Grand Rounds - 1

Lets take a look around the web to see what everyone else is talking about in the world of EMS.

Paramedicine 101's own contributers:

The Prehospital 12-Lead blog

Look at the most recent ECG Tom B has posted over at one of my favorite blogs. If you haven't checked out the prehospital 12-lead blog, you are truly missing out. Do yourself a favor and get involved in the discussions. Tom's blog has become a regular read by many and a great educational resource. I have learned so much from going through his old posts.

Rogue Medic

Now if you don't know who Tim Noonan, the Rogue Medic is, I suspect you haven't been reading EMS blogs for a long time. He is a regular guest on a few EMS podcasts, and a big time contributer to Paramedicine 101. Now he will repost a lot of his educational stuff over here directly from his blog, but there is plenty of good reading over at his blog that can't be found here. He is more known for his controversial posts, but I have to admit, he is usually on the right side of the argument--at least as far as I am concerned. He sides with the side of science. He has helped me advocate evidence-based medicine. He is the research king as far as I am concerned. GO, READ, LEARN, DO.

A Day In The Life Of An Ambulance Driver

I'd be kidding myself to think that you have somehow read my blog and never made it over to Ambulance Driver's site. Kelly Grayson has posted her a time or two, and is a very well known blogger. He is a published author, with his own book, and many articles scattered throughout the EMS literary schmorgasboard. He is a gun owner and a dad. His blog contains some prehospital discussion from time to time, but his unique writing style seems to take on many forms. His blog is extremely entertaining, and it is obvious why he has become so popular. Go and have a laugh courtesy of AD, via me.

The Happy Medic

The Happy Medic is one of Paramedicine 101's newest additions. He is the founder of EMS 2.0 and the American side of Chronicles of EMS, which is a great collection of EMS-talk videos which includes a reality series. The reality series is about a british paramedic's experience riding along with San Francisco FD so far. Next, I believe HM goes to Great Britain to show us the other side of things. I hear they have big plans, and many places to go. Keep an eye on these videos.

Medic999

Paramedicine 101's first international addition Medic999 has become quite popular recently. He is the UK part of Chronicles of EMS, and has been an EMS blogger for some time now. His most recent post is about how a patient can make a liar out of you in front of the nursing staff. I have had this happened to me many times. Ever have a patient point to their lower abdomen when you first ask them where the pain is, than point to their upper abdomen during transport, then point to their chest when the RN in the ER asks them? ERRRR. Go read Medic999's blog, and I will tell you now, it helps to read it with an English accent.

9-Echo-1

Rogue Medic recently made a new addition to Paramedicine 101. I have been a fan of 9-Echo-1's blog for a while now, and I am pleased to have him join us. His most recent post explains quite well, how us paramedic types may seem a bit cold-hearted as a need for survival. People seem to forget what it takes to be an EMT or paramedic. We come home to our families every day after seeing the worst stuff imaginable. Please go read his post, simply titled Survival.

Pink, Warm, & Dry

I’m a Mom to two amazing kids, an EMT, and occasionally I take some pictures. I love to write, laugh, and score swag at EMS conferences. I have a serious Diet Pepsi addiction. I have trauma shears and I’m not afraid to use them. I’m in medic school thanks to my online angels.

No, I didn't just start doing a patient assessment in the middle of this blog post. Pink, Warm, & Dry is the name of Epijunky's blog. Even though I haven't seen her post anything on here just yet, she is listed as a contributer and I bet something will eventually be posted, some day. It takes a lot to run a blog, and we have lives outside the blogosphere and outside of EMS, believe it or not. So there are a few contributers that have not yet contributed. Maybe they are awaiting inspiration. Anyhow, in her most recent post she gets nostalgic, talking about, what seems to have been a pretty busy shift, as a wide-eyed student.

Life Under The Lights

Life Under The Lights is a blog by Paramedicine 101 contributer Ckemtp. Ckemtp is the very man who gave Paramedicine 101 the shout out on A Seat at the Table so how could I not give him a shout out. He is yet another hibernating contributer, but I think he suffers from the dreaded first post jitters that many of us have gone through. Anyhow, he is no stranger to writing good posts. There is so much on his blog to read through and lose yourself in. He has just given an update on The Handover blog carnival and he even gave a Handover fashion set of Grand Rounds himself (Paramedicine 101 was left out, but he made up for it with the previous shout out).

12-Lead ECG Blog - (Cardiology & Electrocardiography Experts)

This blog was started by Jason Winter. I invited Jason to be a contributer to Paramedicine 101 after seeing his very popular ECG Experts facebook page. He has since started his own blog with the help of Tom B, and it has become quite popular as well. I would recommend browsing through some of the cases over there. They are quite interesting. Above is one of the 12-leads that sparked a pretty great discussion that I happened to get involved in. I believe it is not as it appears at first glance. Go check out what I said...

My Variables Only Have 6 Letters

Christopher was an addition courtesy of Tom B. His blog is quite a good one. He is an engineer, and has decided to do what we do FOR FREE. I am thinking of switching things up on him and doing some software engineering for free. Just have to learn how to do it first. Doing what Christopher does for a living seems to give him a different outlook on EMS. He seems to deduce things quite well. His recent post about improving BLS to ALS patient transfers in cardiac arrest is very good. He provides some research and explains it. I hope to see more posts from Christopher, I enjoyed his research on Glucagon.

