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A Mother’s Day Memory (reprint)

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My first ambulance field rotation was on Mother's Day, 1971.

I was a high school senior taking the "Emergency Medical Technician/Ambulance" course offered through the adult and vocational training division of the community college.

Mike DeWalt was in the class and let me ride with him at Northern Virginia Doctor's Ambulance. This was a private ambulance service that provided occasional back-up for the Alexandria Fire Department.

A Busy Sunday

The EMT-in-charge was a tall, skinny musician who worked part-time at the ambulance service. A very friendly and helpful guy, he was reading Dale Dubin's Rapid Interpretation of EKG's

While Virginia had not authorized a paramedic training program, Glenn Luedtke wanted to be prepared. 

Some of you know Glenn from his work on the NAEMT EMS Safety Course.

Or his tenure as the EMS Director for Sussex County (Delaware) or Cape and Islands (Massachusetts).

There were six nursing home-to-house transports scheduled that morning. Followed by six return trips that evening.

Idealistic high schooler meets complex relationships

With nearly no life experiences, and that teenaged sense of "how things SHOULD be," it seemed to me that many of these patients were going to homes hostile to the visit.

I could not understand why Glenn talked so loud to the patients, or why he insisted on talking with the family before we moved the stretcher into the house. 

Now I get it

During the past five years I have been on a geriatric journey with my parents. Including an acceleration in 2011 that requires more action than discussion.

I whined about an interfacility transport experience (On Airline Travel and Ambulance Transfers ) and finding my "Adult Command Voice" (“The Greatest Generation” white-knuckles through another Winter Carnival ).

The novelty of being the designated adult/primary caregiver has worn off.

We are in the day-to-day grind of assuring a safe and comfortable environment for a couple who are struggling to maintain as much independence and autonomy as they can while medical conditions continue to change.

Just before Mother's Day in 2011 was an intense effort get Mom out of a hospital and into an assisted living facility that evening. Worked with Dad to visit a couple of places and make a decision by early afternoon. Not a lot of choices within our timeframe.

Followed by an evening stand-off with my Dad who wanted to take her home (where there was no assistance in place and physically inappropriate).

We told you …

The language of federally-regulated health care ranks right up with airline travel. Accurate statements made in a neutral tone using industry terms. 

They were told on admission that she was on "observational" status and would be discharged in three days. They did not realize it until her last night.

Even with this issue, the federally-regulated part of health care provides much better information than the unregulated parts of health care. 

"What I want is …"

… not what we can get you.  It sometimes feels like I am explaining to a 9 year old why he cannot drive the car.

When I wrote the original post I was at work at the university. It was the final day of EMS testing and I was looking at the list of things to do that week. Wondering if it is safe to make a business trip and resenting the probable answer.

On Mother's Day 2011 I finally understood the complex emotions felt by the children when we delivered their Mom for a visit in 1971. Relationship defined by decades of experience, conflict and compromise.

Mother!

Mike "FossilMedic" Ward

originally published May 8, 2011

Innovative hemmorage control device

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Innovative clamp gains European Union approval

Good Afternoon-
I wanted to share some information that may be of interest to you and your Fire/EMS readers.  A company founded in Edmonton, Canada has developed a wound closure device to control severe bleeding within seconds of application called the iTClamp. 

The makers of the iTClamp have just received EU CE Mark approval. You can learn more about the iTClamp and see the clamp in action at http://www.itraumacare.com/

The full release on CE Mark approval can be found below. Thank you for your consideration.

Regards -
Brandy

Medical Device Firm iTraumaCare
Receives European Union CE Marking for
iTClampTM Hemorrhage Control System

[March 21, 2013 – SAN ANTONIO, TEXAS]  iTraumaCare, an early-stage medical device firm focused on developing traumatic injury solutions for first responder and military medicine applications, has achieved its second regulatory milestone.  The company received CE Mark approval to market its first product, the iTClampTM Hemorrhage Control System, in participating European Union countries.  The product, which was licensed for sale in Canada in late 2012, will be available to medical professionals in participating European Union countries within 30 to 45 days. 

The iTClamp is designed to address massive hemorrhage – a leading cause of death in traumatic injury – by controlling critical bleeding in seconds.  The iTClamp seals the edges of a wound closed to create a temporary pool of blood under pressure, which forms a stable clot that mitigates further blood loss until the wound can be surgically repaired.

CE Mark approval is a key indicator of a product's compliance with EU legislation and enables the free movement of products within the European market. This CE Mark approval applies to the use of the iTClamp Hemorrhage Control System in participating European Union countries only and does not apply in the US. The company expects US clearance of the iTClamp from the FDA in 2013.

iTraumaCare’s CEO and founder, Dr. Dennis Filips, said, “We are delighted with the rapid acceptance of the iTClamp and look forward to launching in Europe soon.”

Incorporated in 2010 and based in Edmonton, Canada with a global commercialization headquarters in San Antonio, Texas, iTraumaCare is addressing unmet needs in the field of emergency medicine by developing, manufacturing, and commercializing solutions to treat common causes of preventable death in traumatic injury scenarios. 

Pretty neat.

Mike "FossilMedic" Ward

 

Blurring the ALS/BLS distinction

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One step closer to mobile healthcare

One of the themes I noticed in the 2013 State of the EMS Science conference was a continued blurring of the distinction between paramedic and emt level skills. This was reinforced by preparing refresher lectures for agencies that have expanded the skill sets of EMTs into areas I never imagined would be provided by a basic life support provider.

You can read the details in my ems1.com column "Is the line between BLS and ALS getting fuzzy? Doing the best for the patient may mean changing the EMT's role."

Others have recently written about this issue:

Emotional Issue

Peter Canning, writing in Street Watch: Notes from a Paramedic, provided his perspective on enhanced EMTs with this item "Where I Stand  (Today)"

I believe there are a number of medications and interventions that BLS can be taught to do outside of becoming paramedics themselves that will benefit patients, enhance the public’s experience of EMS and cause little to no harm.

