They Say More Lives Are Saved by BLS Than ALS, but...

I've heard, more than once, that "more lives are saved by BLS than ALS."

Maybe so.  CPR is a BLS skill, after all.  As is controlling bleeding.  And we can assist, or provide, ventilations.

But sometimes, there are some ALS options that sure would be nice to have available.  

I happen to live in a region that doesn't allow BLS (or ILS) providers to do much of anything.  It is very, very conservative.  So although we have to test out at the state level for everything in the state curriculum, much of it, we can't actually do in the field.

Most of the time, it doesn't make much of a difference.  We don't often have the opportunity.

But sometimes, there are some things I'd like to be able to do.

D50 comes to mind.  I can start an IV, on a patient older than 16, but can't do anything with it other than a lock, or saline.

Some people would argue for LMAs, but they aren't used in this region at all, let alone for BLS or ILS providers.  And I can't intubate, because the region requires capnography, and my agency does not have the equipment, or the finances to get it.

Chest decompression is disallowed by my region.  I've had a couple of patients where it sure would have been nice not to have to wait, even though I don't think it ultimately made much difference that there was a delay of a few minutes.

The current thing I would like to be able to provide? Breathing treatments for someone not previously diagnosed with Asthma.

Had a very sick patient recently.  Bilateral wheezing. Significant respiratory effort, enough not to be sustainable for long.

What was I allowed to do?

Put oxygen on 'em.  That was about it.

Frustrating.

Almost enough to get me to look into that medic class sooner than I was planning. Almost.

Number One Complaint

I went to a county training event a few months ago that was a pretty good opportunity. One day of classes, lunch provided, with around 30 or 40 people in attendance.  The keynote speaker was a woman from the state DOH.  She gave a talk on CQI.

One of the things she said really got me thinking.  She said that part of her job was to answer complaints.  That if anyone in the state has a problem with an EMS provider, and they are bothered enough to send a complaint to the state, she is the one who reads them and responds.  She asked the audience if they could guess what the most frequent complaint is, and said that there is one thing she sees by far the most often.

People guessed things ranging from "they took too long" to "it costs too much."

It wasn't either of those. It was something far simpler.  And unlike some types of complaints, it was something that we can change, immediately.

"They weren't nice to me."

Whether the complainant was the patient, or a family member, the most frequent thing that bothered them enough to actually find a way to send it to the state was that the EMS provider "wasn't nice."

Now sometimes, we get busy, focused on some intense situation, like a full arrest, and maybe our primary thought isn't to make idle chit chat with the family.  If someone complains about that, then I guess there isn't a lot we can do.

But there is plenty we can do to be "nice" most of the time.

I would think that most providers out there are pretty nice people, most of the time. Certainly most of the ones I know are.  But apparently not everyone- or that wouldn't be the most common complaint, would it?  So maybe we need to focus on, or share, little things we can do to provide a higher level of "niceness."  Especially for us, as non-transporting, so we are frequently still on scene after the ambulance leaves, there are many things we can do to be nice to the family, as well as the patient.

A short, non-inclusive list:

1. Simplest first: I always introduce myself by name and as often as possible, use theirs.

2. I make eye contact, and listen to them.

3. I have held hands, held someone's head while they vomit, rubbed backs, wiped sweat, fetched jackets, bathrobes and socks, and done a hundred other small things in the name of personal comfort.

4. For ALS calls, if the IV is started before the ambulance leaves, and a family member is riding along, I make sure they understand that the "delay" is simply because there are some procedures that are easier to do when the ambulance isn't moving.  I don't want them to feel ignored, or to be sitting there imagining the worst, that the delay is because all the EMTs/Medics are frantically busy.

5. I make sure family members know which hospital the ambulance is going to, and if necessary, how to get there.

6. "I'm sorry for your loss," said with true feeling, may not be able to fix things, but it's by far better than not saying anything.

7. If we are on scene after the ambulance leaves, with family members who are stressed out, I always check to see how they are doing and ask if there is anything we can do for them before we leave.  This sometimes, but not usually, includes a full assessment.

8. Most of the time, I reassure people that they did the right thing by calling.  Remember, we have far more trouble here with people not calling when they should, than people calling when they shouldn't.  We hear a lot of "I didn't want to trouble anyone."

I started this post last night. Had a call today where I wish they had called sooner.  I'd love to hear if anyone has suggestions for pub ed to help people have a better understanding of when they should call.

