In Defense of the LUCAS

“There is no price that justifies no improvement” –Rogue Medic

Fellow paramedic and blogger, Rogue Medic recently wrote two blog posts questioning the motives of EMS services that purchase LUCAS devices 1 2. One of the biggest reasons was the failure of the device to improve outcomes during a recent study that compared mechanical CPR to traditional CPR (LINC Trial).

Before I even begin to debate the data, let’s figure out what kind of price we would pay for “no improvement”.

Before writing this response, I took some time to examine the equipment I use on a daily basis. Needless to say, I was shocked to discover that we spend a lot of money of items that really don’t improve patient outcomes at all. One example is the Stryker Power Cot. Although I tried, I couldn’t find any studies that compared patient outcomes to those transported using a manual cot. Another major purchase was the LifePak 15 ECG monitor / defibrillator. Once again, I couldn’t find anything showing improved patient outcomes. It appears that both of these devices only make the responder’s job easier.

All sarcasm aside, I think it’s perfectly acceptable for a service to spend money on equipment that improves the working environment. Stair chairs, video laryngoscopes, fancy heart monitors, power cots, and nice ambulances are all examples of things that don’t improve patient outcomes, but do improve our ability to do our job effectively.

Now, back to the LUCAS. Even if I didn’t dispute the data that Rogue Medic provided during his recent articles (and I will), I could still justify spending the money on the devices. It’s a glass half-full vs half-empty kind of thing. Saying that the device “failed to improve outcomes” makes the thing sound worthless. What if we said that the LUCAS proved to be “just as effective as high-quality manual CPR”? Now it sounds like we’re spending money on something that takes less physical exertion, requires fewer responders and produces the same results. Interesting.

No, there isn’t much data to suggest that using a LUCAS improves outcomes. Likewise, we aren’t discovering that it’s hurting people either. So at the very worst, it’s a luxury item. Most of us that have used it – especially those working in rural areas – know that it’s more than that. Now I’m not running around yelling that the “LUCAS saved my patient”, as Brooks Walsh pointed out in a recent article 3. I am however, saying that it makes my job a hell of a lot easier.

Having spent the last 3 years of my career in rural Texas, I can say that the device has earned its spot on my ambulance. Moving out of the big city and going to work in an area that utilizes volunteers as first-responders means that I often find myself working a resuscitation with just me and my partner. If – and I emphasize the word “if” – we happen to get first-responders to these calls, we still have no idea what kind of training or experience they have.

As I’m writing this article, I can already see the e-mails coming in saying that “the answer is to train our people to do better CPR”. I don’t disagree, but we can only control what’s in our control. If I’m running the EMS system in Seattle and I have direct access to all the responders, then implementing that kind of training should be happening. I’m sorry, but controlling the quality of care provided by the rancher in rural Texas that’s showing up for free on his day off isn’t exactly an easy task.

I’m not knocking the care provided by volunteers. I too have been a volunteer and I know the value of the care they provide. Having said that, it’s hard to get strict on training when they are already going out of their way to provide service to their community.

Now on to the data.

The LINC trial studied 2,589 patients with out-of-hospital cardiac arrest. The patients were randomized to receive either manual CPR or mechanical CPR. They mainly looked at the four-hour survival rate of the selected patients with a secondary focus on six-month survival with good neurological outcome 4. One advantage that the mechanical CPR devices had, was the ability to deliver shocks while continuous CPR was being performed. Many people have argued that this alone should have resulted in a slam-dunk for the LUCAS and the absence of a significant rate of survival proves that it doesn’t do any good.

Now, let’s take a step back and examine our thought process here. Based on what we currently believe to be the best way to improve outcomes, this should have produced better results. The LUCAS does everything we want, right? It delivers hard, fast and continuous chest compressions. It doesn’t stop and it doesn’t fatigue. Hell, it even keeps going during defibrillation. So do these results reflect on a device that’s over-hyped, or are we missing something in our current CPR guidelines? Keep in mind that this study involved highly trained and prepared responders using the most up-to-date recommendations for CPR delivery. We developed a machine to do exactly what we tell it to. It follows the guidelines exactly as we want, and yet, it can’t produce the results we hoped for. Perhaps the machine isn’t the problem.

Another issue I have with this data, is that it doesn’t address the following variables:

  • Down time
  • Whether or not bystander CPR was performed
  • Medications used
  • Whether or not an advanced airway was placed
  • Length of resuscitation

All of these things are important when looking at the effectiveness of the LUCAS. Had all of these cases been witnessed full-arrests with immediate intervention, then I might feel differently. Perhaps they did look at these things, but from the data that’s available to the general public, I can’t determine whether or not the LUCAS doesn’t “do any good”. From what we can see, at the very worst it keeps up with some of the best-trained responders out there. Not bad, if you ask me.