Medications:

Epi-Pen
ASA
IN Narcan
IM Glucagon
Combivent
Zofran ODT
Tylenol PO
Benadryl PO
IM Versed injector (for status epilepticus)
Morphine injector (for distant rural services)

Interventions

CPAP
Selective Spinal Immobilization
12-Lead Transmission
Supraglottic Airway

Having said that I believe each of these items needs to be approved by the services’s medical director and weighed carefully against any number of factors, including great benefit versus little risk to patient, cost, need, resources, service area and ability to train and oversee.

His post quickly got 11 responses.

Chris Kaiser responded to Canning's post in "Pushing Down The Skills – Bringing New Skills to BLS."  Kaiser referred to an earlier Life Under The Lights article:

“Allowed only if there is a demonstrated need.” I like that statement, even if I can come up with arguments against it in both an academic and practical sense. As I stated some years back in a previous post: “A Late Night Rant about Petty Politics in EMS” there is a hierarchy of things that guide too many EMS decisions, and they’re not positive things, they are:

  1. Revenue Preservation
  2. Area Preservation
  3. Ego Preservation
  4. Political Capital Preservation

Make no mistake. Those four things are at play in this whole debate on what skills should be in the scope of practice for every EMS level. I’d bet that if I were to take an informal poll, most BLS providers would support their being allowed to perform many new skills now considered to be in the realm of the “advanced” provider. I’d also say that most ALS providers would not support giving a lot of those skills to BLS. There would be some disagreement, as some BLS providers would see the additional education required as being burdensome, and some ALS providers would see giving ALS skills to BLS providers as lessening their workload by reducing the number of calls where they are needed. However, I look at it as a very contentious issue.

Moving to mobile and unscheduled healthcare

Agencies that define EMS as medical transportation will have a rough decade. Technology, demographics and economics will result in EMS expanding into the area of mobile and unscheduled healthcare. The practices needed to provide 24/7/365 ambulance service provides EMS with a strategic advantage over existing health care providers who provide regular or as-needed home-based medical services.

Chris has laid out the battlefield.

Mike "FossilMedic" Ward

Online course in cardiac arrest resuscitation science

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Cardiac Arrest, Hypothermia, and Resuscitation Science

Benjamin Abella, MD MPhil

This course will explore new breakthroughs in the treatment of patients during cardiac arrest and after successful resuscitation, including new approaches to cardiopulmonary resuscitation (CPR) and post-arrest care.

About the Course

This course will explore new breakthroughs in the treatment of patients during cardiac arrest and after successful resuscitation, including new approaches to cardiopulmonary resuscitation (CPR) and post-arrest care. Topics will include: (1) the underlying challenges of cardiac arrest in public health, (2) the important role of chest compressions and ventilations, and new thinking about how to improve these approaches in resuscitation care, (3) the role of defibrillation and the exciting growth of automatic external defibrillation (AED) programs, and (4) the new science of targeted temperature management, also known as therapeutic hypothermia, to improve brain function after circulation is restored. This course is designed for a broad audience including the lay public, emergency medical personnel and other health care providers.

About the Instructor:

Dr. Benjamin Abella is an Assistant Professor of Emergency Medicine and the Clinical Research Director of the Center for Resuscitation Science at the Perelman School of Medicine of the University of Pennsylvania. His research focuses on the clinical care of cardiac arrest victims, with a special emphasis on methods to improve the quality and training of cardiopulmonary resuscitation (CPR). He also maintains an active research program in the use of therapeutic hypothermia to improve survival after resuscitation from cardiac arrest. He is the medical director for the nation's only therapeutic hypothermia intensive training and certification course, based at the University of Pennsylvania. Dr. Abella also serves on the Medical Advisory Board of the Sudden Cardiac Arrest Association.

Dr. Abella graduated magna cum laude from Washington University in St. Louis and then received a Masters degree in Genetics from Cambridge University in England. After attending medical school at Johns Hopkins University School of Medicine, he completed dual residency training in both Emergency Medicine and Internal Medicine at the University of Chicago Hospitals, where he won the Hilger Perry Jenkins Award for outstanding teaching and patient care, given to only one resident hospital-wide each year.

Dr. Abella has spoken widely on cardiac arrest and therapeutic hypothermia, as an invited speaker at national and international meetings. He has been active in national initiatives on resuscitation care through his volunteer activities with the American Heart Association (AHA). Dr. Abella has won numerous awards for his work, including the "health breakthrough award" from Ladies Home Journal Magazine. His work has been featured in Newsweek and Popular Science, as well as on National Geographic, CNN, and the ABC Network program 20/20. He recently appeared on the Today Show with Matt Lauer to discuss the importance of CPR.

For more information about the therapeutic hypothermia training program for which Dr. Abella serves as the Medical Director, look here.

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Go HERE for more information from coursera

Tip of the digital helmet to Mic Gunderson for his alert.

Mike "FossilMedic" Ward

 

Tachycardia in the Emerald City

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Keeping it together over the holdays

It was probably Christmas Eve-Eve and I was in my paramedic internship.

Medic 2 was dispatched to a family restaurant for "cardiac problems." Traffic was near gridlock as the restaurant was across from a regional shopping mall on the south side of "The Emerald City."

We started working up a thin, thirty-something male who said that his heart was racing.

Protocol says …

Chief complaint was that his heart started racing and he broke out in "flop sweat" while finishing dinner.

He was no longer sweating, was tachycardic at 136 with a blood pressure of 146/90.

Recoiled when I unfurled the IV starter kit. Did not allow me to put a tourniquet on his arm.

Plan B, aspirin and a quick transport … patient not interested in that either.

Situational Awareness

I was focused on completing my clinical assessment and clicking-off the required paramedic skills.

Completely missed the two elementary school age boys who were being very brave. The fire company captain took the boys on a tour of the engine as we expanded our assessment.

Divorced dad with custody of his kids today – Daddy's Christmas. They will spend the real holiday with mom and her new beau.