Basic First Aid

I took my first Red Cross First Aid class when I was 8 years old. It was called Basic First Aid then, and I remember using my allowance money to buy the set of four books. Just now, I looked on ebay to see if I could find the same set, but couldn't.  I kept those books for years, re-reading them from time to time.  I got the first aid badge in Girl Scouts, and generally kept as current as I could, believing it to be important all through my life.

I've taken CPR classes so many times, I've lost count. Much like how challenging it has been over the years to keep straight how many compressions to how many breaths for what age person, until they finally consolidated it to the current "compression only" version.  I think I took at least one class for each change.  The last time I took a Red Cross class, it was somewhat amusing to see that each person in the class had originally learned CPR differently.  We had a whole smorgasbord of technique in that room.

The first time I ever had an opportunity to use CPR was when I was 34 years old.  I happened to be there when an 18 month old seized, and stopped breathing.  I immediately directed the father to call 911, and placed the child on a flat surface.

My thoughts were racing.  It had been a while since I had taken a formal CPR class, and I wasn't entirely sure I remembered exactly what to do. And all I could think of in that moment was "What if it's already too late?  What if it doesn't work?  What if there is nothing I can do?  Some things can't be fixed."

While I checked for a pulse, the child took a gasping breath, and started breathing. Shortly afterwards, she opened her eyes.

I had only once before been so relieved in my life (that's another story).

I didn't fully realize until years later that what I had done was to position her so that I opened her airway, and that was all I needed to do in that particular case.

That child was my daughter.

Some of you met her last week.

There are a lot of fears surrounding having to do any sort of emergency care of a family member, and rightly so.  The stakes are high.  The adrenalin is high- higher than on a "normal" call.  Or is it?

I've had people tell me that it is not possible to stay calm and provide high quality care for a family member.  I'm not so sure that's true.

When I first became an EMT-B, a few years ago, I'll admit that each time the pager went off, I had a somewhat heightened reaction. I'm sure you know what I mean.  This led to more than one early error, usually in forgetting to do something.  Fortunately, most of those were very minor, and after each call, we'd talk about it, and fairly quickly developed a rhythm, and a method (but not the rhythm method!) for assessments and the rest of a call.  We learned to mentally prepare en route.  We developed communication skills.  We learned to watch our ALS backup medics like hawks, to learn as much as we could from them at each call.

But mostly, what we learned was to incorporate all of this, into part of who we are. (My son and I were certified at the same time, and went to almost every call together, as partners.)  Through graduated exposure, we were much better able to stay calm and focused during a call.  We still run across new things, all the time, and have something of a learning curve to go through for that particular issue, but many of the typical calls we get, we now have SOME idea of what we're doing.

A couple of years ago now, in about the middle of this adventure, my kids and I were going to a music and arts festival near here, in the "real" town in our county, about ten to fifteen minutes away.  We had just parked the car and reached the ground level of the parking garage, starting to walk towards the festival itself, when our pagers went off.  Ah, bummer.  Terrible timing.  But maybe it's not a big deal, maybe it's something someone else could handle, or maybe, if we're really lucky, it's actually for our sister company, which had the same tones.

Scratch that thought in a hurry.

Not only was it for our department, it was for my father.

His AICD, which he had had for a few months, had activated.

I took a deep breath, and for the first time (and only time), we ran, not walked, for the car.

I had the sense to have my son drive.

I called dispatch to let them know we'd be going directly to the scene.

We got there moments after the ALS ambulance.

Short version: things were basically okay, or as okay as they can be in that situation.  My favorite three words: conscious, alert and breathing.  Sometimes, the rest is just details.

The medic let me ride in back to the hospital, which was a bit unusual, but he knew me and technically it was our call and we can ride with if necessary.  I wanted to go with because I know my father's medical history and current condition, and he pretty much doesn't.  He didn't understand all this, specially with it being pretty new to him at the time.  And he wasn't exactly in a condition to be having a lot of conversation.

I gave the medic his history, meds, allergies, etc.  Told him when and where the AICD was implanted and why, and that this was the first time it had activated.  He was able to proceed with appropriate care quickly and effectively.

But the most important thing I did was hold my Dad's hand, and answer him when he asked me "Am I going to die?"

I learned SO MUCH from that call.

