Archive for the 'Good Medicine' Category

23
Oct
11

A view from the other side.

By Jeramedic Leave a Comment
Categories: Good Medicine and Rants
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Lately I have been spending some time in other parts of the company other then the back of an ambulance. I must admit that I was a bit apprehensive when I started to take on some duties behind the scenes. But I found it to have been a very eye opening and educational experience in the world of EMS, especially from the prospective of a field provider.

I thought I would share a little of what I have learned with you, in the hopes that perhaps you will think a little different about your job the next time you pull into the station, or are dispatched to a call.

So here are a few things that as a field provider, you may not of necessarily known was going on while you were out running calls.

  • You are posting, or on a move up because other units are busy. its as simple as that. Its not because the dispatcher doesn’t like you, or because “those knuckleheads at station 18 can’t handle their area”. It’s because coverage is being lost left and right, and you are one of only a small number of crews left in the city.
  • Document Document Document. I know that may sound obvious, but if you knew how many calls come through every day from lawyers asking for patient care records, you would think twice about what you’re signing.
  • No one likes to run the non-emergent, “BS”, system abuser calls. It’s one of the issues being handled in EMS 2.0. But would you believe that many people, (sometime several a day) call non emergency phone numbers, asking for simple BLS transport for things like: Chest pain with shortness of breath. Altered levels of consciousnesses. Seizures. And Obstetrical problems.
  • It really takes a lot of time, money, and energy to keep “your” ambulances and equipment in working order. So please take care of them when you’ve got them.
  • Dispatch is not a cushy job. Its had work. It might just be me, but I found dispatching to be more challenging and stressful then any field work. So when the dispatcher does’t copy you back, understand that sometimes it’s loud, business phones are ringing, while emergencies are coming in, while neighboring cities are calling for mutual aid, and any number of other distractions. So please… Give them a minute.
  • And finally, and this one is important so pay attention. We all know that reputations mean everything in this industry. When you are in a position where you can watch over fifty field staff working throughout a shift, and over multiple shifts, you realize that it doesn’t require much effort to stand out from the crowd, in both positive and negative ways. And that should be your take home message. Small changes in your behavior and work ethic, really make big differences.
So there you go, just a few tidbits of insight from the other side. Do with it what you will, but do good, and be safe.
16
Dec
10

Finding Zen In A Career of Chaos

By Jeramedic 1 Comment
Categories: Good Medicine and Uncategorized
Tags: , , , , , , , , , ,

The Zen tradition holds that in meditation practice, notions of doctrine and teachings necessitate the creation of various notions and appearances that obscure the transcendent wisdom of each being’s Buddha-nature.

Another way to think about is: A total state of focus that incorporates a total togetherness of body and mind. Zen is a way of being. It also is a state of mind. Zen involves dropping illusion and seeing things without distortion created by your own thoughts.

I think of Zen as a Physical, Mental, and Emotional homeostasis. A personal “set” point where you are at your best, In mood, health, and effectiveness.

My personal interpretation and practice can be summed up in;

  • Chilling out .
  • Refueling.
  • De-stressing.
  • And getting ready.

I will break these down with the goal of helping you find a little Zen of your own.

Chilling out: Resting is a huge part of returning to, and maintaining your center point. We, humans have a limited amount of physical, mental and emotional energy at our disposal. And despite our best (or addictive) attempts, no safe amount of coffee, V-Tac in a can, or 5hr B12 Vitamin shot  can compete with the natural energy and focus that is created from rest. Now I’ll admit I do enjoy the effects of a caffeinated beverage or two, but with in reason.

I know that in this field, rest is often hard to come across. But I find that if you are  proactive in your quest for rest, you’ll be surprised at how many opportunities there actually are. It starts at home, if you can get a good nights sleep before your shift, you will be miles ahead of most of your coworkers. Think of yourself like a cell phone: If you are not going to have access to a charger for the next 24hrs,  it would be best to start with a full battery.

Rest can be found even at work. If you post a lot, there’s nothing wrong with taking some of that time that you would have spent playing on your phone, walking through shops, or complaining about unimportant administrative matters with your partner, and directing towards some rest. It doesn’t have to be a nap. Just sitting still, and quieting your mind for a few minutes can really help. Kinda sounds like meditating, doesn’t it?

If you spend your time at a station between calls and assignments, thats even better. Some departments and companies have policies about sleeping during the day. But, like i said, it doesn’t have to be a nap. Just chill out for a bit.

Refueling: What you put into your body, will directly effect what kind of performance you can get out of it.   Since your shift is predictably unpredictable, like rest, its start at home. Insuring that you are appropriately fueled up before your shift, or packing healthy food with  you to have at the station during your shift, Will keep your mind and body capable of handling the challenges ahead. While in contrast, too much fast food wreaks havoc on your body. And being dehydrated, and mildly hypoglycemic is a major Zen killer.

Depending on the length of your shift, and call volume of your area, you could compare it to a work out, or marathon of sorts. I work 24hrs and sometimes 48hrs in a busy area. Lately I have experimented with “Carbo-loading” the day before, or between 4pm-7pm during my shift. I have found that it has increased my stamina during the day, and helped with my performance on 3am calls. This isn’t just for work, because  having a healthy diet off shift, will make it easier to maintain one while you’re on shift.