Things not covered in paramedic school

My preceptor, Joseph B., conducted through and detailed assessments. Kept notes and EKG strips. Would call patients days later to see how they were doing. Recorded information in a "run sheet" for each patient.

Given a specific patient complaint – like belly pain - he could assemble a collection of patient assessments and eventual outcomes. This made Joseph a sophisticated clinician.

When the focused assessment was done, the pulse was now 118 with a 130/86 blood pressure. Joseph felt there was something missing.

With just the three of us at the table, the patient removed the non-rebreather face mask and provided the missing item.

Competent cocaine user

Turns out that dad is a "moderate" cocaine user, who bumped-up his dosage today.  In 1978 the clinical documentation of functioning cocaine addicts was thin. The Eighties provided much research opportunity.  

Tom Decorte's 2000 book The taming of cocaine. Cocaine use in European and American cities. (VUB University Press) provides a perspective:

Decorte says that ‘our data and those from some major community samples… show that cocaine provides a wide range of positive effects to those who use it in moderation: more energy, an intellectual focus, enhanced sensations and increased sociability and social intimacy. Social, sexual or recreational activities and work can be enlivened, and many respondents use the drug not only in pleasurable but also in productive ways’ (p. 260.)

“Usually, health professionals, law enforcement agencies, politicians and media reports take the position that in the long run, illicit substances can only have adverse effects……Contrary to this official discourse, our repondents’ accounts show that well known adverse effects are often experienced as minor discomforts, and that level of use (including dose and frequency of use) set, and setting factors all have important impact on the balance of positive and negative experiences with cocaine ”. (p. 261)

This was my first encounter with this type of patient. We spoke with him for another ten minutes.

When his pulse remained at 110, we had him sign the release. 

Keeping your stuff together

The brutal incidents this month had me reflecting on the challenge of parenting when there are monsters over your shoulder, both internal and external. And a patient encounter 34 years ago that remains troubling.

Mike "FossilMedic" Ward

If you are working, may your day be boring.

I hope that it is full of food, laughter, fellowship & joy.

Please spend a minute thinking about our brothers and sisters in the armed forces that are deployed in hostile, desolate or dangerous environments.

Kentland 33 Saves Christmas

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From our colleagues on the other side of the river.

Squad Company and Chief 33 responded to the Inner-loop of the Capitol Beltway (I-495) at Pennsylvania Avenue this afternoon for the vehicle accident with one-trapped.

Upon the arrival of Engine Company No. 37, it was confirmed that one-passenger of an overturned taxi cab was in-fact trapped. The crew from Squad Company No. 33 began to extricate the patient and much to their surprise… It was Santa Clause that was trapped! Luckily, Santa was removed within 7-minutes and had some "choice" words for the event that just happened and the $44.00 meter fee.

We hope everyone can rest comfortably now, knowing that Christmas was saved by Company 33.

Kentland on FaceBook

Mike "FossilMedic" Ward

Showdown at the Backboard skill station

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The "Old Way" is no longer the best way.

It was the final activity in a long journey to become an Educational Standards credentialed EMT Instructor.

My home state Office of EMS (OEMS) is known for being on the front line of ems education, a strong player among the National Association of State EMS Officials and early advocate for the National EMS Education Standards.

OEMS puts on an annual symposium that rivals national conferences, with an impressive roster of nationally recognized speakers. Reflecting the Commonwealth's large cadre of rural and volunteer providers, a judicious selection of symposium courses will meet all of your required continuing education requirements before your next recertification.

Skills Review

EMTs are required to have 3.0 hours of skill review as a Category 1 continuing education requirement. Saturday afternoon at the symposium had a three hour Skill Review as part of their "BLS Academy" program.

New psychomotor assessment sheets were issued in July. This November session was the first state-run skill session using the new evaluations. My hope was to take away some tips and techniques to share with my fellow "EMT/Ancient" instructors.

I was not the only state instructor attending as a student …

"When attending as a student …"

The skill session was over-subscribed, with about 100 attendees. The lead instructor recruited additional Educational Standards credentialed instructors to double-staff eight skill stations.

My cohort included a factory worker who was part of the in-house safety team, a couple of rural providers and a couple of suburban providers. One of the cohort members was a fellow ancient instructor.

I learned this in the second skill station when she wanted to show the instructor "… how WE do this skill." It was clear my sixty-something cohort instructor/partner was not a fan of the new skill sheets and seemed to be on a mission to convince every instructor we encountered we needed to go back to the EMT/Ambulance skill sheets of the 1980s.

"Who the hell taught you to put the straps on THIS way?"

The inevitable collision occured at the sixth skill station. We were doing spinal immobilization using a backboard. My instructor/partner was putting on the straps. The thirty-something Educational Standards credentialed instructor, who has a job that includes delivering EMT instruction every week, disagreed with the procedure used by the more experienced student/instructor.

The estrogen was flying. While the sixty-something and thirty-something were hardening their positions and raising their voices, a willowy twenty-something student/newlywed burst into tears and walked away from the group.

I was still partially secured to the backboard.

All the industrial EMT and I wanted was to finish the two remaining skill stations and get our 3 hours of credit.

The twenty-something was upset because in a prior skill station she was chastised by another female instructor because she was never shown how to apply a tourniquet. Apparently more than one student at this skill station received the "we no longer use tourniquets" information in their initial EMT course.

In my recent ems1.com column, I advocate that EMT Instructors Need to Step Up. They are the key to successful providers in the Educational Standards era.

Dan Limmer, an EMT textbook author, points out that the Educational Standards eliminates the linear procedures that were a dominant feature in NSC curriculum.

Limmer points out that a better student understanding of physiology and pathology creates a foundation of understanding that allows the EMT to make a complaint-based approach to patient assessment.

In order to accomplish this, the EMT instructor needs to develop educational experiences that focus on decision-making and not regurgitation of a memorized standardized checklist.

This is a new instructor skillset that is not familiar to many.

EMT instructors must move beyond teaching a linear approach to patient care. Instructors have to invest in themselves and reconsider their role.