Conclusion

We need to be looking at the whole picture here. If we can design a machine to do textbook-perfect CPR, and it doesn’t produce textbook results, then maybe we need to re-evaluate our textbook. Even if the studies do prove that the device isn’t improving survival rates, we still can’t discard the device as “worthless”. It has its place in situations with limited responders. And yes, the data supports that.

Notes:

  1. The Failure of LUCAS to Improve Outcomes in the LINC Trial. (2014, March 05). Retrieved from Rogue Medic: http://roguemedic.com/2014/03/the-failure-of-lucas-to-improve-outcomes-in-the-linc-trial/
  2. The LUCAS, Research, and Wishful Thinking. (2014, March 07). Retrieved from Rogue Medic: http://roguemedic.com/2014/03/the-lucas-research-and-wishful-thinking/
  3. Walsh, B. (2014, March 3). “We had a LUCAS save!” – No, you didn’t. Retrieved from Mill Hill Ave Command: http://millhillavecommand.blogspot.com/2014/03/we-had-lucas-save-no-you-didnt.html
  4. JAMA. (2014, Jan 1). Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized tria. Retrieved from PubMed: http://www.ncbi.nlm.nih.gov/pubmed/24240611

Holding the Wall

If you have ever worked on an ambulance in the State of California, then you probably already know what this article is about. “Holding the wall” is a term frequently used by EMS providers to describe the act of waiting for a bed assignment in the ED. If you haven’t experienced this, you’re probably reading this with a touch of confusion.

Allow me to explain.

Ambulance crews in most areas of California share the frustration of waiting for bed assignments. When the emergency department becomes over-filled with patients, the ambulance crews are typically instructed to sit with the patient – usually up against a wall, in a hallway – until a bed becomes available. It is not uncommon for crews to experience wait times of 2-3 hours. My personal record is 11.5 hours. During this time, the crew is not available to respond to emergency calls or perform any duties other than monitoring the patient. This creates a major problem for EMS systems as it decreases the amount of available ambulances in any given response area.

The Fresno Bee recently ran an article bringing attention to the problem: http://http://www.fresnobee.com/2014/02/15/3773014/emergency-services-nearly-paralyzed.html

This isn’t a new problem. Ambulance crews have been plagued with long wait times for over a decade. The California Nurses Association (CNA) fought for over 13 years and sponsored legislation to implement mandatory staffing ratios 1. With the passage of AB 394 in 1999, the Department of Public Health was tasked with creating what they deemed to be fair and safe nurse-to-patient ratios 2. These ratios went into effect Jan 1, 2004 and remain in place today. While many argue that AB 394 improved patient safety and created a better working environment for nurses, it didn’t come without it’s share of problems. One of the unintended consequences of these policies is extended waiting times for ambulance crews.

The long waiting periods aren’t as much a product of limited bed availability as it is nurse availability. Emergency departments can throw extra beds in hallways, rooms, lounges, etc. What they usually can’t do is provide enough staff to manage those beds. So what does this mean for the ambulance crews? It means we either get to place our patient in the waiting room, or sit with them until a bed comes available. Obviously, the severity of the patient’s condition dictates which route we go.

“Holding the wall” can be a very frustrating task, especially if you don’t understand the staffing laws. I have seen many crews accuse the staff of being “lazy”, or even intentionally delaying the ambulance crews in an effort to divert other crews to other hospitals. This usually isn’t the case. It’s a system problem, not a nurse problem. Do some hospitals see this happening more often than others? Sure, but this is either due to different patient loads or different ways the hospitals have chosen to deal with the problem.

To compound the problem, more hospitals are shifting their attention to patient-flow in an effort to stay competitive. Many hospitals have implemented policies that direct the nursing staff to fill up all the ED beds regardless of the patient’s acuity, rather than dedicate a fixed number of beds to address the non-urgent patients. This practice often leaves no room for patients that actually have emergent conditions, hence the constant delay of ambulance crews.

What frustrates me about this situation is that the hospitals have effectively taken this from a hospital problem and turned it into an EMS problem. Most of them have flat out refused to address this issue. What’s even worse is how the EMS systems in California have essentially rolled over and allowed it to happen. Bottom line is, this is a problem that the CNA and Department of Public Health have created, and they need to fix it.

As far as the EMS systems are concerned, we have pretty much accepted it and tried to do what we can on our part to lesson the blow to our staffing needs. I have seen management go as far as to send a supervisor with several extra gurneys so that one ambulance crew can monitor all the patients waiting for beds while the others place the spare gurneys in their ambulances and clear the hospital. What I haven’t seen, is an EMS service force the hospitals to address the issue by refusing to wait and placing the patients in a bed or a chair.

