Category Archives: Patient Management

Better Lifting for Better Care

Anyone who has been to a national EMS conference in the last few years has probably seen Rick Binder in the exhibit hall. If that name is not familiar, you may be more likely to remember his life-size teddy bear wearing a vinyl vest surrounded with brightly colored handles. While we are friends now, I have absolutely no financial interest to disclaim. In fact, I had initially avoided both him and the product that his dad had developed whenever I saw the booth at trade shows. Personally, I just didn’t see the need for it since I was a master with a hospital sheet and had acquired a wide repertoire in the many ways to use it. But there are times that peer pressure can be a good thing. Other teammates from my service had visited with him at EMS Today and appeared to be impressed. Curiosity got the better of me and I wanted to learn what I might have overlooked, so I took Rick up on his free offer to field test the device. It was because of my own experience with the Binder Lift that I was finally sold.

I have learned that there are many lifting situations where this device will be an incredible asset to me as well as my patients. The slogan, “because people don’t come with handles” initially led me to think that the use of the Binder Lift was directed primarily at the bariatric patient who requires only a simple lift assist to return them to an upright condition where they can sign my refusal form. While it is certainly useful in such cases, it is definitely not limited only to that situation.

In my first example of these many unique cases, the patient was over six-foot-tall and had been discovered unconscious, but breathing, on his front porch by a third-party caller. I had been to that address before and knew he had a history of stroke that had previously left him unable to drive. We had three responders available and knew we needed to get him to the hospital quickly. After a rapid initial assessment, the patient was rolled to his side so we could apply the Binder Lift. Once secured, one person grabbed his feet while my partner and I were able to grab different handles to balance our height difference and eased his lanky frame down the steps to our stretcher. This movement was much easier on our backs and proved safer for the patient compared to our other options that day.

The simplicity with which we were able to transport this patient made me think back to a previous visit here. I only wish I had had this device when this same patient had been helping his elderly father get to the bathroom toilet. I can only imagine the mishap that led to his naked father falling on top of him – pinning him to the bath tub wall. Then, whether it was due to the fall or just the wait for us to arrive, his dad had defecated quite a lot. The waste had eventually made its way over both of the men. Finding a firm handhold on the slippery gentleman was a challenge made even more difficult by his son being entrapped beneath him. The vinyl construction of the Binder Lift would have made the extrication job much easier to accomplish and also simpler to clean up afterwards. It may have even prevented the need to change my uniform that evening.

In another memorable example, it was about 2AM when the tones dropped for a fall with injury. The husband of a 62-year-old female found his wife on the ground in front of their porch. She had stumbled and fallen forward about a two-foot drop. Unfortunately, she had braced herself for the landing with a stiff arm before reaching the ground. Her primary complaint was pain in the right shoulder which, although closed, did exhibit deformation (a probable dislocation. She denied any other pain along her spine, but as a precaution against a distracting injury, we placed her in a cervical collar per protocol.) Getting the patient to a seated position was accomplished only with significant coaxing and some obvious pain. There was no option of lifting her from beneath her arms and her loose pajamas gave little hope of bearing the weight of her hips to lift her. So after placing her right arm in a sling, we were able to place the Binder Lift around her torso and helped her move her legs into a crouched position without any further aggravation. The patient was then easily lifted upright and the stretcher maneuvered behind her allowing her to simply sit down. The Binder Lift was also helpful in orienting her on the cot. Finally, the slick vinyl material of the vest and straps was easily removed to leave her comfortably in a high Fowler’s position on the stretcher.

In short, the Binder Lift allows for better body mechanics when lifting that not only help to raise the patient safely but can be effective in extending the careers of medics that might otherwise be forced into premature retirement due to back injury. If you don’t try a Binder Lift for your patients, at least do it for yourself. I still carry an extra hospital sheet for many situations, but it always lays right on top of my Binder Lift.

Learn more at http://binderlift.com.

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Filed under Conferences, EMS Health & Safety, EMS Topics, Fire Rescue Topics, Firefighter Safety & Health, News, Opinion, Patient Management, Rescues, Technology & Communications, Training & Development

EMS Today 2018 Highlights

The EMS Today conference is always filled with interesting content both in the classrooms as well as the show floor. My live Twitter feed during the conference referenced highlights of the educational sessions I attended ranging from the Operational category to Advanced practice and even some Basic courses. The complete experience shared by everyone is permanently archived with the official #EMSToday hashtag. 

I traveled the exhibit hall several times last month looking for innovative and practice-changing technology. There was plenty to be found and the “best” will always be subjective. While these are some that I felt were worth sharing, others may have found significant gems I missed. If you were also there, please feel free to use the comment section below to add your own impressions of what you see as important in changing the practice of our field of EMS. 

One of my favorite sessions at any national EMS conference is when you can find a gathering of even a small number of “Eagles” (the top Medical Directors from around the country.) The lightning round of “The Eagles Unplugged” presentations in Charlotte was on February 22, just a week before the huge international Gathering of Eagles in Dallas. One of the first topics requested by the audience was on “spinal immobilization” (or in deference to my friend Rommie Duckworth, the proper term should arguably be “spinal stabilization”.) There was certainly no love in that packed room for most techniques or devices currently in use. In fact, the emphatic consensus statement was that there is simply no literature that shows any benefit to current spinal motion restriction while there are plenty of documented complications. 

