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Ambulance: Tell Me Exactly What Happened

Written by RSS Poster Medic Scribe » Medic Scribe

New Picture (2)

I just finished reading an interesting book, Tell Me Exactly What Happened, which will be published soon by the Minnesota Historical Press. It is the second book by Caroline Burau, a former 911 call taker/dispatcher from Minnesota. It was not what I expected.

When I was in EMT school, I read every book I could find about EMTs and paramedics. I wanted to know what this new field I was considering was like. I wanted any story or tidbit that would help me find my way through the unknown. I never read or even thought about reading a book about 911 dispatch.

I understand the value of the 911 dispatcher, but as a field provider, like I think most field providers (at least in commercial EMS), my relationship with dispatch is at times, more one of annoyance than true camaraderie. That is for two reasons.

Dispatchers

1) Tell us what to do and we have to do what they say. They sit in front of their consoles and play us like we are a video game. They are the proverbial messengers in the don’t kill...

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Ambulance: BLS Skill Creep

Written by RSS Poster Medic Scribe » Medic Scribe

When an ambulance shows up at your house or an EMS scene, they ought to be able to take care of the most common complaints like pain, nausea, and difficulty breathing, to go along obviously with vfib arrest and anaphylaxis. I want the first ambulance to be able to take care of the problem, not say, “OH, shit!, we need to call for the Calvary!”

That’s why I have been a strong proponent of enhancing the BLS level when there is an intervention that can be done safely by BLS that will have a proven benefit to the patient. Starting back with AED, adding epi-pen, and right on through CPAP, Narcan, and as I mentioned in a recent post, Fentanyl (either as an SQ injection or perhaps as a Fentanyl Lollipop). I could throw in oral Zofran and Benadryl, and maybe also include albuterol nebs. Our state recently approved BLS 12-lead for chest pain. The BLS crew doesn’t interpret the 12-lead, but transmits it to the local hospital and if it shows STEMI, they may divert to a PCI center in a farther town. Like Narcan and...

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Ambulance: BLS Fentanyl

Written by RSS Poster Medic Scribe » Medic Scribe

A new article* published in Prehospital Emergency Care  (on-line April 8, 2016), concludes that Basic EMTs can safely give subcutaneous Fentanyl for acute pain in the prehospital setting.

*Subcutaneous Fentanyl: A Novel Approach for Pain Management in a Rural and Suburban Prehospital Setting

BLS EMTs in Canada received a four hour training course, and then were permitted to administer a maximum first dose of Fentanyl 1.5 mcg/kg for patients between 14 and 70 who had a pain scale of 7 or greater.  Patients over 70 could receive a maximum first dose of 50 mcgs.  Both the EMT and the patient had to agree that pain medicine would be given and the EMT  had to obtain permission from the on-line medical control MD prior to administration.

In the study,  284 patients recieved Subcutaneous Fentanyl.  Pain scales decreased significantly and there were no major side effects.  42.9 % of patients had relief of greater than 3 points.  38.6% of the patients received the Fentanyl for pain caused by trauma, 28.1% for abdominal...

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Ambulance: Narcan Dosing and Delivery

Written by RSS Poster Medic Scribe » Medic Scribe

The heroin epidemic continues to rage in Hartford and across our state and nation.  While nearly every other day there seems to be an article in the paper about fatal overdoses in various towns, most of the overdoses we see on the EMS streets, even the fatal ones do not make the news, though they certainly add to the growing statistics documenting the unprecedented epidemic.

My fellow medics and I often share our preferred routes and doses, and the pros and cons of each.  With so many calls, we are all able to experiment with various dosings and delivery.

When I first began in EMS, I gave narcan always IV as my first choice.  Usually, 1.2 mg to start.  I considered this conservative as a paramedic instructor had demonstrated for us his preferred method.  Draw up two of narcan, put in the lock, as you came through the ED doors, slam it so the patient would vomit on the battle ax triage nurse.  I kid you not.

In my then limited experience with narcan, I tended to be impatient, and yes, I will take a...

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Ambulance: Bad Behavior

Written by RSS Poster Medic Scribe » Medic Scribe

Years ago I worked for a United States Senator.  One of my early jobs for him was driving him around the state to campaign functions and speeches.  Every now and then someone would give him a hard time about all the rotten people in Washington.  He had a great answer.  He said we were a representative democracy, and that it shouldn’t surprise anyone that Washington had crooks and womanizers and deviants, likely in the same proportion as all walks of life and the general population.

He had a point.

Unfortunately, the same is true of EMS.  While we have many selfless individuals, we have our share of wayward souls, likely in the same proportion of any other profession.