I’m not advocating that we put our patients at risk, but we do need to shift this problem back to the people that created it. When the hospitals are forced to deal with a number of patients that exceeds their required staffing ratio, maybe they will go back to the Department of Public Health and demand that something be done to fix the problem. The DPH isn’t going to listen to us. In order for them to take action on complaints from EMS services, they would have to do something that rarely happens in government: Admit that they might have been wrong.

Now don’t get me wrong, I’m not bashing staffing ratios. I’m not a nurse and I don’t have enough experience or knowledge in the hospital environment to form an opinion on the matter. However, I will say that the issue of ambulance wait times wasn’t thought out when the bill was written, and it certainly isn’t being addressed now.

As it currently stands, the staffing ratio for non-critical ED patients is 4-1. Hospital administrators love to throw this in our faces and claim that they must follow the law. What’s ironic, that is that same law also states that there must be a nurse dedicated and available to answer EMS radio calls and that nurse can’t be included in the staffing ratio 3. Correct me if I’m wrong, but with a few exceptions, that isn’t happening. I guess following the law is only important when they decide it’s important.

Back in 2011, I left California and moved to North Texas. During that time, I have transported patients to hospitals in areas ranging from Oklahoma to Houston. I have yet to wait on a bed assignment for more than 5 minutes. Actually, 5 minutes is considered a long wait to most of my peers. Is our system here perfect? No. Many would argue that the nurses here are over worked. Having said that, the patients are getting taken care of and the hospital staffing issues aren’t being pushed onto the ambulance crews.

Most of the hospitals in this area have addressed the increased workload by employing support staff in their emergency departments, such as paramedics. Obviously, a paramedic’s function in the ED is limited and they can’t replace the need for nurses. What they can do is perform tasks to help decrease the workload of the nurses. I’m not claiming that employment of paramedics in the ED is the answer. I’m simply pointing out that when a hospital is forced to deal with a problem like ED saturation, they come up with solutions.

The issue with EMS wait times isn’t going to go away until we get serious about addressing the problem. Filing “complaints” or “reports” with the same agency that wrote the law isn’t going to get us anywhere. As long as we continue to allow ourselves to take on the burden of the hospital’s staffing issues, they will never take any real action to address it.

 

Eating Crow Part-2: Government Jobs

secret serviceAfter “coming out” and admitting my love for iPhones, I realized that I have another serving of crow to devour…..public-based EMS. Ever since I stepped foot inside of an ambulance, I have always taken the strong position that the ideal delivery model for EMS was a private-based system. I felt that contractual requirements created accountability and the absence of tax-payer funding allowed for flexibility and eliminated the headaches of getting a budget approved. I actually took such a strong stance, that I felt public providers shouldn’t bill their patients since they already collect their tax dollars. I swore I would never want a politician holding my livelihood in his ink pen, which meant I would never take a government job. That is…….until I took a government job.

A couple months ago, I accepted a paramedic job at an ambulance service, which happens to be a division of a county hospital district. Yes, we receive tax dollars, and YES, we also bill our patients. The only thing that could have contradicted my stance more would have been to go work for a fire department.

The opinion I formed on government-run EMS was mostly biased, as I had spent my entire career working for private-based services. Now don’t get me wrong, I still endorse the private model. If done correctly, it can be a very effective and cost-efficient way to provide ambulance service. However, as much as it breaks my conservative heart to admit this, there are public options that can be just as efficient, if not more so than private-based systems.

bush

One of the big reasons why I didn’t care for the public model was budgets. In most levels of government, keeping a decent budget isn’t nearly as easy as it is in the private-sector. You can’t spend too much, but you also can’t spend too little. If you over-spend, you’re wasting tax dollars and the bean-counters start looking at ways to cut away at your operation to save money. If you spend too little, you’re receiving more money than you need and therefore your savings will be taken and redistributed to other departments or placed in the general fund. Now before any of that can take place, a budget actually has to be passed, and we all know how dedicated our elected officials are to passing budgets in a timely manner. In the private sector, you simply have to spend less than what you take in.

Now this doesn’t mean that the private sector gets off scot-free. There’s a reason private ambulance services often close as fast as they open. Emergency medicine simply isn’t an industry that’s healthy for private business. Now that doesn’t mean a country boy can’t survive, but it does mean that the deck is stacked against him. Medicaid / Medicare reimbursement is beyond laughable, it’s straight up brutal. Collecting 12-15% on what you actually charge isn’t exactly a formula for success. That’s on top of the requirement to treat and transport people that don’t and never will pay. This type of system requires heavily on cost-shifting (Read: Cost Shifting – An EMS Fight for Survival). Some services are able to overcome these hurdles, and when they do, it can become a very efficient means to provide EMS to a community. However, the number of businesses that are able to pull this off are becoming smaller given the increasing demands for service, the shrinking pool of paying customers and a political climate that even a global-warming advocate couldn’t dream of.

