My daughter suggested doing a series of "If I were in charge" posts, since we talk about it all the time.
So. Here goes.
If I were in charge around here, I'd do a lot more coordinating than gets done. I'd work on getting all of the agencies in the county to work together. EMS and Fire.
The way it is right now, each agency does its own training- or not. Some agencies have their shit together, and do a GREAT job of providing regular, high quality training. Others don't. Most are probably somewhere in the middle.
We have found that if we make the effort to find out what training is happening where and when, and ask the right people, we are welcome to go participate in most of the training out there. But in order to do that, we need to know their schedule, and who is in charge, and what they are planning and know all of that in time to ask and get an answer and make plans to go. That is easier to know with some agencies than others, because we know more people in some places than in others.
I have been to training with about 10 other agencies in the county over the years.
It sure would be easier if someone kept all that information in one place, AND if it became "county policy" that all training was "open door," meaning that any county provider would be welcome. It would save a lot of time, it would save money (by not having to pay to provide the same training multiple times to small groups) and it would make a lot more quality training available, especially to the smaller agencies and/or the people from agencies who don't do any in-house training.
I don't understand why this isn't already being done.
We've never run into any problems with going to other agencies to join in their training. Ever. We have always been welcome.
But we (my kids and I) are the only people in the county doing this.
We never see any other people going to training at agencies other than their own except for a couple of pairs of "sister departments" who regularly train together. We don't see individuals making the effort to get invited to training.
Occasionally, on the nightly announcements the county does, an agency will announce their training and specify that "all county monitors are invited to attend" but that happens maybe two or three times a year, at best.
We have a person called the "county coordinator," but he doesn't seem to do any actual coordinating, at least not anything I'd call that. I have no idea what his job actually is, but that's a subject for another day.
Friday, November 4, 2011
Thursday, November 3, 2011
Information Flow
Meant to write about this a while ago, right after the story about my cat, but things didn't go well with the cat, and I was caught up in that for a while, and never got back to the story.
We ended up visiting the vet hospital several times, as the situation went from bad to worse. Turns out the cat had some rare form of bladder cancer. We started him on an experimental treatment, which helped for a while. Longer than we expected, really. But ultimately, there was no cure.
Part of the experience- the part I want to share here- had to do with getting information.
I understand more medical stuff than the average person. I have a fairly large working vocabulary of medical terminology. Anything a doctor (or vet) says to me that I don't understand, I ask about, and ultimately research on my own. I am definitely the kind of person who wants to know what is going on.
It mystifies me that not everyone feels that way. I run into a lot of people who prefer NOT to understand medical issues, even their own.
So there we were, at the vet hospital, in the evening. Cat was whisked off to surgery, I was told to go home, that they'd call me.
They didn't.
I called them.
Was told the cat was doing well and that we could come visit whenever we wanted.
I wanted to go in the middle of the night, but I don't think that's actually what they meant.
We visited the next day, and talked to the vet student assigned to our case. She said there were tests still to come back, and they'd let me know. She ALSO said that the care so far, and the care he still needed, and I don't even remember (red flag!) what all she said, except that it was going to be extraordinarily expensive. And that I had to pay half of it upfront, right now, or end of treatment.
Urp.
To make a long story slightly less long, we ended up seeing two vets, three vet students, the pharmacist, several receptionists and the folks who took the payments.
We spent days (not all in a row) expecting them to call with an update that only sometimes came. Other times, we had to call them, and call them, and try to figure out when to call to get the person we wanted.
In short, I spent a lot of time wanting more information than I was getting. It was frustrating, and it was scary, and we were all already very stressed out by the situation.
And it was right about then that I realized that we see people in that situation ALL THE TIME.
The main problem was that I didn't understand the system there, not having had much experience with it. I didn't know who to talk to about what, how to know when to call or who to call. I had to juggle 5 different medications and their schedules and side effects, something I also had no experience with.
It gave me a huge amount of sympathy, and a reason to take a look at the environment we create when we walk into someone's house after they call 911.
Much of the time, they don't know who we are. They don't necessarily know what is wrong, although sometimes they do. Even when they know what the problem is, they don't always know whether this is capital-S-Serious, or not. They don't know which person on scene to ask, they don't know what our qualifications are, and they don't know what is going to happen next.
All of this "not knowing," on top of a high level of stress, does not generally make for an easy, happy situation.
I have been working on being much more proactive in helping patients and their families understand what is happening, when I can. If I'm involved in a true emergency, and direct patient care is taking all my attention, then I can't direct a lot of energy to the family. My goal is for all of us to get better at that so whoever is able to fill that role, will.
My partner a while back started something that we immediately adopted as our SOP. Hello, my name is ______, this is my partner ______. We're EMTs, and we are here to take care of you until the ambulance gets here.
That is the reality of our role out here. Amazingly, just giving them that much information is a HUGE help in their understanding the flow of things. We used to have a lot of confusion out here, about why so many different people show up, and why there are "two ambulances" when they only need one. (At the time, our rescue was an old ambulance, so although it wasn't actually an ambulance, most people thought it was and were very surprised to find out it isn't. We don't have that problem now- our new rescue looks like a state police car. An entirely different set of issues, that. But people pull over for us!)