Congestive Heart Failure

For an Anatomy & Physiology class I am taking, my professor assigned a research paper for extra credit. The topic was restrained to any of the wide variety of diseases or conditions that the human body can suffer from. I decided to chose CHF, since it happens to be something I know a little bit about. She was surprised when she asked where my references were, and I said I didn't use any. Sure, at some point, I read this information somewhere, but I couldn't remember where if I tried. Guess I skipped the research part of this research paper. Anyhow, I figured I would share it. I have posted on CHF before and covered most of this, but a refresher never hurt anyone and this is much more basic.

Congestive Heart Failure

Congestive heart failure, or CHF, is a condition that afflicts millions of Americans. Over five hundred thousand new diagnoses are made every year. CHF is a condition that is entirely caused by the body’s homeostatic compensatory mechanisms. CHF arises from the condition simply termed, heart failure.

Heart failure is manifested by the heart’s inability to provide adequate perfusion to the body. This occurs due to other conditions or diseases such as chronic hypertension or a previous myocardial infarction. Clinical findings may include a decreased blood pressure, dizziness, or signs of hypoxia.

The body senses this decrease in cardiac output and attempts to maintain homeostasis. Baroreceptors detect inadequate pressure and norepinephrine is released by the adrenal gland. This causes profound vasoconstricion, as well as an increase in inotropy, chronotropy, and dromotropy. This just means that the heart is beating faster and harder due to the catecholamine release. The kidneys also lend a hand by releasing Angiotensin Converting Enzyme, or ACE. ACE converts angiotensin I into angiotensin II, which is yet another vasoconstrictor. The body will also act to increase volume by inhibiting fluid release. The heart itself produces a peptide called Brain or B-type Natriuretic Peptide (BNP).

All of these compensatory mechanisms acting together cause the cardiovascular system to go into overdrive. Too much vasoconstriction and cardiac force cause increased afterload. Afterload is the pressure in which the heart is pumping against. This is also known as arterial pressure and an increase results in an increase in palpable blood pressure. Since the heart can’t pump blood out efficiently against the increased after load, blood backs up. It first backs into the atria from the left ventricle. It then backs up into the pulmonary vein and then the lungs. This is where we get the congestion of congestive heart failure.

Pulmonary congestion is also known as pulmonary edema, and may be a lethal condition. Chest X-rays and BNP levels are used to diagnose CHF patients. Due to the increase in workload, the myocardium of the heart hypertrophies and shows up as an enlarged heart on a chest X-ray. Chronic CHF patients are treated with oral diuretics, and antihypertensives such as beta blockers and ACE inhibitors. The beta-blockers decrease the rate of contraction and ACE inhibitors block the Angiotensin Converting Enzyme.

Emergency treatment may include bronchodilators, nitrates to decrease preload and afterload, and continuous positive airway pressure, also known as CPAP. CPAP provides a continuous flow of air that keeps the alveoli open while forcing the fluid back out of the lungs via pulmonary capillaries, and back into the cardiovascular system. Nitates and CPAP have shown to drastically improve the outcome of emergency CHF patients with marked hypoxia.

Intubation as a Right - No Practice required

I was responding to a comment at 9-ECHO-1, by 9-ECHO-1, when I realized I was beginning to combine my responses to How things get done... and Do we make a difference?

As if I don't already regularly get this little message from Blogger.

Your HTML cannot be accepted: Must be at most 4,096 characters

Your hints are wasted on me, Blogger!

9-ECHO-1 was writing about running a code and keeping it organized and low stress. Something about sitting back with his feet on an ottoman, a drink in his hand, receiving a massage, and . . . Well, he did say that he was sitting back with his feet up on an ottoman. And there is nothing wrong with that. An ottoman could easily be added to crash carts. :-)

9-ECHO-1's description of the role of the person in charge at a code is important. We may not want to put our feet up in front of family, but I don't believe 9-ECHO-1 would do that at a code where family is present. What is important is for the person in charge to communicate clearly to everyone that, This is not a high stress environment.

Stress is the enemy of organization. We have a lot to organize during codes. We have much more to organize, than we have good research to support including in a code, but that will change.

Either there will be some research that supports the Better Resuscitation Through Better Chemistry approach, or AHA/ILCOR will admit that pouring a bunch of cardiotoxic chemicals into a patient, then shaking - not stirring - the patient, is more appropriate for bartenders than for paramedics, nurses, PAs, NPs, doctors . . . .

Although many of us in EMS might appreciate the bump in pay to what a bartender makes.

I have been to some codes that have led me to believe that there is a role for benzodiazepines in the management of cardiac arrest. Not for the patient, but for the EMS personnel exhibiting signs of Tourette syndrome, who show up to treat the cardiac arrest patient. If not benzodiazepines, then this may be an indication for medical marijuana. There might be some problem with the rate and depth of compressions, but that might be less of a problem than the current model of Dr. Fine, Dr. Howard, and Dr. Fine run a code.



Isn't this supposed to be about intubation?

OK. Back on track, or as close as I an going to get.


9-ECHO-1 wrote -

Place the King airway. In our system EMT-Bs on the ambulance can do this. Attach the ETCO2 and verify the waveform. Me personally, I will admit, I prefer the ET tube. I know, I know, there is all sorts of evidence out there about paramedics and tubes. And they all point to two things- practice and experience. More on that later.

