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Bigfoot, Aliens, and Occult Spinal Injury

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Question: What do the above things all have in common?

Answer: All of them are things in which some people desperately wish to believe, despite the utter lack of credible evidence of their existence.

Now, before you roll your eyes and say, “There goes AD again, making unsupported blanket statements just to make his point,” I will cop to just a little hyperbole:

Bigfoot may actually exist.

I’ve seen plaster casts of his feet, after all, and that Patterson film looked pretty convincing to me.

But one thing that I’ve never seen, never treated, never even heard of in fifteen years of EMS, is a spinal injury not accompanied by readily detectable signs and symptoms.

That’s what occult means, after all. Hidden, as in “never had a clue until we looked at the x-rays.”

Yeah, I know every EMT has a colleague who dates an ER nurse in another city who works with the nurse who treated the guy that walked into the ER under his own power with an unstable hangman’s fracture who, had he even turned his head this much (fingers held about an inch apart for dramatic emphasis), would have been paralyzed for life!

Just like the guy who was painting his house in the nude, and somehow fell off the ladder and wound up lodging a paintbrush handle in his rectum, just about every EMT has heard some variation of the occult spinal injury story.

Hell, I’ve even told that story to my students, back when I actually believed there was some benefit to spinal immobilization.

Now, I’m not so sure.

Few EMTs understand the rationale behind spinal immobilization, or since immobilization is rarely possible, more accurately referred to as spinal motion restriction. When you’re trying to convince the belligerent drunk behemoth that he’s strapped to a rigid board for his own good, and he continues to demand that you “Get this Goddamn thing offa mah neck!” while writhing beneath your three straps and your flimsy cardboard or styrofoam head blocks, true immobilization is an academic exercise at best.

What we do instead is document our steps to restrict spinal motion, including everything we did to convince the belligerent drunk behemoth that strapping him to a board isn’t our idea of fun either, but still necessary.

First, spinal cord injury can basically be divided into two broad categories: primary and secondary.

Primary cord injury occurs at the time of the accident. It’s done. Nervous tissue is contused, destroyed, what have you, and it happens when the accident occurs. Immobilization is a moot point for such injuries. Keeping them still is not going to reverse or even limit that damage.

What spinal motion restriction proposes to limit is something we call secondary cord injury, which occurs after the fact. It may result from post-injury cord inflammation and ischemia, or bony fragments impinging on previously undamaged sections of cord, or worsening an existing primary cord lesion. Restricting movement in patients with spinal cord injury limits the potential for further damage.

At least, that’s the theory.

And that’s all it is really, a theory. Peruse all the medical literature out there, and you will find little, if any, evidence that restricting spinal motion actually accomplishes what it proposes. In fact, the best information you will find merely confirms that, at best, it does no harm.

Moreover, we have just about zero evidence that restricting movement for patients with spinal fractures and no cord injury – the patients who are neurologically intact – does any good at all. The vast majority of those patients have stable fractures, and thus gain no benefit from being strapped to a rigid board.

What you will find, however, is an increasing body of evidence that the practice is not a benign, precautionary procedure at all. It does indeed cause harm, and all for the theoretical benefit of reducing secondary cord injury.

Pain and anxiety.

Vomiting and aspiration.

15% reduction in respiratory capacity, and that’s in healthy, non-obese people.

Increases in intracranial pressure.

Pressure necrosis to occiput, sacrum and heels.

All of these things are possibilities when we strap someone to a spine board, and all for a clinical benefit more theoretical than proven.

Here at The Borg, we have a spinal clearance algorithm of sorts. Like all spinal clearance algorithms, it relies on the presence of a very reliable indicator of serious injury: pain. Sure, there are other indicators of neurological compromise that we assess, but the big one is pain.

If someone breaks their neck, pain will result. Not just the diffuse “Man, my neck kinda hurts,” pain that you commonly see in cases of acute insurance-itis, but specific, midline posterior cervical spine tenderness above the area in question.

Of course, there are other elements that point toward spinal cord injury that need be assessed as well – focal neurological deficits, for example. Just the other night I boarded a male motorcyclist who straightened out a curve, based on nothing more than his complaint of numbness and tingling in his hands. It could have been nothing more than cold weather and crappy riding gloves, but it could also have been the telltale signs of a cord lesion.

He swore his neck didn’t hurt, and I found no signs of injury at all – thank God for muddy, grassy fields! – but I boarded him anyway. Of course, after a two-hour wait on the board in a busy ED, it was determined that he didn’t have any spinal injury, and he was taken off the board.

The presence of pain is what makes an occult spinal injury not occult at all, and in all my years in EMS, I have never encountered a single reliable patient with an unstable spinal fracture that didn’t have it.

Not one.

Now, not every patient is reliable, hence the other elements of the spinal clearance algorithms that assess mental status and potential distracting injuries. If the patient is deemed to be unreliable due to organic or chemical impairment, or the fact that he seems to be focusing all his attention on his broken leg rather than your fingers walking down the back of his neck, we restrict spinal motion anyway, just as a precaution. It’s the prudent thing to do.

Well, that is, if you believe that boarding and collaring someone is actually beneficial for a patient with spinal cord injury. There is at least one well-constructed study out there that shows otherwise, in which spinal injury patients who were immobilized had significantly worse neurological outcomes than those who were not. I wrote about it a couple of years ago. Go read that post, and then come back.

Either there's an entire ward full of people in halo devices, or most of these boards were unnecessarily applied.

Either there's an entire ward full of people in halo devices, or most of these boards were unnecessarily applied.

Recently, Baylor College of Medicine released another study that says much the same thing.

For patients with penetrating trauma like knife or gunshot wounds, there is no reason to immobilize if the patient is neurologically intact. Nonetheless, it’s common practice in many EMS systems to collar and board shooting victims, even if the time spent immobilizing in the field doubles the patient’s chances of dying.

By God, we’re gonna save you from being paralyzed, even if it kills you!

The National Emergency X-radiography Utilization Study was designed to develop a specific set of clinical assessment criteria that would help cut down on the number of unnecessary cervical spine x-rays in Emergency Departments around the country. It has been validated in many thousands of patients, and generally speaking, those clinical assessment criteria are more accurate than x-rays in ruling out cervical spine fractures.

Of course, NEXUS is rarely used as it was designed. It’s been my observation that the Emergency Department physicians use it to clear patients off our board, but the patient still gets the x-rays anyway. Now you may ask, why do they remove patients from our boards, when we obviously boarded them for a reason, using the same set of criteria?

The reason is that many EMS spinal clearance algorithms, including the one used by The Borg, do not use NEXUS, but instead are modeled after the Canadian C-Spine Rules, which note a higher incidence of spinal injury in patients over age 65, and patients who have sustained significant injury above the clavicles.

Of course, these two additional criteria don’t mean that the patient has a spinal injury, they just suggest that we look at these patients a little more carefully. EMS often adds an additional criterion, the nebulous and subjective “significant mechanism of injury.”