In regards to spinal stabilization, everyone in the room agreed that the long spine board is gone and immobilization currently consists of just a collar. However, there was no consensus on what that collar should look like while there was no shortage of complaints for what is currently on the market. One of the JEMS “Hot Products” from EMS Today in 2017, however, was the SIPQuik vacuum cervical splint from Care 2 Innovations which I only got to play with this year. Basically, it is a collar-shaped bag filled with tiny styrofoam beads and a generous velcro strap. It has several advantages in that it fits a wide variety of patients and will conform closely to the shape of the neck to provide gentle support in any position. Unlike rigid collars that require the head to be placed in the neutral position for stabilization, the SIPQuik can wrap around the neck and be secured comfortably snug with the strap before the collar is molded to support the head while the air is vacuumed from the collar. The beads are held tightly in place to provide support that minimizes the possibility of further injury. Removing the manual pump without locking the air tube will allow air to reinflate the collar for easy removal. 

Several sessions, and exhibitors, included discussions of safety for care providers while working on the road. In America, we tend to love the large square box we call the patient compartment in our Type I and Type III transport vehicles. The size of the box and position of supplies and equipment requires a significant range of motion and most providers roam about unrestrained. Traditional safety belts are already available in every seat, however, they are just too cumbersome to apply and too restrictive to be used. At least this was my thinking until I placed by arms into the new 6-point “Back Pack” belting system on the EVS2160BPB from Emergency Vehicle Seating, Ltd. Unfortunately, the Back Pack system is not advertised on their website yet, but if you are interested, they will know what you are asking about if you contact them. 

The shoulder straps were as easy to apply as simply slipping my arms through the loops.  But the range of motion was incredible and allowed me to stand up fully and reach clear across my imaginary patient to where I would expect cabinets to be on the other side of the room – while still wearing the shoulder straps and even the lap belt! As I return to the seat the straps automatically tighten and should the vehicle have an accident, the belts would immediately tighten to prevent my head from crashing into those same cabinets across my patient. This quick and easy seat belt access is certified to meet all safety standards of FMVSS and SAE while providing maximum flexibility for the care of my patient. Two EVS1790 captain’s style chairs in place of the typical bench seat also allows comfortable and safe crew seating or can be rotated and tilted forward to allow the transport of a second patient on the non-skid back surface of the seats. Clearly, EVS has been giving plenty of thought to where we put our butts.

Another one of the hottest topics in prehospital treatment of trauma has to be the use of tourniquets and binders. I really thought that the poplar military-style tourniquet had not changed significantly from the belt and windlass configuration of decades ago, but there have been innovations here as well.

The S.T.A.T. Tourniquet is probably the greatest revolution in design. It comes in both a pediatric and adult size, but immediately conjures up the ubiquitous zip tie. It is wrapped around the limb above the injury and the end is inserted and pulled as tight as needed (in 2mm increments) to easily adjust. Although it looks like a zip tie, it is anything but what you find in the hardware store however. It is a wider design to prevent cutting into the skin and the material is a stretchier rubber to hold fast and evenly to secure blood flow. It also has a simple timer that can be activated when applied to measure half hour increments up to a max of 2 hours. Like the common zip tie it resembles, it can be used in combination to create a larger band or used in a series for splinting too. One major difference from the traditional zip tie is that this model also has a release tab to remove the tension. The simple design and lower cost compared to a traditional windlass system makes it ideal for public use in an MCI situation as part of a hemorrhage control kit. S.T.A.T. Medical Devices even sells them preloaded on a carabiner in a quantity of 25 tear-off tourniquets.

 

In case that style of tourniquet design is just too revolutionary, the folks over at SAM Medical have evolved the traditional tourniquet design by adding TRUFORCE Buckle technology to auto-lock the tourniquet during application. Slack in the tourniquet is the main cause of application failure requiring extra time twisting the windlass or even restarting the application. The SAM XT is designed to

require 33 pounds of force to engage two pegs that hold the strap before it is Velcro-ed together and the windlass can be engaged to stop the bleeding. This makes application easier and quicker. They also have a junctional tourniquet to stop pelvic hemorrhage. And my favorite model is the SAM Pelvic Sling II to comfortably apply the correct force to stabilize pelvic fractures. The design looks similar to the SAM XT tourniquet, but uses a patented AUTOSTOP buckle instead that ensures that the optimal compressive force is reached to confirm correct application. It is more expensive than a hospital sheet, but it provides confidence and comfort in a professional design.

I was also impressed by the Water-Jel Burn Dressings which provides a cooling gel (that is water-based, bacteriostatic and biodegradable) that actually stops the burn progression by actively cooling the skin and relieving pain rather than simply covering the wound to protect against airborne contamination. These dressings come in several different sizes and have a shelf-life of 5 years. The other great feature of these dressing is that each dressing has a Total Body Surface Area (TBSA) icon that indicates approximate total body surface area covered with the use of that particular dressing to improve your estimates of the body area covered.