De-stressing. Being able to manage stress healthily and effectively could be the most important strategy for keeping your Zen.

We in emergency services are a unique animal. There is something about the inherent danger, chaos, drama, and unpredictably that pulls at us like moths to flame. Most of  us would claim the we are “immune, desensitized, strong, or can just deal with it.”

That may be true to some degree, but underneath that macho and or calm facade, a million plus years of evolution is responding to the danger,chaos, drama, and unpredictability, and in not so positive ways. Kinda interesting when you think that the stress stimulus that gives some of us an “adrenalin high”, can send others into an anxiety attack.

Leave work, at work.

Easier said then done for a lot of us, myself  included. Anyone can tell you I love my career, in fact I’m kinda a geek about it. If I’m not on shift, I’m usually thinking about, or doing something work related. Which isn’t a bad thing necessarily, but it does blur the lines between EMS life, and “normal” life. The negative side of that, is that many in this field are at risk for developing  Post-traumatic stress disorder. Go ahead and kid yourself, but its rough out there.

Having a good system for stress management both on, and off duty is key. Everyone will have there own practices that work best for them. It will take some experimenting to  find out what fits you personally, but here are some things that I currently do, or have tried and seen good results from.

On duty:

Paperwork, Cleaning and Organizing .

Everyone says they hate doing paperwork and station duties. But I, as well as some station mate  have found that the act of filling out a PCR (patient care report) checking boxes, and recounting the events of the last call through your narrative to be therapeutic at times.  It causes you to focus, and can symbolically bring closure once its  finished and filed away.

Cleaning and organizing gives you a simple and repetitive task, that has a noticeable and positive result. In emergency services we are very result driven: I don’t care how I get there, but i wont the result to be “X”. Reversing brochospasms, Getting a perfusing rhythm, Extricating a patient safely and quickly…. Results. As trivial as it may seem, organizing equipment, or having a clean day room, trips the same result driven reward centers in your brain.

Escaping.

Doing activities between runs that allows you to escape. Things like reading a book, watching a movie, getting lost on the interwebs machine, phoning or Skyping with friends or family, anything that brings you enjoyment. You know the tones are going to go off at some point, why sit around and tap your feet waiting for it?

Stop complaining.

Stop complaining about dispatch, management, the other guy on the other shift, blah blah blah. It only breeds negative feelings. If you really don’t like something, try directing that energy towards changing it for the better.

Off Duty:

Recharge yourself.

Go out and have fun on your days off, live it, use it, its your time. Take a day trip somewhere, go on a date, spend time with your family, just do something good for yourself. If your life can be described as go to work, go home, repeat. Then you need to find some excitement. It doesn’t have to be expensive, or some big deal, just something that is meaningful and enjoyable to you.

On the flip side, you might just need to stay home and do nothing. If you fall more on the Introvert side of the personality spectrum, realize that being on shift, also means being put into one social encounter after another for 12 or 24hrs. Giving yourself the time to be alone, read a book, veg out in front of the T.V, or whatever it is that you need, is very important.

Get Moving.

Physical activity is a great stress reducer. It oxygenates your body, helps to flush out toxins, and it fills your brain with endorphins (happy chemicals) and it keeps you fit.  And as long as we are doing things that give us enjoyment on our off time, why not include a sport that you love. Join a local league or club, or organize a weekly game with your friends. Being in the gym, cycling, swimming, running, its up to you, just move.

I would not recommended exercising on shift though. Unless your department or company has a daily PT program, the fact that we only have so much energy to put to use, and the risk of injury makes working out at work a low priority for me.

Gratitude.

Taking a few minutes to be grateful that you have the skills and knowledge to help people. That you have a job to go to, a home to return to, and a family and friends who love you. And that after all the tragedies you witness, be grateful that none were your emergency.

Getting Ready.

Not being ready for whatever you are expected to do, is a major cause of stress for many people. Misplacing something important, being late for work, feeling lost, these are awful and avoidable.

Many aspects of our job are unpredictable and out of our control. But take control of what you can, and set yourself up for success. Lay out your uniform and pack your car the night before. Give your self plenty of time to get to station at least 15min before you shift starts, and know where you are going. When you get there, make sure all your equipment is working and in its proper place. Also have your personal gear ready, and on the vehicle you are assigned to.

I will continue to experiment and fine tune these practices in my own pursuit of Zen, and I hope this will help you find some Zen of your own.

What ways have you found to keep your Zen?

12
Oct
10

The Community of Paramedicine: Pt 2

By Jeramedic 5 Comments
Categories: Good Medicine, Rants and Uncategorized
Tags: , , , , , , , , , , ,

So in part one I discus the idea of an “EMS Brotherhood”, and that we are all one and the same (even if your partner or common perception tells you otherwise) But after looking at how the industry is set up, and even still how we as members of this industry interact with one another, I am starting to look at things differently.

EMS does not have a “brotherhood” (at least not in the way as defined be our colleagues in Fire and Law) because we already have something . We have a community. And just like any small or mid sized town, we all know each other, we see each other around town, we share stories and ideas, we drive similar yet personalized cars, we all live and work in different areas, and we take pride in our little town, no matter how small it may look compared to the bright lights of New York city.