Rather than use MOI as it was intended – as a conceptual tool to tell us where to focus our assessments – EMS tends to use it as the assessment. We place all of our faith in the mechanism, and precious little in our actual assessment findings. We’ve built an entire belief system around it.

This misplaced faith in mechanism of injury is what transforms a useful clinical tool like a spinal clearance algorithm into just another poorly written protocol, where we shoehorn patients into a set of unnecessary treatment steps that offer no benefit.

The state of Maine, pioneers in the use of a statewide field spinal clearance algorithm, has been using NEXUS criteria for ten years now. Everyone from the newest EMT to the most seasoned medic can apply it. Several years ago, they dropped mechanism of injury from the list of assessment criteria because MOI was too unreliable an indicator of injury.

So far, no one has seen an inordinate percentage of quadriplegics tooling around Bangor or Portland in their motorized wheelchairs, and we’ve heard no reports of juries awarding record monetary damages for the patients who weren’t collared and boarded. It may just be that they’re on to something up there that other EMS systems around the country would do well to copy.

The Borg have a spinal clearance protocol, but its benefits are diluted because they insist on immobilizing anyone with a significant MOI, or patients over age 65, or patients with an injury above the clavicles. Not “exercise due caution” in these patients, mind you, just “immobilize.”

No ifs, ands or buts, no exercising clinical judgment, no consideration of what’s best for your patient, just immobilize. Strap ‘em all to a board, and let the radiologists sort ‘em out.

Now imagine yourself, say, at a bar. You’re flirting with the waitress, nursing a Coke because you’re drew the short straw for designated driver, when all of a sudden and for no reason, Sumdood clocks you right in the mouth. Splits your lower lip and knocks out a tooth, the bastard.

But you’re pretty badassed yourself, and you didn’t even leave your feet. You’re more pissed than anything, really, and would like nothing more than to exact a little revenge, but Sumdood, as he always does, has vanished like a wisp of smoke. Your buddies cluck sympathetically at your mangled lip and missing tooth.

“Dude,” they say, “you oughta get that checked out. Call an ambulance or something. You’re gonna need stitches and everything.”

So then the ambulance arrives, crewed by Rookie Partner and a burly but nonetheless rakishly handsome and devilishly charming paramedic, namely… me, Ambulance Driver.

“Yep, that’ll need stitches,” I agree as I examine your face. Other than the split lip and missing tooth (carefully stashed by your buddy in his go cup filled with a White Russian because it has milk in it, and everyone knows you’re supposed to put dislodged teeth in milk), there isn’t a mark on you. Your pupils are fine, you didn’t lose consciousness, your neck doesn’t hurt when I palpate it, and you’re moving all your limbs appropriately. I even have you close your mouth and smile, checking for malocclusion of your teeth that may tell me you’ve suffered a fractured jaw.

You’re moderately impressed by my thoroughness, and thankful that The Borg employs such dedicated and skilled medics. They’re a pretty damned impressive outfit, you’re thinking. They’ve got their shit together. I’m in good hands, you’re thinking.

And then I say it.

“Um,” I say apologetically, “to take you to the hospital, we’re gonna have to put a collar around your neck and strap you to a board.”

“But I didn’t hurt my neck!” you protest. “Why is that necessary?”

“We have to,” I repeat, mentally biting my tongue to keep from agreeing with you wholeheartedly. “It’s, um… well, it’s the protocol. It’s for the best, really.”

“So you’re saying that strapping a guy with nothing but a split lip to a board is actually in his best interests?” you ask dubiously. “Dude, what have you been smoking?”

But hey, the guy has an injury above the clavicles, and the protocol clearly states that I’m required to immobilize that guy.

That’s a scene I am forced to repeat, day in and day out, several times a shift. And I am faced with the choice of explaining to my patient that my medical director is not a monosynaptic, booger-eating dullard, just that he writes protocols designed to be used by medics that are, or I can follow the protocol as written and have the patient think I’m the monosynaptic, booger-eating dullard.

Either way, it doesn’t reflect well on The Borg, or EMS in general.

Ironically, the same medics who immobilize everyone in the belief that if it keeps even one patient from being paralyzed… are the same medics who are card-carrying members of the No Neck Fits Everyone Society, and believe that three straps are all that’s necessary to properly secure a patient to the board.

Now, being an ornery type who refuses complete assimilation into the Hive Mind, I rebel at doing unnecessary and potentially harmful things to my patients, and carefully explain to them that they have the right to refuse any medical treatment that we offer *wink wink, nudge nudge*. Sometimes I just refuse to follow the protocol, and I get my pee pee whacked for it fairly regularly.

But a great many of my colleagues don’t even go that far, and simply follow the protocol blindly, never questioning the wisdom (or lack thereof) behind it. Some of them even tell the patient things like, “If you want to go to the hospital on my rig, you have to go on the board.”

That’s a practice that doesn’t just flirt with the legal definition of coercion, it gives it a naked lap dance and slips its cell number and hotel key into Coercion’s pocket. It’s wrong, and we shouldn’t make our patients submit to painful and unnecessary treatments just to get the help they seek.

Every time the FTO Drone whacks me on the pee pee for not immobilizing someone needlessly, he’s almost apologetic about it. “It’s not you, AD,” he’ll say as I’m taking the online spinal immobilization tutorial for the umpteenth time, “it’s all these other yahoos who aren’t using their heads at all. If we’re going to discipline them for it, we can’t let you get away with doing the same thing.”

And he’s right. Discipline needs to be applied uniformly, even if it occasionally requires that a good medic who exercises his brain receive the same punishment as the bad medics who didn’t.

Of course, they could also re-write the protocol to allow more freedom to exercise clinical judgment, and hire medics worthy of that level of trust.

Like, you know, ones that don’t believe in Bigfoot, aliens and occult spinal injury.

Posted by Ambulance Driver on February 25, 2010 • Filed under: EMS Topics, EMS dogma, Patient Management, Spinal immobilization, Uncategorized • Tagged: ,

EMS 2.0: Where’s Our Martin Luther?

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For you EMS types, particularly the ones who are involved in the ongoing discussion of EMS 2.0, there’s a new column on the subject at EMS1.

Leave your comments and suggestions here, there, and at the links posted. We need to hear your voices.

Posted by Ambulance Driver on February 2, 2010 • Filed under: Administration & Leadership, EMS 2.0, EMS Topics, The Ambulance Driver's Perspective

“Do, or do not. There is no try.”

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Yoda’s wisdom is applicable to all endeavors, not just becoming a Jedi Knight.

Tonight, a friend was telling me of her struggles with paramedic class. How draining it was, the financial burden, the long drive back and forth to class, how difficult it was for study groups to get together… blah, blah, blah.

My response: “Pull up your big girl panties and get to work.”