Finally, to reduce medication calculation errors in pediatric patients, CertaDose provides syringes printed with color bands that match the Broselow tape used with younger patients. These syringes are clinically proven to reduce critical dosing errors by labeling the correct dosage directed on syringes labeled by the medication to be administered. Simply select the correct drug, match the color zones according to the Broselow tape and draw up the correct dosage.

I should also mention StethoSafe as another highlight from the floor of the show because I rely on their product to protect my stethoscope, but I did a whole other blog on the StethoSafe earlier.

Leave a note about what you found most interesting.

 

 

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Are You an Ambulance Driver Too?

One of the fastest ways to piss off almost anyone in the emergency medical services community is to call them an “ambulance driver.” It has become a triggered response as reliable as setting off the tones for a call. We bristle at the fact that driving an ambulance is such a small part of what we are trained to do – even though “high-flow diesel” can be an effective, legitimate treatment for certain patients. Retired FD captain and bestselling author of Rescuing Providence, Michael Morse, wrote an article last year on accepting the title of “ambulance driver.” His reasoning was due in large part to the variety of nuanced titles that we stubbornly cling to including Paramedic (which is reserved only for “those who can intubate”), EMT, Basic, EMT-I, or AEMT as well as several permutations of NREMT. Quite frankly, we simply do not accept any generalized term for “EMS workers” that is as easy to understand and say as doctor, nurse, firefighter, or cop. And for those who are offended at being lumped into the cadre of “first responders,” at least the term “ambulance driver” does distinguish one of our unique capabilities.

“Ambulance Driver”

While I agree that Morse has a legitimate argument in his assertion that we have made this predicament ourselves, there is another salient point that comes to my mind from the news multiple times each month when an ambulance is involved in a serious wreck. A local Minnesota news channel investigation discovered that the requirements for operating an ambulance in emergency traffic while carrying a sick patient and an often unrestrained paramedic in a moving emergency room is far less than is mandated for a “truck driver hauling a semitrailer load of beer.”

With a shortage of paramedics, more EMTs are being hired to fill out crews. With low starting wages, it is often people who are still too young to legally rent a car by themselves that are put behind the wheel of a 14,000 pound vehicle costing nearly a quarter of a million dollars and loaded with the most vulnerable of human cargo after just a day or two of experience driving a cone course!  

Recently, NHTSA analyzed 20 years of data and found that the nation averages 29 fatal crashes involving an ambulance each year. Furthermore, these accidents result in an average of 33 fatalities annually. For a group of individuals dedicated to saving lives, this should be an unacceptable statistic. Rather than being indignant that the name describes so little of our training, we need to adequately train for the job of driving an ambulance for proficiency just as we train for our skills as a medical clinician. The lives of our patients (and our partners) depend on that skill every bit as much, if not more, than our medical skills.

In addition to my personal credentials as a professional (both in EMS and GIS), I am a fire vollie, a backpacker, an instructor, and an amateur historian. While none of these monikers describe the entirety of my personality, none of them offend me by limiting the description. Why should I be insulted for being recognized for a critical function in safely operating an emergency vehicle? I do not hear doctors being offended by not being identified by their specialty or even by being lumped in with a PhD outside of the medical community. The sad fact is that we just don’t have an agreed generic term for the collection of people with which we share our profession. Although the term “ambulance driver” does not fully define me as a person, or even as an emergency medical professional, I will proudly accept the title as my personal commitment to safely operate my ambulance for the benefit of the public, my patient, my partner, and myself. To any other “ambulance driver” out there, let me thank you for all you do for the public beyond the safe operation of your rig.  

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More Reasons to Support Dynamic Deployment

The “Leverage Real-Time Data for Improved Ambulance Response Times” article that Zoll posted on their blog site did a good job of explaining response times and even the benefits of System Status Management (SSM) planning to the patient. But there is still more to the story that we have learned over the years since Jack Stout first introduced it.

Of course, it is best for the patient (and the service) when an ambulance arrives to the scene in a short time. The media often picks up on poor response times with stories like the GSW patient dying in Cleveland surrounded only by police and fire personnel. Even the doctors at JAMA can’t resist publishing an article showing response times as an inherent failure of EMS in certain cases. Unfortunately, many will read the solution as medics “speeding” to the scene, yet we have learned that lights and sirens have little impact on times and may even prevent some patients from calling for an ambulance in the first place. However, when the deployment of ambulances is responsive to the dynamic demand patterns throughout the day, ambulances can literally be moved closer to the scene even before they are dispatched. Literally hundreds of High Performance EMS agencies across the US have significantly reduced their 90th percentile response rates through technology. Forecasting the future does not involve magic, at least not for predictable phenomenon like emergency calls for service. Not only can we forecast the quantity and types of calls we will receive (necessary for adequate staffing), we can determine where they are likely to originate from with significant accuracy as well. Shortening the distance that an ambulance must travel is a safer alternative than asking a crew to speed in order to achieve the same result.

Another positive impact of shorter response times is patient satisfaction. There are many reasons that healthcare providers should be using patient satisfaction surveys, both for the benefit of the patient as well as simplifying the accreditation process for your service. Beyond safety, satisfaction and simplification; proper SSM can improve finances. Some services have recognized marked reductions in the number of post moves for crews and ultimately reduce the total number of unloaded (read unreimbursed) miles driven which saves on vehicle wear and tear in addition to fuel costs. Other agencies, particularly those who contract their services, can reduce financial penalties for “exceptions,” or late calls beyond the target response time.