But how did we all become residence of “EMSville” ? And how can we expand? Well, like often mentioned, the connections and friendships made with social networking sites combined with the face to face interactions at regional and national, and even international conferences has helped to strengthen the community tremendously. The fact that you are reading this, and even care what I have to say is proof of that.

But Why?

Well, we need more friends. Both in, and out of EMS. We make these friendships by taking a leap, and talking to strangers.  Ever since many of us were little kids, we were told to never talk to strangers. While this was done out of a concern for our safety, many of us have carried this mantra over into adulthood. But its okay now. I don’t think the EMT ride-a-long thats with the other company, or the ER Doc, or the police Sergeant is going to lore you away with a bag of skittles and lost puppy story. And if you are still stuck on the ridiculous notion that “I wear blue, they wear white, we’re not from the same tribe.” All I can say is, Evolve already.

By not talking to, and getting to know your neighbors, you (and we as a community) are losing out.  Your best friend, fellow supporter of a cause, Jedi master educator, or ever your future medical director could be standing next you, and you would never know.

I used to work in an area where my main hospital was also the regional trauma center. Three fire departments and two private ambulances would all transport there, not to mention all the non emergency transport services as well. If you ever wanted a melting pot, the wall of that ER was it. I would talk to everyone, and guess what? I made friends. Friends that had on different uniforms, and made less then me, and who made a lot more then me. And it pays off. When I needed help with a patient, they were there. When then needed help with CE’s or a new job, we were there. Its like borrowing  cup of sugar.

Expanding a small town community into a thriving city is the same for EMS as it is a real town. Strong relationships must be made, trust must be built, and Infrastructure put in place.  There must be a sharing of recourses, and so on. Whats good for you, is good for your neighbor. We are not stealing secrets, we are sharing knowledge.

But How?

First off,  introduce yourself.  Say where you’re are from and what department or company you work with. Don’t think that just because you are in uniform that your patches and badges will speak for themselves.

Take a genuine interest in the other person. Hard to admit, but we all like to talk about ourselves. So Let them talk. Who are they? What are they doing in their career? Where do they want to go? Afterward, remember somethings about that person and the conversation. Next time you see them in the ER, or elsewhere, you’ll have something to talk about.  ”Hey Jen, how’s that fire science class going?” “Mike, I did not see you last week, did you take that vacation you were talking about?”

People like it when you remember their names, and something about them. You may have only just met lest week, but it creates a bond. Before you know it, you’ll have a study buddy, or a great reference for an application. And they will benefit too.

Also, and I must stress this. No egos allowed. When making friends, leave the deck of certs in your pocket. No one uping stories, no Medic vs EMT  rubbish. When speaking to someone with less experience and education then you, remember where you came from. When speaking to someone with more experience and education then you, still remember where you came from. Just be human.

And these gestures of peace are not just for personal gain. These are the people that are going to have your back on a major incident. building a strong relationship with not only your fellow EMS workers, but also Fire, Police, and Hospital staff  is something the strengthens the communities you serve. These were the driving principles behind the TAK Response conference I attended in September. And the San Bruno gas explosion the week before was a great example of expanding their our community aided in the response, fire fight, and patient care.

The community is growing, and with the help of friends like you, it is getting bigger and brighter every day.

06
Oct
10

The Community of Paramedicine: Pt 1

By Jeramedic 4 Comments
Categories: Events, Good Medicine and Rants
Tags: , , , , , , , , , , , , , ,

Last week I spent my time in Dallas at this years EMS Expo. It was a wonderful experience of both personal and professional growth, and something a recommend everyone attend at least once. But this post is not about the event, or the speakers, or the podcasts, blogger meetups, or even the “shhhh, super secret high-viz, bluetooth  enabled airway adjunct/C-Spine translator backpack gurney, that is going revolutionize the way we…”

This is more of an observational post about what happens at events like EMS Expo, and in the online communities. Something that I am seeing more of, but not as much as I’d like. Our friends in Fire Suppression and Law Enforcement have had a “brotherhood” for nearly a century. That unspoken bond that removes the illusion of rank and department and simply says “we are.”

Granted, Fire and Law have had about a century’s head start. And when it comes to the method and delivery of Fire protection and Law enforcement, a  near uniformity exists from one department or city to the next. But when it comes to EMS, there can be near poller opposite within the same county. Private, Public, Volunteer, Hospital based, Progressive protocols, and antiquated equipment, BLS, ILS, ALS, all sharing boarders. And any combination of the above could respond in teams from one on up to six plus. They could be in a car, ambulance, fire engine, or a private vehicle.

No wonder we struggle to find an identity, let alone a brotherhood. In many ways we are our own oppressors. Thanks to the “popularity” of privatized/for profit ambulances, we are treated like numbers, and view other providers from other services as competitors rather than colleagues. This is a an unfortunate and foolish mistake. We are all EMTs and Paramedics. We went through the same testing, we have same card(s) in wallets, we take care of the same people. So can we just be done with this whole tribal nonsense already?

The funny thing about all this, is that it only happens in the field. What is it about driving around in different colored ambulances that makes many of us act this way? You see, I don’t believe that this is our true nature. I don’t act this way, and I know many other who don’t either. But for some reason only at EMS conferences and on social sites like twitter and facebook do these  walls come down on a large scale.

