A few years ago we were dispatched to a cardiac arrest.  It was for a 40 year old woman, and the residence was flagged on our MDT because of  guns and swords in the house.

We pulled up behind our ambulance.  An EMT jumped out of the passenger and ran (literally) into the house.  I walked quickly, but cautiously, behind him and scanned the first floor of the dilapidated house.  Sure enough, there was a cache of guns and swords in the living room near our exit from the house.  We followed the loud voices at the top of the stairs and found our patient in a bedroom.  Her arms were stuck in a bent position and it was obvious she was dead.

Her family members said that our patient appeared fine the last time anyone saw her, and now four rescuers were standing around not doing anything.  “Bring her back! Use the paddles! Do something!” her husband yelled. I looked at his wife, and looked up at him. ” She’s dead, sir.  I’m very sorry.”  I looked him in they eye with a deliberately soft expression on my face.  I wanted to make sure that there was no doubt about what I was telling him, and that there was nothing we could do.  Again, he yelled for us to bring her back, punched a hole in the wall, and stormed out of the room.

I know that is a normal grief response. I also know that a number of upset family members are between us, weapons, and our only way out.  We looked at each other and quickly agreed to leave the residence.  We still needed to attach the monitor and get a strip for our paperwork, but that could wait.  We moved quickly and purposefully out of the house, and stood on other side of our truck while we waited for the police.  They arrived, we went back in, and the rest of the call went fine.

I was trained to do CPR and attach a defibrillator, but was never taught how to manage a scene like this.  It reminded me of how I managed my first call as a brand new EMT, partnered with an equally new CPR-trained driver.  A toddler had partial thickness burns on her face after falling against a grill.  I felt uncomfortable during the 30 minutes we were with her, and it showed.  Her mother called and complained about me.   I may not have done anything wrong, but I certainly didn’t look like I knew what I was doing. I have learned from these and other experiences, but wish I had been better prepared beforehand.

Scenes are dynamic, and repeating ”BSI/Scene Safety” in class before a lab scenario or skill station does not prepare people to recognize this.  Teaching EMS students how to talk to people in stressful situations is also neglected.  Even with the new education standards to become an EMT, very little clinical time is required, there are few opportunities to become comfortable talking to patients, and there is no field internship required.   It’s like reading Power Point slides to 16-year-olds about how to drive a car,  give them a written test,  give them a license, then tell them to learn how to drive.  Like EMS, we hope they don’t kill anyone.

One of the services I worked for did its con-ed at a police academy.  When they had a class going on, the recruits had to be “on” the whole time they were there.  Things were rearranged in the building and they were expected to notice it.  Their individual skills were incorporated into larger scenes that require situational awareness, and cadets fail if they do not perform well.  EMS cal learn a lot from this approach to training.

From a safety and public service perspective, we need to take scene management more seriously.  It should start with initial education and reinforced with continuing education.

Thanks to our good friends at ACEP, More Than a Job. A Calling is the theme of this year’s EMS week.  For me it started with Roy and Johnny, then Rescue 911, police scanners, and chasing ambulances on my bike.  My reservation about getting into EMS was whether I could do it, and then whether I wanted to live at the poverty line, not whether I wanted to do it.

I’ve been so lucky.  After 13 years I still enjoy different challenges each day I go to work, connecting with patients, and helping people feel better.  There’s no other work I would find as fulfilling, or that I would as good at as a paramedic. There’s a dark side to this calling, however, that probably won’t be mentioned at the barbecues next week.

EMS work starts out being fun, even more fun than non-EMS hobbies. There’s always an open shift out there that needs to be filled, too.  Why sleep at home when you can get paid to be at a slow station?  And you had nothing important to do the next day, so it’s no problem staying over when your relief calls off.

As Thom Dick wrote in his excellent book People Care:

EMS is a wonderful thing to devote your life to.  But it can become an addiction, and there’s no such thing as a good addiction… EMS will take everything you have to give, chew you up and spit you out, and then come asking for more.”