Frankly, the public often expects performance measured in minutes. Whether we approve of the measure or not, we are often graded and compared based on response times. Whether the penalties for missing targets are financial, patient satisfaction, or driven by bad press reports, being late simply hurts. Until EMS is designated and funded as a critical service for government, it will be dependent on political funding allocations and insurance reimbursements. As long as performance is measured by how long it takes to be on scene, response times will be critical to the financial well-being of services. The least we can do is perform to the highest safe standards possible.

 

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EMS Today 2016 Review

It was my privilege to have been selected as the Official Blogger of the EMS Today conference for 2016. Like my predecessor, Tom Bouthillet at the EMS 12-Lead blog, I took that role very seriously and visited as many of the sessions, vendor exhibits, and even socials (they are definitely part of the experience) as I possibly could. Throughout the conference I posted my impressions live on Twitter through my @hp_ems account using the hashtag #EMSToday2016. But I know many people either couldn’t, or simply didn’t, watch that whole feed over the four days that I was tweeting live, so I felt a summary blog of the highlights was definitely in order. If you were there, I hope I saw you and that my remarks will echo your own experience. But I would also like to ask that you include your own impressions as comments at the end of this post. If you weren’t there, you missed a lot. And hopefully for you, this article can provide justification for you to make the trip to Salt Lake City next year for EMS Today 2017.

The very first time I attended an EMS Today conference, I arrived on the first day of the show only to discover that I was actually more than 24 hours late. By not arriving early, I had missed tons of great content presented during the pre-conference sessions the day before. While they definitely add an expense to attending the meeting, they also add anywhere from 4 to 8 hours of detailed content (as well as CEH) that you just won’t get in the faster paced 60-minute sessions of the rest of the conference. This year, I opted to attend an afternoon cadaver lab hosted by Teleflex. Training with manikins and simulators is great, but it can only take your skills so far. But flushing a proximal humerus IO access with the chest cavity open, allowed me to witness first-hand the short vascular distance from the infusion point to the heart compared with femoral access. In addition, we had plenty of time to practice ETI with various devices on many different patients. I also had the chance for my very first surgical cricothyroidotomy. While the practice of these skills was highly valuable, the opportunity to simply hold the lungs while they were ventilated and explore the chambers of the heart with my finger were enlightening beyond imagination. Nearby, was another very popular choice for a pre-conference class in the Active Shooter Simulation. It was unfortunate, but just the evening before this shooter simulation class was a vivid reminder of its importance to us in the form of a gunman who killed 3 and wounded 14 more in Hesston, Kansas. Violence leading to an MCI can clearly happen anywhere and we must all know how to respond. Thanks to this timely offering, many more EMS providers are now better prepared.

Moving quickly from the lab to change my clothes, I headed for the formal EMS10 awards ceremony. This invitation-only event hosted by Physio-Control was an opportunity to rub elbows will the people marking their mark to improve the level of care in EMS today. You can always read about the 2015 EMS10 recipients and their innovations, but by being here I was able to run into them several times throughout the conference and even had the chance to speak with some of them to learn their detailed stories.

The next day (which officially began the conference) started early with sessions beginning promptly at 8AM. I was given reasons to consider “Point of Care Testing” by Kevin Collopy who helped me better understand what we can, and cannot, do today based on federal CLIA regulations and why to consider accreditation. Next was Jonathan Washko discussing the success of community paramedicine at North Shore LIJ EMS. The best part of being at a conference with such notables is hearing comments that challenge your work. Jonathan asked “if you can’t manage yourself, or control your own emotions, how can you manage others” and reminded us that it is “the strongest leaders who ask for help.” Then from my virtual visit to NYC, it was on to a global view of self-regulation in paramedicine with Michael Nolan, Gary Wingrove, Becky Donelon, and Peter O’Meara. A couple of great lines prompted a shift in professional thinking, like when being told that “as paramedics it is time to ‘move out of mom and dad’s basement'” and as we argue over the universal meaning of “paramedic” (or “ambulance driver”), “the patient, the media, and your mother should all know what to call you!” Over in the room where Ray Barishansky spoke on “proactive professionalism,” it was crowed as he said “we as a profession have let ourselves down with our behaviors, low pay, and attitudes.” Ray also reminded us that it is “professional EMS providers who own their mistakes, are respectful, and are always advocates for the patient” and asked us to give further thought to the idea that “93% of how you’re judged is based on non-verbal data.”

Plenty of more data was presented at the Prehospital Care Research Forum session hosted by David Page where I am proud to say North Carolina was nicely represented. We also learned interesting tidbits in these lightning talks such as “volunteer EMS services are 27% more likely not to transport (also to accept refusals, or do ‘treat and release’) than paid services” and that the gender differences in the use of restraint (chemical or physical) is not about the sex of the patient, but more likely to happen with male providers even though female providers are the ones statistically more likely to be assaulted. Matt Zavadsky along with Rob Lawrence (filling in for Nick Nudell) also presented plenty of facts in their session on the Data Dichotomy of the current EMS payer landscape. All of these sessions were going on as the JEMS Games preliminary competitions were being held to see who could brag about being the best of the best in EMS. If you want to see how challenging these “games” can be, here is a quick view of the obstacles that participants face to prove they can handle the job.

