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 MDs....you 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?

If You Don't Care....

We have another frequent flyer (read about some others here, here and here). Shocking I know. It seems that when one disappears (dies, moves, is sent to jail) another one appears. Some houses just generate a lot of calls throughout the years. The people living there are in poor health so we go a lot. This was the case for our new frequent flyers. Except they've moved on from calling once every few months to calling 6 times in the last week.

In the last 4 days I've worked this lady had called four times. One time each day. Each time she had complained of pain around her kidneys. The first time we started our assessment but AMR showed up before we got too far into it. We got her on the way to the hospital quickly and I assume the medic on the ambulance took care of pain management.

The next day she called again. I asked if she felt the same as the day before and she said yes. I asked what had been done in the ER and she didn't know. All she knew was they sent her to get her blood drawn at the lab and now she was waiting for the results and she had a script for Vocodin. AMR was Johnny on the spot this time as well and we shipped her off to the hospital rather quickly.

While I was off for the next 4 days she called twice.

Then I came back and started my shift with a call from her. This time the pain was the same. All the answers to the pertinent questions were the same. She still didn't know what was going on. This time she did have her lab results and she said that she was waiting for her Dr. appointment to go over the results with him/her.

The last time she called was the most interesting. This time her son was there. He, assuming I didn't speak Spanish, proceeded to tell me what was wrong with his mom. He said she had a seizure. She denied this. He said she was throwing up. She denied this too. She did say that her lungs hurt in addition to the kidney pain.

Before I could get any further the son said that his mom had had surgery on her stomach last week.

HUH!?!

I asked my patient and she confirmed it. So I asked what type of surgery. No one knew. I asked what it was on and no one knew. I asked if they took something out and again, no one knew. The patient now said that her incision site was bothering her.

And in walked the AMR medic. Thankfully it was one that had been here before. I asked her if she knew about the surgery. She didn't. So I wasn't the only one kept out of the loop on that one. So we loaded her up and sent her off to hospital again. We'll see what happens this time.

My question is how do you let someone slice you open without knowing the reason. How was this surgery going to fix whatever problem she had? I mean if you don't care enough to know what the MD is doing to your body who will?

Why So Serious?

There were cops everywhere. The blue and red lights on their vehicles mixing with our red and white lights caused an almost strobing effect on the scene.

A sergeant met us at the sidewalk and said the guy was inside on the floor. The assailant was gone. Walking around the outside of the house were several other officers. From the back of the K-9 unit a police dog could be heard excitedly barking. In the front yard a woman sat in a state of shock.

The blood trail started on the walkway to the house. As we followed it up the three steps to the front door the splotches of reddish brown grew in size. Through the door I could see my patient laying on his right side. He was wearing a sweatshirt and Levi's which were both soaked with blood. The man was trying to cradle the side of his face and head with a towel.

I squatted down (I didn't want to kneel like I would normally do because of all the blood on the floor) next to my patient and introduced myself. He was alert and oriented but understandably a little panicked. He said that he had been stabbed at least once and then had walked into the bathroom to get a towel. On his way back outside he had only made it to the living room.

I had the man remove his hands and his towel so I could get a look at what I was dealing with. He had a full thickness laceration starting about 2 inches behind his left ear. The knife had sliced forward from that point just missing the ear lobe and stopping less than an inch away from the corner of the mouth. It looked like the knife wielding bad guy had tried to slit my patients throat but was thwarted by a downward tilted head. Unfortunately for my patient the bleeding had stopped. He was too low on blood the keep bleeding from this serious wound.

My engineer started cutting the clothes off my patient while I applied a trauma dressing. As we rolled the patient off of his right side we discovered another stab wound. This one was in the upper right quadrant of his abdomen right where his liver should be. It was bleeding quite a bit and his skin was bulging from blood that had accumulated it. In my mind my patient just went from very serious to critical.