There, out of uniform,  we stand as equals. Its in this space, in person and online where a student from Ohio can be mentored from Louisiana. Where providers from opposite coasts can feel like old friends, when in fact they just met. And where Medics from around the world can come together and create something bigger then themselves, and give back to the community that helped create it.

This community is what strengthens us as a profession, and as individuals. Its this community that wanted EMS 2.0 when its was just called “I wish things were better.” And its this community thats going to gets its wish. We all agree that it take a special kind of person to do this work. Well, what kind of person is it who will take time off of work, and spend money to go be surrounded by work? This is EMS Expo, and this is the community of paramedicine.

This kind of community is what we need when the boots hit the ground. I wear a blue shirt, you a white shirt, and others red and green, But we are all on the same team, and until we start playing like a team, none of us will win.

More to  in part 2.

01
Jun
10

Looking For Trouble: Part 2

By Jeramedic 2 Comments
Categories: Good Medicine
Tags: , , , , , , , , , , , , , ,

In part one I talked about the importance of being thorough in your patient assessment, and to resist falling into bad habits. So in that same vein, Lets talk about an assessment style that is both quick and easy for you, and will lead to a better  assessment and more appropriate patient management.

Lets start off by making sure we have all of the right diagnostic equipment, and enough time to use it all. Equipment: Eyes, ears, hands, and brain. “check.” Time needed: 5 minutes or less. “wait wait, no gear and 5 min?… now who is being lazy” let me explain. I am in no way down playing the enormous benefit of having sophisticated diagnostic equipment in the field, or am I saying that 5 minutes is enough time to know exactly whats wrong and what to do about it. What I am saying is that by just paying attention for a few minutes, and using your  “own” tools, you can actually learn quite a lot about your patient.

The reason I am suggesting you hold off on the “go go gadget Lifepak” for just a moment is two fold: First, I have seen many a practitioner both fresh and seasoned become entranced in the ritual of test that, analyze this, attach the purple thing,  chart that reading that they become blind to the picture that all this data collecting is painting.  Second, is that these assessment techniques can be used by any level of responder, and  there may be a time when the high tech equipment may be malfunctioning  or is unavailable.

So lets start with the first bit of info you receive about the patient: The dispatch. Now it doesn’t take you long to realize that dispatch info can at times be a hit or miss when it come to accuracy. But that doesn’t mean you shouldn’t  start preparing for what you may find while en rout. Consider the Chief Complaint and scene info, from that you can already start to think of a differential diagnosis, and  possible issues like safety and the need for additional resources. Also ask yourself if you know this Patient? Could this illness or injury be similar to one that you have treated them for in the past? If so, what did you learn from the past contacts that could be applied to this one?

Now you’re on scene, and after observing the environment for possible dangers as well as clues the NOI (nature of illness) or MOI (mechanism of injury), you make contact with the patient. This is where the real assessment begins.

The Initial assessment.

This is where you form you general impression. Put simply, how do they look from across the room? Would you know this person was sick if you had not been told? Or did they need a hospital three days ago?  Observe the position they are in. They could be lying on the ground, which should alert you to possible head or neck traumas.

Mental status, Airway, Breathing, and Circulation.

As you approach the patient and introduce yourself, do they respond appropriately? Or at all for that matter? If their response is abnormal or absent, the info you have gathered form you the dispatch, and the last 30ish seconds on scene, should be able to point you in the direction of trauma or medical. Act, and assess accordingly, based on their level of consciousness.

But lets suppose they do respond, and are quite verbal and appear to be  oriented to their surroundings and the situation. Without any obvious respiratory distress, as assessed by observing there posture, speech pattern, effort needed to breath, and the absence of abnormal breath sounds (at least at this stage) you know that for the moment at least. their airway is open, they are breathing adequately, and they have a pulse.

As you ask the patient about why they called  today, bring your self down to their level, and listen. Listen to what your patient tells you. If you don’t pay attention now, they wont feel that inclined to tell you again later .  Ask if you may hold their wrist to check their pulse while they talk. What you are looking for is the rate, rhythm and strength of the pulse. Is it too fast, or too slow? is it regular or irregular? Is it strong or weak? This is a good time to note their skin for color, temperature, moisture, and condition. If you listen,  pulse and skin can tell you a lot about the cardiac status of your patient. As basics, one of my partners and I had a joke that we carried a “LifePak II”.  The II, to represent the two fingers used when palpating a pulse.

Keep Assessing.

As you move on to your SAMPLE and OPQRST questions, make a quick mental note of what you have  observed about you patient so far. As you ask, and they answer, look in their eyes for color, pupil size, shape, and clarity. This is also a good time to look for any facial droop. Also observe their rate and effort of breathing a bit closer. You my also consider doing a quick visual, or semi physical head to toe exam. looking for things like Bruising or discolorations, Scars,  Jugular vein distention, Dependent edema, and so on.

Putting it all together.

So lets recap. In less then five minutes, we established a chief complaint, obtained a baseline mental status, assessed Airway/Breathing/Circulation, did a brief preliminary physical exam, gathered pertinent information as to the chief  complaint/related signs and symptom/medical history/medications, and hopefully established a patient rapport.

so, what did you learn from this assessment? Do your findings correlate with the chief complaint? If they don’t, why not?   Does this patient need immediate interventions and transport? Do you have a working diagnosis?