It was the mid afternoon that the official opening of the conference was held with all of the pomp and circumstance (including fifes, drums, and bagpipes) that you expect at any public safety conference. There was a somber recognition of our brothers and sisters in EMS who have answered their last call due to LODD along with multiple awards and a stirring multi-media presentation by alpinist Brian O’Malley. The prestigious James O. Page award went to NEMSMA for this ground-breaking whitepaper aimed at preventing EMS provider suicide. There was also a brief visit from Maurice Davis to promote his tribute designed to raise awareness and remove the stigmatism that keeps EMS providers, the military, and many others silent and leading all to often to “The Wrong Goodbye“. The video depicting the impact of suicide is something we should all be sharing with our friends.

It is after the keynote presentation that the exhibit hall opens for a brief reception. If you didn’t get to see it, follow along with a bodycam highlight video of the exhibit hall from my friend Jeffery Armstrong. I must also recognize the generosity of Limmer Creative who donated several of their LCReady classes for me to give away during the conference for people who were able to find me and even opportunities for followers who retweeted my post about the contest. Being social is beneficial!

As my friend Bob Holloway put it, “Day 2 was packed with sessions on EMS innovation, MIH (Mobile Integrated Healthcare), and creating value.” And what better way to kick that off than with a cup of coffee and a lightning round called “Ask the Eagles”? If you aren’t similar with the Gathering of Eagles, it is also known less colloquially as the EMS State of the Sciences Conference. This year’s conference was held the previous week in Dallas and consequently the session at EMS Today (always a favorite of mine) is packed with the latest EMS Pearls that will hopefully one day make it into your local protocols. This is where you can hear progressive medical directors from around the country like Bryan Bledsoe busting dogma with comments like “less spinal movement with self extrication compared to backboard extrication.” Unfortunately, I missed it this year to interview Ferno in a video on their innovative iNTraxx system to promote safety, flexible modular design, and increased efficiency. Watch for the interview made in conjunction with my friends from EMTLife later this week.

Over lunch on Friday, I heard Dr. Keith Lurie, CTO of ZOLL Medical, discuss the changing perceptions of resuscitation through “active compression decompression” during CPR and his ResQPOD impedance threshold device that together can increase one-year survival after cardiac arrest by 49%. There was also discussion of heads-up CPR which can significantly decrease ICP during CPR ad many other tips to help us improve CPR survival rates. This discussion was followed up by another visit to the cadaver lab for some hands-on with real human patients. Practice such as this really makes the charts and figures come alive! But what had to be my favorite session of the whole conference had to be the experience of behavioral medicine with David Glendenning and Benjamin Currie. Far from a traditional PowerPoint presentation, we were invited to take a very different look at patients with behavioral issues by experimenting as a group with schizophrenia and delving into the taboo topic of viewing ourselves as potential patients. David suggested that “dealing with PTSD is NOT a rite of passage in EMS and we need to acknowledge it is a real physical condition and begin to talk openly about it.” The session closed with a thought-provoking David Foster Wallace video from a commencement speech explaining how “sometimes the hardest things to see are all around us.” I hope you will take about 9 minutes and watch it. I would also like to recognize the fine efforts of The Code Green Campaign in this same area (as JEMS/Penwell also did.)

Another awesome session well worth mentioning was early on Saturday morning, it was called “Creating a Social EMS Culture” with Carissa O’Brien and Steve Wirth. While there were several good quotes, it is most important to note that “your EMS agency has a legal interest in your use of social media just as you have a professional one.” There are several legal considerations that include the US Constitution, National Labor Relations, defamation laws, HIPAA, harassment laws, and more; but the end game is not “big brother” watching your networking. It must be understood that your agency has a responsibility in “building a culture that breeds responsible digital citizens.” Just as we develop our clinical skills, “we need to train EMS providers in social media just as we would with any other skill.” This discussion is one that can continue even after the conference by participating with the #socialEMS hashtag in your favorite forum.

For those who attended, you can access the conference proceedings with the username and password you received at registration. I also hope you will add your favorite memories below to give others a more accurate record of the whole conference.

I could go on about meeting the paramedics from Nightwatch, my childhood hero Johnny Gage (Randolph Mantooth), being able to sit in Squad 51, or see the original Heartmobile that played a significant role in the development of EMS in America, but I really think it would be best if you just went ahead and registered for your own journey and plan to attend the conference next year.

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Intolerance is Not a Black and White Issue

Of course “Black Lives Matter.” Just like white ones, red ones, blue ones, and every other color that we place as a ‘label’ on a life. All. Lives. Matter. But that isn’t the end of the story.

KingisRightMartin Luther King, Jr’s vision was not just about ending racism, but about stopping every form of intolerance that denies the basic respect that all life deserves. With his transcending attitude of justice, I wonder just how long King would have made it as a paramedic. Facing people on their very worse; day after day, or night after night, has an affect on your mind. Watching people abusing a system that is intended to provide a literal “lifeline” to the sick and injured eats away at compassion. Seeing what people do to themselves as a result of their over-indulgence, arrogance, or addiction can layer a crust over the heart of tolerance.

