to the hospital then getting them to sign the form, and to be honest some still do that now, even though we have better options and more transparent and honest options to take.

Some still think that a patient signature on the refusal of treatment form is a ‘get out of jail free’ card, when in reality it is so much more risky than that, unless, the real discussion is documented and agreed upon.

Here are the options I can get a patient to sign to agree to:

I have seen/examined/treated the patient and have reached the following conclusion:

The patient’s condition is such that medical assessment is strongly advised and that the patient should be transferred to hospital by ambulance, but the patient has refused transfer and has the capacity to make that decision.
The patient’s condition is such that medical assessment is strongly advised. However the patient has refused to undergo any such medical assessment.
The patient’s condition is such that medical or social assessment is advisable and that a visit from the patients G.P or other appropriate healthcare professional should e sought.
The patient requires some medical attention at a hospital or other treatment centre, but is able and willing to make their own way there.
The patient requires assistance only and does not require medical attention.

Agreed Referral Pathways:

G.P
Minor Injury Unit
Urgent Care Team
Emergency Care Practitioner
Mental Health
Falls Team
Social Services
Pharmacy
Police
NHS Direct
Out of Hours Service
A&E
Walk in Centre
Other……………

The patient then signs the form at the end which is worded:

“I agree to the course of treatment described on this form and I am fully aware and understand the advice that I have received from the Ambulance Service. I have been made fully aware that should symptoms persist or a new symptom arise, I should seek medical attention without delay/or dial 999″

Before I get the form signed I also tell the patient that this is not a refusal of treatment form (unless they sign the top option), but instead it is based on my clinical decision and rests on my shoulders.

Yes, it would be a lot easier to get them to sign the old version refusal of treatment box on the patient report form, but in the vast majority of cases, that would be manipulating the patient into making me feel better about persuading them not to go to hospital.

So in answer to the question in the title, when is a refusal really a refusal? Unfortunately not that often at all.

Or do you disagree?

Let me know your thoughts……

P.S Told you it was too long for a comment.

Filed Under: EMS 2.0, Refusal of treatment

Do we make a difference?

03/27/2010 by Adam Thompson, EMT-P 16 Comments

My illustrious training captain has sent out a link to the following article. I found it quite interesting, even though most of this is stuff we already know. Might this mean we don’t need to abolish ALS programs, but rethink them entirely? We at Paramedicine 101 preach evidence-based medicine quite often. I believe every treatment, every procedure, and all outcomes should be researched and reviewed frequently. If I could add anything to the EMS 2.0 movement, it would be a universal online archive for QI/QA. Compliant with all privacy policies of coarse. I just think every agency should have some sort of review team, that not only reviews protocol compliance, but patient outcomes compared to treatments received as well. Let’s progress!

If you are not familiar with the Eagles conference, you should be. I have yet to have the chance to attend, but I hear it is the most impressive clinical-oriented prehospital conference out there. You may not get to play with all the new toys and gadgets, but you would have heard about post-arrest therapeutic hypothermia about two years before everyone else. Maybe the EMS 2.0 movement should implement a similar gathering for those of us actually doing the work. Imagine Rogue Medic with a microphone and a room full of people.

Insights from the Gathering of Eagles – 2010

Shattering the Myths

Once again, Dr. Paul Pepe and the team of illustrious medical directors from the 50 largest municipalities in the United States, Canada and the United Kingdom met in early February to share their insights with over 700 of their closest friends.

As has become tradition at the Eagles Conference, the crowd of mostly pre-hospital EMS professionals was intrigued and oft times confused by the paradigm shifts proffered as a result of the research findings presented during the two day event.

In addition to the startling discovery that most of us who thought we resided in the United Stated were informed that we actually live in “Southern Canada” (during the peak of the Winter Olympic Games in Vancouver), the most startling themes to much of the information presented were:

-ALS care does not really make a difference in patient outcomes in almost all life threatening patient conditions
-Response and transport times in pre-hospital medical emergencies really don’t make a difference in patient outcomes
-Many of the things we thought helped people may not!

In his opening presentation, Dr. Corey Slovis from Nashville reviewed the most important research papers published in 2009. Dr. Slovis’ opening comments brought a hush over the crowd and set the stage for many of the presentations to come…

In the early 1970′s the nationwide survival to discharge rate for out of hospital cardiac arrest was about 5.5%…

Today, the survival to discharge rate for out of hospital cardiac arrest is about 5.5%.