Until recently, I felt that these were the only two options. Being that I usually trust a successful businessman more than any politician, I always leaned toward the private option. However, once I started working for the hospital district, I quickly learned that there is another way to provide these services, and it works quite well.

For the most part, hospital districts have their own tax base. This means that their taxes come directly from an assessment on the properties in their district. This is mostly done in small, rural areas of the country as a means to provide accessible healthcare to the residents. This is something that is voted on by the people residing in the district. What’s nice about this kind of system, is that the money doesn’t come from the general fund. It’s managed by the district’s board of directors, which means the only people in charge of distributing it are completely vested in the service to which it’s going towards. It’s a win-win for both the public, and the district. For the district, it equates to a very nice offset to the shortcomings of Medicaid / Medicare reimbursements and non-payers. This of course means, better wages, nicer equipment, more staff, lower turnover, and ultimately better service. For the public, it means they have an EMS system that is adequately staffed and has a much more stable environment to do business in.

So there you have it. I’m one of “them”, a “G-Man”. Now all that’s missing is my dark, thin sunglasses, an ear-piece, a black suit and a black Chevy Suburban. And yes, your taxes do pay my salary…..but if you throw that in my face, I’m going to ask you for a pay-raise.

Eating Crow Part-1: iPhones

Sean Eddy iPhoneThose of you that have known me or have been following my writing for any length of time have at one point or another heard me talk trash about Apple products. Hell, I authored a freaking blog dedicated to using Android products in EMS. I would have been the LAST guy to be caught using an iPhone. That is, until I had enough…..

I have been using Android phones ever since they were first introduced to the Verizon network. I picked up the original “Motorola Droid” a couple months after it was released. Being the avid Linux user that I am, Android seemed like a perfect fit for me. I absolutely loved it until about a year after my purchase. I started having problems with speed and the device crashing at random times. I spent a lot of time searching Google for fixes and wound up rooting (jail-breaking for all of you that aren’t familiar with Android phones) the phone which seemed to help the speed. While it seemed like a decent fix for the speed of the phone, it turned out to be very buggy and I found that several apps didn’t function right. I eventually attributed the problems to outdated hardware and decided that it was time to change phones.

I wasn’t ready to give up on Android phones. Computer hardware always falls victim to new software and higher system demands as technology progresses, so I figured it was just time to keep up with the curve. I upgraded to a Motorola “Droid X”, which at the time was the top phone on the market. Once again, I loved the phone. Fast forward a year, and I hated it. I had the exact same issues that I had with the original Droid. I was constantly searching Google for bug fixes, waiting on Verizon to release updates, and trying to refrain from placing it in a skeet launcher.

I still wasn’t ready to give up on Android. By this time I figured that I just needed to get a Nexus model Android phone. Being that they had no bloat-ware and no tampering by the cellular carriers, I figured it HAD to be a sure win. So what did I do? I went to the store and bough the latest and greatest…..again, which happened to be a Samsung Galaxy Nexus. Now, right off the bat, I had problems. When I would stream music while it was plugged into a power source, it would spontaneously reboot. This was a major source of irritation as I had an hour commute to work and Pandora was my source of sanity. Having my phone reboot in the middle of a song probably caused more road rage than a minivan driving 20mph below the speed limit when I’m running late for work. What really set me off about this, was that Google had released an update with a fix for the problem, but Verizon hadn’t pushed it through to their customers, and wouldn’t for about another 3 months. Once Verizon released the update, I actually started to enjoy the phone and eventually forgot about the anger it caused me for the first 4 months of owning it.

Over time I noticed that the battery life of the Galaxy Nexus was horrible. And when I say horrible, I mean it in the most literal of ways. I ended up buying an extended battery which brought its run-time up to about where I thought it should be. Once again, I started liking my phone. That is, until Verizon released an update that caused my phone to slow down to Commodore 64 speeds. I searched and searched and searched for answers to this issue. There wasn’t a fix in sight OTHER than the official fix that Google had released that…..wait for it…..Verizon hadn’t pushed through to their customers. I dealt with this problem for nearly 6 months before I finally gave up. Day after day I would watch my partner navigate with the greatest of ease on his flashy iPhone. Sure, I used to talk trash to him about how I “ate apples for lunch” and how only hippies and liberals used iPhones. However, on the day my phone was moving so slow that I wasn’t able to call in report to the receiving hospital, necessitating me to stick my head up to the cab of the ambulance to ask him for his phone, I realized it was time for me to seriously reevaluate my motives for staying with the Android platform.

When I powered up my first iPhone, I knew right away that this was a platform that I was going to enjoy. It’s quick, simple, functional and most of all, consistent. Is it perfect? No. Are there things I miss about Android? Absolutely. Will I ever switch back? Probably not.