I have heard first responders speak openly about those who “do not deserve my compassion.” This mindset justifies the segregation of our patients. It is a segregation not based on skin color, but on some invisible scale of worth. A scale that we try to teach others in order to make us feel better about how we fit upon it. This expression of attitude reminds me, however, to commit myself to practice compassion based on another popular saying instead: “Be kind, for everyone you meet is fighting a battle you know nothing about.â€? In my own past, I have easily given my compassion to a drug-seeker who fooled me with an insincere exhibition of pain. More regretfully, I have also withheld some measure of that compassion for a patient who was in real pain and that I had assumed was simply too lazy to drive himself to the hospital. I prefer now not to be a judge of the character of the heart of any patient I treat because I truly do not know their personal pain nor the extent of their real struggle. And most importantly, because the time that I have to make an impact on their lives is incredibly small. I have come to learn that in those times when I do not know what is the right thing to do, I can live easier with the choice of doing what is the best thing.

This morning, I read a story about an EMT in Minnesota who admitted to stealing $120 from the wallets of two teenage brothers killed in a car wreck. Like all of us, she had bills. Like all of us, she was not paid enough for the public service she rendered.  She simply found the wallets lying in the road when she arrived first on the scene. Not a penny of that money could do any good for those teens any longer. She made a bad choice. A very bad choice. I do not know her, or anything more about the situation, but I would prefer to believe the best about her. At least as the woman she was in the beginning of her career. None of us entered the field with illusions about becoming rich. Most of us have a genuine desire to do good for others. Unfortunately, we too often work in a corrosive environment for our souls. But, as Dr. King reminds us, “The time is always right to do what is right.” So today, challenge yourself to go back to the roots of your service. Instead of trying to toughen up the “FNG” who is just getting started in his journey, borrow some of his fire to rekindle your own passion and renew your spirit. I bet your career in EMS will last longer too.

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Improving EMS Clinical Preceptorships

A guest article by Caitlyn Armisteadparamedic-preceptor

Clinicals are a critical component of EMS education. These dynamic educational environments can be complicated to manage in order to ensure a complete education for each student. Consider these points as you structure your program and develop guidelines for the coming year.

1) Support Strong Mentorships

Formal preceptorship relationships are effective in transferring procedures and protocols to a student; however, the informal dynamics of a solid mentorship are even more effective at conveying not only clinical concepts but positive culture as well. The primary ingredients are time and empathy. A strong teaching environment is built over time in hundreds of small interactions. A student needs time to warm up and build trust; the preceptor needs time to identify strengths, weaknesses, and academic needs. The worst possible way to schedule clinical mentoring is to randomly place students with whomever is available on shift that day.

It is also critical to be selective in whom you choose as mentors. New employees look for role models, and their preceptor is an obvious choice. If mentors are chosen simply from the employees with the most time at your service, there is the risk of jaded viewpoints and out-of-date practices. Mentors should be chosen from among the seasoned employees that you want to replicate within your organization, not simply the one who has managed to hold the same position for the longest time.

2) Reduce Power Symbols

Rules concerning student conduct should be well defined in policy manuals and reviewed with students. However, these rules should be reasonable for the conduction of clinicals and not exist solely to create a false appearance of discipline while demeaning and belittling the student. Even when not written in overt policy, many times these mandates exist de facto at a clinical site. These sometimes include:

-students must only sit at a table and study, with no other permissible activity, for an undefined or

  unreasonable amount of time

-students must never sit in comfortable chairs

-students must never eat at the same table

-students must never ride in the cab, never observe driving operations

-students must only ride to calls in the box, in the dark, without air conditioning and/or

  radio contact

-students must never have radio access (at times, this may be a safety issue on scene)

-students must never be allowed the same safety equipment as the personnel

Rules such as these, whether explicit or implicit, send a very strong message to students. The usual response when rules are questioned is that they create discipline in the student and that “students need to know their place.�

The result of such power symbols varies depending on the student. To some, it is merely annoyance with little gain. Others may be reluctant to engage with a mentor and ask necessary questions. Students motivated by affiliation, however, can be demoralized. This can result in a student losing academic momentum or being more likely to choose inappropriate behavior.

3) Teaching techniques are important

New skills and activities should be introduced, modeled, guided, and supported, just as they are in the classroom. Checking off supplies in the truck is a great activity for a student, but when a student is given a paper and expected to go on a scavenger hunt alone, the benefit is minimal and the teaching opportunity–identifying equipment, telling what it’s used for and why it’s in the location that it is–is lost. If a student is expected to learn efficiently, a teacher needs to be present. If a student is expected to ask questions, the preceptor must be available to provide an answer.

4) Use objective evaluations and rubrics

Evaluations should be clear, precise, and as specific as possible. Students are quick to notice when a critique is based more on their football team preference than their skills in the field, but that can be difficult to prove if the guidelines are vaguely written: “gets along well with EMS staff.� When critiques are unreliable and yet used determine a student’s grade, students driven by achievement and autonomy, in particular, are demotivated. These students want to earn their grade on their own merit and want concise goals and boxes to check off. This requires not only well-designed evaluations, but also well-trained preceptors.