I told her of reciting a very similar litany when I was doing my paramedic clinical rotations, oh-so-many years ago. My paramedic class was 8 hours a day, 3 days a week. I’d get out of bed at the ambulance station at 0700 on Mondays, Wednesdays and Fridays, get showered and dressed, and drive to class. I’d attend class all day, drive back to the ambulance station, put on a jumpsuit, and be on duty until 0700 the next class day. That was my life for an entire year.

No social life.

No days off.

No study groups. Then again, I didn’t study much, outside of class. One of my gifts is that I require very little study.

When I started my hospital clinical rotations, it was more of the same. More than once did I pull a 48 hour stretch without sleep. On one memorable occasion, I had left a 12-hour ER rotation, worked a reverse 24 on an ambulance, went back for another 12-hour night ER rotation, and went directly from the ER to an OR across town for 6 hours of intubations and observing surgical procedures. During a lull between scheduled surgeries, I was dozing in the doctor’s lounge, in that quasi-sleep state that EMTs learn, where they can rest and still be aware of what is going on around them.

“Who’s that, a resident?” I heard one voice say.

“Shhh, let him sleep,” another voice whispered. “He’s a paramedic student. Been on the go for 48 hours now.”

“48 hours?” the first voice marveled. “For that kind of stress, he should gone to fucking med school.”

And you know, there have been many instances in the past fifteen years where I’ve told myself that very thing.

When I started paramedic field rotations, it didn’t get any easier. I worked for a little Mom-and-Pop ambulance service, and we didn’t have a high enough call volume for me to do paramedic field rotations there. All the nearby metropolitan areas were controlled by our direct competitor, a much larger service that had vowed to drive us out of business. Doing rotations with them was not an option.

In the end, our state ambulance inspector -  a personal friend – intervened on my behalf, arranging for me to do field rotations with a municipal agency two hours away, in central Louisiana.

“A word of advice,” he told me before my first shift. “Don’t look for sympathy from your preceptors. They’ve all worked much harder than you to get where they are. They’re not interested in sob stories.”

Well, I couldn’t let that pass. I worked pretty damned hard to get to that point, after all.

“Oh, and just what kind of hardships did they have to endure?” I asked sarcastically.

He went on to tell me how these three men took a night paramedic class at Angola State Penitentiary, two hours away, because it was the only one available. The shortest route to class involved taking the Angola ferry across the Mississippi River every night. Problem was, the ferry shut down every night before class ended. The only alternative was to take the main road out, which added an additional three hours to each leg of their trip – unacceptable.

So what they did was pool their money, and buy a beat-up car for $800, which they parked on the Angola side of the river. Every night they had class, they pooled their gas money, hopped in a truck one of them owned, and drove to the ferry landing on the other side of the river from Angola.

They then parked their truck, unloaded a 10-foot aluminum boat and a 5hp motor, and crossed the Mississippi River in that. They’d beach the boat on the other side, cable-lock it to a piling, hop in their beater car, and drive to class. When class was over, they’d do the same thing in reverse.

Three nights a week, for six months.

Three guys, crowded into a 10-foot aluminum boat powered only by a 5hp outboard motor.

Crossing the mile-wide Mississippi River.

At night.

Suddenly, all the trials and tribulations I endured during paramedic class didn’t seem so tough after all.

So there ya’ go. If you want to be a paramedic bad enough, decide what sacrifices are worth making, and make them. Shut up about it, and do the work.

“Do, or do not. There is no try.”

Posted by Ambulance Driver on February 1, 2010 • Filed under: EMS Topics, Training & Development, Uncategorized

For You EMS Types…

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… there’s a new clinical tip on EMS1.

Enjoy.

Posted by Ambulance Driver on January 6, 2010 • Filed under: EMS Topics, Training & Development

The Handover: Holiday Edition

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handover-new1

Why not the Christmas Edition, you may ask?

For the same reason I don’t call it the Hanukkah Edition, or the Ramadan Edition, or the Winter Solstice Edition, or the Kwanzaa Edition, that’s why.

Or even the Festivus Edition, for you Seinfeld fans.

No matter by what name you call God, this season holds special meaning to many people. Or at least, it should. It’s a time to rejoice in the brotherhood of man, and show the kindness to one another that our respective deities command. Sadly, it’s a commandment often lost in the stress and holiday parties and crass commercialism, and one routinely ignored the other eleven months of the year.

Some of us, like my buddy Mule Breath, prove that kindness and respect for your fellow man need not be inspired by belief in a deity, nor even practiced only one month of the year.

And whatever else may be said of the season, whether you bemoan the commercialism or remember to pray for peace on Earth and good will toward man, it has always been been true that, for as long as the holidays have been observed, there have been people who spend them away from their loved ones to protect us from our enemies, or keep our streets and homes safe, or care for the sick.

Hence the theme for this edition of The Handover: “The call that made the shift.” The sacrifice isn’t always easy to make, but these are the patients, partners and people that make it worthwhile.

Over in the “Bah, humbug!” corner is TOTWTYTR, whose aversion to Christmas cheer probably lies with the fact that he ain’t Christian and isn’t the sentimental type, anyway. But beneath his hard, cynical exterior lies a chewy nougat center, and he did bestow a thoughtful gift on one of our favorite ER nurses one snowy night.

Happy Medic learned one Christmas that, compared to some people, his problems are nothing. And before you think of his story as a downer, consider that, were it not for he and his engine crew, one family would have been out of a home instead a couple of appliances and half their gifts.

Spence over at Siren Voices tells of a frequent flier patient who unexpectedly left him with a smile on one Christmas night. Read about it here.

Ckemtp from Life Under The Lights demonstrates how one simple gesture can melt a career’s worth of cynicism. It would have made me melt too, CK.

Mama Mia of Dust In The Wind, in a neat twist on The Night Before Christmas, tells us of one of those co-workers that make those holiday nights in the ER totally worth it.

Speaking of co-workers that make it totally worth it, EMS Chick from That’s BLS, Not BS gifts her co-workers on major holidays by offering to cover their shifts while they can stay home with their families. And one particular holiday, she received the best gift any EMT could ever receive: the chance to truly make a difference for someone.

Bernice from I Just Call it As I See It offers a cautionary tale for all, but specifically written for the Christmas season.

Medic Scribe from Street Watch: Notes of a Paramedic tells us a tale of a frequent flier patient, the kind we all know and loathe… until they remind us that even our simplest gestures are often appreciated far more than we realize.

And in that same vein, The Insomniac’s Guide to Ambulances tells a powerful story of a lost and forgotten soul, and how he was saved. An act that, as it turns out, brought meaning to more than one life.

999 Medic offers his heartfelt Christmas wishes to all of us working stiffs, and reminds us that to give of yourself is the greatest gift one can bestow, and need not be limited to one day a year.

Mack505 of Notes From Mosquito Hill got to give someone the bestest early Christmas present evar – their life. And if that’s not enough to make your shift worthwhile, I don’t know what is.