Pretty soon mortgages and car payments depend on you working 80 hours each week. When your marriage is falling apart, it seems much easier to manage other people’s short-term problems than your long-term ones.  And that’s fine with the people who need those shifts filled.

But then those slow stations get busier, and running all night is much easier when you’re 25 than when you’re 40.  There’s no time to sleep, exercise, or spend time with non-EMS people – such as your family.  EMS isn’t so fun anymore, especially when patients smell bad and don’t meet your definition of an emergency.  The calling seems more like a job now, only working overtime is no longer a choice.

The calls just seem to run together, and getting them over quickly seems more important than providing good care.  You don’t want to be there and your patients know it.  When you’re worried about working an extra shift to pay your mortgage, becoming a better caregiver and advocating to make EMS a profession isn’t on the radar.  It seems impossible to change careers, and that job seems like a prison sentence now.

EMS is a calling, but it takes work to keep it that way.  Start by reading People Care.  Resist the temptation to make it your life.  If your employer pays less than a living wage, leave and work for someone who does. Building a lifestyle around 80-hour work weeks is unsustainable, and it is not your responsibility to fill every open shift.

If you’re already in the EMS prison, you need to break out.  You’re killing yourself, hurting your family, unhelpful for your patients, and dragging the rest of us down.  Here are some suggestions on how to start.  After People Care, do a Dave Ramsey Total Money Makeover.  In the process, get yourself well.  If there’s no time for the gym, Bryan Fass has tips for EMS people to stay healthy.  A therapist may help with healing strained relationships, re-discovering the EMS calling, or finding fulfillment in something else.

EMS is a calling, but if we’re not careful it becomes a job we hate.

I remember how exciting my first EMS conference was.  As a new paramedic I was in awe of what the speakers had to share, and wondered how they became so knowledgeable about the topics they presented.  Now Jim Hoffman, a true pioneer in online education and podcasting at EMS Office Hours,  has made several nationally recognized speakers available free of charge to anyone with an internet connection.  Several of them have had a significant impact on my career, and I am excited about the possibilities for EMS with them able to reach so many  people.  The EMS Web Summit is Thursday, May 17 from 10am-7PM.

I first read Peter Canning‘s book Paramedic: On the Front Lines of Medicine before I got into EMS.  I was intimidated at first and thought there was no way I could do the things he wrote about.  It gave me a realistic expectation of what EMS work was, so nursing home transfers and idling on street corners came as no surprise.  I reread his book while I struggled as a new paramedic, and appreciate how open he was about his experiences.  Peter has an ongoing series on his blog Street Watch: Notes of a Paramedic about the changes he’s experienced in EMS.  It is a great read, and his discussion at the Web Summit will help us EMS 2.0′ers prepare for what’s ahead.

In paramedic school I was truly lucky to have Dan Limmer as one of my educators.  From writing the textbook to keeping it real in the streets, from clinical care to managing scenes, and from treating patients with compassion to treating each other with respect, Dan gets it.  He is one of the brightest minds in EMS today, and his presentation on being a mentor should not to be missed.

At my first EMS Today Conference I attended Bob Page’s Wide and Fast, In Lead II You’ve Got No Clue lecture.  I was mesmerized by how he made such a complex topic so easy to understand.   Using “edutainment” to emphasize his points, the grim reaper chased a heart around the screen.   I bought and recommend his 12-lead ECG book, and am excited to see what he has to offer at the Web Summit.

At the darkest point of my career, when I dreaded going to work and was close to leaving the field, I stumbled across Steve Whitehead’s blog The EMT Spot.  My life and career has not been the same since.  There are other people out there! I almost said out loud after reading his mission.  As someone who is never content with the status quo yet surrounded by people fighting against anything else, Steve’s writings inspire me to continue working to make EMS better tomorrow, and to treat my next patient with respect and compassion today.  Creating a rapport with our patients is badly neglected in most EMS education programs, and I cannot wait to see what Steve has to say about this.