Plan and act.

By now you should have a pretty good idea of what is going on. If you haven’t done so already, now would be the time get a blood pressure, auscultate lung sounds,  and to start a treatment and transport plan. Now when it comes to the use of the more advanced equipment, ask yourself why you are preforming the test? well the easy answer is that its standard practice, and is part of the protocol for “X” complaint. What I mean is why do You want the test? is it to conform something you suspect? Or is to gather more data to help lead you in a direction?

This is about finding a problem, and doing something about. Always do your best to correct any life threatening conditions as they present. Remember that the low tech assessment is not a replacement for the advanced and detailed assessment. What it does, is it serves as guide to where further assessments and treatment should go. And as a solid foundation on which to build on.

Remember that no matter how much advanced equipment and treatments we can bring to the patients side, the most valuable is parked right outside. The Ambulance it self. Weather the hospital is 10 minutes, or 2 hours away, early, safe and efficient transport is one of, if not the best therapies we have. Also consider that the ambulance is the closest you’ll get to a controlled environment.

Have faith in your abilities, and have faith in yourself.

15
May
10

Hatzalah. A unique model of community/volunteer Paramedicine

By Jeramedic 6 Comments
Categories: Good Medicine
Tags: , , , , , , , , , , ,

For some time now, the idea of a “Community Paramedic” has popped up in many discussions on how to better serve our patients. Some services, like Wake County EMS have instituted such a program with great success. Many other systems are also now taking what Wake County has learned, and are adapting it to fit there needs.

The current model is focused on identifying “at risk patients” (chronically ill, special needs, and what is sometimes referred to as frequent flyers ) and using specially trained Paramedics to better serve their individual needs, in a non emergent setting, with a style of care that mixes a home health nurse, social worker and a primary care physician.

Considering the fact that even in the “911 setting” much of what we do is non emergent primary care, and that unnecessary ER visits and hospitalizations significantly contribute to the rise in health care costs. Community Paramedicine is a logical evolution of the industry.

But what if you have a unique population to serve and want to better the prehospital care in your area? Well one such organization has met the challenge.

Hatzolah/Hatzalah (“rescue” or “relief” in Hebrew: הצלה‎) is a volunteer EMS organization serving mostly Jewish communities around the world. Most local branches operate independently of each other, but use the common name. It is also often called Chevra Hatzolah, which loosely translates as “Company of Rescuers.”

The original Hatzolah EMS was founded in Williamsburg, Brooklyn, New York, by Rabbi Hershel Weber in the late 1960s, to improve rapid emergency medical response in the community, and to mitigate cultural concerns of a Yiddish-speaking, religious Hasidic community. The idea spread to other Orthodox Jewish neighborhoods in the New York city area, and eventually to other regions, countries, and continents. Hatzolah, as an organization, is the largest volunteer ambulance service in the world. Chevra Hatzalah in New York has more than a thousand volunteer EMTs and Paramedics who answer more than 250,000 calls each year with private vehicles and a fleet of more than 70 ambulances.

Hatzalah members were among the first responders to the World Trade Center on September 11, 2001. Alongside other rescue workers, Hatzalah volunteers risked their lives to rescue, treat, and transport countless victims of the terrorist attack. In the process they earned great respect from their peers in the emergency service community.

Hatzolah organizations now function in Israel, Australia, South Africa, Mexico City, Belgium, Switzerland, several provinces of Canada, Russia the United Kingdom, and at least five states in the US.

In Israel, the largest Hatzalah organization is called Ichud Hatzalah (Hebrew: איחוד הצלה‎), Hebrew for, “United Hatzalah.” Ichud was founded in the aftermath of Israel’s Second Lebanon War in 2006 when its founders decided they would like to improve unified central rescue response. A prior organization, Hatzolah Israel, also exists, and is of comparable size.

Hatzolah uses a fly-car system, where members are assigned to a district to respond from in the event of an emergency. The dispatcher requests any units for a particular emergency location. Members who think they will have best response times respond via handheld radios, and the dispatcher confirms the appropriate members. Two members will typically respond directly to the call in their private vehicles. A third member retrieves an ambulance from a base location.

Each directly-dispatched Hatzolah volunteer has a full medical technician “jump kit,” in their car, with oxygen, trauma, and appropriate pharmaceutical supplies. Paramedic members carry a full array of ALS supplies, including EKG monitors, IV equipment , intubation, and more pharmaceuticals. Each volunteer is called a Unit (as in, a crew of one), and is assigned a unit number that starts with a neighborhood code, followed by a serial number for that neighborhood (e.g., F-100 was Flatbush unit number 100, a”h). Ambulances also have unit numbers in the same format, with the first few numbers for each neighborhood reserved for the ambulance numbers. Some neighborhoods have begun to assign 3-digit unit numbers to their ambulances, using numbers out of the range assigned to human member units (e.g. 900-numbers).

In some areas there may be periods where coverage is not strong enough, for example on a summer weekend. When this happens, coordinators may assign an on-call rotation. The rotation may still respond from their houses, or they may stay at the garage through their shift. In such periods, Hatzoloh functions closer to a typical EMS crew setup, though the dispatchers may still seek non-on-call members to respond, and there will still often be a non-ambulance responder as first dispatched, even if that responder starts from the base.