Blasphemy you say? How can that be? We have spent billions of dollars in advanced emergency medical service systems – certainly we have had a HUGE impact in patient outcomes – right!(?)

Consider the following ACLS study findings presented by Dr. Slovis…

Passive Oxygen Insufflation Is Superior to Bag-Valve-Mask Ventilation for Witnessed Ventricular Fibrillation Out-of-Hospital Cardiac Arrest (AnnEmergMed 2009;54:656-662) . Bobrow, et. al. found that for adult, witnessed, ventricular fibrillation/ventricular tachycardia, out-of-hospital cardiac arrest (OHCA) resuscitated with minimally interrupted cardiac resuscitation, adjusted neurologically intact survival to hospital discharge was higher for individuals receiving initial passive ventilation than those receiving initial bag-valve mask ventilation.

Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest ( N Engl J Med 2004;351:647-56) done by Steil, et. al. as part of the OPALS study conducted in 17 cities with 5,638 patients included found that the addition of advanced-life-support interventionsdid not improve the rate of survival after OHCA in a emergency-medical-servicessystem previously optimized with rapid defibrillation. BCLS patients had a 5.0% survival rate and ACLS patients had a 5.1% survival rate.

Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial ( JAMA 2009 Nov 25;302(20):2222-9), by Olasveengan, et. al. analyzed the admission and discharged alive rate for 851 cardiac arrest and found that there was no significant difference in survival to hospital discharge for the intravenous drug group vs. the no intravenous drug group.

Ok, Ok, we get it, but certainly modern EMS systems and protocols make a difference in trauma care and airway management! I mean, paramedics have been doing intubation for decades, and we have Level I and Level II Trauma Centers and numerous aeromedical systems. Certainly that matters, right?

Consider these findings regarding trauma and advanced airway care…
Emergency medical services intervals and survival in trauma: assessment of the “golden hour” in a North American prospective cohort (Ann Emerg. Med. 2010 Mar;55(3):235-246.e4. Epub 2009 Sep 23) by Newgard, et. al. analyzed trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was in-hospital mortality. The study looked at call processing, activation, response, scene and overall task times for the response. The study found that there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.

A Prospective Multicenter Evaluation of Pre-hospital Airway Management Performance in a Large Metropolitan Region ( Prehosp Emerg Care 2009 ; 13:304-310). This is the latest in a series of studies evaluating the efficacy of paramedics doing endotracheal intubation. The study evaluated 1,200 paramedics in 34 EMS transporting agencies. 58% were fire-based, 30% private and 12% were single agency systems. The procedural success rate for the 825 attempted intubations was 74.8%. This is consistent with the findings by others such as Dr. Wang in Pittsburg. Most of the Eagles agreed that intubation, if performed at all, needs to be limited to a single attempt and many were mandating that King airways be used as the main advanced airway procedure.

That’s all fine and dandy, but there must be some time-honored care traditions that DO help – for example, applying cervical collars for suspected spinal trauma, right? Wrong??

Dr. Persse from Houston presented his data from the soon to be published study: C-Collar or De-Collar: Are Cervical Devices Harmful? Dr. Persse demonstrated 3-D CT and MRI scan images of unstable c-spine cadavers after c-collars were applied. In application after application the findings showed that in many cases the patient suffered debilitating spine injuries. Although Dr. Persse indicated that more research is needed, this certainly begins to call into question one of the core processes that we as EMS professionals have performed since essentially the dawning of modern EMS.

So, was there any good news about EMS presented during the conference?? Yep…

There was a lot of discussion about a few emerging trends that most Eagles felt should be studied for presentation next year…

Field Termination of Cardiac Arrest Cases – most systems are aggressively pursuing field termination of CPR cases to prevent unnecessary transports. In one notable quote, transporting a patient who has been systolic for 20 – 30 minutes to the emergency department is simply ” relocating a corpse”.

Community Health and Advanced Practice Paramedics – preventing EMS calls through a targeted approach to frequent emergency service users that can benefit from home visits and dedicated medical homes when they are transported. Similarly, using APPs to do the high risk, low frequency procedures such as endotracheal intubation, hypothermia in ROSC cardiac arrest cases, and medical clearance of psych patients.