Thankfully AMR showed up just then. The paramedic had been told outside that it was a bad facial wound but realized as soon as he saw us working that it was more serious. We placed a hasty dressing on the abdominal wound and lifted the patient onto the gurney. On the way out we put him on oxygen. Since we couldn't strap the mask to his face we simply tried to balance it as best we could.

In the back of the ambulance I checked lung sounds to make sure the knife hadn't caused a pneumothorax. The EMT had everything set up for an IV so I went for it. I heard the driver jump in the front seat. She asked if we were ready to roll. I asked for 5 seconds. Within three seconds there was a large bore IV in his left arm. We then rolled code 3 to the trauma center at the local university.

The patient was compensating well for the loss of blood. While his heart rate had increased his BP stayed above 110 systolic. We watched his BP closely. If it fell too far we would have to give him some fluids to make up for the loss of blood.

With one IV in and dressings on the wounds I found I had the time to do another quick head to toe.I hadn't missed any other wounds. Then I focused on keeping the oxygen mask on my patient and talking to him. Both to reassure him and to continually assess his mental status. An altered mental status would probably be one of the earliest signs that he was losing too much blood.

While talking to my patient I noticed there was some blood coming out from the bandage on his face. A lot of blood. I asked for another trauma dressing and held both in place with direct pressure. The patient was now becoming slow to respond to my questions. His BP was falling. We gave him a fluid challenge to keep it up. The problem with that is that blood carries several vital things to and from the body which saline is not capable of doing. At best we were stop gapping. The patient needed blood and surgery, fast.

The AMR medic started a second line, put the patient on the heart monitor and rechecked vitals. He also called ahead to the medical center to let them know we were coming.

Just a few never ending minutes later we pulled up to the ER. Everyone cleared out of our way and stared at out blood covered patient and gurney. Inside we were met by an army of hospital staff. We swapped the patient over to the hospital gurney and I started to give my report to the MD.

Now I don't mean to offend trauma docs but you guys are arrogant pricks. At least a lot of you are.

I had not even finished my first sentence and the doctor put up his hand and ssshhhhh'ed me. He didn't want to hear a thing I had to say. No chief complaint, vitals, treatments....not a thing. He wanted his trauma nurse to do a once over on the patient and to tell him what she had found. The last thing I heard was the MD yelling (so much for staying calm, cool, and collected) that he wasn't interested in the laceration to the patients face.

After the call the AMR crew cleaned their rig and did paperwork. They were kind enough to drop me off at my station as well. When I got back to the station I had to swap out my turnouts so I could wash out the blood on the ones I was wearing. Then it was back to bed.

What A Month (part 4)

Day 7, Friday

I'd never had Lasix before. It worked really well. Within a couple of hours I was able to breath easier. The fluid build up around my gut had started to abate. This was a good thing. But then my labs came back.

My nurse came in and said that because I had been retaining fluid I my body had diluted its potassium. I'm not sure I believe that explanation. If that were true wouldn't all my electrolytes be diluted? Not that it mattered. They wanted to get my numbers up so I was given IV potassium. Another problem was that the Lasix was causing me to pee off the potassium in my body.

Because I was going to need labs drawn quite a bit my RN suggested a PICC line. This is basically an IV started in the upper arm (under the bicep) but the catheter is inserted to just before the right atrium. There are 3 different lumens allowing multiple fluids or medications to be administered and one line allows for blood draws. This kept me from having to be stuck every time labs were needed.

A specially trained RN came in for the procedure. She explained what she was going to do and then started preparing. Because of where the catheter is placed it is a sterile procedure. She draped me with a sterile sheet and prepped the area. During the insertion I wasn't allowed to look at the area. When I asked why I wasn't she informed me it was because I might breath germs onto the wound. So I asked if I could watch as long as I held my breath. She let me. Within a few minutes I had the PICC line in place. An x-ray tech came buy and confirmed that the placement was good. Every day after that the PICC RN would visit me and check on her line.

The rest of the day was kind of a blur, mostly because there wasn't much to distinguish it from other days. They just kind of meld together. I still wasn't sleeping well. Every night I was getting a fever and then breaking it causing me to sweat everywhere. Mostly I hurt and was miserable. I couldn't get comfortable.