In the comments, I responded -

I agree with you about the intubation. I think that the biggest part of the problem is that the systems studied do not provide excellent oversight of the quality of intubation and BLS. Otherwise, are we supposed to believe that these problems suddenly appeared during the study? More likely that they were there, just unrecognized.

The word unrecognized does not belong in a sentence describing excellent oversight.

9-ECHO-1's response included -

I have read all of the studies about intubation and its 'failings'. What I have noticed is that we NEVER PRACTICE. I used to practice all of the time- get me some spare time and a manikin and I would go at it, even practicing with someone doing chest compressions. But we never do that any more. No damn wonder we can't hit the right hole, and then don't recognize when it comes out or we missed completely.

I completely agree about practice. I used to spend so much time with the mannequin, that if my classmates weren't starting rumors about me, they were missing a good opportunity.

I believe that simulations are a great way to avoid doing real harm to real patients. A lot of practice helps to keep the stress level down and the tunnel vision away.

My first live intubation was an asystolic little old lady. We were running lights and sirens to the hospital, because we didn't know any better. I was riding with a supervisor for orientation vs. see if the new guy can avoid screwing up. We made a rendez-vous with the ambulance, so that they could give the new guy a chance to demonstrate skills on a real live patient.

We still put too much emphasis on the wrong skills.

While the mannequin is not as realistic as we would like, the practice with the laryngoscope and the tube is invaluable, when it comes to manipulating the airway of a real patient. Very handy experience when bouncing down the road about to perform my first tube.

I think that some of my But we did that when we covered airway classmates may be over-represented in the intubation studies with poor success rates/high wrong hole rates.


If medical directors would take more of an interest in the airway management practices of those they authorize to use lethal airways, I might not feel the need to describe endotracheal tubes as lethal airways.

Yearly (even quarterly) observation of mannequin management is not at all oversight of airway management. This is just documentation of an excuse, so that when a medic does mangle airway management, the medical director has an alibi.

It used to be that some schools/employers required medic students/new medics to manage an OR patient's airway with a BVM before ever being allowed to touch an endotracheal tube. I do not believe in good old days. That is just selective memory. However, we have abandoned some useful practices.

Now it seems that being authorized to intubate means never having to touch a BVM again - even in some all medic systems.

That isn't airway management.

Also, less than 8 - intubate, is not a rule, just a handy way of teaching one small idea in the much larger concept of airway management. Critical judgment is much more important than cute little rhymes.

If we think that we should be permitted to intubate, we need to put in the effort to become competent at airway management. Then we need to put in the effort to maintain competence at airway management. And we need to put in the effort to demonstrate excellence at airway management. Intubation is a very small part of airway management.

This is not about any right of the paramedic to intubate. This is about not abusing our patients.


I didn't even get to comments on Do we make a difference? That will be another post.


The Airway Continuum is essential reading for anyone interested in intubation and airway management.

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Journal Club 3: Episode 53

Of the two podcasts I had the opportunity to be on this week, this one is more to my liking, due to my desire to increase the use of research-based treatments. Having the lead author of one of the studies on the show was another positive. Greg Friese hosts Journal Club 3: Episode 53.

There is a much more thorough discussion of these papers on the podcast.

The papers covered are:


Resuscitation on television: realistic or ridiculous? A quantitative observational analysis of the portrayal of cardiopulmonary resuscitation in television medical drama.
Harris D, Willoughby H.
Resuscitation. 2009 Nov;80(11):1275-9. Epub 2009 Aug 20.
PMID: 19699021 [PubMed - indexed for MEDLINE].
Presented by Rob Theriault.

This study raises a lot of interesting questions about the way that people learn about making end of life decisions, what they anticipate the outcome of resuscitation will be, and even how medical professionals may respond to skills presented in TV medical dramas.^[1]

Dismissing TV dramas as trivial ignores the effect that they may have on members of the audience, up to and including doctors.


The Canadian prehospital evidence-based protocols project: knowledge translation in emergency medical services care.
Jensen JL, Petrie DA, Travers AH; PEP Project Team.
Acad Emerg Med. 2009 Jul;16(7):668-73.
PMID: 19691810 [PubMed - indexed for MEDLINE].
Presented by Joe Clark.

This is a study that deserves several posts to cover, so I will not even start here. As with the other studies, this paper is discussed on the podcast.

My impression is that this resource is wonderful. If you know of a relevant paper that they do not cover on the site, send them a link to it. As with all of science, this will always be a work in progress, but that is certainly not a bad thing.

Canadian Prehospital Evidence Based Protocols.


Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial.
Mason S, Knowles E, Colwell B, Dixon S, Wardrope J, Gorringe R, Snooks H, Perrin J, Nicholl J.
BMJ. 2007 Nov 3;335(7626):919. Epub 2007 Oct 4.
PMID: 17916813 [PubMed - indexed for MEDLINE].
Presented by Bill Toon.

In the US, we have studies that show an inability of the medics (at least the medics in US studies) to be able to safely direct patients to alternative destinations, such as an appointment with a general practitioner. Is the basic EMS education difference, between the US and the UK, the reason?

This study does show that specially trained experienced paramedics can identify stable patients and safely direct these patients to more appropriate resources than the Emergency Department (Accident & Emergency in the UK).

This is an education program that appears to focus on critical judgment, rather than protocol adherence. If done the right way, this should be good for patients, and therefore good for EMS and hospitals.


The full text PDFs of the three papers discussed on the podcast are available for free (until the next EMS EduCast Journal Club) at the Journal Club page of the EMS Educast.