As the ambulance arrives (and as the situation allows), I tell the patient that the medics are going to come in, and they will probably ask a lot of the same questions that I've asked. I then introduce the patient and the medics, by name, and make the transfer of care.
Once the patient is in the ambulance, I am usually (but not always) out of that loop. I will wish my (now former) patient well, and let them know I have every confidence they will be well taken care of by the ambulance crew. I can do this because I have made the effort to establish a working relationship with all of the people who might be on that ambulance, so I know them by name, and I know a lot about which I've seen be particularly good at which things. I'm not just mouthing the words.
At that point, my focus shifts to the family and friends.
We make an effort to provide as much support as we can.
We lock doors, turn off lights, feed cats, bring in dogs, etc. We make sure anyone who is going to the hospital knows how to get there. I find myself often explaining to a spouse or child that the fact that the ambulance hasn't left in a hurry isn't because something is wrong- there are some procedures that need to be done that are better done when the ambulance is not moving.
I've talked to children about where their sibling is going.
I've talked to family members about what the sequence of events will be after someone dies, and reassured them that police presence is standard procedure here, and does not mean that anyone thinks they did something wrong.
I've answered I have no idea how many questions about what just happened, what is going to happen, and what isn't going to happen.
I hope I'm able to fill the gap a little, so that people don't feel that additional stress of not knowing who to ask, or what to ask, or where to go.
I just recently had occasion to go to the police department in a city a couple of hours from here. It was a large place, in a large (to me) city, and I had no idea where I was supposed to park, where I was supposed to go, how to get there or what to do once I got to the right window. The entire place was set up with an assumption that everyone who came in there was familiar with the procedures and such. I think almost every "public service" building I've ever been in, from police stations, to jails, to social services buildings, has always had that same sense about it- that you are supposed to already know the drill.
I didn't.
Trying to get someone to help me was a challenge, and the guy who finally answered my question would not win any awards for public relations.
It reminded me, again, of my experience at the vet hospital, and the importance of understanding that many of our patients don't "know the drill," either. They may be going through a totally new experience, having never called 911 before, and have absolutely no idea what is going to happen, or what to expect.
It is way too much to expect them to figure it out on their own under those circumstances. All the SOPs and protocols and procedures we do are very familiar to us, so it's easy to forget that not everyone knows how things go. We have to tell them.
We ended up visiting the vet hospital several times, as the situation went from bad to worse. Turns out the cat had some rare form of bladder cancer. We started him on an experimental treatment, which helped for a while. Longer than we expected, really. But ultimately, there was no cure.
Part of the experience- the part I want to share here- had to do with getting information.
I understand more medical stuff than the average person. I have a fairly large working vocabulary of medical terminology. Anything a doctor (or vet) says to me that I don't understand, I ask about, and ultimately research on my own. I am definitely the kind of person who wants to know what is going on.
It mystifies me that not everyone feels that way. I run into a lot of people who prefer NOT to understand medical issues, even their own.
So there we were, at the vet hospital, in the evening. Cat was whisked off to surgery, I was told to go home, that they'd call me.
They didn't.
I called them.
Was told the cat was doing well and that we could come visit whenever we wanted.
I wanted to go in the middle of the night, but I don't think that's actually what they meant.
We visited the next day, and talked to the vet student assigned to our case. She said there were tests still to come back, and they'd let me know. She ALSO said that the care so far, and the care he still needed, and I don't even remember (red flag!) what all she said, except that it was going to be extraordinarily expensive. And that I had to pay half of it upfront, right now, or end of treatment.
Urp.
To make a long story slightly less long, we ended up seeing two vets, three vet students, the pharmacist, several receptionists and the folks who took the payments.
We spent days (not all in a row) expecting them to call with an update that only sometimes came. Other times, we had to call them, and call them, and try to figure out when to call to get the person we wanted.
In short, I spent a lot of time wanting more information than I was getting. It was frustrating, and it was scary, and we were all already very stressed out by the situation.
And it was right about then that I realized that we see people in that situation ALL THE TIME.
The main problem was that I didn't understand the system there, not having had much experience with it. I didn't know who to talk to about what, how to know when to call or who to call. I had to juggle 5 different medications and their schedules and side effects, something I also had no experience with.
It gave me a huge amount of sympathy, and a reason to take a look at the environment we create when we walk into someone's house after they call 911.
Much of the time, they don't know who we are. They don't necessarily know what is wrong, although sometimes they do. Even when they know what the problem is, they don't always know whether this is capital-S-Serious, or not. They don't know which person on scene to ask, they don't know what our qualifications are, and they don't know what is going to happen next.
All of this "not knowing," on top of a high level of stress, does not generally make for an easy, happy situation.
I have been working on being much more proactive in helping patients and their families understand what is happening, when I can. If I'm involved in a true emergency, and direct patient care is taking all my attention, then I can't direct a lot of energy to the family. My goal is for all of us to get better at that so whoever is able to fill that role, will.
My partner a while back started something that we immediately adopted as our SOP. Hello, my name is ______, this is my partner ______. We're EMTs, and we are here to take care of you until the ambulance gets here.