Greg Friese of Everyday EMS Tips points out that the guys at the firehouse are your family, too, and that sharing dinner with them isn’t such a bad way to spend a holiday. He even goes so far as to wish everyone working a quiet holiday shift, but he’d better be careful…

… because Lieutenant Michael Morse of Rescuing Providence demonstrates just what can happen if you thumb your nose at the EMS Gods and say the Q Word on Christmas night.

I certainly hope Shrtstormtrooper of New Nurse Insanity: Fundus Chop! doesn’t have that kind of shift on her first Christmas in the ER. Word of advice, dear -  don’t say the Q Word or the S Word, and for goodness’ sake, don’t ever say, “You know what? We haven’t gotten a really greasy trauma all night!”

That’s it for the themed submissions for the Holiday Handover, but we did receive a few open submissions:

Rogue Medic, in his typically droll fashion, writes of a routine call that certainly did make his shift.

Medic/Nurse points out that ER nursing experience is not necessarily interchangeable with street skills.

Finally, Mr. Fixit points out that, at least where EMS is concerned, stupidity equals job security.

As for my contribution to The Handover… well, my contribution is remaining silent, and spreading the linky love among all the other bloggers who were kind enough to submit posts for this edition. This is their spotlight, so please, read them all, bookmark them, and shower them with comments. That’s what we bloggers live for, anyway.

Next month’s edition of The Handover will be hosted by Buckman over at Gomerville, theme to be announced in the coming days. This will be the First Anniversary Edition, so get to working on your submissions!

Posted by Ambulance Driver on December 22, 2009 • Filed under: EMS Topics, In the Line of Duty, The Handover, Uncategorized • Tagged: ,

Never Teach A Pig To Sing…

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… it just wastes your time and annoys the pig.

If only Dr. Jim Augustine had followed Heinlein’s advice before he signed on as medical director for DC Fire/EMS.

Dr. Augustine, who has an excellent reputation in EMS circles, has become the latest in a series of medical directors who failed to fix the problems with DC Fire/EMS. The article states that Dr. Augustine resigned due to health concerns. I tend to agree with TOTWTYTR that likely Dr. Augustine was sickened by the climate in DC.

The organizational climate within DC Fire/EMS, that is.*

It’s long been known that the EMS system in our nation’s capitol is littered with the professional corpses of many a medical director who tried, and failed, to teach that pig to carry a tune.

It’s the EMS equivalent of the Oakland Raider’s coaching job; a thankless career dead-end, without the power to affect any meaningful change. It’s almost like the administration takes pride in being the smelly armpit of EMS care in this country. Yet, they seem intent on every employee there being a  medic/firefighter/rescue technician, and ignoring the fact that they fail miserably at providing even basic EMS care.

Don’t get sick in the District of Columbia, folks. The EMS system there doesn’t run any better than any of the other circuses in town.








* If you’re a medic working DC Fire/EMS, and trying to provide quality care, you have my respect and my sympathies. You deserve better administration than you’re getting.

Posted by Ambulance Driver on December 11, 2009 • Filed under: Administration & Leadership, Command & Leadership, EMS Topics, Uncategorized

For You EMS Types…

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… there’s a little clinical tip on EMS1.com.

Enjoy.

Posted by Ambulance Driver on December 11, 2009 • Filed under: EMS Topics, Patient Management, The Ambulance Driver's Perspective, Training & Development, Uncategorized

How Do You Do That Airway Voodoo That You Do So Well?

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“Okay, so how do you bridge from a King LT airway to an endotracheal tube? I’m not familiar with the procedure, and I’m having trouble visualizing it.”

A reader e-mailed me that question a while back, in response to something I wrote in this post. At first, I thought I’d write a simple reply to him detailing how it’s done, but then I said to myself, “Self, a lot of people might like to know that particular nugget as well, and it gives you a chance to talk out of your ass wax philosophic about airway management.”

First, what qualifies me to talk as an expert about airway management?

Answer: not much.

I have no idea of the number of intubations I’ve performed successfully. I quit counting after my paramedic clinical rotations. During my OR rotations, I went 34 for 34 on intubation attempts. A few years later, I had occasion to review three years worth of run data at the Little Ambulance Service That Could, while I was preparing a proposal to add Rapid Sequence Induction to the scope of practice for Louisiana paramedics.

I discovered that, in the three years I’d been a medic, I’d gotten 37 of 38 intubation attempts. The one I missed, I was able to bag successfully for the twenty minute trip to the hospital.

In the fifteen years I’ve been a medic, there  have been four nasotracheal intubations, a few RSIs, and two memorable occasions where I performed digital intubations – both done lying flat on my back, with the patient suspended above me.

Both of those patients died, by the way, but not for lack of an airway or ventilation.

Add another few dozen ET tubes over the next five years at TLASTC, quite a few more during my years working for the Wal Mart of EMS, and the ones I’ve dropped during my current stint at The Borg. Both of those latter two companies track such things, but I never really bothered to track any number other than the ones I’ve missed.

And that number is seven.

Three of those got Combitubes, one got a King LT airway, and two more got an LMA. The first tube I ever missed  was bagged successfully with just a BVM.

Now, I’ve dropped a few more Kings and LMAs, and even a few Cobra airways over the years, but all of those were done as a first attempt. I never attempted intubation on any of those, and most of those were done, well… unofficially. You guys who have worked rural EMS know what it’s like to be the unofficial Code Team for a rural hospital. I’ve been called to a Bandaid station community hospital ER more than a few times to drop a tube that the doctor couldn’t get himself. On a few of those occasions, I didn’t bother to attempt intubation, opting for a supraglottic airway instead.

So there you have it. In fifteen years, seven missed intubation attempts. And I’ve never had a missed esophageal intubation nor, to my way of thinking, had a failed airway. Every time I’ve needed to ventilate someone, or protect against aspiration, I’ve found a way to do it effectively.

How many successful intubation attempts I’ve done, I have no idea, but the number probably approaches a couple of hundred. It’s certainly not many more than that.

It’s worth noting, however, that the American Society of Anesthesiology  considers the minimum competency for an anesthesiologist to be 200 successful intubation attempts. Viewed in that light, I’m less Airway Samurai than I am rookie practitioner still on the wrong side of marginally competent.

So those are my credentials: probably a good bit less than a medic who has worked a busy urban system for 20 years, and nowhere approaching that of an experienced anesthesiologist. Still, I am not without experience and insight.

Because, you see, it’s not how many notches you’ve carved on your laryngoscope handle, but what you’ve learned from each one of them. As I’ve said before, there are a few medics with twenty years of experience, and many, many more with one year of experience, repeated twenty times. The corollary to that is that there are a few airway experts with a couple thousand successful tubes, and likely many more with twenty successful tubes, repeated a hundred times.