Special guests on the show are Joseph F. Clark, PhD of JosephFClark.com and Jan Jensen of the Canadian Prehospital Evidence Based Protocols.


Footnotes:


^ ¹ Positioning prior to endotracheal intubation on a television medical drama: perhaps life mimics art.
Brindley PG, Needham C.
Resuscitation. 2009 May;80(5):604. Epub 2009 Mar 18. No abstract available.
PMID: 19297069 [PubMed - indexed for MEDLINE]

Inadequate positioning of the head and neck was especially prevalent prior to intubation attempts, and improving this was seen as a simple but important first step.

As part of ongoing nationwide efforts to ensure basic resuscitation skills⁵ we explored all potential causes for the inadequate positioning, and this included trainees’ prior experiences. Many trainees reported limited supervision or hands-on training. Remarkably, however, when asked how they had therefore learned, after “trial and error”, a surprising number answered that television medical dramas had been an important influence.

Of the remaining 22, none (0/22) achieved more than one, let alone all three, components of optimal airway positioning. In terms of individual components, the lower cervical-spine was flexed in 0/22, the atlanto-occipital joint extended in 1/22, and the ears level with the sternum in only 3/22 cases.

While few would suggest that medical dramas can be held responsible for physician performance, it has been previously suggested that they can significantly influence beliefs.⁶, ⁷

This does show that ignoring the effect of medical dramas has the potential to be harmful to patients.


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Do we make a difference?

My illustrious training captain has sent out a link to the following article. I found it quite interesting, even though most of this is stuff we already know. Might this mean we don't need to abolish ALS programs, but rethink them entirely? We at Paramedicine 101 preach evidence-based medicine quite often. I believe every treatment, every procedure, and all outcomes should be researched and reviewed frequently. If I could add anything to the EMS 2.0 movement, it would be a universal online archive for QI/QA. Compliant with all privacy policies of coarse. I just think every agency should have some sort of review team, that not only reviews protocol compliance, but patient outcomes compared to treatments received as well. Let's progress!

If you are not familiar with the Eagles conference, you should be. I have yet to have the chance to attend, but I hear it is the most impressive clinical-oriented prehospital conference out there. You may not get to play with all the new toys and gadgets, but you would have heard about post-arrest therapeutic hypothermia about two years before everyone else. Maybe the EMS 2.0 movement should implement a similar gathering for those of us actually doing the work. Imagine Rogue Medic with a microphone and a room full of people.

Insights from the Gathering of Eagles - 2010

Shattering the Myths

Once again, Dr. Paul Pepe and the team of illustrious medical directors from the 50 largest municipalities in the United States, Canada and the United Kingdom met in early February to share their insights with over 700 of their closest friends.

As has become tradition at the Eagles Conference, the crowd of mostly pre-hospital EMS professionals was intrigued and oft times confused by the paradigm shifts proffered as a result of the research findings presented during the two day event.

In addition to the startling discovery that most of us who thought we resided in the United Stated were informed that we actually live in "Southern Canada" (during the peak of the Winter Olympic Games in Vancouver), the most startling themes to much of the information presented were:

-ALS care does not really make a difference in patient outcomes in almost all life threatening patient conditions
-Response and transport times in pre-hospital medical emergencies really don't make a difference in patient outcomes
-Many of the things we thought helped people may not!

In his opening presentation, Dr. Corey Slovis from Nashville reviewed the most important research papers published in 2009. Dr. Slovis' opening comments brought a hush over the crowd and set the stage for many of the presentations to come...

In the early 1970's the nationwide survival to discharge rate for out of hospital cardiac arrest was about 5.5%...

Today, the survival to discharge rate for out of hospital cardiac arrest is about 5.5%.

Blasphemy you say? How can that be? We have spent billions of dollars in advanced emergency medical service systems - certainly we have had a HUGE impact in patient outcomes - right!(?)

Consider the following ACLS study findings presented by Dr. Slovis...

Passive Oxygen Insufflation Is Superior to Bag-Valve-Mask Ventilation for Witnessed Ventricular Fibrillation Out-of-Hospital Cardiac Arrest (AnnEmergMed 2009;54:656-662) . Bobrow, et. al. found that for adult, witnessed, ventricular fibrillation/ventricular tachycardia, out-of-hospital cardiac arrest (OHCA) resuscitated with minimally interrupted cardiac resuscitation, adjusted neurologically intact survival to hospital discharge was higher for individuals receiving initial passive ventilation than those receiving initial bag-valve mask ventilation.

Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest ( N Engl J Med 2004;351:647-56) done by Steil, et. al. as part of the OPALS study conducted in 17 cities with 5,638 patients included found that the addition of advanced-life-support interventionsdid not improve the rate of survival after OHCA in a emergency-medical-servicessystem previously optimized with rapid defibrillation. BCLS patients had a 5.0% survival rate and ACLS patients had a 5.1% survival rate.

Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial ( JAMA 2009 Nov 25;302(20):2222-9), by Olasveengan, et. al. analyzed the admission and discharged alive rate for 851 cardiac arrest and found that there was no significant difference in survival to hospital discharge for the intravenous drug group vs. the no intravenous drug group.



Ok, Ok, we get it, but certainly modern EMS systems and protocols make a difference in trauma care and airway management! I mean, paramedics have been doing intubation for decades, and we have Level I and Level II Trauma Centers and numerous aeromedical systems. Certainly that matters, right?