Transport CPR cases Non-light and siren – Speaking to the concept of “relocating corpses”, anyone who has been in EMS more than a few minutes realizes that if you have worked a CPR case for 30 minutes in the field, there is little to nothing that the hospital can do for the patient than has not already been done. Further, the recent resuscitation studies prove that the most important procedure in CPR is adequate chest compressions. Why then do we risk out lives and livelihood (and that of the public) screaming across town, weaving in and out of traffic, throwing the rescuers around in the back of the ambulance and diminishing the quality of chest compressions all to save 2 – 3 minutes on the transport time?

Those 2 minutes on the tail end of the call makes virtually no difference in the patient’s outcome. Besides, if you want to save those 2 minutes, make a more efficient process for moving the patient from the back of the ambulance to the Code Room at the emergency room. Instead of waiting until the ambulance is in “park” at the emergency room, preparing the patient to be taken from the ambulance right away. Change over to portable O2, move the IVs to the stretcher mounted pole(s), buckle the patient safety harnesses, move the monitor to the stretcher, etc. Having all that done IN ADVANCE will make the unloading process more efficient.

Many of the Eagles felt that the time has come to evaluate non-light and siren transports for CPR cases to see if it makes a difference in the patient’s outcome. It would improve CPR effectiveness, reduce rescuer injury, reduce the incidence of emergency medical vehicle collisions (and “wake effect” collisions from cars moving out of the way), and overall makes sense.

In my 30ish year career in EMS, I’ve had the fortune to attend countless conferences. The Eagles conference continues to be one of the most informative, fast-paced and FUN conferences. If you have not had the chance to attend one yet, you should seriously plan on attending the program next year.

For more information visit http://gatheringofeagles.us/

About the columnist:
Matt Zavadsky is the Associate Director for Operations at MedStar EMS, the Ambulance Authority System serving Fort Worth and 14 suburban cities in North Central Texas. In this role, he is responsible for overall system operations covering the 850,000 people and nearly 100,000 EMS responses.
He holds a Masters Degree in Health Service Administration and has 30 years experience in EMS including volunteer, fire department, public and private sector EMS agencies. He is a former paramedic and has managed private sector ambulance services from 10,000 to more than 100,000 annual call volume in locations including Fairfield, Connecticut; Augusta, Georgia; La Crosse, Wisconsin and Orlando, Florida. He has also served as a regulator in Lincoln, Nebraska and Volusia County (Daytona Beach), Florida.

Matt is a frequent speaker at national conferences and has done consulting on numerous EMS issues, specializing in high performance EMS system operations, public/media relations, public policy, employee recruitment and retention, data analysis, costing strategies and EMS research.

He has served as the American Ambulance Association as Chair of the Industry Image Committee and membership on the Professional Standards, Strategic Development and Management Training Institute Committees.

Matt is an Adjunct Faculty for the University of Central Florida’s College of Health and Public Affairs teaching courses in Healthcare Economics and Policy, Ethics, Managed Care and US Healthcare Systems.

So how do you feel after reading this? If it is a sense of uselessness, you are missing the point. In the world of medicine, EMS is a neonate. We, the ones working right now, can make a huge difference. Please share your thoughts.

Link to article on EMS network

Thanks for stopping by,

Adam Thompson, EMT-P

Filed Under: EMS 2.0, Medical Mythology, Research

Thanks to Chronicles…

03/25/2010 by Adam Thompson, EMT-P Leave a Comment

Tom B pointed out to me that Paramedicine 101 has gotten a shout out on A seat at the table. I am pleased to see that Paramedicine 101 is being read by many and actually used as an educational resource.

I have attached the video that contains the shout out. The discussion is a good one. Can we trust the educational information obtained from the medical blogosphere? The answer, in my opinion, is no. You can’t just trust it. Use your own discretion to decide what you can trust. Many of us use references, or links to prove that the information is factual. I also recommend that you fact check anything that seems suspicious. Most of us warn in our disclaimer that you should not act out of your own guidelines based on anything you read on our blogs. Speaking for myself, I just hope to improve upon what you already do. More often than not, the stuff I learn from the blogs that I trust is assessment based.

PLEASE CHIME IN AND LET US KNOW WHAT YOU THINK

Chronicles of EMS – A Seat at the Table (Ep 6) from Thaddeus Setla on Vimeo.

Thanks for stopping by,

Adam Thompson, EMT-P

ps. don’t forget to read the new posts below.

Filed Under: EMS 2.0, General Discussion

Future Priorities for Parameidcs – Assessment or Interventions?