The first thing I learned was that I CAN stay calm during a call for a family member.  Somehow, I just clicked over into my EMT-self, and having that to support me, I stayed calm and focused.  It felt SO much better than the experience, years before, when it was my daughter not breathing, and I was unsure.  Several orders of magnitude better.

Another thing I learned, or at least had emphasized, was how important it is for the patient to feel like they are being cared for by someone who cares about them.  It may be that their greatest physical need is for the interventions a medic can provide, but what they REMEMBER is how they were treated, and whether they felt cared for, and confident that they were being taken care of.  I still work constantly to improve that aspect of the care I provide, from working on establishing rapport, to communicating during the call, to things like getting out in the community and meeting people so that if we are called for them, I at least won't be a total stranger.

The longer I do this, the more I realize that a lot of what we do isn't just about medicine, it isn't about interventions, it isn't about remembering the protocols and techniques and what all, and it sure as heck isn't about lights and sirens. It's about people.  About reaching out and caring for people.

As if they are ALL "family."

Condensation

Had a call shortly after getting home from Baltimore.  Afterwards, we were supposed to have training, but instead of being the training that we were told it was going to be, it became, as it often does, "we'll go back to the station and see what people want to work on and come up with something."

I am distinctly uninterested.

Spent some time putting the rescue back in service, including re-setting some things that had needed doing for a while.  There was some recently returned equipment that I wanted to swap back onto the truck.  Useful.

During this time, our "EMS Director" (the title used by the dept- there seems to be no consistency at all in what title different departments use!) asked me if I plan to "give a report" about what I learned in Baltimore.  Sure, I said, but there is a lot of information, so it will take a while to organize it and/or present it.  He seemed puzzled.  Thought that I should be able to tell them all about it in a few minutes.

Kind of funny, really.

Four days of intensity, condensed into a few minutes?

I can do that.

I can do it in three words.

"You should go."

Beyond that, trying to distill everything I learned, that's a challenge.

A good one, I think.

Did get a chance to talk to some medics I know near here about some of what I experienced. No one from this area, except for me, went this year, although I know several of them have gone previously.  They tend to go to a closer regional conference, one I haven't gone to yet.  I'm looking into getting there this year.  Much smaller, but if the presenters are as good, well worth the time.

Now to convince some of the blogosphere to come visit!

Focus

Here I am, thinking again.

Must try not to do that.

Thinking about MaddogMedic, on his way home.  Long flight, long drive, and I'm not convinced he's going to an entirely safe place.  But then again, no place is, is it?

Thinking about a blog post I read this morning.  Was bopping around, blog-skipping, and came across a couple of new blogs I had never heard of.  One was Scaredy Fish, and on her blog, she recommended several others.

Especially one.  Ambulance Addiction. With a "must read" post. The Big Picture.

Fair warning: it made me cry. Hard.

And it got me thinking about how easy it is to get caught up on details.  How easy it is to get annoyed, or even angry, about things that might matter... but maybe not as much as it feels like in the moment.  How easy it is to justify our own behavior because someone else "deserves it."

In the story on that blog, I don't want to give away too much in case you haven't gone to read it yet.  The part about the ladder? I would have done the exact same thing.  No question.

Things here, in my tiny town, and in my tiny department, sometimes suck.  Bad.  Some of it is mind boggling, really.

But you know what?

I'm better than that.

I have a note on my computer, there to remind me every day of what is most important in this business.

It says "Focus on the patient, on patient care. The rest doesn't matter."

Keeps me going, some days.

That, and the fact that my real "department," my community, my people... are somewhere out there, spread all over the place. The blogosphere. Y'all keep me sane.  Or as close to sane as I'm ever going to be.

Is the Scene Safe?

Back in our EMT-B class, one of the lectures was about scene safety.  Apparently, they had put an earlier class through a scenario where they were called to the scene of a 16 year old girl with abdominal pain.  Turns out, she's pregnant, and her father doesn't want to allow the EMTs in to treat her.  He argues with them.  He denies she is pregnant, even though it is apparent. The girl, in the background, appears to be getting significantly worse, finally becoming unresponsive.

What to do?

In that scenario, the father met the EMTs at the door, arms crossed, spouting obscenities.

He also had a "gun" in one hand, hidden by his arm.

If the EMT students ignored him, or tried to get around him, or in some other way were unobservant, in their rush to get to the patient (and who can blame them?) he would pull out the "gun" and "shoot them."

In that class, every student was "shot."  Every one.