Consider these findings regarding trauma and advanced airway care...
Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a North American prospective cohort (Ann Emerg. Med. 2010 Mar;55(3):235-246.e4. Epub 2009 Sep 23) by Newgard, et. al. analyzed trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was in-hospital mortality. The study looked at call processing, activation, response, scene and overall task times for the response. The study found that there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.

A Prospective Multicenter Evaluation of Pre-hospital Airway Management Performance in a Large Metropolitan Region ( Prehosp Emerg Care 2009 ; 13:304-310). This is the latest in a series of studies evaluating the efficacy of paramedics doing endotracheal intubation. The study evaluated 1,200 paramedics in 34 EMS transporting agencies. 58% were fire-based, 30% private and 12% were single agency systems. The procedural success rate for the 825 attempted intubations was 74.8%. This is consistent with the findings by others such as Dr. Wang in Pittsburg. Most of the Eagles agreed that intubation, if performed at all, needs to be limited to a single attempt and many were mandating that King airways be used as the main advanced airway procedure.


That's all fine and dandy, but there must be some time-honored care traditions that DO help - for example, applying cervical collars for suspected spinal trauma, right? Wrong??

Dr. Persse from Houston presented his data from the soon to be published study: C-Collar or De-Collar: Are Cervical Devices Harmful? Dr. Persse demonstrated 3-D CT and MRI scan images of unstable c-spine cadavers after c-collars were applied. In application after application the findings showed that in many cases the patient suffered debilitating spine injuries. Although Dr. Persse indicated that more research is needed, this certainly begins to call into question one of the core processes that we as EMS professionals have performed since essentially the dawning of modern EMS.

So, was there any good news about EMS presented during the conference?? Yep...

There was a lot of discussion about a few emerging trends that most Eagles felt should be studied for presentation next year...

Field Termination of Cardiac Arrest Cases - most systems are aggressively pursuing field termination of CPR cases to prevent unnecessary transports. In one notable quote, transporting a patient who has been systolic for 20 - 30 minutes to the emergency department is simply " relocating a corpse".

Community Health and Advanced Practice Paramedics - preventing EMS calls through a targeted approach to frequent emergency service users that can benefit from home visits and dedicated medical homes when they are transported. Similarly, using APPs to do the high risk, low frequency procedures such as endotracheal intubation, hypothermia in ROSC cardiac arrest cases, and medical clearance of psych patients.

Transport CPR cases Non-light and siren - Speaking to the concept of "relocating corpses", anyone who has been in EMS more than a few minutes realizes that if you have worked a CPR case for 30 minutes in the field, there is little to nothing that the hospital can do for the patient than has not already been done. Further, the recent resuscitation studies prove that the most important procedure in CPR is adequate chest compressions. Why then do we risk out lives and livelihood (and that of the public) screaming across town, weaving in and out of traffic, throwing the rescuers around in the back of the ambulance and diminishing the quality of chest compressions all to save 2 - 3 minutes on the transport time?

Those 2 minutes on the tail end of the call makes virtually no difference in the patient's outcome. Besides, if you want to save those 2 minutes, make a more efficient process for moving the patient from the back of the ambulance to the Code Room at the emergency room. Instead of waiting until the ambulance is in "park" at the emergency room, preparing the patient to be taken from the ambulance right away. Change over to portable O2, move the IVs to the stretcher mounted pole(s), buckle the patient safety harnesses, move the monitor to the stretcher, etc. Having all that done IN ADVANCE will make the unloading process more efficient.

Many of the Eagles felt that the time has come to evaluate non-light and siren transports for CPR cases to see if it makes a difference in the patient's outcome. It would improve CPR effectiveness, reduce rescuer injury, reduce the incidence of emergency medical vehicle collisions (and "wake effect" collisions from cars moving out of the way), and overall makes sense.


In my 30ish year career in EMS, I've had the fortune to attend countless conferences. The Eagles conference continues to be one of the most informative, fast-paced and FUN conferences. If you have not had the chance to attend one yet, you should seriously plan on attending the program next year.

For more information visit http://gatheringofeagles.us/

About the columnist:
Matt Zavadsky is the Associate Director for Operations at MedStar EMS, the Ambulance Authority System serving Fort Worth and 14 suburban cities in North Central Texas. In this role, he is responsible for overall system operations covering the 850,000 people and nearly 100,000 EMS responses.
He holds a Masters Degree in Health Service Administration and has 30 years experience in EMS including volunteer, fire department, public and private sector EMS agencies. He is a former paramedic and has managed private sector ambulance services from 10,000 to more than 100,000 annual call volume in locations including Fairfield, Connecticut; Augusta, Georgia; La Crosse, Wisconsin and Orlando, Florida. He has also served as a regulator in Lincoln, Nebraska and Volusia County (Daytona Beach), Florida.

Matt is a frequent speaker at national conferences and has done consulting on numerous EMS issues, specializing in high performance EMS system operations, public/media relations, public policy, employee recruitment and retention, data analysis, costing strategies and EMS research.

He has served as the American Ambulance Association as Chair of the Industry Image Committee and membership on the Professional Standards, Strategic Development and Management Training Institute Committees.

Matt is an Adjunct Faculty for the University of Central Florida's College of Health and Public Affairs teaching courses in Healthcare Economics and Policy, Ethics, Managed Care and US Healthcare Systems.