I by no means think that iOS is God’s gift to mobile technology. I don’t like the fact that the phone is locked down. I miss being able to set default apps for things like web-browsing, navigation, etc. However, I think that the speed and consistency that iPhone users enjoy might be a direct result of the restricted operating system. One of the major challenges of an open operating system, like Android, is trying to maintain a stable working environment when you literally have thousands of apps available that change settings, use hardware in unpredictable ways and take up resources. Not to mention the fact that Google is trying to maintain an operating system that is distributed on thousands of different devices, as opposed to just one.

As you probably noticed, I have a major problem with cell providers holding updates hostage. Apple had the right idea when they decided that the cell providers would have absolutely nothing to do with device updates. All of that comes directly from Apple, which is the way it should be. This way, when there’s an issue, the manufacture can immediately release the fix and save people months of headaches.

Now to be fair, when it comes to features and flexibility, Android wins, hands down. If it weren’t for all the bugs and inconsistencies, I would have never switched. I’m a feature guy. I like to customize things and make them my own. However, I’m also a busy guy and don’t have time to be fixing my phone every day. I’m at a point in my life where I just need things to work. Sitting in the back of an ambulance with a sick patient, waiting on my phone to “un-freeze” itself so I can call my report into the hospital, just isn’t going to work for me. Sure, I could probably root the phone, install a custom ROM and fix the problem, but I’m tired of having to do crap like that to get what I consider to be basic functionality out of a device.

So there you have it. I love my iPhone. It’s fast, simple, does everything I could possibly want it to, and it’s consistent. As for the crow I’m having to eat……I’m still trying to find a recipe to make it taste better.

Happy Thanksgiving

I want to start this post off by thanking all of you that are currently on-duty or overseas, spending this wonderful holiday away from your families and loved ones. Your dedicated service to our country and your individual communities is greatly appreciated.

For me, this year has seen it’s ups and downs, but overall, I have so much to be thankful for. Jesus, my family, my job and my health are just a few things that come to mind when I start to count my blessings.

A little over a year ago, I was getting through life, but I definitely felt like something was missing in my soul. I had certainly been stronger in my faith and my overall attitude about life had seen it’s better days. I felt like I had this big void and no matter how many overtime shifts I pulled, or how many gigs I booked with my band, I just couldn’t fill it. At that time, I felt like I had more to be angry about than thankful for. This all changed when I accepted Christ back into my life. Now, it’s funny to say “accepted Christ back into my life”, because the phrase gives the impression that he left and came back. He never left. He was there the whole time and it was me that chose to ignore him and try to take on this crazy life by myself.

About this time last year, I was becoming acquainted with a special someone that I would quickly find out was a blessing sent my way straight from Heaven. I spent many nights transporting patients to a small rural hospital in the town that I called home and I would see her almost every night. It took a long time, but with a little courage and possibly some divine intervention, I eventually worked up the courage to ask her out on a date. I’m very thankful for everything she has done for me and for opening her arms and heart and accepting me into her life.

This year marks 10 years that I have spent in EMS and I am very thankful for every job I have ever had. Every employer, past and present, have always provided me with a steady income, good working environment and an amazing group of people that I consider to be family. As I write this, I am just coming off of a 24-hour shift that I was able to work in place of Thanksgiving. It is a true blessing to have a job with the kind of flexibility that allows me to spend precious time with the people I love during this holiday. I couldn’t have asked for a better place to work.

Over the last year, I have watched some people very close to me struggle with their health, and on one occasion, lose a life. Seeing this has been both painful, but also inspirational. I found strength in people that I didn’t know existed. These people have taught me to cherish every moment I have on this Earth and to count my blessings every day that I wake up in good health.

Today is a good day. I’m going to spend it with some amazing people and I’m going to eat lots of amazing food. I’m going to hold my loved-ones tight and count my blessings every second of the day. But most importantly, I’m going to watch the Raiders smack the Cowboys all over the football field :-)

Wishing you all a very happy Thanksgiving.

Joseph Duda

joeWords cannot adequately describe how I felt when I heard my long-time friend and former coworker, Joe had become severely ill and was fighting for his life in ICU. It had been less than a week before that we were bantering back and forth with a mutual friend over baseball and partaking in the customary bashing of the Yankees (sorry Vince).

I first met Joe when I started in EMS at the ripe age of 19. I had landed a part-time job with a rural ambulance service where Joe had been employed full-time already. I did my first ride-out with him. I can remember being nervous as hell and driving slower than the speed limit while responding lights-and-sirens to a call way out in the country. Joe was sitting in the passenger seat joking about how the semi-trucks were passing us and he informed me that I WAS allowed to drive at the posted speed limit and perhaps a little faster if I was feeling adventurous. Joe’s sense of humor really helped me during a very stressful period when I learning the ropes in EMS. He made work fun and I always enjoyed working shifts when he was on duty.