That is the reality of our role out here. Amazingly, just giving them that much information is a HUGE help in their understanding the flow of things. We used to have a lot of confusion out here, about why so many different people show up, and why there are "two ambulances" when they only need one. (At the time, our rescue was an old ambulance, so although it wasn't actually an ambulance, most people thought it was and were very surprised to find out it isn't. We don't have that problem now- our new rescue looks like a state police car. An entirely different set of issues, that. But people pull over for us!)
As the ambulance arrives (and as the situation allows), I tell the patient that the medics are going to come in, and they will probably ask a lot of the same questions that I've asked. I then introduce the patient and the medics, by name, and make the transfer of care.
Once the patient is in the ambulance, I am usually (but not always) out of that loop. I will wish my (now former) patient well, and let them know I have every confidence they will be well taken care of by the ambulance crew. I can do this because I have made the effort to establish a working relationship with all of the people who might be on that ambulance, so I know them by name, and I know a lot about which I've seen be particularly good at which things. I'm not just mouthing the words.
At that point, my focus shifts to the family and friends.
We make an effort to provide as much support as we can.
We lock doors, turn off lights, feed cats, bring in dogs, etc. We make sure anyone who is going to the hospital knows how to get there. I find myself often explaining to a spouse or child that the fact that the ambulance hasn't left in a hurry isn't because something is wrong- there are some procedures that need to be done that are better done when the ambulance is not moving.
I've talked to children about where their sibling is going.
I've talked to family members about what the sequence of events will be after someone dies, and reassured them that police presence is standard procedure here, and does not mean that anyone thinks they did something wrong.
I've answered I have no idea how many questions about what just happened, what is going to happen, and what isn't going to happen.
I hope I'm able to fill the gap a little, so that people don't feel that additional stress of not knowing who to ask, or what to ask, or where to go.
I just recently had occasion to go to the police department in a city a couple of hours from here. It was a large place, in a large (to me) city, and I had no idea where I was supposed to park, where I was supposed to go, how to get there or what to do once I got to the right window. The entire place was set up with an assumption that everyone who came in there was familiar with the procedures and such. I think almost every "public service" building I've ever been in, from police stations, to jails, to social services buildings, has always had that same sense about it- that you are supposed to already know the drill.
I didn't.
Trying to get someone to help me was a challenge, and the guy who finally answered my question would not win any awards for public relations.
It reminded me, again, of my experience at the vet hospital, and the importance of understanding that many of our patients don't "know the drill," either. They may be going through a totally new experience, having never called 911 before, and have absolutely no idea what is going to happen, or what to expect.
It is way too much to expect them to figure it out on their own under those circumstances. All the SOPs and protocols and procedures we do are very familiar to us, so it's easy to forget that not everyone knows how things go. We have to tell them.
Wednesday, November 2, 2011
Making a decision
Here we are, on NaBloPoMo day #2. I've kept up so far! Ha!
I have a decision to make.
I have about a month in which to make the decision, maybe a little longer.
Here's the situation:
Currently, I am an EMT-I in a low volume, non-transporting, volunteer situation.
What that means is that since becoming an Intermediate, I have had zero opportunity to practice any of the Intermediate skills out here. That's not a complaint, exactly. I knew, going in, that there would be little such opportunity.
Because of the agency I volunteer for, I have also had zero support for continuing training in any of those skills (or any other, for that matter). I have access to equipment to practice intubation with, so I do that on my own. I do not have access to a way to practice IVs, so I have to basically "mime" my way through that, and do everything except the actual stick.
This is not an optimal situation, by any means.
Starting in January, I have the opportunity to take the EMT-CC class, should I choose to do so. This is the decision I need to make.
On the "take it!" side of the decision:
1. Regular, quality training. Classes twice a week for much of a semester. Far and away better than I have available now.
2. I don't know how much lab time is devoted to the skills I already know, but I'm sure I could work something out and come in early or something to get some practice time, if it isn't already built in. And it may well be.
3. Cardiology! A lot of the "new" information in the class is about 12-leads, and I LOVE this stuff. I already know more about it than most people at my level of training, both because I find it so interesting, and because of a patient or two who provided an opportunity to study up. If I had my life to do over, I'd be a cardiologist.
4. Ride time. That means supervised practice with high-quality professional folks. Can only be a good thing.
On the "I'm not so sure" side of the "argument":
1. I will not have any opportunity to do any of the new skills out here. Period. This agency does not support them. No monitor. No ability to give drugs above the Basic level. I have no reason to expect that it would change unless there is a dramatic change of leadership out here, and even then, even if we HAD those abilities, we still have automatic ALS/transport back up on the way, so rarely get more than a few minutes with a patient.
2. Time. Time taken away from my already full plate of stuff I do. Not just for classes, but for any clinical and ride time. As much as I need it, and enjoy it, and want to do it... there's still the matter of WHEN to get things done. This was a HUGE issue during Intermediate. It took me WAY longer to get all the procedures in because the call volume and types of calls on the shifts I did weren't particularly helpful a lot of the time. Yes, I learned a LOT of stuff on every shift- but as a single parent, the sheer amount of time was an issue.
SO.
How do I find the balance here?
I need the training, I'd love the classes, it's all stuff I want to do... but I have kids, and a job, and the time commitment is a challenge.
I can negate the "wouldn't be able to use it out here" issue by finding a job with an ambulance company, and this training would definitely make that easier.