Around the same time I discovered Tim Noonan’s Rogue Medic blog.  As the status quo’s worst enemy, he challenges us to support every treatment we deliver with evidence that it helps patients.  When I’m preparing a presentation or article, his blog is my first search engine for the latest research.  I don’t always agree with his interpretations, but if a study is recent and relevant, Tim has it covered.  Who would dare question using epinephrine for cardiac arrest, no less a paramedic?  Tim does, and I guarantee you will view resuscitation differently after his presentation.

I am still recovering from my experiences as a new EMS educator.  Five minutes before speaking to 50 people, I was given a canned presentation covering a generic topic that I had no special knowledge about.  When my three hour class was done in 30 minutes, people were running for the door.  I vowed never to do that again and wanted to be better prepared.  Greg Friese and his EMS Educast co-hosts feature experts in all aspects of EMS education, and is a great resource for developing instructors.  Greg despises the ticket-punch, say we did it con-ed model so prevalent in our industry, and he strives to deliver current, in-depth content as Director of Education for CentreLearn Solutions.  Anyone who says quality education cannot be done online has never met Greg, and the Web Summit is the perfect medium to learn what he has to say about it.

Kelly Grayson is also a fierce advocate for EMS professionalism and improving our education standards.  Starting with the title of his blog, A Day In The Life of an Ambulance Driver, Kelly is also hilarious and reminds us not to take ourselves too seriously. His presentation will surely be as entertaining as it is educational.

Finally, I met Dave Konig at last year’s EMS Today.  I told him I liked to write and have ideas I’d like to share, but that I know almost nothing about computers.  I was in good hands, because Dave is the EMS master of social media.  His and Greg Friese’s PIO Social Media Training is the go-to resource for agencies to embrace and use social media instead of fearing it.  I had a great time hanging out with Dave at the last EMS Today, and got to meet other great people in person whom he helped me connect with through blogging.  Dave will be right at home at the Web Summit.

Those are the speakers whose work I am most familiar with or have a personal connection to.  Troy Shaffer, Sean Kivlehan, Jamie Todd, Rommie Duckworth, and Evan Feuer are equally accomplished experts in what they are presenting, and I look forward to learning what they have to share.

The EMS Web Summit Thursday, May 17 from 10 AM to 7 PM.  It’s Free. Don’t miss it. Register here.

Rogue Medic has a great  post about medical oversight for EMS, and I am looking forward to reading part 2.  It reminded me of a JEMS column Bryan Bledsoe wrote a few years ago titled Adios Rampart.

Both debunk the myth that patients can be kept safe if paramedics must request permission before doing something that might be dangerous.  Unfortunately the highest risk/lowest frequency interventions are the ones that must be done most quickly.  Instead of focusing on what the patient needs, paramedics in mother-may-I systems must pick up a phone and clearly articulate why a patient needs a surgical airway, cardioversion, chest decompression, or chemical restraint.

This puts everyone in a difficult position.  If the paramedic does not sound like they know what they are doing over the phone (not an uncommon occurrence), but the patient needs an invasive procedure, what is the doctor supposed to do?  Allow a paramedic to deliver potentially life-saving treatment and be on the hook if they screw up, or deny their request and hope the patient stays alive long enough to get to the hospital?

A paramedic, already in a stressful situation, must decide if they should follow the order, not follow it and risk getting in trouble, or “lose cell phone service.”  Other interventions that require permission simply don’t get offered, such as pain management or steroids.  None of the options are good for anyone, especially the patient.

Medical command should be available for advice in complicated situations, just as  ED physicians have specialists available.  It is useful to ask for advice when a number of treatment options are available, or which hospital is best equipped to handle a particular patient.  If a patient refuses to be transported, having them talk to a physician on a taped line gives us some extra liability protection.  Advice is good, permission is not.

If paramedics  cannot be trusted to work independently in critical situations, their medical director needs to be involved way before they are actually in one.  We need medical directors who knows what education we have, understand the environment we work in, and are familiar with the strengths and weaknesses of their particular service.

Give us direction before the next call, don’t make us ask for it when we’re on one.