Throughout the majority of my EMS career, Joe has literally been at my side. During my time in California, I worked for 4 different ambulance services, all of which Joe worked at. When I finally left the mom-and-pop services to work for a large metropolitan-based service, Joe poked fun at me for switching to the dark side to work for the “Orange Giant”, but he ultimately wished me luck and we continued to stay in touch. We tackled paramedic school and Joe eventually switched to the dark side as well and wound up on the same night-shift as me. Even though we staffed different ambulances, we frequently texted and caught up at the ER’s. And the end of every shift, we always talked about our calls and picked each others brains. We were both new paramedics and just getting our feet wet in a busy 911 system. I learned so much from him and I truly believe that I am the medic I am today because of our experiences together.

We eventually parted ways professionally, but stayed in touch. When I moved to Texas, he used to constantly joke that he hated me because he wanted to be where I was. Of course, I wasn’t above posting a picture of a nice cold Lone Star Beer just to rub it in a little from time to time. We shared a love for Texas music and Texas baseball (Go Rangers) and we both shared a dislike for California politics.

When I heard of Joe’s passing, I felt both sadness for the loss of a good friend and relief because I knew that he was no longer suffering. I prayed that God look over his family and all of those close to him. I know he’s in a better place and now I get to be the one jealous because he’s living in paradise.

Thank you Joe, for all the great memories and for everything you did for me when I was coming up in this crazy profession. You are an amazing man and you will be truly missed. Until we meet again…..

At Least I’m Still Human

It never fails….I’m sitting at a table, socializing with people I just met. Eventually somebody is going to drop the “what do you do” question. I used to be quick on the draw when it came to waving the “life saver” flag – be it in a feeble and unsuccessful attempt to pick up on women, or to simply impress somebody – but that quickly changed. After I got over myself, I actually started dreading that question because I know where the conversation is going to go. People want to know what I have seen and how I deal with the “horrible” things that they think we come across every day. Of course, their definition of horrible is much different than mine.

Movies and TV have given society the impression that we see a bunch of really nasty, mangled and bloody patients, then just drive them to the hospital.  What they don’t see on TV is a paramedic talking to a grieving father after his 8-month-old child choked on a water balloon and is showing no signs of life. They don’t glamorize the mother of a little girl that was found beat up and left for dead in a trash pile, only to find out that her own husband was the one that tried to kill their daughter. When someone inquires about the “worst” thing I have ever seen, they usually aren’t expecting one of those answers. For the sake of not ruining casual conversation, I typically just tell some humorous story and keep those painful memories to myself.

When I started in EMS, death didn’t bother me like I thought it would. My first full-arrest was a rush. I was applying newly learned skills and doing something exciting. Most of my friends from high school were still smoking pot, partying, and enjoying life under the shade of the parental umbrella. Not me. I was pumping on chests, driving fast, and looking freaking awesome while I did it. I didn’t quite grasp the seriousness of the work I was doing. While I’m glad I started out when I did, I often wonder if I was mature enough to handle the job I signed up for. Fortunately for me, it wasn’t until sometime later that I truly experienced my first case where I got hit with the ole’ reality sledgehammer.

I’ll never forget the day I transported an elderly lady in full-arrest from a nursing home who was pronounced dead shortly after arrival at the ER. For me, this just another old person that died. I couldn’t even begin to count the amount of calls like this that I had run during my career. It was business as usual until I walked into the room of the now deceased patient to find a little girl crying by her side saying “I’ll miss you, Grandma”. It wasn’t the emotion from the family that bothered me, it was the guilt of not feeling anything. I wondered how I could have watched so many people die and never lost a night of sleep? Was I even human anymore? What was wrong with me?

I took a big look back on my career and couldn’t help but think about the all the times I ran a critical call, and went about my day like nothing happened. Hell, I even joked about some of these calls. The deeper I dug, the worse I felt. This was the start of many years of feeling guilt and questioning myself as a person.

For the longest time, I have felt that EMS has changed me as a person. I often question my morals, and at one point, I even questioned my faith. The things that bother me aren’t death or crippling injuries….it’s misuse of ambulance services, the entitlement mentality that many of our patients have, and the on-going joke called Medicaid reimbursement.

I often wonder if I’m so calloused as a person that something like the death of somebody’s loved one just doesn’t touch me. It’s not that I don’t care, I just don’t have any emotion invested in it. I know that as an EMS provider, I can’t be emotionally tied up in all my patients or their tragedies. If I was, I would be mess. We all would.

Now having said all that, I must clarify that I’m far from bullet-proof. I can go about my business of providing on-the-spot taxi services for those who refuse to care for themselves, pumping on grandma’s chest and doing my part to combat natural selection. That is, until I run into one of “those” calls that jump right out of nowhere and hit you right in the face. Like a young man in his early 20′s that was tragically killed in an unfortunate accident at work. Life is fine and dandy until I have to notify his father and inform him that his only son just died during a freak accident at a low-risk job.