Mike "FossilMedic" Ward

UK’s National Health Trust Drops Down Two More Rungs

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You Didn't Really Think It Could Get Any Worse, Did You?

THE NATIONAL HEALTH TRUST SERVICE of Great Britain is known for its incompetence and inability to make good decisions on patient care. This is the outfit that will not dispatch an ambulance to a heart attack call a few feet away from the station if the crew are on their mandatory lunch break. We have also reported on the dispicably dirty conditions in some of the hospitals and their practice of leaving emergency medical victims in the ambulances for up to two hours because they are too busy inside.

More than once Firegeezer has reported on instances where a victim was laying in an inch or two of water but the emergency crew is forbidden under penalty of dismissal from entering water without special training or a boat, even in one inch of dangerous water.

The list goes on, but we don't have time here to fill it out with other outrageous examples because the grandaddy of ambulance dispatches took place a few days ago that we are passing on to you today.  It's been 20 years since Firegeezer ran a medical call, but I sure haven't forgotten the basics.  See how many contra-indicators you can spot:

IAN TAYLOR, A RETIRED ARCHITECT, is lucky to have survived his recent experience with the National Health Trust Service a few days ago.  His ordeal began when he passed out in his home where he lives alone, and struck his head.  After laying unconscious "for hours," he woke up in a pool of blood and called for a doctor.  The doctor came to his house and stopped the bleeding and bandaged Ian up, then left him.  This was despite the fact that he had been unconscious and has a history of stroke. (Most doctors in UK, but not all, are employed in the NHT.  None of the news reports stated whether this doctor is or not…ed.)

Ian Taylor  (SWNS / Jones)

Later that evening Mr. Taylor went out to a party and returned home just before his wound opened up and started bleeding again.

"It was quite scary because I was bleeding profusely," he said.

"I thought ‘What I am going to do now?’ as it was too late to call family or friends at around 11.30pm and I was mindful of the fact I had had a stroke some years ago, so I made the decision to call 999 at 11.49pm."

Little did he know that his adventure was just beginning.  Despite his medical history and having passed out earlier in the day, the East of England Ambulance Service Trust dispatcher coded him as a priority 4 – non-life threatening – and dispatched an ambulance that was over 60 miles away in another county.  It took the ambulance 90 minutes to arrive at Ian's home where they first treated him before putting him in the ambulance and setting off for the Addenbrooke's Hospital which is only three miles from Taylor's home.  The Cambridge News picks up the story:

(they) treated Mr Taylor and set off at 1.55am – only to go the wrong way.

He added: "When we left my house here instead of going right through Shelford to the hospital they went left and got lost. "I can only assume they went through Whittlesford and Sawston and I think they went onto the A505."

By this point he realised they were lost and told the ambulance technician next to him that it shouldn’t be taking so long. Mr Taylor, who has lived in the area for 45 years, said: "He asked the driver who said he was lost and that the sat-nav said Addenbrooke’s doesn’t exist. I thought ‘This is stupid’ as we were so close to Addenbrooke’s.

Addenbrooke's Hospital is hard to see …. because
"it doesn't exist."  (PA photo)

"I said ‘Carry on until I recognise something’ and finally we passed the pub called The Rose at Stapleford and by that time we were heading back towards Cambridge." They arrived at Addenbrooke’s 62 minutes after setting off at 2.57am.

He added that he could have cycled to the hospital in 15 minutes or even walked in less than an hour but was told by the emergency call handler to wait for an ambulance to arrive.

According to another report in the Daily Mail, the ambulance had two "sat-nav" systems installed and both of them were malfunctioning.

Read the full account in the Cambridge News HERE.
More details in the Daily Mail HERE.

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A different Chicago story – 1,000 shooting survivors

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Chicago's crime problem has an EMS backstory

 

 

 

 

 

 

 

 

 

 

Chicago Fire Fighters Union spokesman Tim O'Brien said the untold story of the city's violence this year was not the homicides, which had already topped the total for last year and were on pace to close in on 500, but the lives saved by paramedics and emergency medical technicians in shootings.

"Nobody's talking about the 1,000 shooting victims who survived because of the work Chicago firefighters did and Chicago Fire Department paramedics," O'Brien said. "What an incredible job by our members.

Read more: http://www.dnainfo.com/chicago/20121129/chicago/city-gunplays-untold-story-1500-saved-by-fire-department#ixzz2DeMGru8h

 

You need to read this entire article,

Go HERE.

Mike "FossilMedic" Ward

 

EMS Education Evolution

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Teaching Critical Thinking

At last week's EMS Expo in New Orleans I got a chance to see how other educators are implementing the 2009 Educational Standards.

Elimination of Linear Checklists

EMT textbook author Dan Limmer points out that the emphasis on student understanding of pathophysiology and physiology is eliminating rote memorization of a linear checklist. 

But this will be a challenge.

In an earlier version of the EMT textbook, a graphic was used to provide a big picture of patient assessment. The graphic was eliminated when it was learned that the students were using it as a step-by-step linear checklist.

Limmer is promoting complaint-based patient assessment. When he teaches EMT he presents a patient situation and asks the students:

"What three questions will you ask the patient?"

Wearing his other hat, Limmer released two free smart phone applications at the Expo:

101 Last Minute Study Tips (paramedic and emt versions)  Click HERE

Problem Based Learning

Art Hsieh, Paramedic Program director at Santa Rosa Junior College and textbook author, demonstrated the technique of using problem based learning to teach complex ems topics.

Working in small groups, students use the textbook, internet, smart phone and experiences to evaluate a patient, provide a differential diagnosis and develop a treatment plan.

The faculty member functions as facilitator. Each case study takes about an hour.

Hsieh says that he used five patient case studies to cover all of the medical conditions in the paramedic educational standards -  outside of cardiac and respiratory. Students exposed to problem based learning tend to do better on exams than those that memorized a check list.