5) Avoid turf wars

When two or more students are assigned to the same station, truck, or even the same calls, learning opportunities per student are reduced. This can also lead to the student focusing on jumping calls instead of gaining knowledge and building the mentoring relationship. “Nice� students, who defer calls to others, may end up with sub-par clinical experiences. When setting schedules, attempt to ensure adequate call resources for all students and enforce these guidelines.

6) Choose healthy clinical sites

EMS services with toxic work environments easily infect students with poor work ethic, bad habits, and out-of-date dogma. This becomes critical if laws and standards of care are broken, and huge problems can result if a student is caught in the middle or is forced to become a whistleblower. When all possible, avoid such sites and use other services and hospitals for clinicals.

7) Ensure respect

Female, minority, and older EMS students, participating in FISDAP, reported significantly lower preceptor performance ratings compared to Caucasian males (Page, 2013). While this issue needs further study, in the meantime, it is important that all students be treated with respect and empathy. If uniforms are required, make sure there are options designed for females. Harassment and hazing policies should be easily understood and enforced. Student concerns should be welcomed and anonymous reporting available.

Conclusion

Clinical rotations and field training are expensive for a service; they divert time from the best field personnel to a student or new employee. It only makes sense to make the most of these opportunities. Preceptors must embrace the concept of being a mentor. And the training staff, with the support of administration, needs to provide a healthy environment where both formal and informal education can occur. By constructing thoughtful policies and implementing solid practice, clinicals become a valuable dynamic education experience that pays long-term dividends.

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Building Political Capital

Every EMS agency could use a little more political clout. After all, we deserve it. We actually save lives! “They” should just automatically recognize “our” value, right? Well, if you have ever thought/said that statement, you are going about it all wrong. I don’t care what financial/political model your agency operates under, politics work basically the same in any situation. There is seldom a true political “win,” your mindset should be at least to seek a “win/win,” if not a “win/win/win.” What do I mean? Imagine going for a hike in the woods when you and a friend come upon a hungry bear. You know they can run faster than you, but then you realize that you really only need to outrun your “friend.” Sure, you won that time, but at what cost? Now imagine that instead of running, you kill the bear (this is only an analogy, I do not advocate harming animals in any of my posts.) In this story, both you AND your friend win. Besides that, you are now a hero. You built political clout with that friend. Not bad. Finally, however, let’s consider a third option. This time you drop a pack of “wholesome organic bear treats” on the trail to distract (and feed) the bear while you and your now loyal companion escape. Everybody won!

The common primary mistake most people make in political situations is to begin with an “us” versus “them” mentality. “We obviously need more money for <fill in the blank> so ‘we’ need to build a justification that is more impressive than any one else’s.” In economic terms, this is called a “zero sum game.” There are finite resources available; so my gain is, by default, someone else’s loss. These are difficult games to win, so I prefer not to play them at all. One of the first rules of politics is to only engage in battles where you have a good chance to “win” (or preferably “win/win/win.”)

So, how do you change the game? This is why a good “leader” thinks outside the box of the normal paradigm of thinking of a county budget (or whatever your funding source) as a fixed pot of money that is available to dip into if you can get there before its all gone. If you have to hurt someone else in order to get what you want, you will not build any useful political capital – only political fear. You may be hailed temporarily within some small tribe of constituents, but you become an enemy of all others outside your particular clique. It can be more effective to think of of ways to change the pot itself.

One way to change the dynamics is to bring outside money to it – or at least reduce your dependence on it as your only sustenance. This can be done by forging new partnerships. Most of us already partner with CMS as an outside funding source, but trying to get more reimbursement from Medicare/Medicaid is a tough sell right now. Build your political capital stockpile before going after that bear. So, how about your local hospital instead? What financial pains are they facing that you might be able to impact? The ACA law has changed the rules for their reimbursements so that if a patient is readmitted for the same condition too soon, they lose funds. You are uniquely positioned between the patient’s home and the ER door that leads to readmission. If you can ensure that a patient is safe, happy, and healthy at home (a win for them), you can save the hospital money (a win for them) and possibly partner to share in that savings (a win for you.) This is not my idea, it is called “Mobile Integrated Healthcare” (or “Community Paramedicine.”) To implement this idea, you need a partner and a willingness to change your operations if the savings are greater than the costs. This is called “increasing the size of the pie” in economics. Your slice may not be any bigger proportionally, but you still get more of it.

Another way to “sweeten the pot” is to help others become more efficient in their use of funding. You don’t have to look too far outside your organization to find effective partnerships. There may be departments you work beside that could use help you can easily provide. When your vehicles are out driving the county doing “road surveys” can they watch for anything else? Who handles your addressing in the county? Do you ever visit an address that is not in the system? Do you find roads that aren’t correct on the GIS map? Do you see recurring potholes in roadways or recognize water leaks coming from cracks in the pavement? Is there a particular curve or hill that consistently has motor vehicle accidents? Do you ever pass these discoveries along to those who are responsible? It is called “good citizenship” and it can be great politics as well. Building a report with other agencies builds political clout. And if you help them become more efficient, the pie grows again.