A couple of years later, at a training on scene safety, the instructor (who was very good, and I'd recommend him) told us a story about a time when he was one of the evaluators for a practical exam.  After repeating the same thing over and over for each candidate for most of the day, he decided to change one small thing.

When students asked "Is the scene safe?" as we are all trained to do, they got the answer "Yes. For now."

"What do you mean, for now?!?" cried most of the students.

"I mean yes, the scene is safe, for now."

"Do you mean I am supposed to keep checking?"

YES.  YES YOU ARE.

Totally freaked out a bunch of students, and he had to stop doing it, but it is part of what caused him to start teaching safety classes. We are all told to check that the scene is safe, but how often are we told HOW to do that?  What does it mean?  What should we look for? How often should we look?  All the training just mentions it in passing, once, at the beginning.

Sometimes, it's obvious.

Sometimes, it's not.

It is very, very easy to miss things, in the adrenalin rush, and the focus on the patient.

This is one of my daughter's most important functions at our calls- she is our eyes and ears, and watches the scene, while we watch the patient.  She has noticed numerous things that may have caused us some trouble had no one noticed.  Sometimes, things I can't believe I didn't see.

We live in a pretty mellow, low key kind of place, and for the most part, people aren't out to do us any harm.

And believing that is the quickest way to end up in trouble.

We had a call once, a couple of years back, where we were met at the door with a shotgun, and told to get off the property.

We did.

Hastily.

The only correct answer to that is "Yes, ma'am" or "Yes, sir."

Bugged the crap out of me for a long time, though.

I wasn't second guessing our actions.  We did the right thing.

That patient had a delayed transport to the hospital.  And died there the next day.  The delay probably made no difference, but still.

It seems to me to be incredibly unfair that someone can deny another person medical care.  And I never understood why they called in the first place.

Months later, at a company training, someone brought up a call from years ago, long before we were in the department.  There was some weapon present, and no one noticed it. In the telling, the storyteller stopped the story before that point, and asked what people thought was going on, expecting no one to even consider there being a weapon involved.  The person telling the story said something along the lines of "none of us ever really pay attention to scene safety, do we?"

Well. No. Some of us do.

If you have the chance to have a scene safety class, I recommend it.  All sorts of weird crap happens out there, and reminders to keep eyes and ears open can't hurt.  And if you have the resources to assign someone to be safety officer on EMS calls, I recommend that, too.  It's really helpful to have someone not directly involved in patient care to stand back and see the whole picture.

Any suggestions for other ways to improve our safety?  Any tips or resources?  Any good habits or SOPs?  What is your weak point, and what is your strong suit?  What do you worry about the most?  Anything in particular?

A Real Post

I'm one of those people who watched Emergency! when it was first on.  Wanted to be a paramedic since way back then.

Didn't happen, though.  Various things- mostly misinformation, but some simply timing, or different choices- combined to send me in other directions for most of my life.  Got married, had kids, raised them.  Did a bunch of other, seemingly unrelated, stuff.

And then joined the local fire department. At the age of... never mind.  Let's say significantly older than most new recruits, but not older than most of the members.  One of the first things they wanted to know was whether I was interested in fire (yes!) or in EMS.  Oh... I can do that?  Really?  And the training is free?  Seriously?

How come no one ever told me, all this time, that if I joined the freakin' fire department, I could be an EMT?  I'm not sure I really knew that all I had to do to join was walk down the road and... join.  And last I knew, women couldn't be firefighters, not that I'd ever heard.

Which means, primarily, that I had a spent a lot of years not paying attention.

And the local department had spent a lot of years... not recruiting.

So I took the EMT-B class, and checked one thing off my bucket list.

I went into the class with a greater than average  knowledge of medical things, in general.  Not that that means a whole lot, but it means something.  The class wasn't difficult.  I took my first Red Cross first aid class in the mid-seventies.  And I had three kids- can't get through that without SOME medical knowledge, like it or not.

And I like it.  A lot.

My Basic class had two primary instructors, with one assistant who was basically student teaching, in order to become qualified to be a lead instructor.

The two primary instructors were fabulous. I couldn't have asked for better.

The student teacher? Not so much.  She had heart, I'll give her that, but was not very comfortable in front of the class, and was limited to reading powerpoint slides.

Have I mentioned I hate when people read powerpoint slides?  Please just let me read the book.  Please.

When my son and I (we were in the same class) got our cards, we were excited.

And then...

we realized something. Something important.