The biggest thing was the ability to breath easier.

That night my wife left my side and went up to labor and delivery. The baby had been having moments where his heart rate would drop so they wanted her to stay the night. I told her that if she had the kid I'd hobble my way up there.

Day 8, Saturday

I was still being treated with the Lasix and the Potassium. My nurse, frustrated with my continuing low lab levels, asked if I'd be willing take some Potassium by mouth. It comes in about an ounce of fluid. It's super salty and nasty. At first they were going to dilute it in orange juice but I decided that was a bad idea. That would make it so I had to drink several ounces of bad tasting medicine. Instead I slammed the medication and then used the orange juice as a chaser.

All day we alternated between checking my blood for potassium and me drinking it. Talk about a bad day.

That evening, just after shift change, my RN looked in before making a lot of noise and noticed I was asleep. She let me sleep and came back 2 hours later. Such a great nurse! That night I was feeling better than I had for a week but that's not saying much. I decided to take myself off of the oxygen to see if I would de-sat. I didn't. I also stopped taking my pain medication. Not because I wasn't in pain but because I don't like the way it makes me feel. At that point I'd rather deal with the pain than the side effects.

Day 9, Sunday

By this point I was tired of being in the hospital. Sunday was much like Saturday with the RN constantly checking my potassium levels and giving more of the stuff. I was also to the point where I would try to stay off of the telemetry as much as possible. It's a real pain to have all those cables, cannula, and IV tubing connected to you all the time.

That afternoon the doc came by. He asked me how I was doing so I told him I wanted to go home. I listed the ways in which I had improved. He agreed that me wanting to go home was a good sign but he still had some concerns. We talked about the fact that I had a kid on the way....soon. Finally he agreed. He told me that since I knew what complications to keep an eye out for that he was willing to send me home but that I had to come back immediately if something was amiss. I reassured him with a joke that I was just going to be upstairs in L&D.

By 1930 I was home. It had taken them more than an hour to finish all of the paperwork and get everything else ready to send me home. Once at home I realized that my bed was not comfortable at all in my current condition. Still, it was good to be home.

Day 10, Monday

Monday morning my wife and I went back to the hospital. This time for her. She had a non stress test done to check on the baby. All was relatively well so they sent us home. The rest of the day was spent napping, at least by me.

Day 11, Tuesday

Again we packed up and headed to the hospital. Instead of a test they were going to induce labor. You can read more about the entire experience and see some cute pictures of the baby on my wife's blog.

Needles to say we were thrilled that that month is over.

The Choice

You ever run a call on that homeless guy, or the drunk (sometimes the same person) and had PD there. If so, I'm sure you've probably heard the cop give the individual in need of "help" this offer: You either go to jail or to the hospital.

I hate this phrase. I understand why officers do this. They don't want to deal with said person, they don't want to do the paperwork and they probably figure that the hospital will do more good than jail. I completely understand those points. If I were in their shoes I would be tempted to do the same thing.

But, this practice comes at a price. Now this probably inebriated person is going to 'choose' to go to the hospital. Most of the time they never called 911 and they have no medical complaint. Now we have to take an ambulance out of service.

For those of you that don't know, ambulances don't grow on trees. If you have an emergency in my area, a firefighter paramedic will be there fast and is able to perform advanced life saving medicine. But he can't get you to the hospital. So now the ambulance that would have been there in 5 minutes is now transporting someone that doesn't really want to go to the hospital. The next ambulance is coming but they are 15 minutes away.

Once the patient gets to the ER he'll take up a bed. Have you ever had to wait to be seen in the ER? Now this patient will be seated in the ER waiting room since he has no real medical complaint but he's still taking up time, space and money when he originally didn't want to be there.

So is the answer to have to cops take the guy into custody? Is that going to accomplish anything? Would it be more wasteful? Maybe there's another answer out there. I'm not sure. I just hate that offer, jail or hospital.