I’ve written about the mindset necessary to effective airway management in the post entitled A Treatise On Marksmanship, and in columns and lectures on The Airway Continuum. If you haven’t read those, I encourage you to go check them out. You may find them enlightening, and I’ll be here when you get back.

**********

Okay, everybody back? Good.

Now, I’m not going to presume to alter anyone’s intubation technique. Aside from the fundamentals, like staying off the teeth, holding the scope in your left hand, and things of that sort, intubation technique is as personal and varied a thing as, say, a golf swing. How pretty it looks isn’t as important as practicing it enough that it’s infinitely repeatable.

Then again, maybe I should talk about technique a bit. After all, not all medics received the same level of instruction. I once had a preceptor, a very experienced CRNA, tell my students that it didn’t matter so much if you broke a few teeth now and then, that sometimes it was inevitable. That same preceptor also took it upon himself to correct a few of my female students’ technique, which actually made it harder for them to intubate someone.

I lost a great deal of respect for that preceptor that day, but I learned a very important lesson: Just because someone has far more experience and training than you, doesn’t mean they’ve learned anything from it.

As I said before, twenty successful intubations, repeated a hundred times.

So, on second thought, I will offer just one critique of what many people consider proper technique. If, when intubating, your left elbow is akimbo, pull it in towards the midline of your body. You should be able to draw a straight line through your shoulder and left forearm, a line that tracks across the left side of your patient’s face,  extending to an imaginary point high on the wall beyond the patient’s feet.

Have you ever seen someone trying to intubate, grunting and straining to displace the jaw forward, with their elbow all cocked to one side, hand and arm shaking with the exertion? Or perhaps you’ve done it yourself. One of the most common refrains I hear from airway novices – petite female nurses, usually -  is, “My arm just isn’t strong enough to do this!”

Wrong.

If you’re relying more on arm strength than finesse, you’re doing it wrong. I can take the biggest snowman out there, with no neck to speak of, and displace his lower jaw enough to pass an endotracheal tube, using nothing more than the index finger and thumb of my left hand. For the infrequent patient where that isn’t sufficient, I have other tricks up my sleeve, which we’ll get to in a minute.

So whether you’re one of those “sweep the tongue to the left” types or the medic who walks the blade down the tongue incrementally, if you find yourself straining to displace  the jaw, pull your left elbow back in line with your body. It makes for much better body mechanics, allowing you to use the strength of your shoulder, and your upper body weight, if need be. Heck, if necessary, brace your left forearm on the patient’s face and forehead. Unless they’ve got massive facial fractures, you’re not going to hurt them by doing it.

Now, for the infrequent patient where manual displacement of the jaw isn’t sufficient, comes the first of my little airway tricks: try external laryngeal manipulation (ELM).

Any medic who has wielded a laryngoscope a few times has either asked for, or provided, cricoid pressure. Sellick’s Maneuver, as it is often called, is an excellent technique for limiting air entry into the esophagus, or just as importantly, for keeping vomit from coming up. When you need to occlude the esophagus, it works well.

But if you’re trying to visualize the glottic opening during laryngoscopy, there’s a better way to do it, and that way is called the BURP technique.

Rather than manipulating the cricoid cartilage, BURP involves directed manipulation of the thyroid cartilage. It stands for Backwards, Upwards, Rightward Pressure.

Facing the patient, place your thumb and index finger on either side of the thyroid cartilage – the Adam’s Apple – and press back towards the spine, up towards the top of the head, and rightward pressure in the direction of the patient’s right ear.

Try this on a manikin, and you’ll see the difference it makes. In clinical practice, it can improve a laryngoscopic view by at least one Cormack and LeHane grade, and sometimes even two. It can make the moderately difficult tubes easy, and the very difficult tubes manageable.

And if you don’t know what Cormack and LeHane grading is, or Mallampati scoring, or LEMON, get thee hence and fill that gaping hole in your airway management knowledge. If you carry paralytics and aren’t intimately familiar with those things, you are, well… dangerous.

If you couple the BURP technique with gentle lip retraction at the right corner of the mouth, you can improve your laryngoscopic view, and the room to manipulate a tube, significantly.

Last, but certainly not least, there is the $5 piece of equipment no airway kit should be without, and that is the Eschmann Intubation Stylet, commonly referred to as a bougie:

bougie

Typically, you use a bougie to intubate the trachea when you are faced with one of those folks with a very anterior glottis – typically less than three finger breadth’s across the middle knuckle (roughly 7 cm) of thyromental distance.

[On a side note, next time a colleague blames his difficulty intubating a patient on that "anterior larynx," check the patient's thyromental distance to see if it truly is. The anterior larynx is one of the biggest "run home to Momma" excuses in paramedicine, right on up there with "looks like atrial fib" and "I was up against a valve."]

One usually inserts the Coude tip of the bougie in that anterior glottic opening, feeding it gently forward and feeling it “tick” on the tracheal rings as you do so, until the stylet holds up at the level of the carina. Then, you simply slide a lubricated ET tube of the appropriate size down the bougie, and – voila! – the patient is intubated.

Seriously, it is a very effective tool, and too damned inexpensive not to have one.

Besides being an effective aid to conventional intubation, the bougie is also an effective means of transitioning from a supraglottic airway to an endotracheal tube.

To answer my reader’s original question, one simply feeds the bougie down the King airway -or LMA, or Cobra, for that matter – feeling it “tick” against the tracheal rings for confirmation of endotracheal placement. Then, stabilize the bougie with one hand while deflating the cuff and removing your supraglottic airway with the other. Then, simply slide an endotracheal tube down the bougie and you’ve got the patient intubated. It will work on any supraglottic airway except the PTL and the Combitube.

Practice it on a manikin first, until you feel proficient with the technique. Neck extension and judicious application of cricoid pressure may facilitate lowering of the glottic opening and allowing easier passage of the bougie.

That’s all there is to it!

Posted by Ambulance Driver on November 30, 2009 • Filed under: EMS Topics, Patient Management, Training & Development, Uncategorized, airway management

For You EMS Types…

Comments

… there’s another column about EMS 2.0 over on EMS1.com.

Weigh in with your comments. They’d be appreciated by a number of others with interest in the subject, not just my little approval-whoring self.

Take a look, and let us know what you think.

Posted by Ambulance Driver on October 28, 2009 • Filed under: EMS Topics, Training & Development • Tagged: , , ,

EMS 2.0: An Inconvenient EMS Truth

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This talk of rebooting EMS has spurred a few additional thoughts on the subject.

I’ve said before that I believe EMS 2.0 should mean a leaner, more efficient version of prehospital care than what we have now, with the future equivalent of an EMT-Basic as the default EMS provider for most communities. Paramedics will be a relatively few, exquisitely trained providers capable of providing what we have always professed EMS to be, but so rarely is: an extension of the Emergency Department into the field.

To do that, we’re going to have to re-educate the general public and public officials about the capabilities and limitations of EMS, and probably the Emergency Department as well.