So how do I handle that? I finish my PCR, help my partner finish cleaning the ambulance, and try to go about my day as I always do. I’ll eventually reach a quiet moment where the emotion from the event hits home. I think to myself that it could have easily been me or any one of my friends or family members. I put myself in the shoes of the grieving father and imagine how I would feel if I received that phone call. Then I take a look at myself and maybe even crack a little smile, because all the emotion I’m experiencing means that I’m still human. I remind myself of the reasons I do this job, then head out to start the cycle all over again.

If Motorcop Was A Paramedic

mcMost of the readers of this blog are probably familiar with this weeks “Celebrity Medic”. If you’re not, go check him out of Facebook and read his blog. When he isn’t busy crushing the souls of the sinners of the highway, you might be able to find him chatting it up on the Crossover Show, or bragging about making people cry on Facebook. Although being a motorcycle cop sounds pretty freaking cool, I can’t help but wonder if one day MC will hang up his helmet and boots. What if he decided to leave the Dark Side and take up a career in pre-hospital emergency medicine? That would leave us no other choice but to ask ourselves the big question of the week:

What kind of Paramedic would Motorcop be?

First and foremost, guys like MC need a saying or a slogan. “Soul Crusher” just doesn’t seem fitting for a paramedic…..”Disease Crusher” however, does. Perhaps a patch featuring a picture of him stomping out disease and punching bacteria in the face would be appropriate.

I couldn’t imagine that MC would be happy working on an ambulance as it’s too big and too slow. I could see him working in a first-responder vehicle or perhaps even one of the lucky few that get to work EMS on a motorcycle. I couldn’t see him working 24 hour shifts, instead he would probably seek the traditional law enforcement schedule of 8-10 hours.

Instead of following a set of protocols, MC would set rules or guidelines for the body systems of patients to operate under. Any deviation from the rules would result in citations or fines. He would most likely specialize in motor vehicle collisions and his trauma care would mostly consist of investigating the mechanism of injury. Patients receiving transcutaneous pacing or electrical cardioversion would not receive sedation. Instead, they would be told “If you got shocked, you deserved it”.

Transitioning from a law enforcement job to EMS would require some specialized equipment. Here is a list of essential equipment for MC’s medic bike:

  • Baton: Used a long-bone splint.
  • Bullet Proof Vest: Used as a make-shift KED.
  • Taser: Used as an Automatic External Defibrillator.
  • Breathalyzer: Modified to detect CO2 for use in confirming ET tube placement.
  • Handcuffs: Made larger for use as a tourniquet.
  • Radar Gun: Used as a portable x-ray device.
  • Gun: Still used to shoot bad guys…….

Overall, I think MC would be a perfect candidate for a job in EMS. Response times wouldn’t be an issue and scene safety would be assumed. While obtaining blood samples would require a search warrant, pt’s would otherwise not have the ability to refuse treatment. Patient rights would be replaced with Miranda Rights, and patient care reports would be replaced by citations. While the transition would be tough, I think he would fit right in with the rest of us gurney-pushers.

Have an idea for next week’s “Celebrity Medic”? Send me an e-mail at sean@medicmadness.com 

While We’re On The Topic of Baseball

ballparkA fellow nurse blogger and I were sitting together watching baseball at our local family watering hole (Go Rangers) a couple nights ago when she got the idea to write an article comparing the game of Baseball to the day-to-day operations in the Emergency Department. Once the ideas started rolling in, we pulled out the laptops (yes, we are THOSE bloggers) and signaled our bartender to keep the brews coming. And when I say brews, I mean brews. None of that light crap. If I can see through the glass, it aint’ dark enough…..

Moving along……

As I am attempting to unwind from the day by having a beer and watching the Texas Rangers kick some Chicago White Sox ass, it occurred to me that ED is much like baseball…..Please, allow me to elaborate……

Emergency Medicine: Lets Play Ball!!!! (A Comparison of the ED and America’s Favorite Pastime) - thekristening.com

If you haven’t read the article, go check it out and come on back when you’re done.

Seeing how well her article played out, I decided to shamelessly steal  expand on the idea and write a comparison of EMS and the game of Baseball.

Batter: (Paramedic) Whether on a street corner or housed in a station, this is the guy that sits in a rotation just waiting for his turn at the plate. The better he and his teammates are, the more times he goes up to bat. The paramedic may enjoy his share of the action, but ultimately just wants to head straight for home.

Pitcher: (Dispatch) The Clash of Titans often occurs between a paramedic crew and a dispatcher. When the dispatcher throws junk calls their way, they try their best to stand back and avoid them, keeping themselves available for the next pitch. That is until that crazy trauma call gets thrown right in the wheelhouse for them to take a swing to get a nice big piece of the ball and send them home with a sense of accomplishment and satisfaction.