So how do you feel after reading this? If it is a sense of uselessness, you are missing the point. In the world of medicine, EMS is a neonate. We, the ones working right now, can make a huge difference. Please share your thoughts.

Link to article on EMS network

Thanks for stopping by,

Adam Thompson, EMT-P

Thanks to Chronicles...

Tom B pointed out to me that Paramedicine 101 has gotten a shout out on A seat at the table. I am pleased to see that Paramedicine 101 is being read by many and actually used as an educational resource.

I have attached the video that contains the shout out. The discussion is a good one. Can we trust the educational information obtained from the medical blogosphere? The answer, in my opinion, is no. You can't just trust it. Use your own discretion to decide what you can trust. Many of us use references, or links to prove that the information is factual. I also recommend that you fact check anything that seems suspicious. Most of us warn in our disclaimer that you should not act out of your own guidelines based on anything you read on our blogs. Speaking for myself, I just hope to improve upon what you already do. More often than not, the stuff I learn from the blogs that I trust is assessment based.

PLEASE CHIME IN AND LET US KNOW WHAT YOU THINK

Chronicles of EMS - A Seat at the Table (Ep 6) from Thaddeus Setla on Vimeo.

Thanks for stopping by,

Adam Thompson, EMT-P

ps. don't forget to read the new posts below.

Rose by any other name...

The title is not a typographical error or omission, I meant it to play on the line from Romeo and Juliet.

In the Shakespeare play, Romeo proclaims that his love for Juliet transcends their family names and political differences by saying

"...That which we call a rose
By any other name would smell as sweet."

And this line certainly conveys that feeling, as does the rest of their exchange, but try calling Rose, your 78 year old patient, by another name and let's see if she stays as sweet.

It can not be repeated enough so I will keep repeating it until I either snap and become un-Happy or until I stop hearing certain words at the scenes of emergency responses.

If you choose to use profanity I have issues with you.

If you use inappropriate terms to describe ethnic groups, I have issues with you.

If you can't learn and use your patient's name then we not only have issues, but you are lazy.

Things I have heard on scenes throughout my travels are terms like Pal, Buddy, Honey, Sweetie and my least favorite, Dear.

Let me assure you I have fallen victim to the occasional frustrated or suddenly confused Buddy or Dear comments, but constantly using such terms only proves you don't care enough to even learn their name.

And another point of clarification, while we're on the topic of names, your patients are not expected to remember yours. Notice I said remember, not learn, because of course we are introducing ourselves to our patients, then using the names they tell us to address them.

Aren't we?

When entering a scene keep in mind what you look like. Uniformed, carrying bags, wearing gloves, possibly even a mask and asking questions. Not to mention all that ruckus outside. That's scary. Not just for the kiddos, but everyone.
Now imagine the confusion when I come racing up the stairs in full turnouts fresh from a fire call doing the same thing.

So when you approach these folks, put them at ease from the first words out of your mouth.
I prefer a simple phrase like, "Hi there" or "Good (afternoon, evening, morning)" just to remind them I'm a human being too.

Now to the tricky stuff that comes from experience, the introduction.
"What's wrong?" is a poor opening line,
"What happened?" can lead down roads not concerning the present Chief Complaint, and
"Why did you call 911?" often leads to people looking away and saying "um..."

Start by offering a hand and simply saying hello, then your name. When they reach to shake in introduction not only do you have an ABC assessment complete, but you make them smile and feel at ease.

Now remember the name they give you.

Repeat it to them.
"Hi Jessica, how did you end up on the floor today?"
Write it on your glove if you must, but remember it. Use it. Call them by it.

If Jessica introduces herself as Mrs Johnson, you call her Mrs Johnson until she tells you otherwise. Not Jessica and certainly not Dear or Sweetie.

Not using a patient's name when speaking to them shows not only disinterest in your patient but disinterest in your profession.
If you lose the trust of your patient then all you are is an expensive ride.
Earn their trust and do it from the beginning with a smile, an offer of a hand, a hello and referring to them by their name.
It's a little step that goes a long way and will not get you noticed when you do it, but will stand out glaringly if you don't.

Imagine if Juliet showed Romeo the amount of interest many in EMS do and called out,
"Buddy, Guy, oh where for art thou Pal?"

I think Romeo would have turned tail and found someone that could at least remember his name.

--

Speaking of names, I broke my own rule there didn't I. I'm Justin Schorr from HappyMedic.com and the Chronicles of EMS, a recent addition to the contributors here at Paramedicine101.
It is an honor to be considered worthy of inclusion in such an influential forum and I hope to live up to the standard set by those who came before me.
You can reach me at thehappymedic@gmail.com with any questions, comments or concerns. So until next time, see you in the interwebs.

Future Priorities for Parameidcs - Assessment or Interventions?

Firstly, I would like to say thank you to Paramedicine 101 for the invite to start posting some of my thoughts on this blog. I am flattered to be asked, and I look forward to having some discussions with some new readers about my thoughts and musings.

This post is a combination of two that I have had over at my blog this week, and I post it here as I would like to have your opinions too....

I have just finished reading a fascinating short article over on EMS1.com by Brian Bledsoe, entitled'Speed and Time in prehospital trauma care'.

I figured that I should read it as I am due on the EMS garage podcast in 20 mins and we will be discussing it!

However, it has left me with more questions that I expected.