We’ve done a pretty fair job of educating the public about the capabilities of EMS, despite the fact that quite a few of my patients seem to think I drive a smaller version of a mass transit bus, only with Bandaids and free morphine. Where we have monumentally failed is in educating the public about what EMS cannot do.

That isn’t a failing unique to EMS. The public has totally unrealistic expectations of the capabilities of medical care in general.

Despite what you see on House, the best doctors are not unredeemable Vicodin-addicted assholes, nor are they geniuses with encyclopedic knowledge of every disease pathophysiology ever identified. I’ve never seen an episode of ER that showed the legions of people in the waiting room with toothaches, or demanding work excuses or inappropriate antibiotics for their viral syndromes. Despite what we saw on Emergency, 95% of our cardiac arrest patients stay that way despite our best efforts, and the camera never showed Johnny Gage showing up on a call at oh-dawn-thirty with dragon breath and his uniform shirt tucked into his underwear.

And before you comment on his bed head, everyone’s hair looked like that in the 70’s.

I watched Rescue 911 for years, and yet to this day, I’ve never been invited to a patient’s “new” birthday party. On the other hand, I have been subpoenaed invited to attend the lawsuit one filed against me to commemorate the day I saved his life.

In fact, if you want to see the most realistic medical show on television, just watch Scrubs. The medicine is generally correct if not terribly exciting, but the interpersonal relationships are spot-on.

#1 Dinosaur’s First Law states “The art of medicine consists in amusing the patient while nature cures the disease.” She may have cribbed the quote from Voltaire, but the reason she considers it her First Law of the Dinosaur is that nothing has come along in the 200+ years since Voltaire’s death to prove it demonstrably untrue.

So, if we’re going to re-invent EMS, we must first start with dispelling some of the dogma in EMS – not just in the care we provide, but in system design as well. So now I’ll channel my inner Al Gore (although, hopefully, without the blandness), and speak some Inconvenient EMS Truths. Actually, there are a number of Inconvenient EMS Truths, but I’ll confine this post to the biggie, the one that affects everything from EMS system design, to trauma triage guidelines, to the justification of EMS helicopter transport:

Inconvenient Truth #1: Very few of our calls are actually all that time-sensitive.

That admission alone can utterly transform EMS, folks.

With the exception of stroke, evolving MI, hypoglycemia and severe respiratory distress, very few of our calls require a rapid EMS response, and for most of those categories, prompt response usually only has the potential to effect morbidity, not mortality. I’ll even include multi-systems trauma in the category of calls that are not all that time-sensitive.

Most current research on trauma deaths indicates a trimodal distribution of trauma mortality: death within minutes due to neurological or vascular causes; death within hours due to hypoxia or hypovolemia; and death within days or weeks due to sepsis, Multiple Organ Dysfunction Syndrome, or other complications.

Of those three identified categories of trauma death, EMS has the potential to positively impact only one: those who would die within hours due to hypovolemia or hypoxia. Funny thing is, the outcomes in those patients don’t seem to reflect much difference between the patients who made it to surgery within the Golden Hour and those who made it in the Aluminum Afternoon.

And if you look at the reasons that middle group die – hypoxia and hypovolemia – one might argue that a good, old-fashioned EMT-Intermediate trained under the 1985 curriculum would be the most appropriate EMS provider for them.

That is, unless you pay attention to Ken Mattox’s research supporting permissive hypotension, and the studies that show poorer outcomes in trauma patients who are intubated. Then, you might say that the best EMS provider for a critically injured trauma patient is someone who can plug the holes, apply oxygen, and make an intelligent decision as to appropriate receiving facilities. That provider would be an EMT-Basic, pretty much the same critter as envisioned in the EMS White Paper way back in 1966.

We’ve built an entire belief system based on the myth of the Golden Hour, and extrapolated from it our own proprietary myth of the Platinum Ten Minutes. Nowadays, that Platinum Ten Minutes has more relevance to maximizing Unit Hour Utilization than to patient care, although your system’s managers will be loathe to admit it.

Most urban EMS systems in this country operate on an artificially contrived response time standard of eight minutes or less. Read the municipal ordinances that govern such things, and you’ll often see it actually required by law that the EMS system in a given area  arrive at the scene of emergency calls in eight minutes or less, 90% of the time.

Ask the city council members or lawyers as to why it’s written that way, and you’ll get a chorus of blank looks, much like you’d get if you asked a chimpanzee to perform calculus.

You may find an occasional one that will bloviate on and on about how the standards were derived, but – and primate experts and political commentators will back me up on this – the only thing worse than a chimp that can’t do calculus is a pompous chimp who pretends otherwise.

I’ll tell you what that eight minute response time standard is based on:

chain_of_survival

See that fourth link there, the one about Early Advanced Care?

Yeah, that one. For as long as I’ve been teaching their courses, the American Heart Association has stated that ALS care within eight minutes of arrest improves survival rates. That is what we’re basing that response time standard upon. There are only two problems with that:

  1. That number is based less upon science than conjecture, and the only two interventions proven to improve survival to hospital discharge are early and uninterrupted chest compressions, and early defibrillation – both BLS interventions. The benefit of ALS is, at best, theoretical. Now, with the advent of things like post-ROSC induced hypothermia, that may indeed change. But for now, there is precious little evidence to support the efficacy of ALS in cardiac arrest.
  2. It’s a chain. Take out any of the first three links, and the best ALS care in the world is essentially meaningless. Fact is, the only meaningful response time standard is four minutes or less. If you can’t meet that standard, then the next best bet is just as reliably derived by using the Magic Eight Ball as it is by copying the ambulance ordinance from the next town over.

While we’re on the subject of time, and its overstated importance in what we do, let’s look at lights and siren transport, shall we?

I’ve often said that twin water-cooled .50 caliber machine guns and a snowplow bumper would be more effective than lights and siren, and I was only half-joking. Lights and siren usually don’t buy you that much time, but throwing a burst of armor-piercing rounds into the Prius plodding along at 45 mph in the left lane would improve my job satisfaction by an order of magnitude.

In a North Carolina study, lights and siren response saved an average of 43.5 seconds. In Syracuse, NY, it was 1 minute, 46 seconds. In Minneapolis, it was a whopping 3.02 minutes. Yet, as I’ve pointed out earlier in this post, unless those time savings represent, consistently, the difference between a four minute response and something more than four minutes – on the 1% of EMS calls that involve cardiac arrest – then the end result is simply rapid conversion of money into noise and diesel fumes.

When it comes to the benefit of transporting with lights and siren, I’ll refer you to this quote from an article by Bryan Bledsoe, another EMS heretic who does a much better job than I at questioning EMS dogma:

“…Pennsylvania researchers studied a county-wide, single-provider, private EMS system that used 11 ALS ambulances. Annual call volume for the service area was 14,000, and the county population was approximately 90,000. A medical protocol was developed, and carried on each ambulance, that provided medical criteria for lights and siren transport. A total of 1,625 patients were entered into the study. Based on the medical protocol, 92% of patients were transported without lights and sirens, while 8% were transported with lights and sirens. No adverse outcomes were identified as being related to non-lights and siren transport.”