Catcher: (Lead Dispatcher) While the dispatcher and medic crew are typically in the center of the spotlight, the lead dispatcher is sitting behind everyone, calling the pitches and directing all the players on the field.

1st, 2nd and 3rd Basemen: (Patients) The patients are always there, waiting, eager to tag you at the most inopportune time. A good and fast paramedic will run right through them all on his way home.

Shortstop: (Frequent Flyer) This person isn’t your average patient. They play the game and they play it well. They are the ones that will jump up out of nowhere and jack your world up before you even knew what hit you. They are known for jumping in the middle of the game at the worst time and stopping you in your tracks on your way to a good run. This person is the vacuum of the field, nothing gets by them and they will suck you dry.

Outfielder: (Firefighters) These are the guys that are usually standing around at a distance unless the paramedic is working. Just when you think you have hit a home run, they are there to jump up and steal the glory.

Manager: (Field Supervisor) This supervisor is the one watching over everything. They get to decide who to put in the game and who to take out. A good team can make the games and their career successful, while a poor team can make for some miserable work days. A good manager will stand back and watch while his team plays the game, making minimal changes when necessary.

Bat Boy: (Supply Tech) This is the guy that the players tend to dump on and is often unappreciated. A good supply tech works fast to clear out equipment and re-supply the team. They often go unnoticed until the one time they slip up and a used ball gets left on the field.

Base Coach: (Base Physician) When the Medics are rounding the bases, this is the person they look to for the go-ahead when they want to run the extra mile.

Umpire: (Law Enforcement) Nuff said.

Fans: (Bystanders) These are the friends, family members, and Monday morning quarter backs that stand around and watch you work. They all believe that they know your job better than you do and are the first to complain when things don’t go their way.

Go Rangers!

Now we just need someone to do write up on the fire service and police department. I’m looking right at you Happy Medic and Motorcop!

The Fishiest Call I Ever Ran

fish pondSo there I was, minding my own damn business, when the tones go off over the radio. My partner and I hop in the ambulance and immediately crank up the heater as the outside temperature was 28 degrees (Fahrenheit, for all your blokes across the pond). We arrived at the residence of an elderly male that had a complaint of abdominal pain and requested to be transported to a hospital about 40 minutes away from his house (St. Furthest as The Happy Medic would describe it).

Getting to this patient wasn’t easy, as the hallway and living room made maneuvering a gurney very difficult. With me being the lazy bastard creative gurney navigator that I am, I found a route through the back door that seemed much easier than attempting to bring the patient back through the front of the house.

After loading the patient on the gurney, we started through the back door and found that there was no lighting whatsoever in the back yard.

No big deal, I got this.

I instruct my partner to continue forward as I reach for my flashlight. About the time I heard him say “Woah!”, I felt my left foot slipping into what initially felt like a puddle of water……only my foot kept slipping until I was up passed my waist in water. I somehow managed to push the gurney away from me to avoid it falling in on top of me. The next thing I knew, the chief of the volunteer fire department that responded with us was on his stomach trying to grab me, and my partner was pulling the gurney away and asking if I was OK. I quickly jumped out of the freezing water and continued about what I was doing like nothing happened. I turned to my partner and said. “I’m fine, just needed to go for a quick dip to cool off”. I figured I might as well own it with pride.

I had fallen into a fish pond in the patient’s back yard that I obviously was unable to see. I was covered in water, and miserable. My partner suggested that I call the on-duty supervisor and have another ambulance responded so that I could go back to the station to dry off. I respectfully declined and insisted that we continue to St. Furthest.

After 40 minutes of misery, we arrived at the hospital and offloaded our patient. Still soaked in fish-pond water, I stood next to the receiving nurse – completely oblivious to my condition – and gave a bedside report. The conversation went something like this:

After finishing my verbal report…..

Nurse: “Do you have a medication list”

I reach in my pocket and pull out a soaked medication list and slap it on the counter….water and all. 

Nurse: “What the hell happened to to this?”

Sean: “It fell in the fish pond.”

Nurse: (looking at me for the first time) “Whaaa……what the HELL happened to you?”

Sean: “I went in after it.”

Nurse: “Are you kidding me? Why would you do that?”

Sean: “I know how you nurses get when we don’t bring in a med list. It’s called dedication. Have a good night.” (utilizing the biggest shit-eating grin I could come up with).

Not another word was spoken to me from anyone in that ER. I walked out of there like a boss, grabbed a towel on the way out, threw it on the front seat of the ambulance, and looked right at my partner who was still looking at me with disbelief.

Sean: “Drive it like you fucking stole it, I’m freezing”.

Partner: “You know….the only thing that could have made that better, was if you had come out of the water with a fish in your mouth”.

Sean: “Fuck you”