One area where Hatzalah gets huge kudos from me is in the cultural consideration department. Cultural sensitives are an issue for any EMS that covers immigrant areas, especially when a given immigrant population is relatively small, speaks a unique language, and has a specialized insular culture. Hatzolah was formed in the Hasidic enclave of Williamsburg, in Brooklyn, NY, a community that matches this description. Language, religion, and culture barriers made emergency medical situations more difficult than they might be otherwise, especially as regards laws of the Jewish Sabbath and Holidays, and laws of modestly in clothing, and contact between males and females.

While the primary reason Hatzolah was formed was to speed up medical response, the cultural issues play no small part. Though long established in America and elsewhere, Hasidic communities in Williamsburg and elsewhere, to this date, continue to have the same milieu found when Hatzolah was formed.

A Jew reluctant to violate Sabbath rules when receiving medical attention from an “outsider,” may be more at ease and easily convinced of the medical urgency, when the EMT or Paramedic is a fellow Orthodox Jew, speaking the same patois of Yiddish, English, and Hebrew. A female worried about physical modesty and contact, knows that a Jewish provider is more aware of the details of her concerns, and will reduce the problem as much as possible.

In addition, in areas where EMS charges a fee, there is an additional factor. Lower income clientele that may lack health insurance may have a reluctance to call for an ambulance unless the evidence of urgency is overwhelming even to the layman. This may result in true emergencies not getting treatment until symptoms worsen, to avoid the cost. A volunteer service, with sensitivities to the local community, tends to reduce that reluctance; Hatzolah is well known for its willingness to handle the “check-out” case, where there is frequently no real emergency, without charge and with great patient sensitivity. In this way, the true emergencies among those check-outs may be recognized and treated quickly, where the caller might have otherwise not sought treatment.

We all experience cultural differences, but having a provider of the same heritage is priceless. Your community my not be as unique, but there is a lot to be learned from Hatzalah’s operation. For more information check out their website, and take a look at a true “community” EMS system.

I heard an interview with a Hatzalah EMT, and was interested in the service. I found Wikipedia to have the most content, and much of the information here is from that article. If anyone has any more info, or has experience working with them let me know.

02
May
10

Looking For Trouble: Part 1

By Jeramedic 2 Comments
Categories: Good Medicine
Tags: , , , , , , , , , , , , ,

What do you think one of the most important skills a EMT or Paramedic can have? is it good IV skills? Maybe good airway management? Or how about a friendly bed side manor? theses are all without argument very important skills to have, but what about assessment skills?

It is the first treatment every one of  our patients receive, and one that should be continued until care is transferred. It is the one skill that no matter what the chief complaint, is always preformed… or is it?

Do you really, fully and properly assess and examine every patient? Do you take into consideration every thing the patient and the scene is telling you before making a treatment or transport decision? Unfortunately no, and I’ll the first to admit I’ve cut corners from time to time. The sad truth is we all get lazy, and can fall into bad habits of sorts. But why?

I see over confidence being a major cause of inconsistent assessments. It’s easy to roll up and say “oh it’s just another fill in the blank , their fine, lets ship it.” I have seen it too many times, and having it result in “less then appropriate care.” Perhaps another problem is the way we as individuals approach assessments. In school when it come to assessments we stress the points of being consistent and thorough. Then during field training, the advice changes, and we are told to get our assessments down to a system. And the mantra of  “don’t treat the monitor (any diagnostic equipment) treat the patient” is drilled.  Sound advice, but is it being understood?

Based on my experience of observing others assessment “habits”, I believe there may be a misinterpretation of what is being taught. ” Be consistent and thorough”  could be interpreted as “memorize an algorithm and hit every mark.”  So with that, are you using and understanding the information that your assessment is presenting? Or are you too worried about forgetting to palpate “that”, and ask “this” question?

“Don’t treat the monitor, treat the patient” could be (and I have seen)  practiced as “treat at face value, if they look ok, meh… they are probably ok.”  Now that’s having a great index of suspicion.

I’m going to ask you to shift the way you approach your assessments, and to show up looking for trouble. This is my philosophy, and I think it makes a lot of sense. Let my explain. If you (the patient) or a by stander felt it necessary to dial 911, for whatever reason, this implies that there “is” or “was”  some sort of problem needing attention. If I arrive and find you (the patient) to be in  no apparent distress, I become suspicious.

The way I see it, by the very act of using 911 you have now bought yourself an assessment. And in essence must prove me wrong to your need of my service. Now I don’t mean to be rude about it, but I would rather look for a problem and find nothing, then to just take a BP and call it good.

Beyond the normal set of vitals and an appropriate physical exam, I like to take the time to learn about the patient and the their reason for calling. Its very important to be clear on the circumstances surrounding the summon for EMS. Listen to the patient. Let them describe the event, and how they felt or are feeling in their own words. Listen without filling in the blanks or leading their answers.