03/18/2010 by Adam Thompson, EMT-P 4 Comments

Firstly, I would like to say thank you to Paramedicine 101 for the invite to start posting some of my thoughts on this blog. I am flattered to be asked, and I look forward to having some discussions with some new readers about my thoughts and musings.

This post is a combination of two that I have had over at my blog this week, and I post it here as I would like to have your opinions too….

I have just finished reading a fascinating short article over on EMS1.com by Brian Bledsoe, entitled‘Speed and Time in prehospital trauma care’.

I figured that I should read it as I am due on the EMS garage podcast in 20 mins and we will be discussing it!

However, it has left me with more questions that I expected.

I am already aware of the recent move to disprove the concept of the Golden Hour, and when I have been talking to colleagues at work about it, I have basically said that all it proves is that if your injuries are going to kill you, then it doesn’t matter if you are on scene for 10 minutes or 30 minutes (or so the current thinking is telling us), and likewise if you are going to survive, then you will unless you are kept out of the hospital for a significantly prolonged period of time.

I know that this goes against all of our training and is pretty much against the core values of how we look after our trauma patients.

But….

It has also got me thinking about other things.

Mrs999 and I have just had a conversation about it, and I came to a conclusion that I want to put out there and I would love to hear your thoughts on it.

There has and always will be the need for an ALS component to pre-hospital care. However, in the future (very near future in the UK already) will an ALS provider be defined by his or her ‘intervention capability’ or will a true ALS provider be defined by their assessment and diagnosis ability.

More and more in the UK, we have more varied options open to us for our patients. If I have a patient who is having a CVA, they go to a certain hospital or unit. An M.I will go to a different unit. Potentially significant head injuries go to one hospital whilst ‘less’ serious head injuries can go to a normal A&E unit. The list goes on and on, but shows that it is becoming more and more the paramedic’s responsibility to actually provide a provisional diagnosis to base their transport decision on.

If you get it wrong, then you can place your patient at risk by taking them to a hospital that may not be equipped to look after their needs at that time.

It also moves into the realms of minor injury and illness. Our experienced paramedics can ‘treat and refer’ or’ respond not convey’, which is completely reliant on a sound and thorough clinical assessment and a professional and eloquent patient care record.

Just take a look at how often you pull out the magic box of ALS tricks and be honest and see how often they actually make a real and significant difference.

Now, don’t get me wrong, I am not saying that we should lose these skills and interventions. I have seen the benefit of them, and they are the times where we really, really feel good about what we can do and the differences that we make. All I am saying is, as we move forward with EMS 2.0, what really is the most important tool in our repertoire?

Is it our ‘awesome’ intubation, cannulation and drug therapies?

Or, is it our ability to make a clinical diagnosis, based on highly developed assessment skills and move our patient to the correct place for them to receive definitive care?

I agree that treatment and assessment are intertwined and to be an efficient and effective EMS provider, you need to be proficient at both, but I also think there is another way to think about it.

Are we now getting close to the limit of what we can do with interventions for our patients?

I for one cannot see much more that would be of benefit or that would be practicable to try and perform in an out of hospital setting with our current level of technology (who knows ones we get into Star Trek land though!).

I have been on a number of courses around assessing and treating a patient suffering from traunatic injuries (ATLS, PHTLS), but there are very few advanced general assessment courses, primarily aimed at the medical patient for me to go on.

If we take it as I said that we cannot physically do much more for our patients, then should we now be looking at where we can go to further help our patients by concentrating more on our assessment and diagnostic abilities?

Or maybe I am just barking up the wrong tree??

Filed Under: Assessment, EMS 2.0, EMT, paramedics

03/13/2010 by Adam Thompson, EMT-P 4 Comments

Passionate members of the EMS community, you are not alone.

I first came across, what is termed EMS 2.0, on Ambulance Driver’s blog. It is actually a movement that was initiated by The Happy Medic. The Happy Medic is Justin Schorr a firefighter-paramedic from San Francisco. Unfortunately The Happy Medic’s blog has not been a regular read of mine. I am regrettably a creature of habit, and just didn’t get addicted to hist stuff–until now. I don’t feel as bad since paramedicine 101 is absent from his blogroll as well.

