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Thursday, September 18, 2014

Postponing The Inevitable

In my area resources are dispatched to EMS calls in two waves. First, as soon as the location of the medical emergency is confirmed, the fire department is dispatched. We roll with lights and sirens to all of them because the person calling 911 doesn't always get things right (for instance calling because their husband fell and needs help getting up only for us to find out he fell because he's dead). The call taker in dispatch then triages the call (using an EMD program). Once the severity of the call is determined the ambulance is dispatched with the appropriate response (code 2/3, low, medium or high priority). This allows the most critical patients to have access to an ambulance theory. Once the ambulance is dispatched the dispatcher will inform us on the radio the nature of our call.

We were on our way to get dinner in the East end of our district. While sitting at a signal light waiting for the green arrow the radio chirped. Beep beep, "Truck 51, medical response. 1234 5th street. Map page 117 xray."

We were only a couple of blacks from the address and we were facing the right direction. My engineer flipped on the lights and hit the air horn. We were no longer waiting for that green arrow.

We pulled up to the house less than a minute later. The 911 call taker was still getting information from the caller when we walked up. The ambulance had yet to be dispatched.

I asked the lady what was going on. She replied that her husband had collapsed in the bathroom and was no longer breathing. The call had taken a turn for the more serious.

I turned to my captain and asked him to go grab the Autopulse. I grabbed the victim and drug him out into the bedroom where we would have enough room to work. I immediately checked for a pulse and then started on chest compressions. He couldn't have been down very long.

My engineer grabbed the BVM and started breathing for the patient. My captain soon returned and let me know he had called for the next due engine just in case we needed the manpower. Once the Autopulse was on things started to get a little less hectic. I placed the defib pads on the patients chest and checked a heart rhythm. PEA or pulseless electrical activity.

PEA is a heart rhythm where the heart, electrically speaking, is working ok. The problem is the muscles are not responding to the electrical impulses telling them to pump.

We resumed resuscitation efforts. AMR showed up and they had an intern with them (the son of a member my department). I allowed him to start the IO and then to intubate the patient. The intern performed both skills perfectly.

We then settled into a routine of medication administration, CPR and heart rhythm/pulse checks. My captain had already talked to the wife and explained what was going on. She was prepared for the worst.

After a third round of Epinephrine and some more chest compressions we preformed another rhythm/pulse check. On the heart monitor the wave form had changed. And at my patients neck there was a corresponding pulse of blood.

 He had a pulse.

We quickly but carefully moved our entire operation to the back of the ambulance. There the poor intern tried to remember all that he had to do while being peppered with questions from his preceptor and me. He did a good job.

Before arriving at the ER we had a repeat set of vitals, a 12 lead EKG and had started inducing hypothermia. My patient was even starting to fight the ET tube. A good sign. He might actually live.


A couple of weeks later we stopped by the house where my patient had lived to check on him. His wife informed us that he had lived for 10 days in the ICU under heavy sedation. He had suffered a stroke which had caused the cardiac arrest. There was no possibility for recovery. All we did was postpone the inevitable and give the family a chance to say good bye.

Thursday, September 4, 2014

Emergency Medical .....Prevention?

In the fire service there is a saying. The fire service is 200 years of tradition unimpeded by progress.

While not really true it can, at times, feel like it is. There seems to be some in the EMS world that are trying to follow that tradition.

Recently an article was written for the Contra Costa Times that covered a pilot program in Alameda County. Some of the paramedics from two departments within the county (Hayward and Alameda City) are receiving extra training. They, along with medics from a total of 12 projects throughout the state, are going to be able to not take patients to the hospital. Instead they will have the latitude to take the patient to an urgent care or other health clinic. This would potentially save the patient an expensive ambulance ride to the hospital and would (again potentially) free up the emergency department to treat someone that is actually seriously ill.

The program also includes post clinic visits by the paramedics for some limited patient follow up. The goal is to prevent the need for another 911 call. Prevention is better than a cure.

There has been some serious opposition to this pilot project. I'll start with the opposition in the paper...The nurses union. The nurses union is screaming that paramedics aren't capable of doing something like this. That we lack the training/knowledge.

Tricia Hunter, executive director of American Nurses Association/California said, "They're still not licensed registered nurses, not licensed physicians, not licensed mental health professionals." 

She's absolutely right. Paramedics are not RN's or MD's. We are however licensed paramedics. Paramedics can do most (if not all) of the commonly accepted nursing skills in CA (starting IV's, assessments, medications administration...) plus medics can do some things that RN's can't like pleural decompression. For a list of what paramedics can do in CA click here and scroll down to scope of practice. Oh, and did I mention that paramedics are trained to do these things generally under standing medical orders (meaning we diagnose which patients need what treatment and do the treatment without consulting anyone) and to do them in the field? Anyone can start an IV in a well lit Emergency Room. Try it on a freeway, in a wrecked car that's upside down, in the rain and at night.