Asking about a patients past medical history is something we all do instinctively. But how much are you really pursuing it? When you ask “do you have any medical problems” and they answer “no”, do you follow that with “do you see a doctor for anything?”   Nearly 4 out of 10 Americans has at least one chronic medical condition, and if it is being well managed, and has been for some time, some patients my not consider their chronic illness as a “Problem” because to them its not. Lets suppose they report that they do not see a doctor for any reason. Now do you ask when was the last time they were seen by a doctor? If someone has not seen a doctor in 10-15-20 years, could it be possible that they may have high cholesterol, un managed hypertension, the plague… Yes, and all the more reason to do a full and thorough assessment.

In part 2, I will explain how to do a rather detailed assessment with out using any equipment. But for now, think of how you assess your patients, and if they deserve a little more. After all, you cant treat  something unless you know its there.

15
Apr
10

Care Free

By Jeramedic 4 Comments
Categories: Good Medicine
Tags: , , , , , , , , , , , , ,

The state of emergency medical services, or  any medical service for that matter, is no care free business. But yet much of what we provide ends up being free. Hospitals around the country lose  tens of thousands of dollars a month, often through the emergency department. EMS services routinely treat and transport “non paying patients”, and the already huge cost of health care rises because of it.

Do I think its right? No. Do I think uninsured patients should be refused treatment? Of course not. I take pride in my ability to provide care to anyone, paying or not. I am also aware that as this trend continues, it becomes more difficult to maintain a functional system of care delivery. What am I saying… Its already broken.

Now this country’s recent health care reform has been met with some very, shall I say “mixed” reviews. This post is not about that. Perhaps I’ll say something on it later, but not now. I will report this however. A friend recently told me that because of the now, even lower reimbursement rate from medicare and medicaid, that his company is cutting back on ambulance coverage in the poorer communities. This to me, does not sound like a viable solution.

In a perfect world, medical care would be free. Even in this “economic climate” (meh… I feel like CNN saying that) I actually advocate more free care. I have always said that providing free monthly health screenings, and community CPR classes is a great way to bring back the “public” in public health/safety. Another practice I advocate, is to keep copies of community resources in your clip board or in the ambulance.  As we all know, many patients use 911 and the ER because they have no other choice. By educating them of alternative, and in many cases more appropriate and affordable means of care, the financial burden is lessened for both the patient, and the system.

On that note, I would like to introduce you to the National Association of Free Clinics. The National Association of Free Clinics (NAFC) is the only nonprofit organization whose mission is solely focused on the issues and needs of the more than 1,200 free clinics and the people they serve in the United States .
Founded in 2001 and headquartered in Washington , D.C. , the NAFC is an effective advocate for the issues and concerns of free clinics, their volunteer workforce of doctors, dentists, nurses, therapists, pharmacists, nurse practitioners, technicians and other health care professionals, and the patients served by free clinics in communities throughout the nation.

The NAFC provides  guidance and training for new and existing Free Clinics. As the national voice for Free Clinics, the NAFC has an active role in helping to shape national health care policy and legislation that affect Free Clinics and the people they serve. With the help of the NAFC, In 2007 alone, over $40 million dollars in donated major pharmaceuticals were distributed to free clinics.

On their website they can help you find free clinics in you area,this information can then be passed on to your patients. While you there, you can become a member of the NAFC, and of course make a donation. Seeing as it’s tax season, who would argue with worthwhile right off?

Care free my friends.


20
Mar
10

Don’t Just Do Something, Stand There!

By Jeramedic 4 Comments
Categories: Good Medicine
Tags: , , , , , , , , , , , , , , , ,

Being a passionate provider, as I’m sure many of you are as well. We are drawn to this line of work because of a sometimes overpowering drive to do the best and the most we can for others. There are however times when doing the best for our patients means doing nothing.

This can be a difficult time for anyone put in this situation. We want to do all that we can, no matter what.  Sometimes we find ourselves in scenarios where we are unable to provide care do to safety issues, or at other times having reached the limit of what can be done in the field. Either way, in any situation the EMT or Paramedic is sometimes left feeling helpless, frustrated, and angry at themselves or at others involved. There is a lot of talk and research on the other, more commonly thought of job stresses. Things like, sleep loss, post traumatic stress, the time spent away from home and its impact on families and so on. But I see this occurrence as an equally significant, and yet less mentioned stress.

Some of us take patient outcomes very seriously, and we all like to be in control.  When put in a situation were things are out of our control, or there is nothing else that can be done, feelings of stress can soon follow. When feelings get out of hand, I see basically two behaviors. One having thoughts and feelings directed towards  our self, such as feelings of failure or inadequacies. The other being directed outward, such as blaming others for what happened.

Like other forms of stress, over time these feeling and behaviors will negatively effect your professional and personal life. Proper management and care must be taken in order to have a long and healthy career. I say this because I have experienced these feeling myself. I can remember arriving to shootings before the police, and having to wait a block or two down the street until the scene was secured. I could see the incident, I could tell that I was needed, and yet I couldn’t help. There were times when someone would run down the street to the ambulance pleading for us to help. Often they would not understand why we had to wait, and I would find myself feeling helpless and frustrated.

There have also been times when I’ve had to take care of someone who was very sick, and yet had nothing for them. Again, more feeling of helplessness and frustration. I found this to be a common scenario when I was an EMT Basic while waiting for ALS to arrive. Even still, as an ALS provider there are times when you cant fix the problem. And what you do have to treat the patient, may actually do more harm then good.