I am already aware of the recent move to disprove the concept of the Golden Hour, and when I have been talking to colleagues at work about it, I have basically said that all it proves is that if your injuries are going to kill you, then it doesn’t matter if you are on scene for 10 minutes or 30 minutes (or so the current thinking is telling us), and likewise if you are going to survive, then you will unless you are kept out of the hospital for a significantly prolonged period of time.

I know that this goes against all of our training and is pretty much against the core values of how we look after our trauma patients.

But....

It has also got me thinking about other things.

Mrs999 and I have just had a conversation about it, and I came to a conclusion that I want to put out there and I would love to hear your thoughts on it.

There has and always will be the need for an ALS component to pre-hospital care. However, in the future (very near future in the UK already) will an ALS provider be defined by his or her 'intervention capability' or will a true ALS provider be defined by their assessment and diagnosis ability.

More and more in the UK, we have more varied options open to us for our patients. If I have a patient who is having a CVA, they go to a certain hospital or unit. An M.I will go to a different unit. Potentially significant head injuries go to one hospital whilst 'less' serious head injuries can go to a normal A&E unit. The list goes on and on, but shows that it is becoming more and more the paramedic’s responsibility to actually provide a provisional diagnosis to base their transport decision on.

If you get it wrong, then you can place your patient at risk by taking them to a hospital that may not be equipped to look after their needs at that time.

It also moves into the realms of minor injury and illness. Our experienced paramedics can 'treat and refer' or' respond not convey', which is completely reliant on a sound and thorough clinical assessment and a professional and eloquent patient care record.

Just take a look at how often you pull out the magic box of ALS tricks and be honest and see how often they actually make a real and significant difference.

Now, don’t get me wrong, I am not saying that we should lose these skills and interventions. I have seen the benefit of them, and they are the times where we really, really feel good about what we can do and the differences that we make. All I am saying is, as we move forward with EMS 2.0, what really is the most important tool in our repertoire?

Is it our 'awesome' intubation, cannulation and drug therapies?

Or, is it our ability to make a clinical diagnosis, based on highly developed assessment skills and move our patient to the correct place for them to receive definitive care?

I agree that treatment and assessment are intertwined and to be an efficient and effective EMS provider, you need to be proficient at both, but I also think there is another way to think about it.

Are we now getting close to the limit of what we can do with interventions for our patients?

I for one cannot see much more that would be of benefit or that would be practicable to try and perform in an out of hospital setting with our current level of technology (who knows ones we get into Star Trek land though!).

I have been on a number of courses around assessing and treating a patient suffering from traunatic injuries (ATLS, PHTLS), but there are very few advanced general assessment courses, primarily aimed at the medical patient for me to go on.

If we take it as I said that we cannot physically do much more for our patients, then should we now be looking at where we can go to further help our patients by concentrating more on our assessment and diagnostic abilities?

Or maybe I am just barking up the wrong tree??

EMS 2.0

Passionate members of the EMS community, you are not alone.

I first came across, what is termed EMS 2.0, on Ambulance Driver's blog. It is actually a movement that was initiated by The Happy Medic. The Happy Medic is Justin Schorr a firefighter-paramedic from San Francisco. Unfortunately The Happy Medic's blog has not been a regular read of mine. I am regrettably a creature of habit, and just didn't get addicted to hist stuff--until now. I don't feel as bad since paramedicine 101 is absent from his blogroll as well.

One of my partners asked me if I had been watching the Chronicles of EMS. An EMS webcast that was started by Justin Schorr and Mark Glencorse of Medic999. Mark is a UK paramedic who contacted Justin with the intent of a foreign-exchange work program of sort. They are taking part in witnessing each other work in their own respective EMS systems. They share stories and explain how each system is different and, in some ways, the same.

After watching the first episode of the Chronicles of EMS reality show, which featured these two fellow EMSers, I was hooked. I then watched a few episodes of A seat at the table, which is all about EMS 2.0. I am more than hooked at this point, I want in. As far as I am concerned, there are two types of people in this world of EMS workers--the people that complain about problems, and the people that try and solve problems. I believe EMS 2.0 looks to be a solid start. I hope to inspire the paramedicine 101 readers to head over to these sites and check out this movement on their own.

Link - EMS 2.0

Previous post by Rogue Medic on Paramedicine 101

Examples of the videos I spoke of:

Chronicles of EMS - A Seat at the Table "EMS 2.0 Part 1" from Thaddeus Setla on Vimeo.

Chronicles of EMS - The Reality Series (Season 1 Episode 1) from Thaddeus Setla on Vimeo.

Justin, Mike, Thaddeus, I hope it was okay I robbed your site of these videos and the EMS 2.0 logo. I invite you to contact me via paramedicine101@gmail.com. I would love to be involved.

Thanks for stopping by,

Adam Thompson, EMT-P

Correction on Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.

In Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial,^[1], ^[2] I missed some important information. I think I expected more detail to be in the text, than in the charts and figures, so I did not read Figure 2 carefully enough. Regardless of the reason, I did miss some important information.

In response, Anonymous left this comment -

RM: I was doing some reading on this article and came across your commentary. I am unsure if you will even see this since your blog was posted a few months ago, but I just thought I would clear something up for you and anyone else who reads your commentary. You seem to have done an inadequate job of reading and understanding this article.

Yes, I did.

Specifically, you state that a major shortcoming of the study is that 10% of the no-IV group received IV medications. You actually go on make a joke about "falling on a IV" as being an unacceptable excuse.