 

 

 

 

 

 

 

 

 

 

 

 

Both educators are blazing paths that we need to follow to better serve the ems student.  Just as New Orleans EMS utilize this narrow transport unit when working large events, like Halloween in the French Quarter.

Mike "FossilMedic" Ward

Fire Mangled Ambulance Deployment

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Ambulance deployment – a missing chief fire executive knowledge item

When I arrived in academia, one of my research interests was urban ambulance deployment.

Did a comparison of Los Angeles and Baltimore cities as they scrambled to increase staffing in the early 2000s.

LAFD streamlined the hiring process of paramedic credentialed candidates.

Baltimore closed fire companies.

 

 

 

 

 

 

 

 

 

 

 

 

Looking at other fire-administered EMS systems, it is clear that there is an ambulance deployment knowledge/experience gap.

This month's column in EMS1.com provides some interesting details:

How fire departments mangle ambulance deployment

Mike "FossilMedic" Ward

My Hometown Heros

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Shameless bragging on my brothers and sisters

A spot played in the Washington, D.C. area "local cutaway" during the 2012 Labor Day Weekend MDA Telethon.

Thanks to the generosity of the citizens and visitors of Fairfax County, we collected and raised $568,634.89 for Greater Washington MDA.

This amount was the most collected during any 2012 Fill the Boot campaign nationwide and was also the most raised in the 58 year tradition in the International Association of Firefighters.

I responded to a last-minute request to cover a retiree's spot on Friday night at the Local 2068 office to count money.

That is a lot of one dollar bills!

 

 

 

 

 

 

 

 

 

 

It is a team effort: firefighters, dispatchers, fire administration, police and county government. 

Joel Kobersteen is one of my heros … even if beating Houston is a personal "thing" for him.

Glad I could be a small part of an amazing event.

Mike "FossilMedic" Ward

Live from the intertubes … Saturday Night “Zero to Hero”

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Who is supposed to bring the beer to a webcast?

John Boyles is a great colleague.

When he asked if I could talk about the EMT experience (Zero to Hero article) I immediately said yes.

Then I checked the schedule:

 

 

 

 

 

 

 

 

 

 

 

 

 

11:30 pm to 12:30 am

Man, I am asleep by 10 pm …

Go here to check it out:

 
Mike "FossilMedic" Ward

Zero to Hero: EMT street time does not impact success as a paramedic

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A year working as an EMT before starting paramedic school is a waste of time

After three years working on implementation of the 2009 Educational Standards and three months immersed in EMT instruction this summer, it is clear that spending a year riding on an ambulance has scant benefit in improving your performance as a paramedic student in a CoAEMSP accredited paramedic program.

The gory details can be found in this article posted on ems1.com:

EMT experience not needed for paramedic certification

 

 

 

 

Greg Friese, Rob Theriault, and Bill Toon get together every Wednesday night to discuss ems education issues, 144 sessions to date.

Tonight I am joining them to discuss this ems1.com article.

Go to EMS EdUCast for details.

 

 

 

 

Mike "FossilMedic" Ward

Liquid Carbon Dioxide creates 2011 near-miss in Phoenix

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May 2011 EMS call to fast food restaurant results in troubling discovery

A change in how carbonated beverages are created in fast food and convenience stores creates a new hazard.

Phoenix Fire Department created this video to share their near-miss and lessons learned:

EHS Safety News noted other liquid carbon dioxide incidents:

Pooler (Georgia) police chief Mark Revenew said Anne Felton of Ponte Vedra, Fla., died of asphyxiation after carbon dioxide, used to make the restaurant’s sodas fizzy, leaked into the women’s bathroom of the McDonald’s on Sept. 7 (2011).

Nine people — including three firefighters, a McDonald’s employee and a Savannah family of three who tried to help Felton and Barry — were taken to the hospital with dizziness and trouble breathing. Felton died the next day. The other eight people have since been released from Memorial University Medical Center.

Constance Cooper (September 24, 2011) Deaths & Injury Incidents on the Rise at Restaurants Using Liquid CO2

Tip of the helmet to Falls Church Lieutenant Brendan Meehan.

Mike "FossilMedic" Ward

New Fire based EMS Medical Director resource

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U.S. Fire Administration and the Department of Homeland Security Office of Health Affairs Develop Online Educational Outreach Program for EMS Medical Directors

EMMITSBURG, MD – The Department of Homeland Security's (DHS) U.S. Fire Administration (USFA), in partnership with the DHS Office of Health Affairs (OHA) and the International Association of Fire Chiefs (IAFC), has developed an innovative online educational outreach program and focused website for physician medical directors of local departments and agencies who are involved in emergency medical services (EMS) response.

"This web-based program for current and prospective EMS medical directors will provide information in a conveniently accessible format to support key roles in the provision of EMS to communities," said U.S. Fire Administrator Ernest Mitchell.

The online program, developed by the IAFC as part of a cooperative agreement with the DHS OHA and USFA, complements the recently released Handbook for EMS Medical Directors and covers a wide variety of topics for the EMS medical director ranging from occupational health and safety to liability issues.

"DHS Office of Health Affairs is committed to supporting the critical role of the EMS medical directors," said Dr. Alexander G. Garza, DHS Assistant Secretary for Health Affairs and Chief Medical Officer. "This program will assist them in the delivery of effective emergency medical treatment by emergency medical providers."

This initiative is designed to assist EMS medical directors in their role of providing medical oversight and direction, training, protocol development, and resource deployment advice.

"The IAFC and its EMS Section were pleased to work in partnership with the USFA and DHS OHA in this effort to continually support medical directors who are crucial to the effective delivery of EMS throughout this country," said IAFC President and Chairman of the Board, Chief Al Gillespie.

Further information on USFA's EMS research initiatives may be found on the USFA website.