On weekdays, sandwiched between diverse groups of frequent EMS users having their paternity test results read before millions of viewers, are commercials for schools that train people to become medical assistants.  Those commercials appear between others for lawyers, sub-prime loans, and ones soliciting volunteers for pharmeceutical trials.

For people who are, or were, medical assistants, please forgive my ignorance about what you do.  I know as much about your job as the people say I drive an ambulance know about EMS.  Since I watch more television on the clock than off, you probably work harder on a typical day than I do.   I’m also impressed with how much education you have, and discouraged about how little we get.

From what I’ve seen in doctor’s offices, medical assistants bring patients to the exam room, take vital signs, do an initial assessment, and report it to the doctor.  I’m sure much more goes on behind the scenes.  Medical assistants appear to work with a team, in a public place, with lots of backup nearby if someone is really sick.

The EMT curriculum has increased to 150 hours.  While it good that it includes more anatomy and pathophysiology, the only clinical requirements are ED observation and patient assessment.  EMT’s are often the highest level of care on a scene, work alone in sometimes hostile environments, at all hours of the day and night.  Yet there is no requirement for EMT’s to demonstrate that they can actually do what they’ve learned on live patients before they are certified.

A while ago I was called to a career center, and took care of an instructor who trained medical assistants.  On the way to the hospital I asked how long it takes to become one.  Ten months, she told me, which includes clinical time.  I was embarrassed to tell her low long it takes to become an EMT.

To quote another daytime TV personality, how’s this working out for us?  We really have no idea.  A few services measure cardiac arrest survival, and a few more measure response times.   Clinically high performing services add much more to the minimum education requirements for their people and have strong oversight.  But no one has to do this, and many don’t.  Why don’t we ensure competence before certification? What about measuring how well our services do?

Meanwhile, we keep complaining about low wages, resist learning anything that doesn’t come with a pay raise, and resist increasing initial education to make it harder to get in because of low or non-existent wages.  More money will come if we apply a phrase heard on another daytime TV show: STOP RESISTING!

It takes two years to practice BLS in Canada, the UK, and Australia.  A 150 hour class is all that’s required to be chief of many EMS services in the US.   We need to take our responsibilities as seriously as they do in other countries, and at least as seriously as other allied health professions in this country do.

When you pick a cell phone, cable, or internet plan, packages range from basic to premium, extreme, or turbo. When you call 911, that choice is made by local system design and a dispatch triage program.

On EMS Office Hours, Jim, Josh, and I discussed whether certain medications should be included in the BLS scope of practice.  It was prompted by a proposal to have BLS providers in one system administer Narcan.

To me, this goes deeper than the tired ALS/BLS debate.  We need to ask what treatment is needed by patients in our community, how safely that treatment is delivered by all provider levels,  and how reliably is it made available by their service.

EMS has traditionally been more about what treatment we choose to learn about and deliver than what our patients actually need.  Systems fail patients who do not receive treatment that should be available.

Here are a few interventions that are widely available by EMS, are proven to be effective, and can be delivered safely by competent providers.  I believe the basic EMS package should make them available to every patient before transport is initiated.

1. 12-lead ECG’s, aspirin, and a STEMI alert program.  For every 15 STEMI patients who receive this treatment bundle, one death, second heart attack, or stroke is prevented (1).  STEMI patients do not alway complain of chest pain or alway tell a dispatcher they have it.  If a patient calls 911 with a STEMI, EMS needs to get patients into a system of care that is able to manage it.  There is no excuse for one to go undetected by EMS.

2. CPAP and nebulized bronchodilators.  For every six patients in pulmonary edema who receive CPAP and nitroglycerine, one death or intubation is prevented (1).  Supplemental oxygen and ventilation with a bag valve mask are taught at the first responder level, and CPAP falls in between.  Patients who are short of breath from bronchospasm need medications that open their airways way more often than they need extra oxygen.  No patient should have to keep breathing through a straw during transport.

