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And that is why we assess our patients

January 29, 2010 By 5 Comments

We get dispatched to a familiar address for “difficulty breathing”. As we pull up on scene, the fire captain walks up to the ambulance and says “he’s having another asthma attack, my guys are walking him out right now”. I wasn’t particularly thrilled with his decision to walk the patient, but at this point the patient was already walking up to the ambulance.

The patient is 67 years old, deaf and has a history of chronic asthma. He typically calls about once a week when he runs out of his Albuterol and gets short of breath. The call started out pretty much just like every other time I have transported him. I’m initially thinking “O2, monitor, IV and an Albuterol treatment and we should be good to go”.

I listen to his lung sounds and hear wheezes in all fields. This is pretty much normal for him as mild wheezes are pretty much his baseline. He happens to read lips quite well, but doesn’t really speak. I look him in the eye and ask, “are having another asthma attack?”. To my surprise he shakes his head “no”. A bit puzzled, I ask “are you short of breath?”. He motions “yes”. So now I start with a different route of questioning.

Sean: Does this feel like your asthma is acting up?

Patient: No

Sean: Are you having pain?

Patient: Yes (and points to his chest)

Sean: Have you ever felt this way before?

Patient: No

So now my treatment plan completely changed from a respiratory emergency to cardiac. I wasn’t able to determine length of time or a pain scale due to the language barrier, but I did know enough to start treating him.

I placed him on oxygen, started an IV and administered 325mg of ASA. His bp was 98/palp so I did not administer nitro. His monitor showed sinus tach at 110 and an Sp02 of 99%. We arrive at the ER, place him in a bed and the staff does a 12-lead ecg. Sure enough, the patient was having an MI and was taken to the cath lab.

This call really got me thinking about how easy it would have been to just run with the asthma idea and completely mistreat the patient. Administering Albuterol would have increased the workload on the heart and potentially made the MI worse. Who’s to say that the hospital would catch the error?

If anyone else has similar stories, I would love to hear it.


Filed Under: Field Medicine Tagged With: , , , ,

If my heart monitor could talk, I would have to shoot it…

January 24, 2010 By 6 Comments

The service that I work for recently made a rather large purchase of new heart monitors. We are switching from the Zoll “M” series monitor to the Zoll “E” series. This of course comes with a ton of neat upgrades. Built in c02 Capnography, NIBP, and 12-lead monitoring are all new features that come with the devices.

There is one feature that I forgot to mention…..

The monitors record the Sp02, c02, NIBP and ECG for the entire call. They also have Bluetooth capabilities and sync the entire call to our electronic PCR’s. You heard that right, big brother is coming to town!

Before I get to far into this post, I will say that I am 100% for recording and keeping the data, but I’ll get into that later.

I heard several people say that they are troubled by the new devices because they feel like they are being “watched” or “spied on”. Many paramedics fear that the feature will lead to a lot of “Monday night quarterbacking”, or questioning of paramedics practices if you will. I personally believe that the people that fear this system are just not comfortable with their own skills. I am actually quite bothered by this response and can’t help but wonder if it will have some negative impact on the care provided by the “affected paramedics”.

Ever get the feeling that your being watched? Have you ever noticed that you don’t act like yourself when you know you are being watched or recorded? Well imagine that feeling being applied to every ALS call you run. My fear is that some paramedics are going to second guess themselves to the point where nothing gets done. Unfortunately everyone always assumes that surveillance is a bad thing.

Lets look at an example on how closer monitoring of patient care can be helpful:

Have you had a patient present to you one way on scene, and completely change either en route or at the time you arrive at the ED? If you have, then you have most likely had the nursing staff or the ER doctor question your assessment or treatment. Rather than just saying “you weren’t there”, you can show them solid evidence and spare yourself from being the topic of their conversations for the rest of the day.

ECG recording can be used to improve QA programs, defend yourself in court and help the hospital staff continue the care that you started. Having someone review your calls and ECG interpretation will ultimately help you. It is far better to have someone correct an issue, than let it go without being addressed, and possibly harming someone. If you feel that uncomfortable with your knowledge or skills, then read up and get confident!

Don’t be afraid of big brother. He’s really there to help.


Filed Under: Field Medicine Tagged With: , , , ,

Sunny California…..

January 23, 2010 By Leave a Comment

Why do I live and work in Southern California? Duh…..the beaches, hot babes, and the sun.

So how the hell did I end up like this on my last shift?