So let us not go down the road of paramedics not having the training.

Really the nurses union is worried about losing jobs. Paramedics taking their patients to other care facilities and  medics going out and trying to prevent the need for emergency health care in the first place (by visiting patients in their homes) could lessen the need for nurses. I get it. That's the role of a union. Save jobs. But I don't agree with that, if it means we can't even look into the possibility of a better method of health care delivery .

Vicki Bermudez of the California Nurses Association said, "We think the money is better spent on existing services we know work." 

Really? You think our current model of health care works? Long wait times in Emergency Departments. Outrageous costs. Everyone seems to blame health insurance companies but they're not the ones charging $5 for two pills of Tylenol. Clearly you haven't been a patient in a while. Anyone with some common sense can reasonably deduce that our current health care delivery model isn't working. Let's try to fix the system. I'm not saying this is the solution but it may be part of one. Let's try it and find out. 

And obviously the guys with the medical license (the know...the guys and gals that medics and nurses work for) think this idea has merit. So get with the program.

Enough with me ragging on the nurses union.
Now I'll move on to other complaints I've come across from people that have read this article. I'm going to generalize these somewhat.

There is the complaint about a cousin/brother/father/grandmother that was treated incorrectly on a call one time ergo medics can't do this. All these stories are anecdotal. To the people that use these arguments I have two points. First, you weren't there and you probably don't have all the facts. It's quite possible what the medic did was correct. Second, hypothetically speaking, if you were there AND had all the facts, that doesn't preclude the possibility or even the likelihood that the medic that treated your family member/friend/significant other was probably an idiot. They are out there in every profession. You may have just been unlucky and got one.

Then there are people that claim medics can't do this because of liability issues. Now remember, I'm talking about CA and not anywhere else. I don't know the laws in the other states. Here (and I assume almost everywhere else) medics work under the medical license of a doctor. As long as paramedics follow proper protocols they are covered. 

The CA Health and Safety Code Section 1799.104 (b) states "No EMT-II or mobile intensive care paramedic rendering care within the scope of his duties who, in good faith and in a nonnegligent manner, follows the instructions of a physician or nurse shall be liable for any civil damages as a result of following such instructions."

Section 1799.106 (a) goes further and states, "In addition to the provisions of Section 1799.104 of this code, Section 2727.5 of the Business and Professions Code, and Section 1714.2 of the Civil Code, and in order to encourage the provision of emergency medical services by firefighters, police officers or other law enforcement officers, EMT-I, EMT-II, EMT-P, or registered nurses, a firefighter, police officer or other law enforcement officer, EMT-I, EMT-II, EMT-P, or registered nurse who renders emergency medical services at the scene of an emergency or during an emergency air or ground ambulance transport shall only be liable in civil damages for acts or omissions performed in a grossly negligent manner or acts or omissions not performed in good faith. A public agency employing such a firefighter, police officer or other law enforcement officer, EMT-I, EMT-II, EMT-P, or registered nurse shall not be liable for civil damages if the firefighter, police officer or other law enforcement officer, EMT-I, EMT-II, EMT-P, or registered nurse is not liable."

As long as medics aren't negligent I think we're ok.

Next there are those out there that think paramagics don't have the ability to figure out where a patient should go.

Are you kidding me? Paramedics make destination decisions all the time. where I work we have to decide between the closest hospital, trauma centers, stroke centers, burn centers, and cardiac centers all while keeping in mind patient condition, traffic, helicopter flight time and helipad at the hospital, and patient requests. In other counties in which I've worked we had to decided weather a kid needed to go to an emergency department approved for pediatrics, a pediatric medical center or a pediatric trauma center....and that was just for the kids. I don't think that adding one or two more possible places to drop off our patients is going to be very taxing.

Another thing detractors say is that the medics in their area are too busy to do follow up visits. News flash. Paramedics in almost every urban area are busy. But if we take the time to do a little preventative maintenance on our frequent flyers maybe, just maybe, they will call 911 a little less often. Which in turn will me the medics will be a little less busy. Also I'd much rather do a follow up visit at 2 in the afternoon versus responding to a 911 call to the same person at 2 in the morning. That's the same as saying that fire departments are too busy to work on fire prevention. Do you have any idea how many lives have been saved by smoke alarms/detectors, better fire codes when in building construction, sprinkler systems and the like? I bet it's not a small number. Again, prevention is better than a cure.

And the safety net (my phrase not theirs) that the nurses union says we are operating without (I know I said I was done picking on them. I'm not)....that's why we have cell phones. My medical director, a doctor, is just a call away. When in doubt, call for further direction. And if we're not sure weather a patient should be going to an ER or Urgent Care....take them to the ER.

Now I understand that this is a pilot program. When we try it things may not work out the way they are supposed to. But the current system is broken. We need to do something. Why not this?

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