Regularly it seems we see news stories like this one:

N.M. Paramedic Accused of Charging $11,000 on Dead Man’s Debit Card

I wonder when I read these stories what drove these EMS criminals to their actions.  Was this paramedic completely evil?  Did he lack positive role models? Was he mentally ill?  Or was there something more complex and...

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Ambulance: The End of Pain Scales?

Written by RSS Poster Medic Scribe » Medic Scribe

A bill has been introduced in Congress that will eliminate the financial penalty (in the form of reduced Medicare reimbursements) hospitals pay for failure to keep patients pain-free.

Currently the amount of money Medicare pays a hospital is affected by the results of a patient satisfaction survey known as the “Hospital Consumer Survey of Healthcare Providers and Systems.”  If a hospital does poorly on the survey, they receive less money from the government than if they ace the survey.  Hospitals devote an enormous amount of time and resources to score well on this survey as well as to do well on numerous care benchmarks and quality indicators (Door-to-Balloon times, hospital readmission rates, infection rates etc) that are also tied to reimbursement.

The survey has three pain management questions:

1. During this hospital stay, did you need medicine for pain?

2. During this hospital stay, how often was your pain well controlled?

3. During this hospital stay, how often did the hospital staff do...

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Ambulance: Amiodarone vs. Lidocaine vs. Placebo

Written by RSS Poster Medic Scribe » Medic Scribe

The results are in.  In an article, Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest, published in yesterday’s New England Journal of Medicine by Peter J. Kudenchuk, M.D., Siobhan P. Brown, Ph.D, and others, the results of a major randomized double blinded study involving paramedics from ten major cities in North America (The Resuscitation Outcomes Consortium (ROC)), and enrolling over 3,000 patients, concluded there was no significant difference in outcomes between the drugs and a placebo when administered to patients in refractory v-fib or pulseless v-tach arrests.

Here are the numbers on survival to hospital discharge:

Amiodarone   24.4%

Lidocaine        23.7%

Placebo            21.0%

While amio and lido outdid placebo, the margin was too small to be statistically significant.

The researchers, who thought the drugs would show a greater effect, now admit that they should have done a larger study.  If these results had held true over 9000, not 3000,...

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Ambulance: Burnout (With Footnotes)

Written by RSS Poster Medic Scribe » Medic Scribe

I wrote this a couple months ago when I was feeling really burned out.  The burnout passed, as I knew it would, and I am back to myself, so I can post it now. (1)

I have been responding to 911 calls for twenty-six years, 21 as a full time paramedic with a busy urban commercial service (2). I have had periods of burnout, more when I first began than in my later years. Once you get used to the business, the stress and emotions of the job are easier to handle; they become almost routine. Lately, however, I confess, I have felt burnout creeping back up on me. It is less a burnout from the emotions of the job and more a larger existential tiredness.

I can identify a number of causes:

Our call volume is as high as it has ever been or perhaps a better way to put it is the ratio of calls to the number of available units is as high as it has ever been. (1/2) Most days I am cranking from the moment I sign on at 5:30 A.M. to the inevitable late call I get twelve hours later as I am trying to get back to the...

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Ambulance: New EMS Books

Written by RSS Poster Medic Scribe » Medic Scribe

This past year has been a banner year for new EMS books, memoirs and fiction. Each book  that reaches an audience outside of the EMS world increases the public’s understanding of what we do and hopefully, increases their respect for us. Here is a roundup of recent books.

New Picture (24)

Lights and Sirens: The Education of a Paramedic by Kevin Grange published by Berkley. This a great account of a young man going through paramedic school. I reviewed it in more detail in this post:

Lights and Sirens

New Picture (43)
A Thousand Naked Strangers: A Paramedic’s Wild Ride to the Edge and Back by Kevin Hazzard published by Scribner. This is also a tremendously well written book covering the EMS career of an Atlanta, Georgia paramedic from eager EMT to eventual burn out and fade away nearly a decade later.

New Picture (44)

Our friend Michael Morse of the Rescuing Providence blog has had his first two excellent books Rescuing Providence and Rescue 1 Responding  combined into one book and published by Post Hill Press and distributed by Simon and Shuster.  Morse also...

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Ambulance: Junior doctor contract imposition is flawed on every level

Written by RSS Poster Garth Marenghi
Background The government is currently in the process of unilaterally imposing a contract on the junior doctors of England.  The Scottish, Welsh and Northern Irish government have decided it is not in the public interest to do the same.  The Review Body on Doctors’ and Dentists’ Renumeration (DDRB) report published in July 2015 forms the backbone for the government’s rationale for contract



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