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March 2012 Handbook for EMS Medical Directors  (92 pages, 2.58 MB Adobe Acrobat file)

IAFC "Handbook for EMS Medical Directors" website

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Mike "FossilMedic" Ward

Making Paramedicine a Profession

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Time to build our paramedic profession infrastructure

It appears that our physician colleagues accomplished more than paramedics since 1968, establishing Emergency Medicine as a specialty in 1979 and Emergency Medical Services as a subspecialty in 2010. (How EMS physicians became recognized and rewarded)

The development of the National EMS Educational Standards in 2009 is a more significant development. (EMS Future is HERE)

Emergency Medicine built upon an existing graduate medical education structure

The significant physician accomplishments were built upon a well-established graduate medical education infrastructure.

A September 2006 article in the New England Journal of Medicine describes the foundation of medical education:

Almost a century ago, Abraham Flexner, a research scholar at the Carnegie Foundation for the Advancement of Teaching, undertook an assessment of medical education in North America, visiting all 155 medical schools then in operation in the United States and Canada. His 1910 report, addressed primarily to the public, helped change the face of American medical education.

American Medical Education 100 Years after the Flexner Report

Two physician members of the National Emergency Medical Services Advisory Committee referenced the Flexner report when discussing update options to the 2009 National EMS Educational Standards in an all-day roundable on March 28, 2012 (agenda).

All professions with significant academic preparation go through this type of review process.

I used the results from evaluation of the Masters in Business Administration program to discuss the state of EMS Education in 2009.

The Ford Foundation and Carnegie Corporation criticized business graduate education in 1959 as filled with:

  • Weak Students
  • Inappropriately trained faculty members
  • Unintellectual curriculum
  • Poor research

What Direction for EMS Education?

From "sticky side down" first aid mechanic to health care professional

The 2009 Educational Standards vaults paramedicine out of the vocational training arena. It will have the same impact as the Flexner report had on physician education and the Ford/Carnegie reports had on Masters in Business Administration programs.

But we have signficant gaps to fill to satisfy the medical professional model.

Need appropriately trained faculty members

I will never forget talking to a community college assistant dean about the Educational Standards. An experienced paramedic with years as a state-credentialed paramedic instructor, she shared that she recently got her associate degree. The associate degree was from the same paramedic program she was running. Not sure she could complete a bachelor degree.

Most community college leaders are required to have master's degree, often they have a Ph.D. or Ed.D. terminal degree.

I have no doubt she is a dedicated, passionate and effective paramedic instructor … but she needs better academic credentials.

The biggest push back to CoAEMSP accreditation of paramedic programs was the requirement that the program director have a bachelor degree. (2008 fact sheet)

In the academic world, those with terminal doctorial degrees "create knowledge" and impact professional/graduate educational programs.

Will you step up?

Mike "FossilMedic" Ward

“We have a firefighter shot” Scott Miller 1992

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Remembering a near-miss with LAFD Light Force 35

The 1992 Los Angeles riots after the Rodney King verdict forever changed the perception that firefighters and paramedics were immune to violence during civil disorders.

This eight minute compilation of news video and LAFD radio traffic shows the chaos encountered by the crews.  Crews were "losing windshields" and encountering bottles, bricks and gunfire … with no police assistance available.

At 2:30 into the video is the alert by Light Force 35 that they have a firefighter shot … followed by other companies reporting gunfire.

 

Jordan was riding directly behind Miller as Truck Company 35 navigated through the smoke and mayhem of Western Avenue. He saw the handgun, then the flash. "Geez, they're shooting at us," Jordan recalled thinking.

Craning his neck, Jordan saw Miller slumped on the wheel. The captain pulled an emergency brake and the 55-foot-long vehicle lumbered to a stop.

Blood was squirting from Miller's neck. Jordan, a wiry firefighter who had worked at some of the city's busiest stations, had seen his share of gunshot wounds. This one wasn't good. "I thought he was going to die," he said. Another firefighter pressed his hand against Miller's neck to stem the bleeding as the crew loaded him into the back of the truck.

Jordan jumped behind the wheel and took off for Cedars-Sinai Medical Center.

Robert L. Lopez (May 04, 2009) 'Miracle' firefighter shot during '92 LA riots back on job. Los Angeles Times

 

 

 

 

 

 

 

 

 

 

Near exsanguination results in stroke

Laying on the engine cover of the open cab Seagrave tiller truck, Miller, 33,had lost so much blood through his ripped carotid artery that he suffered a stroke.

Scott Harris (April 29, 1993) The Right Choice for Capt. Scott Miller : This 34-year-old Granada Hills family man, this grown-up boy-next-door . . . seems to understand what is expected of him. It has become a matter of duty. Los Angeles Times.

Los Angeles Times also did a video on Miller in 2009:

20th Anniversary Observation:

John North (April 27. 2012) LA riots anniversary: firefighters recall dangers   KABC-TV, Channel 7.

Mike "FossilMedic" Ward

“Rush” recreation of Niki Lauda ’76 crash

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Another Great Racing Movie in the Making

The 1966 "Grand Prix" movie remains a motorhead's favorite, with real racing scenes and cameos by many of the era's competitors. Got a Blu-Ray copy last year for a "boy's night in."

Ron Howard is producing "Rush" which chronicles the 1976 Formula 1 season-long battle between Austria's Niki Lauda and Britain's James Hunt.  Lauda suffers a near fatal crash on the first lap at the Nürburgring.

During the first lap of the 1976 German Grand Prix, Niki Lauda's Ferrari 312B2 spun and hit an embankment off the side of the track. His helmet became dislodged form the impact, and the car fuel tank ruptured.

The car was then hit by another, and it caught fire. Niki Lauda escaped with his life thanks to the combined actions of fellow drivers Arturo Merzario, Guy Edwards, Brett Lunger and Harald Ertl rather than by the ill-equipped track marshals.

At the time, safety vehicles took about 10 minutes to reach the driver, since the accident occurred several miles along the circuit.

RECREATING THE INCIDENT

Dale, (or nurburgdale) writing in the Nürburgring-focused blog Bridge to Gantry, documents recreation of the pivital scene as posted by PistonHeads:

For the full story check my blog post here: http://goo.gl/upJ9v.