3. Seizure medication.  Seizures are one problem we have a magic bullet to fix.  One in 4 patients in status epilepticus who receive medication from EMS will have their seizure terminated (1).  Priority Medical Dispatch does not reliable differentiate between seizures that require medication and which ones don’t (2).  It is unacceptable for EMS to scoop-and-run to the hospital with a patient who is seizing.

4. Pain medication.  Most patients who call EMS are in some type of pain.  People who do not receive pain medication from EMS often wait hours to get it in the hospital (3).  This is after they are moved to the ambulance, possibly strapped to a hard board, and are transported in a bumpy ambulance.  Helping patients feel better is important, even if their symptoms do not meet our definition of an emergency.  If pain medication is available in the hospital, I believe we should be have it available for patients before they are moved.

When we talk about specializing in EMS and being professionals, we need to look at how well we do today and figure out how to do better tomorrow.

References:

1. Myers JB, Slovis CM, Eckstein M, et al: Evidence based performance measures for emergency medical services systems: a model for expanded EMS benchmarking. Prehospital Emergency Care 2008; 12:141-151.
2. Sporer KA, Youngblood GM, Rodriguez RM: The ability of emergency medical dispatch codes of medical complaints to predict ALS prehospital interventions. Prehospital Emergency Care 2007; 11(2):192-198.
3. Abbuhl FB, Reed DB: Time to analgesia for patients with painful extremity injuries transported to the emergency department by ambulance. Prehospital Emergency Care; 2003; 7(4):445-447

I’ve worked with some extraordinary people since I started in EMS.  One of the most extraordinary people, hands down, is Captain Kevin Przybyl.  I met Kevin on my very first day in EMS on a tour of the volunteer ambulance station I had joined.  Later I worked with him at a private company that went on 911 calls. We were partners for a few shifts in the inner city of Buffalo, NY, and I was lucky to have him as a mentor.

Kevin has cystic fibrosis, which is a genetic disease that until recently people were not expected to live with past adolescence.  Its most known for its effect on the lungs, but also causes serious digestive problems.  Patients must do physical therapy each day, take several medications, use frequent breathing treatments, and adhere to a strict diet to preserve their lung function and digestive system.

Kevin held several officer positions with our volunteer service, was a dispatcher with our company, and endured the same 12+ hour street corner posting assignments in the hood as everyone else.  His small physical size earned him the nickname “Bubba,” but his huge heart more than compensated for it.

Kevin has since moved to Florida, is married, and has a toddler.  He owns Orlando Trophy Bass, where he charters fishing trips near Disney World.  Now in his early 30′s, he does all this with 30% lung function. A portion of each trip is donated to his foundation, which raises money to help people with cystic fibrosis pay for the medications needed to sustain their life.

Cystic fibrosis is a disease that is not covered in depth by most EMS education programs, and it may be encountered on calls for special needs children.  Kevin’s blog is a good resource about the disease, and readers can appreciate what it’s like to live with it.

To read more about fishing and cystic fibrosis, or to book a trip, click here.

To read Kevin’s blog, click here.

To donate to the Kevin A. Przybyl Breathe Easy Foundation, click here.

Last Sunday the EMS gods were nice enough to me to wait until after EMS Office Hours to punish me, so that I could join Jim and Josh for a great discussion about one community considering combining fire, police, and EMS into one service.   We also talked about Community Paramedics, which would create a specialty area for EMS to branch into.

This raises two fundamental questions about what EMS is and what it should be.  Have the responsibilities of EMS grown large enough to warrant dedicating people to specialize in its delivery, or is it an ancillary activity to another mission?

Medical directors seem to have recognized what many of us have been saying – that they don’t fully grasp our strengths and limitations.  This is  from Dr. Ray Fowler’s website:

“EMS Medical Direction is a part-time job for so many EMS docs, who also do it for free. The overwhelming majority of people who come to this meeting don’t have EMS as the primary part of their practice.” – Jeff Goodloe

Sound familiar? In many communities, the lead EMS providers are also responsible for firefighting, or do it as a hobby outside of their primary job.  This is an excerpt from Dr. Mickey Eisenberg’s book Resuscitate: How to Improve Survival from Sudden Cardiac Arrest:

Dual-training an individual to be both a firefighter and a paramedic, and then expecting stellar performance in both jobs, reflects a hope based on what is probably a flawed concept.  Do we dual-train doctors as police officers? …The point is that paramedics must be allowed to learn the skills they need and then to hone them as professionals.  This is not to say that they cannot work within fire departments, but only that, except in emergencies, they should not be expected to perform the duties of firefighters.