Filed Under: Misc Tagged With: , ,

HIPAA vs EMS Bloggers

January 22, 2010 By 15 Comments

Yes I’m bringing up the much feared “H” word…..but for a good reason!

I read various EMS-related blogs and Twitter posts every day. Most come with some pretty interesting stories about calls ran. Unfortunately, some are a little too detailed and have the potential to get some people in trouble. I know this because I speak from first hand experience.

Being guilty of sharing my calls for the day with the world, I have been known to give out a little too much information. On one occasion, my boss actually called me into his office because he received a complaint about a story I posted on my blog. Luckily it just amounted to me pulling the post off my blog and no real damage was done. However, had it have been pushed any further, I could have easily been fined thousands of dollars. My employer would have also been fined, which would have probably translated into me being unemployed.

Many EMS bloggers violate HIPAA and don’t even know it. There is a huge misconception that leaving out patient names protects us from privacy laws. The truth is, you have to pretty much leave out any details that could even remotely link the story to a patient. For example; if the patient can read your blog and identify the story as being their incident, then HIPAA has been violated.

So how do I HIPAA-Proof my blog?

The only way to make your blog 100% compliant is to just not reference calls without a patient’s permission. If you read my blog, you obviously know this is not how I practice. I do however, take several steps to minimize my risks.

First and foremost, NEVER use patient names, addresses, pictures, etc. Anything that directly links your story to the patient is just an attorneys payday waiting to happen. Making up fake names or not using names at all is an easy way around this.

We all like to brag about who we work for right? Well don’t do it. Don’t even mention what agency or company you work for. Doing so places yourself and your employer at risk. This goes for the entire blog, not just the story.

Don’t talk about where you work, or even where you live.  Be vague when discussing your location. Use terms like “Southern California” rather than “Los Angeles California”. This also applies to the entire blog.

Don’t get detailed when discussing call locations. Describing your scene as “Chili’s Restaurant on 4th street”, is a bad idea. Instead either make up a fake establishment or just don’t even mention any business names.

Blogging is like journalism, so aren’t I covered under the “freedom of the press?”

No, no and hell no.

Sure Geraldo Rivera can pretty much say anything he wants on TV and be covered under the constitution, but Geraldo isn’t a paramedic (thank god). We are healthcare providers and we sign HIPAA agreements when we go through school and start employment. As a matter of fact, posting protected information on the internet is about the worst way you can violate privacy laws.

Don’t get me wrong people, I love reading about how you intubated 2 people at the same time or successfully stuck an IV in someones earlobe. Just please be careful and protect yourself!

If anyone is interested, more HIPAA information can be found at http://www.hhs.gov/ocr/privacy.


Filed Under: Education, Politics Tagged With: , , , , , ,

My Sp02 Rant……

January 19, 2010 By Leave a Comment

The other day I heard a couple coworkers talking about the calls they ran for the shift. One of them started to talk about a “BS” patient complaining of difficulty breathing. The part that caught my attention was when he said that he pulled out the “lie detector”, AKA the pulse oximeter, to confirm that the patient was indeed, “full of shit”.

Statements like this absolutely make me cringe. Perhaps I just like to live in my dream world where paramedics are professional and knowledgeable in their field. Don’t get me wrong, I hate transporting the “911 abusers” just as much as everyone else, but I also understand that it’s part of my job.

Now for the medical part of my rant……

I am 100% convinced that we as paramedics can perform our jobs and treat our patients effectively without ever touching a pulse oximeter. Sure it’s a handy tool and it serves it purpose, but it’s nothing more than a luxury.

If a patient presents to me with stable skin signs, clear and equal lung sounds, a good respiratory rate and speaks in full sentences, I can probably assume that they are breathing just fine. Likewise, if someone presents in a “tripod” position with wheezes and speaks in 1-2 word sentences, then I can definitely assume they are in respiratory distress. No pulse oximeter needed. Treat the patients people, not the monitor!

The pulse oximeter only measures a patient’s oxygen saturation in the blood. It cannot determine the metabolism or amount of oxygen actually being used by the body. This is why conditions like respiratory acidosis and carbon monoxide poisoning can give a high Sp02 reading, when in fact the patient is suffering from hypoxia.

So whats the moral of the story?

Do your job dumbass. Assess your patients, get a detailed history and for God’s sake, act professionally.


Filed Under: Field Medicine, Opinion Tagged With: , , , ,