But that adds another whole dimension to the decision, since working for an ambulance means less time for the job I have NOW, which I also love (and have trained for 12 years to do!).
What I really need is more hours in a day.
Working for an ambulance, I'd get more WAKING hours in a day, but not more total hours. :-0
Maybe the answer is simply to get a LOT more efficient at time management.
Or to move somewhere with public transportation so we wouldn't end up needing more cars, if I'm not providing transportation.
Or to win the lottery. Money can make a lot of stumbling blocks go away.
Or to find a co-parent, which isn't a realistic possibility, for a variety of reasons.
What I'd really like to do isn't an option, I don't think.
I'd love to take the class just for the information and training. Not for getting certified. Just to know more, to be better at BLS. To have more supervised practice at things.
That way, I could do as much ride time as is practical, without having to stress out my entire family.
But if I do that... the state doesn't pay, and I can't afford to pay for it myself.
I have a decision to make.
I have about a month in which to make the decision, maybe a little longer.
Here's the situation:
Currently, I am an EMT-I in a low volume, non-transporting, volunteer situation.
What that means is that since becoming an Intermediate, I have had zero opportunity to practice any of the Intermediate skills out here. That's not a complaint, exactly. I knew, going in, that there would be little such opportunity.
Because of the agency I volunteer for, I have also had zero support for continuing training in any of those skills (or any other, for that matter). I have access to equipment to practice intubation with, so I do that on my own. I do not have access to a way to practice IVs, so I have to basically "mime" my way through that, and do everything except the actual stick.
This is not an optimal situation, by any means.
Starting in January, I have the opportunity to take the EMT-CC class, should I choose to do so. This is the decision I need to make.
On the "take it!" side of the decision:
1. Regular, quality training. Classes twice a week for much of a semester. Far and away better than I have available now.
2. I don't know how much lab time is devoted to the skills I already know, but I'm sure I could work something out and come in early or something to get some practice time, if it isn't already built in. And it may well be.
3. Cardiology! A lot of the "new" information in the class is about 12-leads, and I LOVE this stuff. I already know more about it than most people at my level of training, both because I find it so interesting, and because of a patient or two who provided an opportunity to study up. If I had my life to do over, I'd be a cardiologist.
4. Ride time. That means supervised practice with high-quality professional folks. Can only be a good thing.
On the "I'm not so sure" side of the "argument":
1. I will not have any opportunity to do any of the new skills out here. Period. This agency does not support them. No monitor. No ability to give drugs above the Basic level. I have no reason to expect that it would change unless there is a dramatic change of leadership out here, and even then, even if we HAD those abilities, we still have automatic ALS/transport back up on the way, so rarely get more than a few minutes with a patient.
2. Time. Time taken away from my already full plate of stuff I do. Not just for classes, but for any clinical and ride time. As much as I need it, and enjoy it, and want to do it... there's still the matter of WHEN to get things done. This was a HUGE issue during Intermediate. It took me WAY longer to get all the procedures in because the call volume and types of calls on the shifts I did weren't particularly helpful a lot of the time. Yes, I learned a LOT of stuff on every shift- but as a single parent, the sheer amount of time was an issue.
SO.
How do I find the balance here?
I need the training, I'd love the classes, it's all stuff I want to do... but I have kids, and a job, and the time commitment is a challenge.
I can negate the "wouldn't be able to use it out here" issue by finding a job with an ambulance company, and this training would definitely make that easier.
But that adds another whole dimension to the decision, since working for an ambulance means less time for the job I have NOW, which I also love (and have trained for 12 years to do!).
What I really need is more hours in a day.
Working for an ambulance, I'd get more WAKING hours in a day, but not more total hours. :-0
Maybe the answer is simply to get a LOT more efficient at time management.
Or to move somewhere with public transportation so we wouldn't end up needing more cars, if I'm not providing transportation.
Or to win the lottery. Money can make a lot of stumbling blocks go away.
Or to find a co-parent, which isn't a realistic possibility, for a variety of reasons.
What I'd really like to do isn't an option, I don't think.
I'd love to take the class just for the information and training. Not for getting certified. Just to know more, to be better at BLS. To have more supervised practice at things.
That way, I could do as much ride time as is practical, without having to stress out my entire family.
But if I do that... the state doesn't pay, and I can't afford to pay for it myself.
Tuesday, November 1, 2011
November
Once again, here I am, not having written in approximately forever.
I haven't had writer's block, exactly.
It's not that I haven't had anything to say.
It's a combination of things which include being very demotivated in some ways.
I've decided to participate in NaBloPoMo to see if it helps me get back into frequent posting. Hopefully (for me, and for anyone who happens to read this) it won't end up being a bunch of hastily written, uninteresting posts. Like this one. Oops.
We don't have enough call volume out here to make it reasonable to post about an incident every day. Still, I'd like to give people some idea of what it's like in my little EMS life.
That means I'll talk a lot about training. :-)
Latest interesting training tidbit:
We went down to Reading, PA to a 2-day event hosted by Reading Hospital. Apparently they do this every year, and I definitely plan to make attending a habit. For one thing, they host Bob Page, who is one of the most dynamic presenters I've seen in the EMS world. For another- it's free. Yes. Two days, excellent presentations, no cost (other than the hotel- which was also very reasonably priced). They even fed us breakfast and an excellent lunch the day I was there.