Out walking the dog and I happen across one of the most amazing scenes in Ron Howard's new movie; "Rush". Of course, I had my trusty pocket cam… don't know about you but I can't wait to see this movie. Anticipation!

More info at http://www.bridgetogantry.com

It was the last time a Formula 1 race was held at the 'Ring.  The PistonHeads link includes pictures of the production.

Mike "FossilMedic" Ward

Update:  If interested, the BBC Four documentary mentioned by Joseph Schmoe in the comments is excellent!

Eagles “State of the Science” 2012 Agenda

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Topics that will be covered in 10 minute data bursts

The 2012 Agenda for the EMS State of the Science was posted.

Here are the topics the U.S. Metropolitan Municipalities EMS Medical Directors Consortium will be covering Friday and Saturday:

  • Myocardial Infarction
  • The Outcome of Recent Outcome Studies
  • New Devices, New Protocols and New Concerns: Navigating in the "New" Times of Budgetary Constraint
  • Mini-Symposium about Call Center Issues in EMS
  • Mini-Symposium about EMS and Trauma Care
  • Alternatives to EMS patient disposition: Handling 9-1-1 System "Loyalty Program Members"
  • Evolving Considerations in Prehospital Emergency Care Practice
  • The Therapeutic Edge: Challenges in Pregnancy and Asthma
  • Issues in Destination Hospitals and Process Analysis
  • Approaches to Termination of Resuscitation
  • Safety and Risk Management Concerns in PreHospital Care
  • Evolving Considerations in EMS Data Evaluation

More than 50 nuggets presented in ten minute blasts. Hundreds more contacts, conversations, and socializing. Plus, lightning rounds with the Eagles.

It is to EMS what FDIC is to fire.

Mike "FossilMedic" Ward

related posts:

Christmas Dawn 1971

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My first Winter Carnival on the job

Brian and I joined the volunteer fire department at the same time. At 18, he was already focused on his goal to be a physician, attending classes at the local university.

To expand his portfolio, Brian was working as a part-time emergency department technician at the flagship community hospital.

I spend Christmas Eve evening as the ambulance crewmember in charge on the VFD ambulance, Brian was working at the hospital.

It was a dry and warm day, almost hitting 60 degrees. Was above freezing that night, much warmer that the night we ran the sports car crash on the parkway (story here).

Carrying people to the hospital

Advanced First Aid was the certification required to ride as the crewmember-in-charge.  Gasoline and oxygen were the two primary elements of care.

Already experienced the thrill of a 90+ mile-per-hour transport doing chest compressions in a low-top Cadillac ambulance. My shoulders were firm against the ceiling as the backboarded patient was on the stretcher. That 472 cubic inch motor was strong!

Our new Ford/Swab modular ambulance came with an advanced resuscitation tool, a Brunswick HLR 50-90 oxygen powered mechanical resuscitator. Bought a second one for the high-top Cadillac

pontiacambulance provides a video of the operation:

Our experience was that the chest compressor would "walk" even with the chest and shoulder straps tight.

When the fire company responded to assist on a cardiac arrest, they would place the patient in a "Reeves" flexible stretcher.

The plunger would be further secured with triangular bandages tied to the sides of the Reeves stretcher.

The fire company prided itself on the speed and smoothness in applying the HLR machine. It was one of the skill drills frequently performed in the station.

Telephone dispatch

Ambulance runs after 11 pm were dispatched over the "red phone." It was less disturbing than striking the station's tones, turning on the bunkroom lights and activating the volunteer pagers.

Fire companies were rarely dispatched with the ambulance. The ambulance would need to call for assistance once arriving at the scene. A little tricky, since none of the ambulances were provided a portable radio.

"Husband is gurgling in the bed"

That was the information dispatch gave me over the red phone at 4 am Christmas morning.

We were still responding to the incident when our fire company was toned out. The wife called back and used one of the few trigger phrases for an automatic fire company ambulance assist – cardiac arrest.

Many of the lights were on at the house and front door was open. She was doing CPR when we ran up the stairs with oxygen, suction, bag-mask-valve and aide bag. 

Following the HLR protocol, we got him off the bed and into a larger room.  Suctioned his airway, placed an oral airway and started two-rescuer CPR with the bag-valve mask. 

By time we were in a rhythm, I could hear the faint sounds of a wailing Federal 2QB.

I assured the wife that we were doing everything possible for him, and that another crew would be arriving soon to move her husband to the ambulance.

 

 

 

 

 

 

 

 

 

 

 

 

 

If we had not called dispatch, or were not standing at the ambulance, the fire company assumed CPR was in progress. 

Two of the guys pulled out the HLR machine and Reeves. The engine driver would re-position the ambulance for rapid departure, then set up the stretcher.

The performance was great. Smooth packaging and quick movement to the back of the Ford/Swab ambulance.

We were getting pulses with compression throughout the transport.

Once we got him on the hospital gurney, the physician looked into the wide and fixed pupils with an ophthalmoscope. The vessels radiating from the optic nerve showed coagulated blood, appearing as a railroad train.

The appearance of "box cars" in the back wall of the pupil were a grave prognosis. It was used as an indicator of death when ambulances delivered pre-paramedic cardiac arrest patients.

Ran into Brian, who was looking a little shell-shocked. This was the fourth or fifth patient he had to wheel to the morgue since 11 pm Christmas Eve.

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We had done everything we knew in 1971.

In re-telling the story, I feel like Squad 10 Firefighter Johnny Gage after he "rescued" an electrocuted lineman in the two hour pilot of the Emergency show. 

I wonder if there would have been a different outcome if we had an AED?

Mike "FossilMedic" Ward

If you are working, may your day be boring. I hope that it is full of food, laughter & joy.

Please spend a minute thinking about our brothers and sisters in the armed forces that are deployed in hostile, desolate or dangerous environments.

Detroit EMS: One Year Later

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Charlie LeDuff posts an update

One Year Later: Detroit's EMS System Still in Need of a Cure: MyFoxDETROIT.com

DETROIT (WJBK) – It's a story we've been covering for more than a year — FOX 2 taking a closer look at the way Detroit manages its ambulance service. What we uncovered was a deadly system on the verge of collapse.