In 2010, the American Board of Medical Specialties formally recognized EMS as a subspecialty – for physicians. This is from EMS1:

“The purpose of subspecialty certification in EMS is to standardize physician training and qualifications for EMS practice, to improve patient safety and enhance the quality of emergency medical care provided to patients in the prehospital environment, and to facilitate further integration of prehospital patient treatment into the continuum of patient care,” said Mark T. Stelle, M.D., President of the American Board of Emergency Medicine Board of Directors.

I think it’s great that physicians interested in overseeing EMS can now specialize in it, but we’re the ones going on calls every day.  We need to accept more responsibility for our performance, from figuring out what the best treatment is,  measuring how well that treatment is delivered, and adjusting operations so  it is delivered consistently.   So my question is, how many hats can we be expected to wear and provide excellent care? Can communities to rely on volunteers do this in addition to their full-time job?

With all the choices available to physicians, we are lucky to have a few who choose to specialize in EMS.  If we want to be respected as a profession, we need to do the same.

The most media attention ever given to a call I was on was a house fire with children trapped.  Two toddlers were pulled out by firefighters who were doing CPR.  My patient was a three-year-old girl, and we rushed her to the ambulance.  After a few chest compressions, a few squeezes of a bag valve mask, and suctioning black secretions out of her mouth, she started breathing again.  She was still unconscious and I wanted to protect her airway from the secretions, but she bit down when I tried to intubate her.  Her teeth were clenched, but we were able to maintian a pulse-ox in the 90′s, an end-tidal (connected to the BVM) in the 50′s, and equal breath sounds.  What we had was way to good to risk losing with RSI, especially 15 minutes away from our children’s hospital. 

After being hospitalized for several weeks, both she and her brother made full recoveries.  While our treatment was guided by an expanded knowledge of respiratory physiology, it was BLS interventions done well that made the difference.  I learned this the hard way, which is how the title refers to me. 

Several years ago I responded to another house fire, with another toddler who was having CPR done when we arrived.  I had been a medic long enough to know better, but this was my first child pulled out from a house fire.  I spent about 15 of a 20 minute transport with a laryngoscope blade in his mouth.  I felt better when an anethesiologist had difficulty intubating him, but horrible when nurse was able to bag his pulse-ox up to 100%.  Getting the tube seemed more important, and the media only had a tragedy to report about.

We have been called heroes about what we did at the last fire, but we just did our jobs.  Any of my coworkers would have done the same thing and had the same outcome. 

We all have calls that don’t go well, and we’ve all made mistakes.  Even Superman has Kryptonite.  We owe it to our next patient to learn from those calls, and to let the next EMS generation learn from them. 

For those of you who do not follow EMS research closely, for the last 10 years Henry Wang has dared to question the effectiveness of paramedic intubation.  While this has made him one of the least popular names mentioned over adult beverages at EMS conferences, most people admit that what he’s found is true.  Paramedics get less training than other intubators, , it frequently requires multiple attempts for us to intubate someone, chest compressions get interrupted far to long during intubation, and procedural experience with intubation is associated with better outcomes.

Flipping through the abstracts from the 2012 NAEMSP Scientific Assembly, I glanced over the words “Wang” and “intubation.”  Oh no, I thought, how bad is this one going to be? I was shocked to read:

Conclusions. In this prospective multicenter North American OHCA series, ETI was associated with improved ROSC, 24-hour survival, and survival to hospital discharge over SGA. ETI was not associated with secondary complications. ETI may be preferable to SGA in OHCA airway management.