One of my partners asked me if I had been watching the Chronicles of EMS. An EMS webcast that was started by Justin Schorr and Mark Glencorse of Medic999. Mark is a UK paramedic who contacted Justin with the intent of a foreign-exchange work program of sort. They are taking part in witnessing each other work in their own respective EMS systems. They share stories and explain how each system is different and, in some ways, the same.

After watching the first episode of the Chronicles of EMS reality show, which featured these two fellow EMSers, I was hooked. I then watched a few episodes of A seat at the table, which is all about EMS 2.0. I am more than hooked at this point, I want in. As far as I am concerned, there are two types of people in this world of EMS workers–the people that complain about problems, and the people that try and solve problems. I believe EMS 2.0 looks to be a solid start. I hope to inspire the paramedicine 101 readers to head over to these sites and check out this movement on their own.

Link – EMS 2.0

Previous post by Rogue Medic on Paramedicine 101

Examples of the videos I spoke of:

Chronicles of EMS – A Seat at the Table “EMS 2.0 Part 1″ from Thaddeus Setla on Vimeo.

Chronicles of EMS – The Reality Series (Season 1 Episode 1) from Thaddeus Setla on Vimeo.

Justin, Mike, Thaddeus, I hope it was okay I robbed your site of these videos and the EMS 2.0 logo. I invite you to contact me via paramedicine101@gmail.com. I would love to be involved.

Thanks for stopping by,

Adam Thompson, EMT-P

Filed Under: EMS 2.0, General Discussion

EMS 2.0: Critical Thinking in Prehospital Training

11/05/2009 by Adam Thompson, EMT-P 1 Comment

Even though EMS 2.0 may not be any more successful at changing EMS than previous efforts at improving patient care, it does seem to be getting more attention. One place is EMS1.com. The names do not share etymology beyond the letters EMS, although both have been wise enough to get Kelly Grayson to contribute. Kelly is also the author behind A Day In the Life of An Ambulance Driver.

Kelly wrote an article called EMS 2.0: Critical Thinking in Prehospital Training. In the article, he does make reference to my blog, but that is not the reason for this post. Although, he does summarize many of my points very nicely.

He also mentions a debate on paramedic-initiated refusals. A debate that I have not commented on, because I have not been able to sit down and read through enough comments to get caught up to the current comments. This is a debate that has also taken place many times before.

Here is an example of the commentary -

“We’ve got 12-lead EKGs and capnography, and if we had I-Stats to do point-of-care labs, think of how many unnecessary transports we could avoid!” they gushed.

And that statement exposes the gaping hole in their logic while simultaneously demonstrating the flaws in the EMS mindset:

We focus on the things we can do, rather than what we know.

This is the essence of the problem. Too many people still believe that the right technology will produce a foolproof^TM paramedic/nurse/doctor/et cetera.

Too many people still believe that the right technology will produce a foolproof^TM human.

This completely ignores the Law of Unintended Consequences.^{^TM} This law is far too important and entertaining to ignore.

In another article on EMS1.com, Stop Talking, Dan White suggests that providing continuous transmissions of all of the information we are looking at in the ambulance – ECG, SpO₂, EtCO₂, BP, et cetera – will lead to more concise communication with the ED. While he means well, I think that he is overlooking the probability that the Unintended Consequence gremlins are just waiting to pounce. As Kelly writes -

All the fancy diagnostic tools in the world are wasted without the education and critical thinking skills to make effective use of those tools.

Many places have made pulse oximetry a BLS skill. How many of them use it appropriately? Nursing homes regularly send patients to the ED because of a low sat.

The fancy equipment does not lead to better care. It often only leads to toggle switch care. Sat of X or less = emergency. Sat of more than X = no problem. There is nothing in between. Everything is either an emergency, or does not meet treatment criteria.

Less than 8 – intubate. More than 8 – procrastinate.

Or should our patients receive airway management from someone who has an understanding of airway managment that goes beyond a nursery school rhyme?

Kelly continues with -

EMS education in its current form is only barely adequate to prepare us to use the tools already in our arsenal.

Adding to the EMS scope of practice presumes that we are already good at what is in our scope of practice. The debate about paramedic-initiated refusals is an example of this. How many paramedic schools spend any time on education about which patients do not need to go to the ED? It is not really something we receive training to do, so it is no surprise that when we arrogantly do what we are not trained to do, we provide many examples of incompetence.