We only attended the second day of the program, for four sessions. Two of which I had been actively looking for since seeing Bob at EMSToday in Baltimore last March.
One was a shorter version of his full "Slap the Cap" presentation. I'd still love to do the full 4-hour version, but this one provided something I very much needed. My agency has been dragging their feet in this. They argue that we don't "need capnography" because it's just for intubation, and we rarely have an opportunity to intubate out here, with automatic ALS back-up. I've tried to explain other uses, but they don't listen to me. This workshop at least gave me written materials to give them. Not to mention, a better understanding for myself.
The second that I had been looking for was his "Stethoscopy for Dummies" class. He had mentioned it during the "How Vital are Vital Signs" session at EMSToday. He rightly pointed out that while everyone in EMS has a stethoscope, or access to one to use, what actual training is provided on how to use it? The best part of this sessions was that we were able to listen to actual lung sounds and learn to distinguish between different sounds and what they mean. Much better than being given a one-word description ("rales"), perhaps an instructor's imitation of the sound, and then being expected to be able to translate that to an actual situation.
In order to listen to various sounds, we used these cool sounders, made for this very purpose. They connect to any sound output (like the headphone jack on your laptop or iPod). You can get a wide variety of sounds to listen to, some for free online, or you can buy them. You can find the one we used here, and that page also lists some of the sounds and other training materials that are available. The sounder itself is $45, which is a reasonable price, especially if you have a group of people who will practice with it.
Another of the four sessions we attended was "Zapped," which was about managing the patient with an AICD. He told us that the idea for the class came from attending a support group meeting at a hospital, for patients with pacemakers and defibrillators, and asking them what they wanted EMS to know. They replied "make them stop looking like a deer in headlights." It went over the devices, how they work, and what kinds of things can happen if they fail. It was a good class for someone with little knowledge of the devices, but I happen to know a fair amount about them, so it wasn't a critical need for me.
The fourth class was "What's Up With This?" a brief tour through some of the things EMS does without much (or any) scientific reasoning.
Overall, it was a productive day. Well worth the drive. I'm looking forward to seeing what they offer next year.
You can find Bob's schedule on his website, to see if he is bringing any of his classes near you.
Starting tomorrow, Nov 2nd, he will be at the New Jersey EMS Summit and if you can get there, I recommend it. I'd also recommend getting him to come to where you are, but I think there is a significant wait time, due to his busy schedule. Still, check it out and see if it might work out. He has a long list of topics he offers, ranging from very basic things to more advanced.
I haven't had writer's block, exactly.
It's not that I haven't had anything to say.
It's a combination of things which include being very demotivated in some ways.
I've decided to participate in NaBloPoMo to see if it helps me get back into frequent posting. Hopefully (for me, and for anyone who happens to read this) it won't end up being a bunch of hastily written, uninteresting posts. Like this one. Oops.
We don't have enough call volume out here to make it reasonable to post about an incident every day. Still, I'd like to give people some idea of what it's like in my little EMS life.
That means I'll talk a lot about training. :-)
Latest interesting training tidbit:
We went down to Reading, PA to a 2-day event hosted by Reading Hospital. Apparently they do this every year, and I definitely plan to make attending a habit. For one thing, they host Bob Page, who is one of the most dynamic presenters I've seen in the EMS world. For another- it's free. Yes. Two days, excellent presentations, no cost (other than the hotel- which was also very reasonably priced). They even fed us breakfast and an excellent lunch the day I was there.
We only attended the second day of the program, for four sessions. Two of which I had been actively looking for since seeing Bob at EMSToday in Baltimore last March.
One was a shorter version of his full "Slap the Cap" presentation. I'd still love to do the full 4-hour version, but this one provided something I very much needed. My agency has been dragging their feet in this. They argue that we don't "need capnography" because it's just for intubation, and we rarely have an opportunity to intubate out here, with automatic ALS back-up. I've tried to explain other uses, but they don't listen to me. This workshop at least gave me written materials to give them. Not to mention, a better understanding for myself.
The second that I had been looking for was his "Stethoscopy for Dummies" class. He had mentioned it during the "How Vital are Vital Signs" session at EMSToday. He rightly pointed out that while everyone in EMS has a stethoscope, or access to one to use, what actual training is provided on how to use it? The best part of this sessions was that we were able to listen to actual lung sounds and learn to distinguish between different sounds and what they mean. Much better than being given a one-word description ("rales"), perhaps an instructor's imitation of the sound, and then being expected to be able to translate that to an actual situation.
In order to listen to various sounds, we used these cool sounders, made for this very purpose. They connect to any sound output (like the headphone jack on your laptop or iPod). You can get a wide variety of sounds to listen to, some for free online, or you can buy them. You can find the one we used here, and that page also lists some of the sounds and other training materials that are available. The sounder itself is $45, which is a reasonable price, especially if you have a group of people who will practice with it.
Another of the four sessions we attended was "Zapped," which was about managing the patient with an AICD. He told us that the idea for the class came from attending a support group meeting at a hospital, for patients with pacemakers and defibrillators, and asking them what they wanted EMS to know. They replied "make them stop looking like a deer in headlights." It went over the devices, how they work, and what kinds of things can happen if they fail. It was a good class for someone with little knowledge of the devices, but I happen to know a fair amount about them, so it wasn't a critical need for me.