It’s important to be rational about these situations. And to come to terms with your limitations, and to work with them the best you can. Remember that on calls of a hazardous nature like violent crimes, and HazMat, that the safety of yourself and your partner or crew is vital. I know you have heard it before, but I can not stress it enough. You can not help anyone if become a patient yourself. As hard as it may be sometimes, just stop. Stop and wait for the scene to be safe. Your grand kids will thank you for it.

Also, be honest with yourself about your limitations. Now prehospital care has made huge advances in a relatively short period of time. But as much as we can diagnose and treat in the field, very little of that is definitive care. And very often just getting the patient to the hospital is still the best treatment we have. I know that statement may go against what many progressive system are working towards. Like alternative transport and treat and release protocols, but its true. Despite what your ego may tell you, you are not a superhero. And being a good clinician not only means knowing what to do, but also knowing what not to do.

There are of course other situations when no treatment is the best treatment. Like when honoring a Do Not Resuscitate order, or having to triage a Mass Casualty Indicant. The decision to stop or withhold treatment can be a difficult one, even when you know it’s the right one.

Remember why you do this, and that you do make a difference.

Be well my friends, I promise you  it’s all worth it.

An episode of the GenMed show was inspired by this post, and recorded soon after. To listen to the show click here

06
Mar
10

Low Cost, Low Risk Strategies For EMS 2.0

By Jeramedic 1 Comment
Categories: Good Medicine
Tags: , , , , , , , , , ,

Lately I have been having a lot of discussions with fellow EMS providers and the general public about the state of health care, and the delivery of EMS in this country. The opinions expressed in these conversations are as varied as the individual, but one thing remains the same. “There has to be a better way.”

When doing some research on the subject, I was frankly overwhelmed. If you search for information concerning health care reform, public opinion or pros vs cons. You’ll be met with a mountain of research, pseudo research, statistics, projected statistics, public polls from three different news agencies with three different results, propaganda and conspiracy theories.

In the pursuit of better health care and delivery of EMS the debate is ginormous, the hurdles are tall, and the road is long. But there is a better way. There are in fact many ways. The United Kingdom, Canada, The Netherlands, New Zealand and Aulstralia are just a few examples of countries that provide health care and EMS differently and arguably in some ways better then the United states. I do not know what the best way to provide health care and EMS is. Every system has it’s good points,and it’s bad. But I do know there is a better way.

As it stands right now. No mater how much education, training and specialized equipment we possess, we are left with one option to deliver care.  Take the patient to the Emergency Room. Now on paper that makes sense. We are an emergency service that responds to emergency calls. Naturally we should transport to emergency departments.

The reality is that many of our patients are not in a state of emergency. That is not to say that they are not in need of care, they are. Often they are in need of a lot of care, just not the care that is available at the emergency room, or in the back of the ambulance. What this means is that we are not providing appropriate care. And as long as we continue to do so, we are  causing a huge disservice to the patient, the ER, the EMS system and are contributing to the problem.

“Oh, and by the way. Can I have $1500 for the ride I gave you to that inappropriate facility where you did not get your problem corrected? Thanks very much and feel free to call us back anytime”

*                    *                    *

There is a better way. And there will be change. It wont be next month or next year, it may not be for many years. But there are ways you can start providing better care, and help to get the EMS 2.0 ball rolling a bit faster.

  • Provide your patients with resources. Online and in the ER are lists of community resources like homeless shelters and food banks, free and low cost clinics, mental health services  and counseling, detox/rehab centers and 12 step groups and more. Make copies of these lists and keep them in the ambulance. When you have a patient “in need” provide them with a copy of the list, and take the time to explain the other options that are   available. Of course never refuse transport, and reassure them that the ambulance will always be there. But reiterate that there are other services that may be able to help them more appropriately. A good time to do this is during transport when you have a private “teaching” moment with the patient
  • Provide monthly or bi-monthly free community health screenings. Partner up with a local hospital or urgent care clinic and hold the event in their parking lot. Other great places are schools and community centers. Along with the health screenings, give a short talk about health and safety. And teach the signs and symptoms of things like heart attacks and strokes. Why not go one step farther and teach basic CPR. It’s all about compressions, and a lay person doesn’t need a paper card from the AHA to do compressions.  What this does is it puts EMS into the community and back on peoples minds.
  • Show the Chronicles of EMS to everyone. Show it to the medical field and the public alike. Show them that there is another way, show them that the current system is broken. the status quo remains not just because of the fear and reluctance to change, but also because many people are unaware of the problems and their possible solutions.
  • Educate the public, and start a petition. explain to patients (stable and non emergent) the limitations of the current EMS and health care system. Explain that there are other places in the world that do things differently and have more flexibility to provide appropriate care.  Ask them “If I could take you somewhere other then the ER or provide  more and or different care and service, would you want that? Where would you like to go? What would you like me to be able to do for you? Collect the signatures and take them to your chiefs, hospital administrators, medical directors, representatives, and  politicians.

These are just a few ideas. and I am sure you can think of some more strategies that may be better suited for your system and community.  Please feel free to share your ideas, and things that you or your agencies are doing to provide better care and advance the profession.

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