Years ago, this town was known for having the best rescue squad in the county.  They had some of the local pioneers, people who really worked hard to improve EMS here. Even some volunteer paramedics, which is not a common thing.

But now?

Not so much.

Since joining the department, there had been several EMTs who moved away, left the department, or simply did not recertify.

Suddenly- quite suddenly- it was only us.

The only more experienced EMT we had didn't go to calls. He has since let his certification lapse and as far as I know, does not plan to recert.

There was one person who became an EMT a few months before us, but he only ever attended one call.  He was actually a bunker about 45 minutes away, finishing a fire technology program, and he never came back to the department.

In the next year, nine additional people took the class.

Sounds great, right?

Well.

In the first group of four, one failed the class. Two moved away after going to 3 or 4 calls.

The other is still here, but has attended very few calls, and has almost no experience or further training.

The next group of four, two quit the department before finishing the class.

One moved away right after finishing, having never attended a call.

The other got a job on an ambulance, and has never come to a call out here.

The next one to finish the class moved away AND started working for the ambulance.  No calls out here.

We had an EMT move here from somewhere else, join, go to one or two calls, and then move away again.

And we've had a career firefighter join the volunteer company. He's also an EMT, but hasn't come to any calls.

So out of twelve other potential EMTs... we have one.  The one who spent most of the past 2 1/2 years not going to calls and not training.  

So the question is...

WHY did all these people not stay here, and/or not go to calls here?

What is going on?

I can't know for sure, but I sure have a theory.

This is my theory:

There is nothing here to keep anyone.

No training.

No mentors.

No way to advance.

No way to maintain skills.

Nothing.

And that doesn't even take into account how new people are treated. Our one recent new EMT is not so sure she wants to stay, based on how she has been treated.

In order not to write a dissertation here, I'll keep this short.

I'll talk a little about how it affects ME.

First, it's dangerous.  And disrespectful.

Second, it puts me in a position to have to scramble to find ways to maintain my skills on my own, and to get training on my own.

I've done a number of things.

I've gone to nearby companies and joined their training.

I've continued communication with my former teachers.

I took the EMT-I class. Twice.  There's a story there, for another time.

I've taken advantage of some regional training opportunities.

I've taken advantage of one county training opportunity, the only one there has been.

I've bought a lot of educational books.

Done some online training.

Talked with the medics at the nearby ambulance company.

Did a LOT of ride time during my EMT-I class(es).

And I took the scary step of applying for a scholarship to go to EMS Today- and got it.

Had to get creative with my budget to be able to swing transportation and a hotel room.

Won't be able to do that often.

EMS Today was my first experience with any major EMS conference.

I wasn't sure what to expect.

What I GOT was fabulous.  I'll be writing about this for quite some time to come.

But here is the thought I wanted to share, the reason for this entire lengthy post.

I heard some rumblings, some... dissatisfaction with EMS Today. The one that stuck out for me had to do with the sessions being not the most interesting topics.

I understand that for people who have been doing this a long time, the sessions must get repetitive.  Most of the information isn't new, by any means.  Aside from the possibility of a new topic coming up like the changed AHA guidelines (which isn't really that new), most of it has been seen before. And before. And before.

I get that. I really do.

And what it means for those people is they can go and choose to focus on other aspects of the event, like socializing or "networking." Which is great, and is EXACTLY what I used to do at conventions I used to go to years ago.  I was the head of an organization, and a dealer, and I didn't actually attend any of the stuff scheduled for the paying folks. Didn't need to, and didn't have any interest. Had plenty other things to do.

But for this, for EMS Today, those sessions that probably most medics have already done to death, they were a GODSEND to me.

I DON'T know all this stuff.

I haven't done these classes before.

I picked up a huge amount of information I hadn't seen before, or hadn't thought about. Some of it subtle. Some of it not.

So while I wish that there would be new, interesting sessions, for the most experienced people attending, something that would knock their socks off... I am immensely grateful for the stuff for the LEAST experienced among us.

Because that might very well be me.  Or at least, I'm not far from that end of the scale.

I learned more in four days than I have in the past year, and that wasn't without trying.

I learned more in four days than my department has offered in four years. 

So I wish, I really wish, that I could be in a position to find these events boring. That I could go to one and have already seen all the presenters before, and be familiar with the sessions they give.  That I could spend four days and have there be nothing new, nothing I hadn't done before.

I really do.

Maybe I'll get there someday.