The fourth class was "What's Up With This?" a brief tour through some of the things EMS does without much (or any) scientific reasoning.
Overall, it was a productive day. Well worth the drive. I'm looking forward to seeing what they offer next year.
You can find Bob's schedule on his website, to see if he is bringing any of his classes near you.
Starting tomorrow, Nov 2nd, he will be at the New Jersey EMS Summit and if you can get there, I recommend it. I'd also recommend getting him to come to where you are, but I think there is a significant wait time, due to his busy schedule. Still, check it out and see if it might work out. He has a long list of topics he offers, ranging from very basic things to more advanced.
Thursday, July 28, 2011
Nothing
Haven't posted in a while.
Had a house guest for a while, did a bit of traveling. Been keeping busy, enjoying surviving the heat of summer.
Worked EMS at a music festival. Volunteers were explicitly and specifically prohibited from writing about anything that happened there. A little social media paranoia there, if you ask me, but it's not my call to make. It's true that there are people who seem not to be bright enough to accurately decide what is appropriate to post and what is not, so I guess this is the simplest solution.
So I won't say anything about what I did or what I saw, as far as the events themselves.
I learned some stuff.
One of the things that struck me as interesting is something I've been talking to my students about, in what most would consider an unrelated field. It has to do with practice, or preparation, or warming up.
Frequently, people do much better on a second try at something, having just had the chance to go through it once and be reminded of things. Having had a "warm up" or "practice run."
The thing is, of course, that in "real life," it doesn't work that way. If you have a patient in cardiac arrest, and things don't go well, you don't get to try again. You get the time you get with a patient, to do whatever you do, as far as assessment and management, and then they leave your hands to go to the next level of care. You can evaluate your performance, and see if there was anything you missed, or anything you might do differently next time, but you don't get to apply that to that most recent patient, but only to future patients.
When we get a call, we have developed a pattern of preparing for it We have from here to the station, and then from the station to wherever the call is. Sometimes, that could be ten minutes or more. That's a LONG time.
We go over what dispatch said. We discuss whether we've seen the patient before, and if so, for what, and what happened. We plan who will do what on arrival. We review that particulars of the stated emergency, and remind ourselves what we need to be sure to ask or do.
It's a fairly good system.
But at the festival... we didn't go to patients; they came to us.
So instead of 5 or 10 minutes of preparation during travel, we got "here you go" as a patient was dropped into our laps, sometimes almost literally.
Quite a different experience. No prep time.
Which, of course, means we need to be doing more "prep time" in general, all the time.
Training.
Practice.
Big lesson of the weekend:
Sometimes, we don't know nothing about nothing.
Ouch.
Or as that insurance company's ads go: Life comes at you fast.
Had a house guest for a while, did a bit of traveling. Been keeping busy, enjoying surviving the heat of summer.
Worked EMS at a music festival. Volunteers were explicitly and specifically prohibited from writing about anything that happened there. A little social media paranoia there, if you ask me, but it's not my call to make. It's true that there are people who seem not to be bright enough to accurately decide what is appropriate to post and what is not, so I guess this is the simplest solution.
So I won't say anything about what I did or what I saw, as far as the events themselves.
I learned some stuff.
One of the things that struck me as interesting is something I've been talking to my students about, in what most would consider an unrelated field. It has to do with practice, or preparation, or warming up.
Frequently, people do much better on a second try at something, having just had the chance to go through it once and be reminded of things. Having had a "warm up" or "practice run."
The thing is, of course, that in "real life," it doesn't work that way. If you have a patient in cardiac arrest, and things don't go well, you don't get to try again. You get the time you get with a patient, to do whatever you do, as far as assessment and management, and then they leave your hands to go to the next level of care. You can evaluate your performance, and see if there was anything you missed, or anything you might do differently next time, but you don't get to apply that to that most recent patient, but only to future patients.
When we get a call, we have developed a pattern of preparing for it We have from here to the station, and then from the station to wherever the call is. Sometimes, that could be ten minutes or more. That's a LONG time.
We go over what dispatch said. We discuss whether we've seen the patient before, and if so, for what, and what happened. We plan who will do what on arrival. We review that particulars of the stated emergency, and remind ourselves what we need to be sure to ask or do.
It's a fairly good system.
But at the festival... we didn't go to patients; they came to us.
So instead of 5 or 10 minutes of preparation during travel, we got "here you go" as a patient was dropped into our laps, sometimes almost literally.
Quite a different experience. No prep time.
Which, of course, means we need to be doing more "prep time" in general, all the time.
Training.
Practice.
Big lesson of the weekend:
Sometimes, we don't know nothing about nothing.
Ouch.
Or as that insurance company's ads go: Life comes at you fast.
Monday, June 13, 2011
PCRs on the run
Been reading some great stuff about patient assessment this morning, over on Ckemtp's blog, Life Under the Lights. Followed the links at the bottom to some previous posts he has made on the topic, and also, one about writing good patient narratives.
Writing a great narrative is definitely a skill, and any skill requires practice.
I especially like his suggestion (he's not the only one who suggests it, but it was his blog I was reading today) to think about what you are going to write, organize it in your head, and afterwards, re-read it. Have your partner re-read it. It's a great idea.