Finally, you can do better at utilizing resources yourself. Don’t take that necessarily to mean unilaterally cutting your own budget. Sometimes a financial investment returns a significant cost savings. When you make a good decision, do you have a means to promote the savings to your political officials? But wait, before you go tooting your own horn to prove what a shrewd financial steward you are; consider sharing that credit first. Politicians love praise and in reality you didn’t do it all yourself (even if you really did) because the funds were somehow allocated to you. When you promote a new cost saving idea, do the work of calculating the actual cost/value and jointly publish it as a wise decision on the part of those who hold your purse strings to have given you the opportunity to save so much money. Be sure to quantify the savings in dollars. Intangible benefits (like “saving lives”) is nice, but saving a specific number of lives – or even a single life BY NAME – is political gold. If an external consultant was instrumental in the process, stroke them too. If they helped you once, they may do so again. Don’t leave any valuable partner out in the cold or you may never see them again. There are always bears stalking the financial woods.

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Where is Wearable Technology Heading?

This post is from an invited guest blogger. Andrew Randazzo is the Director of Prime Medical Training and is a Nationally Registered Paramedic. Aside from teaching, Andrew’s faith and church play a big role in his life, and he also enjoys backpacking, scuba diving, competing in triathlons, and international travel.

Disclaimer: I am not being compensated in any way for any of the products I talk about in this article.

I find that when people learn about EMS and all the tools we have at our disposal, they are surprised. Even those who are in the healthcare field are surprised, or perhaps just ignorant, about what our monitors are capable of measuring. It may be because so many other facilities have multiple pieces of equipment that do what our one monitor can do.

Now imagine that one monitor being out of date. That’s right, the good ole LifePak 15s and Zoll Xs need to say hello to the Visi Mobile. The Visi is a all-in-one monitor that you wear on your wrist. Not only does it do all your vital signs including respiratory rate, it can also do EKGs.visi-mobile-2

What I find the coolest about the Visi is the built in accelerometer that detects what position you are in in bed, if you’ve been walking around, fallen, etc. That feature alone makes it invaluable for hospitals and nursing homes.

Another breakthrough is Continuous Non-Invasive Blood Pressure. What you do is put a normal BP cuff on the patient that takes their initial BP. Then you can take the cuff off and the Visi is able to measure subsequent blood pressures without the cuff being on the patient.

Everything that is monitored can also be transmitted wirelessly and displayed at the nurse’s station in real-time. The Visi Mobile reduces injuries for the patients first of all, but it also allows more people to be moved to less intensive floors (which frees up beds) due the fact that the patients need less 1-1 monitoring.

By the way, I almost forgot to mention this device costs a few hundred in comparison to the thousands you have to spend on current monitors.

The company also plans in the future to expand, to allow monitoring patients post-discharge, in order to avoid hospital re-admission.

This is the wave of the future. I’m excited to see it coming and what else is out there. What are your thoughts on the Visi Mobile or other things you see coming? Please comment as a reply below.

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In Support of Backboards

ProperPlacement of LBB

“Proper Placement of Backboard”

One of my first really successful posts years ago was “A Short Take on Long Boards” where I found myself piling on the negatives regarding our habitual dependence on the Long Spine Board. I do not feel as though I can take any credit, however, for agencies such as the Palm Beach Florida Fire Department or the New York City Regional Medical Advisory Committee who have since chosen to abandon the practice of its use.  Many others have made their displeasure of the practice clear in endless commentaries on the topic. And the photo above on the “Proper Placement of Backboard” garnered many “Likes” on social media. It is the traditional reliance on the backboard, in an attempt to totally immobilize patients, based predominately on the MOI that has lead some to parody the practice in a clever cartoon episode. As a matter of fact, the only evidence I could find to support the use of the spine board as an immobilization device for transport was this randomized clinical trial setting it up against a vacuum mattress splint in a false dichotomy that I could only hope is a mocking satire. In an even deeper insult to our immobilization practice, Dr. Bryan Bledsoe, emergency physician and EMS textbook author, has also gone on to suggest limiting use of the rigid cervical collar as well. Suddenly, the topic of immobilization seems to be much more fluid.

Still, I fear some may have gone too far in calling for the removal of the LBB from ambulances everywhere. In general, we are often all too willing to jump from one bandwagon to another in an “all or nothing” dance to be more “evidence-based” than the next medic. I have heard colleagues suggest that the KED is the rightful heir to the immobilization throne, but in my mind that is like replacing the standard stretcher with a stair chair. In some cases one may be more appropriate than another, but the recognition that a tool has limitations does not mean it should be replaced in every instance. We simply need to become more aware of when to use it, not just remove the tool from the toolbox altogether. I feel we have done the same thing with response times, if they don’t ALWAYS matter, then they NEVER matter (but that is a topic for another post.)

The backboard remains a flexible extrication tool that is widely available and already well understood by first responders. Furthermore, it can be adapted for other uses. Another topic that is hot in EMS right now is High Performance CPR. While the basics of CPR have been around for decades, we are learning better ways to apply it and even understanding more about the science behind the mechanics of how it works. We know, for instance, that the patient must be on a firm platform for effective compressions and the backboard fits that need very well.  More recent research also suggests that tilting the compression platform to a semi-fowlers’ position decreases ICP for better brain perfusion. Instead of introducing a new device, the backboard can be adapted to this use by raising the head about the height of your bag.

It is great when we can improve the efficacy of our work without adding anything to the expense of it! The most difficult change is in our attitude.

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