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Archive for the ‘rants’ Category

No really, your paperwork is imoprtant.

with 15 comments

I’ve told my crews hundreds of times that “your paperwork is just as important as any other part of the call and you must complete your paperwork before returning to service.”

I am a hypocrite.

Ambulance services constantly tell their crews how important it is to complete paperwork and that there is no way they should ever return to service before turning in a run sheet at the hospital. Then, when it gets busy, dispatch tones a crew that has just gone out at the hospital with another call.

Let’s stop this.

Run sheets are important. They’re our legal record of care given to a patient, they (sometimes) provide valuable insight about a patient’s condition to hospital personnel, and they’re how we get paid. But they’re never as important as you are if you’re the only ambulance in the system that is even remotely close to returning to service.

Next time, I’m going to tell my crews this: It is important to get our paperwork completed in a timely fashion, but not as important as providing ambulance service to the next customer in the community we are committed to serving. I insist that you complete your paperwork at the hospital whenever you can, but understand it is expected that you will break off if you have to run a call.

Written by ben

December 24th, 2009 at 8:08 pm

Posted in rants

Mechanism of injury

with one comment

Rogue Medic has a great post up on trauma triage criteria, leading into some harsh criticism of mechanism of injury as a treatment criteria.

Treatment based on mechanism needs to go the way of bloodletting and alchemy. I recall being trained to assess a patient based on signs and symptoms, not the vague possibility that they might at some point have sustained some hypothetical injury.

A good example of this is vehicle crashes. It is not uncommon to arrive on scene of a rough looking crash at highway speeds and see a patient who appears lucid and uninjured being encouraged to get down on a backboard, despite his protests that “I feel fine. No, my neck doesn’t hurt. Stop that.” Modern vehicles are designed to be destroyed in a crash. The vehicle will be subjected to far greater forces than the occupants. So when you see a car that’s crunched up like a pop can and a guy sitting on the curb, there’s not necessarily a need to toss him on a back board and run him emergent to the ED while you place bilateral 14′s and cut off all of his clothes. He needs assessed and treated based on his signs and symptoms, not those of the vehicle.

I am prepared to make the bold, unsupported claim that treatment based on mechanism is lazy medicine that creates unnecessary ambulance rides for a lot of “patients.”

Pop on over and check out Rogue Medic’s post. It’s worth your time.

Written by ben

December 9th, 2009 at 12:00 pm

Posted in links,rants

Why do we still Intubate?

with 7 comments

Seriously. If we are so bad at it, why don’t we just stop?

Opportunities for intubation in the field are rare, I’ll argue that they’re too rare to gain or maintain mastery of the skill, even in very busy systems. And please don’t try to tell me that intubating a mannequin is the same as intubating a person. It is risible to think that intubating the same plastic thing 10 times is equivalent to 10 completely different field intubations (different airway anatomy, different airway secretions, different amounts of vomit, different patent positions, different scene lighting, etc).

There are safe, effective, proven alternatives to intubation, including King LT, CombiTube, LMA, and plain old BVM with OPA/NPA. I’m not even convinced anyone needs RSI, no matter how long your transports.

Throwing the rest to the wind and completely playing devils advocate, I’ll offer that the only reason we still try to intubate is because of some macho paramedic thing: “you can’t take away my toys or I won’t be as cool.”

Written by ben

June 10th, 2009 at 10:09 am

Posted in rants

Most Emergencies aren’t.

with 5 comments

One of the most important lessons I have learned in EMS is this:

Most emergencies are not emergencies, they are only perceived as such by the people involved.

As far as the job is concerned, this has 2 very important implications.

  1. One of the most important things to do first on scene is to quickly learn whether this is an emergency or not and
  2. No matter the situation, your patient and any concerned bystanders (anyone on scene with an emotional attachment to the patent; friends, family, etc) need to understand whether and why this is or is not an emergency and what happens next.

A witnessed arrest is probably pretty clearly an emergency. An unconscious drunk college student with no signs of trauma who wakes to verbal stimuli maybe is not an emergency, but his hysterical roommates who called might feel differently. The job starts the same in either case: we are called to someone’s emergency. But the requirements of each become vastly different when we arrive and see whether it is an emergency or not.

In either situation, we have work to do.

cf.  Patients Define Their Emergencies (The EMT Spot)

Written by ben

May 27th, 2009 at 1:21 pm

Posted in ideas,rants

This looks like absolute crap*

with 2 comments

In the spirit of ER, Emergency!, and medical shows everywhere that glorify the profession, drastically skew public expectation, and generally make me want to cry, I give you NBC’s Trauma:

I don’t know why I’m upset… It’s not like anyone would watch a show where a guy posts for 12 hours, drinks 4 Venti coffees, takes a nap on the pram, watches 3 movies, and goes home.

Added: HT to Rogue Medic (whoops).

*I’ll probably watch it anyways.

Written by ben

May 13th, 2009 at 5:45 pm

Posted in rants

What happens if we say no?

with 5 comments

In a meeting today, someone offered the timeless reminder that we can’t say no. If someone calls an ambulance and says “I need to go to the hospital” we can’t say “Well, we aren’t taking you because you don’t need to go.”

Why not? I realize that there are probably legal concerns, so what are they?

I want to envision a well-monitored program that allows a the Paramedics in a system to tell a patient that we won’t be taking them to the hospital. This differs from the idea of the “Paramedic-initiated refusal” in that no one is convincing the patent to refuse; we are telling the patient that we won’t be taking them to the hospital.

Surely there is a discreet, teachable, easily monitored set of evaluation criteria that can filter those patients who will not die if they don’t go to the hospital by ambulance. This would be best supported by some public transport system like Access-a-Ride that we have here in Colorado.

It might look something like this:

Patient: “I want to go to the hospital.”
Paramedic: “We aren’t taking you, you oren’t sick.”
Patient: “Well, what am I supposed to do.”
Paramedic: “I’ll call my dispatch and have them send a van over to give you a ride.”
…and so on.

Does anyone do this? Where and how?

Written by ben

April 15th, 2009 at 12:11 pm

Posted in ideas,rants

more paramedics is not congruous with better care

without comments

I’d rather have a Paramedic who runs 1500 calls per year arrive at my emergency in 15 minutes than a paramedic who runs 500 calls in 5 minutes.

Written by ben

September 25th, 2008 at 6:48 pm

Posted in rants