Posted December 20, 2011

Mike "FossilMedic" Ward

Earlier posts:

July 02, 2011: “More Ambulances, More Training, Less Fear” New Detroit Fire Commissioner Donald Austin reaches out to medical community, says 22 new transport units will start arriving in January. Not writing up guys for minor uniform infractions

Yesterday's report raises questions if the ambulances have been ordered.

Not dead until the ambulance crew assesses the patient. A Winter Carnival memory.

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"… he a member of (prestigious) Rescue Squad"

This is the fifth Winter Carnival with Firegeezer. Each December 25 I post a Christmas-related story from my time "on the job." 

For 2011 I am going to share a story about two teen-aged volunteer firefighter/EMTs working their first Christmas Eve.  Brian and I started at the same time with the hometown volunteer fire and rescue department.

In thinking about the story, I remember an incident when we were both on the ambulance … and a lasting lesson.

"Respond to the GW Parkway for a Signal 9-I on fire "

The George Washington Memorial Parkway is a limited access highway build in the early 1930s that runs down the Virginia side of the Potomac River, originally designed as a "grand gateway and greenway to the Nation's Capital."

Signage is rare on a scenic greenway. In many fire department responses, the actual location of the car crash would be somewhere else on the parkway.

Our response protocol was for the fire company to head to the reported location of the crash, the ambulance would go the opposite direction.

On this winter night, the engine company arrived first. Reported a sports car overturned and on fire. Brian was driving the ambulance and took the next cut-over so we could turn around and get to the scene.

"Fire is out, police say the driver is deceased"

That was the radio report from the engine lieutenant. In that era, none of the firefighters on the engine were EMT-credentialed. Brian and I took one of the first EMT classes run at the community college earlier that year.

The lieutenant had four years at our station. Ran a lot of calls on the parkway and knew many of the Park Police officers on a first-name basis.

The first arriving police officer was a member of a prestigious rescue squad on the other side of the river. The officer used the cruiser's dry-chem to knock down the fire in the interior of the upside down convertible sports car.  The engine crew delivered a couple of blasts from the pre-connect to knock the rest of the fire down.

As we walked up to the scene, it appeared that the car drifted into a stone barrier wall, flipped over and skidded for a couple of hundred yards. The convertible top was ripped off.

There was just enough space between the car and the wall to partially open the driver's door. The driver remained belted into his seat.

Before we got to the patient, the lieutenant told us to get the body bag and lay it out on the stretcher. Fire was building up behind the dashboard. The lieutenant has his crew blast the interior one more time.

Crowing

Crowing is a high pitched sound upon inspiration. More audible than a wheeze. Usually associated with Croup or upper respiratory blockage issues or partial obstruction of the trachea.

It sounded like a baby's cry. Right after the blast from the fire hose.

That startled everyone.

We quickly removed the driver and placed him on the stretcher. In the cold air I could see that he was breathing. His face, arms and chest were black with soot and flecked with yellow dry chemical powder.

We quickly got him into the ambulance, started oxygen and a trauma assessment. He was breathing too slow and Brian started using the bag-valve-mask to breath for the patient.

He had partial thickness burns on his face and full thickness burns to the top of his hands and forearms. It looked like the tops of his hands may have been dragged along the road after the car overturned.  There was some head trauma.

I was finishing the rapid assessment when the lieutenant opened up the ambulance door and said no baby was found. He gave us a driver and we headed to the trauma center.

After this crash, I NEVER accepted as gospel some stranger's assessment of the patient. They were not dead until I assess the patient.

We did something right, here is your subpoena

Almost two years later, everyone on the incident was deposed.

The driver survived and was suing the park police, fire department, federal government (owns the parkway), designer of the brick retaining wall, manufacture of the 15 year old sports car, the shop that maintained the sports car and the Moon to recover damages from his accident.

We never went beyond the deposition phase.

Mike "FossilMedic" Ward

Police CPR Saves Houston Reporter

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Right place, right time

Richard Connelly got my attention with this opening in the November 14 Houston Press:

John P. Zepeda of the Metro PD's canine squad had performed a routine bomb search at the Ensemble light-rail station October 28. Finding nothing, he tried to head back.

But train after train was filled with morning commuters headed downtown, so he and his dog waited things out. Which turned out to be a lucky thing, for as they were waiting for yet another train they heard someone yell for help.

That someone was dragging Houston Press music editor Chris Gray off the tracks, where he had fallen after suffering a heart attack.

Music Editor Chris Gray Had Luck on His Side When He Had His Heart Attack

Security camera documentation of incident:

Chris Gray Rescue Video from Village Voice Media on Vimeo.

Music Editor Chris Gray's Heart Attack: The Video

Nice work!

Update:  FireHat points out that Officer Zepeda is a retired Houston Fire Captain.

Mike "FossilMedic" Ward

Congrats to Captain Happy Medic

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Paramedic/firefighter Justin Shorr takes a headquarters gig

From his website:

On Monday I hang up my turnouts and late nights without sleep in exchange for a promotion and a reassignment downtown. That also means giving up that ever so comfortable and vacation friendly schedule.

I was bummed at first until I realized that now the HMjrs are in school and we can’t just pick up and go somewhere whenever we feel like it anymore. When this job at headquarters opened up it seemed too perfect a fit.

Monday I will take over the vacant CQI position that has been retooled ever so slightly to now officially include research. Talk about a perfect chance to mine the data to see what is really going on out there. I have lofty goals for my service, but it’s going to be a long while of playing catch up and learning the new job before I can start going forward with new ideas.

I also have a new political landscape to consider and will be in direct contact and communication with the regulatory agencies, budget writers and vendors that all have a stake in patient care in my jurisdiction.

It’s an amazing opportunity for me both professionally and personally and I am beyond excited to get started.

A Whole New World

Great job!

Mike "FossilMedic" Ward