Unfortunately, it is of limited use in the situation in which we typically find ourselves. We simply don't have much time.
Being non-transporting means that another agency transports the patient.
What this means for us as far as the written report, the narrative, the PCR, is that we have to write it FAST because one copy goes with the ambulance.
If we make changes or additions after that, that information has to get to where the patient is, either by fax or by hand delivery.
Yes. We still use paper PCRs. It's going to take a while to haul the dept out of the dark ages, for a variety of reasons. We don't have a computer, of any kind, available to anyone other than the line officers and company secretary. No computer, no e-PCR. What I wouldn't give some days for an iPad.
It has never been made clear exactly what the procedure is for faxing the information without violating HIPAA. There was a period of time when we did not have access to a fax machine. So basically, we don't fax to the ER. I HAVE hand delivered a PCR a few times, when it was an intense call that needed a LOT of narrative, and we didn't get ANY of it done before the ambulance left because we were too busy with patient care.
Anyhow.
Most of the time, by far, I end up filling out the PCR for the simple reason that I write fastest. Well, that, and I'm the EMT in charge on the call, and often the only one there, but that's beside the point at the moment. But back when I wasn't the only EMT, I still wrote fastest, so I've gotten the most experience with writing the things for the past several years.
What happens NOW is that sometimes, someone else will want to help with the PCR. This is GREAT. I need to be providing patient care, not secretarial support. The problem comes when that person doesn't know HOW to do a PCR. They may not know where the information goes, or which information they should be writing down. Even people who you'd think would know how to do this, people with "years of experience," don't always do it very well.
Having a partially filled in and written on PCR handed to me between the door of the house and the back door of the ambulance, for me to finish and hand off to the ALS crew, which is filled with errors and stuff in the wrong place is REALLY ANNOYING, PEOPLE. Seriously. I either have to quickly cross out and re-write and scramble and end up with a PCR that looks like CRAP, or I have to scrap the entire thing, and figure out how I'm going to get the new one up to the ER.
Not to mention: if a copy of my PCR does not go with the ambulance, then all that information I gathered before the medics arrived, THEY WON'T HAVE ACCESS TO IT. And that is not a lot of help, to anyone. Some of the time, it doesn't matter a whole lot. But on a call where we actually do something that improves the condition of the patient, so what we found when we got there, and what the medics see, are very different- it would be good for that information to be available.
I have picked up a few pointers on getting a decent PCR written in a very short period of time, on scene.
1. Start before you get there. Some of the information, you already know. Assuming you are not driving, start to fill out the form on the way. The date, agency code, location code, apparatus number, whether it's an emergency or not, whether it's a residence or somewhere else, your agency's name, what dispatch said and the address of the call are all known to you before you arrive. So fill that part in. They can be filled in by anyone, not just an EMT.
2. You may also know who is responding. In charge, Driver, and the rest of the crew can be filled in on the bottom before you get there, much of the time.
3. Learn your way around the PCR. If you are doing the writing while an EMT is providing patient care, know what bits of information to be listening for, and where they go. Name, birthday, medical conditions, medications, blood pressure, respiration, pulse... these all have places to go on the form, and you'll hear them spoken out loud.
4. Once at the call, be alert for any information that needs to go on the form. Listen for it, and prioritize it. For example, you can write in the patient's address, especially if it's the location of the call, at any point, so if you are in the middle of that, and hear some of the priority information, STOP writing in the address, go write in the priority information, and come back to the stuff that you already know. Especially prioritize numbers.
5. Practice outside calls. Have someone do an assessment, and verbalize their findings, and have another person put that information on a PCR.
6. If you are NOT the EMT in charge, don't fill in the narrative UNLESS the two of you have an agreement, and an understanding of how to write it. PLEASE don't just start writing stuff wherever you want, in whatever order you want. I swear, if anyone hands me another PCR that has obscure codes scribbled in my narrative spaces, and subjective information in the objective space, or vice versa, with no space left to write the information I actually need to have there, I'm going to smack someone. My partners already know that there is one person who I do not want touching my PCR, ever, on a call, and they are well informed in keeping the clipboard away from that person. But he's not the only one who has written stuff where it doesn't belong.
7. If you really, really want to write ANYTHING in the narrative spaces, PLEASE do yourself and me and the rest of the universe a favor, and learn the DIFFERENCE between "subjective" and "objective." It's not hard. Short version: subjective is what they tell you, what they feel; objective is what you observe, what you measure and what you do.
8. There are a couple of times during the call that are generally best suited to writing. Some of it depends on the condition of the patient.
a) If you have help, and the patient is alert and oriented, if your general impression is good, then you can write as you gather the information. Maintain connection with the patient, don't just stare at the page, but you should be able to fill in a lot while you are having a conversation.
b) If the patient is unstable, or you don't have help, you may not be able to write much while doing the assessment. In that case, use the time from when you transfer care to the transporting agency, until the patient is in the ambulance, IF you are not needed to help with continuing patient care. I write narratives between the doors, often. I follow the stretcher, writing madly as I go. Do the narrative then, quickly check to see that all your boxes and been filled and checked. Have a method for the checking so you don't miss anything.
c) If you ARE needed, obviously, the patient is more important than the paperwork.