Sometimes I think I am funnier than I actually am.

If you had read the article closely you would have noticed a perfectly adequate explanation for this, as well as the 18% of the IV med group who did not receive meds.

Yes. It is not hidden. It should not have required a close reading, but I did miss both of these.

The reason the no-IV did receive drugs was because of ROSC (Return Of Spontaneous Circulation) then subsequent new cardiac arrest (27), hospital admission (13), breach of protocol (5)...45/433=10%. I would argue that 5/433 (1%), is pretty good for a study of this magnitude.

I agree. However, if the breach of protocol had been 10%, that would have been ten times higher and reason for comment. Clearly the breach of protocol was not that high and my criticism was inappropriate.

Paramedics often make mistakes. Arrests are stressful. It seems unreasonable for you to criticize this study for 5 episodes. It would be difficult if not impossible for the researchers to have controlled that any better short of being in every ambulance. I hope this sheds a little light on the topic for you.

I agree. I was wrong. Thank you for correcting me.

On the other hand, I think that cardiac arrests should not be stressful. We spend so much time on teaching the use of medications, advanced airways, and IVs. We have no evidence that any of these lead to better survival. These unproven interventions are just more to distract EMS from what has been shown to work by good evidence. We create unnecessary stress.

What you pointed out only lends more support to conclusion of the study - that IV medications do not improve outcomes from cardiac arrest. There still is no evidence that routine use of IV medication does anything to improve survival from cardiac arrest. Without evidence to show improved survival, these treatments should only be considered experimental.

In the bizarre world of medical research in the US, these experimental treatments have become the standard of care. The lack of research cannot be overturned with anything less than the highest quality research. That research is more likely to be done outside of the US, because it is considered unethical to deprive US study participants of a standard of care, even though there is absolutely no evidence of improved survival with the standard IV medications in cardiac arrest.


Anyway, back to my errors. I made the same mistake with the protocol deviations in the IV arm of the study.

442 Randomized to intravenous administration group

418 (95% of 442) Included in primary analysis

24 (5% of 442) Excluded due to predefined exclusion criteria

17 (4% or 442) Cardiac arrest witnessed by ambulance crew

6 (1% or 442) Resuscitation not attempted

1 (<1% or 442) Traumatic etiology

344 (82% of the 418 Included in primary analysis) Intravenous drug administration established and administered as randomized

74 (18% of 418) Intravenous drug administration not established prior to end of resuscitation

42 (10% of 418) Restoration of spontaneous circulation before intravenous administration

12 (3% of 418) Inability to establish intravenous access

12 (3% of 418) Intravenous administration considered futile

8 (2% of 418) No explanation given

For the information already mentioned by Anonymous -

474 Randomized to no intravenous administration group

433 (91% of 474) Included in primary analysis

41 (9% of 474) Excluded due to predefined exclusion criteria

17 (4% of 474) Bystander physician ordered treatment

14 (3% of 474) Cardiac arrest witnessed by ambulance crew

5 (1% of 474) Resuscitation not attempted

4 (1% of 474) Traumatic etiology

1 Asthma-induced cardiac arrest

388 (90% of 433 Included in primary analysis) No intravenous drug administration established or administered as randomized

45 (10% of 433) Intravenous drug administration occurred

27 (6% of 433) Restoration of spontaneous circulation and new cardiac arrest

13 (3% of 433) Hospital admission

5 (1% of 433) Breach of protocol

I am a bit confused by the meaning of Hospital admission. Were these EMS responses to treat patients in hospitals? Elsewhere Hospital admission is used as a measurement of short term outcome - whether the patient survived to the hospital. Survival to the hospital is just a short term outcome that has led to the adoption of treatments which have later been shown to increased long term harm. therefore, these short term outcomes probably should be ignored, rather than highlighted.

For the IV group, there were 2% listed as no explanation given, but nothing specifically listed as protocol violations.

Rather than an IV/No IV approach, blinded randomization to use of a placebo syringe/active drug syringe should not be that much more difficult.

And we need to stop the ethicists from forcing experimental treatments on unsuspecting uninformed patients in the name of ethics.


Footnotes:

^ ¹ Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.
Rogue Medic
Article


^ ² Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.
Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L.
JAMA. 2009 Nov 25;302(20):2222-9.
PMID: 19934423 [PubMed - indexed for MEDLINE]

If you want to read the entire study, this link opens it in PDF.


.

One Year Down...

Paramedicine 101 was started by me about one year ago. Initially, I didn't know what would come of it, or what I wanted to come of it. As I browsed many other EMS blogs, I realized I wanted to provide something educational. Information probably not taught in most paramedic schools. Information that a brand new, and a very experienced prehospital provider would both appreciate. Most importantly, I wanted to provide evidence-based information; something funny or opinionated from time to time, as well. I soon realized that I am not the bearer of all this information. I quickly recruited well known, and respected bloggers who I thought might help carry the load, and boy have they. The blog has become a regular read by many, and even though I have been extremely busy with other projects, my cohorts have done a good job providing new posts. There are many contributers, some who post more than others, but all are very appreciated. I also continue to welcome new contributors.

All-in-all, I have to say that I am very pleased with the paramedicine 101 blog. I hope to become as productive as I once was with it shortly. Please, until then, read through the archived posts. There has been a myriad of information covered so far, and much more to come.

Happy Birthday Paramedicine 101

Thanks for stopping by,

Adam Thompson, EMT-P