From later in the article, comes this:

“Do the benefits of lights and siren transport outweigh the possible risks? Again, this must be a local decision. A recent study estimated that the fatality rate for EMS personnel is 12.7 fatalities per 100,000 EMS workers annually, which compares with 14.2 for police, 16.5 for firefighters, and a national average of 5.0 during the same time period. Most fatalities were due to traffic accidents.7 Some industry experts have estimated that there are 12,000 ambulance-related crashes annually in the United States, causing nearly 120 deaths.”

It’s pretty clear that, despite what we tell the public, despite what we tell ourselves, that the vast majority of EMS calls aren’t a life-or-death struggle set to the ominous ticking of a clock. It’s time we stopped pretending otherwise, and started doing research to determine exactly what calls are that time-sensitive, and what is the optimum response time standard for those types of calls.

And while we’re at it, start the long and arduous task of educating John Q. Public that, should he call an ambulance for the knee pain he’s had for a month, he can expect an ambulance in roughly the same time frame he can expect his cable television installer – some time next Thursday, between the hours of 8:00 am and 5:00 pm.

**********

That’s all the preaching I’ll do for now. There may be Inconvenient Truths to come, unless my ADHD kicks in and I – Hey guys, let’s all go ride our bikes!

Posted by Ambulance Driver on October 25, 2009 • Filed under: EMS Topics, Uncategorized, Vehicle Operation & Ambulances • Tagged: ,

EMS 2.0: The Wet Blanket Post

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It started in a response to Rogue Medic’s reply to an anonymous commenter, and my subsequent reply.

Happy Medic opined in his blog that EMS as we know it needs a reboot. EMS 2.0, he called it. Just a throwaway line, really, about how we need to re-think the way we’ve educated ourselves in the past, and how we will in the future.

Funny how those throwaway lines can ignite a firestorm. Since then, much of the EMS blogosphere has latched onto the concept, riffing on the ways we’re going to drag our profession kicking and screaming into the 21st century. We’re going to expand our scope of practice, broaden and deepen our education, and reinvent EMS into something its founders never envisioned.

We’re going to demand, and deserve, our rightful seat at the table with the grownups in health care, and we’re going to save lives and stamp out disease and pestilence, and who better to do it than us, right?

We’re paramedics, after all. We’re on the front lines of medicine.

[cue inspirational music here]

It would be more inspiring if it weren’t something I hadn’t seen a hundred times before. The reinvention of EMS is a meme that has been circling the various EMS internet forums and use groups ever since I first discovered the wonders of a modem back in 1995, and no doubt was hotly debated in hotel bars at every EMS conference for years before that.

It’s not a new subject.

It’s a meme with legs, however. It never quite dies, and I suppose that’s a good thing. The topic will be debated, grand ideas will be discussed, old medics will be called dinosaurs resistant to change and new medics will be ridiculed for their unrealistic idealism, volunteers will be lauded and bashed, fire service EMS will be lionized and demonized, and everyone will claim to have the answers…

… and then everyone will just drop it, because there are dialysis runs to be made, after all, and Homeless Hank needs his weekly ride to detox. We’re working too damned hard to endlessly debate these high-minded ideas.

And so the thread becomes dormant again, much like the varicella virus, lying in wait along the nerve roots of our collective psyche, biding its time until a new crop of medics can bring it to flower again, their infectious enthusiasm enough to weaken the defenses of the most jaded medics until -  BOOM! – it bursts forth in a rash of red, itchy Idealism Shingles.

And it always seems to be in a dermatome I can’t quite scratch.

Once upon a time, I was that idealistic new medic whose grand ideas were rudely extinguished by the wet blanket of reality, wielded by more experienced medics like TOTWTYTR. Some of our arguments back in the day were pretty damned fierce.

And now I find myself that older medic impelled to dash the hopes of a new generation of dreamers. On the other hand, I’m not quite jaded enough not to hope. I’m a paramedic, after all, a member of a profession still in its adolescence.

And like any adolescent, we are capable of boundless enthusiasm, hindered only by our astounding naivete. I suppose that naivete is of some use, however. Many of the greatest ideas of man came to fruition only because some genius was too damned stupid to know that what he proposed wasn’t possible.

But if we’re ever going to bring EMS 2.0 to fruition, we must first start with a little perspective. George Santayana once wrote, “Those who cannot remember the past are condemned to repeat it.”

Phrased another way, we have no idea where we’re going, unless we first know where we’ve been. Well, where we’ve been is a surprisingly short road. Napolean’s private surgeon may have invented the ambulance concept in 1792, but modern EMS as we know it stems from an innocuous government document written just 43 short years ago; “Accidental Death and Disability: The Neglected Disease of Modern Society.”

Forty three years.

That’s our entire institutional history, folks. I find it apropos that Happy Medic chose EMS 2.0 as the term for his concept. If EMS were software, we’d be a Beta release – full of promise, but still with plenty of bugs.

And much like software developers, many of our professional organizations like NAEMT do nothing to fix the problems, choosing instead to insist, “They’re not bugs, they’re features!”

Add many more features, and we’ll be the public safety version of Windows Vista: bloated and slow, prone to crashes, and a hog of system resources.

In the intervening 43 years since the EMS White Paper, our role has grown far beyond that of the BLS trauma technician envisioned in the original document. Along the way we’ve become the medical safety net for the entire health care system system.

For a huge demographic in the United States, we are their primary care providers.

Some of us may see that as the natural evolution of our profession; our role expanding in pace with our growing skills and knowledge base. And they might ask, as with EMS 2.0, where we go from here, and how far might we rise?

Then again, a military commander might define many of the responsibilities we’re thinking of shouldering as mission creep. We cannot be all things to all people, and to try ultimately only lessens our effectiveness for the people who really need us.

Happy Medic gives his vision of some of the technological advances we’ll see under EMS 2.0:

“…Hospital radio reports via instant message, electronic patient care reports downloaded wirelessly on arrival, care back in the hands of the caregivers, not the bureaucrats. Alternates to automatically defaulting to transport in an ALS ambulance to an ER.”

With the exception of that last item, most of those things are easily enough done, and to my mind they represent embracing emerging technology more than an entire system redesign.

More problematic is that last goal: Alternates to automatically defaulting to transport in an ALS ambulance to an ER.

Even board-certified emergency physicians wrestle with the decision to admit someone to the hospital or not, and sometimes they make the wrong decision despite their vastly superior education. I’ll put it bluntly: paramedics are not capable of making transport/no transport decisions. We do not have the education needed to be system gatekeepers.