At one place where I used to work, they kept track of what happened to patients who refused or were triaged to BLS after being assessed by paramedics. Their main criterion was whether the patient ended up in the ICU. Unless something changes dramatically in the patient presentation, none of these patients should end up in the ICU. Yes, some stubborn refusals will, but the chart should reflect that the paramedic saw the potential for significant complications and did not just say, OK. Sign here.

I have seen refusals, where the full narrative is – Medical command consents to refusal. Patient signed AMA form. Available at XX:xx. Indicating a total scene time – leaving the vehicle, assessing the patient, contacting medical comand, getting a signature from the patient, and notifyinging dispatch that the medic is available – of less than 5 minutes. The medic is only surpassed by the medical director in lack of attention to the problem.

Some of you may argue that things aren’t that bad. You may know of EMS educational programs that excel at turning out capable EMTs.

There are excellent programs. These excellent programs exist in spite of the National Registry’s No Paramedic Left Behind dog and pony show.

The National Registry does not just share responsibility with the bad EMS programs for the pathetic state of EMS education, the National Registry pushes the envelope to the point where stupid, dangerous, and irresponsible all begin to sound like compliments.

But for the most part, those medics are as good as they are in spite of their EMS education and not because of it, and it’s not those superior medics that we should use as measure of the effectiveness of EMS education. They are, by definition, outliers.

Sad, but true.

It’s when the rank-and-file, average medic in an EMS system can make those decisions and get those tubes that we’ll know that EMS education is where it should be. And likely as not, when we get there, those medics are going to know enough to realize that they need to do very little for most of their patients.

There are many, who suggest that all we need to do is to require more education to improve EMS. All it takes is a degree to make EMS a respectable profession. As long as we keep doing things the same way, does it matter if we require 3 months of misinformation?

What if we require 6 months of misinformation?

What if we require 1 year of misinformation?

What if we require an Associate’s degree in Misinformation?

What if we require a Bachelor’s degree in Misinformation?

What if we require a Master’s degree in Misinformation?

Should we just pile it higher and deeper?

Until we get rid of the misinformation in EMS education, it does not matter how much time we spend making students memorize misinformation – we are not providing a useful education. We are not protecting patients.

There are schools that do a good job. We need to find out what they are doing well. We should not be telling everyone that more of the same is the solution to bad education.

For some other perspectives on this, Unconventional Thoughts On Emergency Services by Steve Whitehead at The EMT Spot. Not really an education post, but all of his posts are education posts. Nice clear posts that get us to look at things differently.

And I’m Hangin’ Up My AHA Spurs by Buckman at Gomerville. Great writing and he tells a story as well as Kelly does, which is no small achievement.

^ ^TM Unintended Consequence
Wikipedia
Like Murphy’s law, again a humorous expression rather than an actual law of nature, this law is a warning against the hubristic belief that humans can fully control the world around them.
Article

Possible causes of unintended consequences include the world’s inherent complexity (parts of a system responding to changes in the environment), perverse incentives, human stupidity, self-deception, failure to account for human nature or other cognitive or emotional biases. As a sub-component of complexity (in the scientific sense), the chaotic nature of the universe – and especially its quality of having small, apparently insignificant changes with far-reaching effects (e.g., the Butterfly effect) – applies.

Robert K. Merton listed five possible causes of unanticipated consequences:^[8]
Ignorance (It is impossible to anticipate everything, thereby leading to incomplete analysis)
Error (Incorrect analysis of the problem or following habits that worked in the past but may not apply to the current situation)
Immediate interest, which may override long-term interests
Basic values may require or prohibit certain actions even if the long-term result might be unfavorable (these long-term consequences may eventually cause changes in basic values)
Self-defeating prophecy (Fear of some consequence drives people to find solutions before the problem occurs, thus the non-occurrence of the problem is unanticipated)

The Relevance paradox where decision makers think they know the areas of ignorance about an issue, and go and obtain the necessary information to fill the ignorance, but neglect certain other areas of ignorance, because, due to not having the information, its relevance is not obvious, is also cited as a cause.

Filed Under: Critical Judgment, Education, EMS 2.0, Heresy, Rogue Medic

#CoEMS: CPR Effectiveness

Empathetic vs. Pathetic

Prehospital 12-Lead ECG Efficiency

Chronicles of EMS – A double edged sword?

When is a refusal really a refusal?

Do we make a difference?

Thanks to Chronicles…

Future Priorities for Parameidcs – Assessment or Interventions?

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EMS 2.0: Critical Thinking in Prehospital Training

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