9. Be observant. Learn to experience the call with the narrative developing in your head as you go.
10. This may seem obvious, but perhaps not. Practice writing narratives. Practice the order you want to put information in so you don't have to think about it. If you have a running narrative in your head, it will be easier to write it down. "The patient was found... <level of consciousness>," etc. "Patient reports having...<various symptoms and experiences> denies...<critical negatives>." Come up with a method that works for you, and use it. If you know of people who write great narratives, use them as role models. There is a pair of medics near here who write exceptional narratives, and I learned a LOT by riding with them and seeing how they organize information.
11. Don't be afraid to use a continuation form if you need one. And if it simply can't be done, having a finished PCR ready to go with the ambulance, then it can't. Don't sweat it. Fax it if you can, or deliver it, or whatever is necessary to keep that information with the patient. There shouldn't be many times that this happens.
12. A small, but important thing: have extra pens. I keep one attached to the PCR clipboard, and two extras inside it. I also carry a "space pen" that can write on wet paper. It doesn't take long for a PCR to get soaked out in the weather!
It would be great if we had the luxury of writing the PCR after the call, when we're back somewhere dry and reasonably comfortable, but we don't. Even so, with good practice, good planning, and doing as much as possible on the way there, it is possible to produce a reasonably good PCR in a very short period of time. They key is knowing what needs to be on it, and where that information goes, so you don't waste any time hunting around for anything.
Over on his blog, Chris says "EMS documentation doesn't have to be hard, It doesn't have to be tedious, and it certainly doesn't have to be done poorly to save time."
I agree.
You can save a LOT of time with good planning and organizational skills, so that you do not sacrifice quality when you have no time to spare.
Monday, April 25, 2011
Door to Door
The moment I saw him, I knew something was wrong.
He had been sleeping all day, while I was at work, but now that I was home, he came out of the bedroom to greet me.
The first thing I noticed was that his legs were soaked. With urine. And he didn't seem to realize it. He stumbled, and nearly fell down the stairs.
I grabbed the phone. Called the doctor's office.
Got the answering machine, telling me to call the back up Doc if I had an emergency.
Was this an emergency?
Well... it wasn't a good thing, that's for sure.
I called the back up number.
Got a message saying to press one for an emergency, and to wait on the line otherwise.
I waited.
And waited.
No answer.
So I hung up, called back, and pressed one.
The woman who answered wanted to know what my emergency was, and I told her I wasn't sure it was an absolute emergency. I explained what was going on, and we agreed that I should head for the ER, and she would let them know I was coming.
On our arrival, we were met at the door.
The patient was ushered back to be examined, while I filled out paperwork. Before I had the chance to sit back down after handing the paperwork to the person at the desk, the doc had come out to find me. Sat down with me, briefly explained what she had found, asked what I wanted to do, had me sign papers giving permission for the procedures, and went back to start prepping the patient for surgery.
Total elapsed time, including the drive:
25 minutes.
The shortest time from noticing symptoms to definitive care I have ever seen.
The interesting part?
This wasn't a trauma center. It wasn't even the local hospital.
It was the Vet Hospital's Emergency Department.
The patient is my cat.
If our situation had been reversed, if I was the one who was sick, things would have gone quite differently.
First, someone would have had to notice I was sick, if I wasn't able to express it myself.
Then, they probably would have had to argue with me about whether or not to call an ambulance.
Assuming I was too ill to put up much of an argument, they'd call.
I don't know if my kids would go to the station to get the rescue or not- probably not, unless they needed the AED.
So we'd wait for the ambulance.
That would take from 10-15 minutes or more, depending on the priority given to the call, how busy they are, and where, exactly they are coming here from.
They'd spend at least 5 minutes on scene.
The drive to the hospital is about 15-20 minutes.
Giving all those the best possible time, that's half an hour already.
Once at the hospital, things would likely slow down. The ER is busy, most of the time, and unless I was clearly critical at that moment, I'd be put in a room, asked to change into a gown, and a nurse would put me on the monitor there. If an IV hadn't been started before, it would be now. Blood would be taken for testing. I'd be asked a lot of questions. Might be asked to pee in a cup.
And then, most likely, I'd sit there. Might be for hours.
A doctor would come in at some point. Might be before or after the results from the blood and urine tests.
May, or may not, order further testing.
If I had the same problem as the cat, and needed surgery... I honestly don't know how long that would take. It's a relatively small hospital. I might need to be transferred to a larger hospital, more set up for emergency surgery.
That would be an hour trip.
At any rate, the total elapsed time from noticing symptoms to definitive care- to prep for surgery- would be considerably longer than it was for my cat.
Why is that?
There are several reasons that all contribute to the difference.
The most obvious reason is that at the vet hospital, there wasn't a waiting room and ER full of people who didn't really need to be there. We didn't have to wait because there isn't the rampant abuse of the system.
We drove ourselves to the vet, which reduced some of the time. But paramedics can start some treatment, so it's hard to say which of those options is "better." It depends on the specific situation.
But don't forget the other likely reason for any delay of MY treatment... I'd argue against considering it an emergency, and wouldn't want to go.
The cat didn't do that. :-)
Next... what's going on? Information flow... or not.
Subscribe to:
Posts (Atom)