I’m not saying some of us can’t do it. I may be capable of making those decisions, and being right far more often than not. So may Rogue Medic, or Happy Medic, or TOTWTYTR, or many of the top tier medics in every EMS system in this country.

But then, it’s not only those medics who will be making those decisions, is it? Until every medic – even the barely competent knuckle dragger who barely passed the certification exam on his sixth try – is capable of that level of thinking, triaging patients to places other than the Emergency Department is a pipe dream.

The Fire Critic hit upon several good points in his post on the subject:

At what point in advancing more in-depth treatments, on scene surgical protocols, more advanced medicine treatments, and all around increase in skills will the Paramedics be required to go to longer schooling? This longer term in schooling might mean that many decide to go the route of a PA, Nurse Practitioner, or MD.

Exactly. Right now, medics barely have the education necessary to master their current scope of practice, much less a greatly expanded one. There are some excellent paramedic education programs out there, but for the most part, the curricula, top to bottom, is woefully inadequate.

Implementation of the National EMS Education Standards will go a long way toward addressing that problem, but even then, there may well be a ceiling to EMS education. IS there a uniquely prehospital knowledge base that is broad and deep enough to encompass, say, Master’s Degree paramedics? Doctorates in paramedicine, perhaps?

Maybe so, but color me skeptical.

At what point will this increase in overall medical knowledge require higher paying salaries?

As Fire Critic pointed out, there are already providers trained at the level to which we aspire. They call themselves nurses and physician’s assistants, and neither of them are going to work for the chump change that they pay paramedics.

You will find no one in EMS that believes they are paid what they’re worth. And you know what? Every single one of them is right. There are many EMTs whose pay is not commensurate with their training and education. On the other hand, there are thousands more knuckleheads out there who are paid far more than they are worth.

Which brings me to my next point: Even if we do significantly raise the bar for EMS education, and the salaries follow, to enjoy any meaningful increase in pay, we are not only going to have to transform EMS, but the whole friggin’ health care reimbursement system.

That’s a pretty tall order for a fledgling profession still trying to decide whether it belongs in health care or public safety, and for whom  the majority of its practitioners provide their services for free.

Make no mistake; the current debate isn’t about health care reform, despite what the politicians on either side of the aisle will tell you. No, the debate is about health care payment reform. The sticking point isn’t one of access, or quality of care, it is who will pay for it all.

Whether we foot the bill through increased insurance premiums or higher taxes, either way we’re going to pay. Pick your poison.

The only sure bets for the future of health care, including EMS, is that 1) it will cost more to deliver, or 2) we will be paid less to deliver it.

And there’s a better than even chance both will happen.  Costs to insurers and taxpayers will skyrocket, and reimbursement for services will plummet.

So the question then becomes, if we are going to reboot the system, release EMS 2.0, how will we pay for it?

The short answer is, I don’t know. And if anyone else tells you they know, they’re either liars, or running for public office.

But then, I repeat myself.

But since we’re dreaming big, and revolution is spurred by the dreamers too naive to know what is impossible, I’ll tell you what I think EMS 2.0 should be:

Less EMS.

There, I said it.

Perversely, EMS has been the victim of its own PR success. We’ve spent decades exhorting the public to call us, even for the most trivial of issues. Call 911, and Johnny and Roy showed up on your doorstep, and nobody they treated ever died.

Heartburn? Could be angina. Best call the paramedics.

Dizzy? Could be a stroke. Call the paramedics.

Witness an accident? Don’t move the victim. Call the professionals who know how to do it.

Drive yourself to the hospital? What if your heart stops while you’re driving? What if you black out? Best err on the side of caution and call the medics.

I don’t begrudge the non-emergent calls I do, even the most trivial ones, because we have conditioned several generations of Americans that they shouldn’t ever feel ill, or suffer pain, or be inconvenienced in any way, and that the wonders of medicine will cure all their ills, and that despite the fact that Grandma hasn’t spoken in seven years, or moved in three, send her to the hospital anyway, because maybe this time the Fluorescent Light Therapy she gets in the ER will magically make her whole again.

And until we can convince Joe Sixpack, Suzy Soccermom and Tyrone Rockslinger that no, they in fact don’t need to go to the ED for their viral syndrome, and that no, they don’t need narcotic painkillers when Tylenol will do, and that no, the ambulance isn’t free, even if they never receive a bill, and that yes, Walgreen’s has the same home pregnancy tests that the ER does, at a tenth of the price, and that Grandma is suffering, and there is nothing that medical science can do but prolong her pain…

… then not a damned thing will change about the delivery of EMS in the United States. We first have to change the public’s expectation of health care, and that’s a task that will take generations to accomplish, if ever.

What we need is an army of guys like Chopper:

YouTube Preview Image

If people took his advice to heart, every EMS system in this entire country could deliver top-notch care with 1/5 of their current personnel, trucks and equipment. ED overcrowding would be a thing of the past. Health care costs would plummet, and the cost savings would be enough to drastically increase reimbursement to primary care physicians, enough so that accepting Medicare or Medicaid patients would no longer be a money-losing proposition.

Poof, there goes the problem of access to primary care.

But the problem is, America isn’t going to harden the fuck up, at least not until future generations are raised to expect less than their parents are getting now.

So until that day comes, I believe EMS 2.0 is going to involve not giving the public what they want, but what they need.

That means more EMTs, and less paramedics. As noble as the sentiment may be, every EMS call does not deserve a paramedic. In point of fact, not every EMS call even deserves a response, but we’ll leave that can of worms unopened until we can totally overhaul our tort system.

Educate the EMTs better, and train and equip the paramedics as exquisitely as you want. Use a third service, tiered response system, with the vast majority of care delivered by an extensive cadre of EMTs. Keep only a few paramedics on duty at any one time, and develop an effective medical priority dispatch system (not the current one), that assures that paramedics only get sent to paramedic level responses. In one fell swoop, gone is the paramedic shortage, and gone is the EMT glut.

Your EMTs become medical care providers they were trained to be, instead of ambulance drivers and stretcher fetchers, and your paramedics avoid the rust-out that inevitably follows skill dilution. Medical directors, with a much smaller cadre of ALS providers to oversee, feel more comfortable with expanded skill sets. Heck, maybe they’ll even, you know, provide some medical direction to the medics’ initial education programs.

Make the EMT not the entry-level EMS provider, but the default EMS provider. If a community wants the luxury of paramedics, then let them subsidize it with their tax dollars.

EMS systems become smaller, and leaner, but demonstrably more efficient. There will still be paramedics, only they’ll be a much better educated, more elite class of provider than the current version. And their reduction in numbers, and the cost savings from training and equipping less of them, will allow higher salaries for the ones that remain.

That’s EMS 2.0 as I see it.

Posted by Ambulance Driver on October 23, 2009 • Filed under: EMS Topics, Training & Development, Uncategorized, technology-communications-ems-topics • Tagged: , ,