"Staffed by Paramedics"

My fellow blogger Chris Kaiser from Life Under the Lights recently posted an interesting blog responding to an ambulance he saw at the Fire Department Instructors’ Conference (FDIC) in Indianapolis, IN that had emblazoned on the side the provocative words "Staffed by Nurses". You can find his post here, and I strongly suggest reading it before continuing.

This post will be a response to that attention-gathering ambulance. When I first saw the picture of the ambulance, I wasn't quite sure what to say. So I let my thoughts stew for a while before I decided to write this blog.

On his blog, Mr. Kaiser asks, "Does anybody see anything wrong with that picture?" And my answer is YES! I do see something wrong with that picture. Now, before I go into detail, let me clarify a couple of things: first of all, I have absolutely no problem with nurses. Have I met nurses that made me a little... worried? Yes! But I've met paramedics that have made me nervous as well. It all comes down to individual skill and knowledge. There are good paramedics and good nurses, and bad paramedics and bad nurses. At the end of the day, I'm not biased against any one group or profession and I even plan on getting my BSN once I'm finished with paramedic school.

The thing I see that's most wrong with this picture is that we, as a profession, have allowed the phrase "Staffed with Nurses" to imply that better care is being given to that ambulance's patients than what would be delivered by a paramedic truck. This isn't to imply that paramedic-RN teams aren't great, but to reaffirm that paramedic-staffed trucks are not inferior to RN-staffed ambulances. Unfortunately, at the end of the day, the anonymous ambulance manager person or AAMP (as Mr. Kaiser refers to him or her), is going to do the sound business tactic of trying to make his service appear better than the others; and unfortunately, the state of our profession is such that the general public really IS under the notion that better care will be delivered by a nurse than a paramedic.

What does this say about paramedics and EMS everywhere? That we've been lazy. We've become content with putting in our hours, going home, and trying to make the best out of the situation we've gotten ourselves into. We've accepted the fact that EMS pay doesn't come close to what it should be, and that the majority of the public (and even other healthcare professionals) view us as mere "ambulance drivers" and we've simply stopped trying to fix the problem.

If people will look at that service's slogan and truly believe that since that ambulance is "Staffed by Nurses" they're receiving better care than they would from us, it should be a wake up call to everyone in EMS to get out there and promote their profession. And what better time to get animated about EMS than just before National EMS week?

Here's the deal, our patients don't know who we are or what we do. Half of the healthcare industry doesn't know who we are or what we do. And the situation's gotten dire, to the point that marketing our stupidity is actually a sound business tactic. This is the time for us to take action, not to bash on nurses or anyone else in the healthcare industry, but to get out there and educate our communities and our local hospitals about EMS. Until they know just what a paramedic is, nobody will ever get excited when they see an ambulance that reads "Staffed by Paramedics".

So as National EMS Week approaches, I encourage you all to come up with a plan of action. Go out there and spread your message to the public, let them know who we are, let them know what we are, and let them know that there's no better person to have in the back of an ambulance than someone who's patch reads EMT-P. Even if it's just one person, a friend or family member that isn't involved in EMS and doesn't know a whole lot about us; take some time this National EMS Week and educate them on who the real "ambulance drivers" are.

And to my fellow paramedic students, there's no reason why we shouldn't participate as well. In just a few short months, each of us will have a gold patch as well, along with all of the responsibility that comes with it. Let's not think that we should have to wait until we're paramedic certified to begin taking a role in our profession's many problems, after all, we're all EMTs and that makes EMS ours as well. So what can we do as a class to highlight our profession as National EMS Week comes around? Maybe this would be a good time to take a class field trip and represent ourselves, our college, and our profession.

Let the truth about us spread like wildfire throughout the nation.

The Uniform Stays On

This last week I had my very first day of early field internship, working solely as an EMT-B on the truck. The idea behind early internship is to give us humble students a chance to hone our BLS skills before we jump right into ALS--and, really, it's a great concept. Most of us have never worked on an EMS service, and those that have may have been out of the business for a while and forgotten some of the basics of ambulance operations and patient care. In addition, it takes care of the observational phase of internship; which, for us, consists of an observation phase, a team member phase, and finally a team leader phase.

My shift went great, and I learned a LOT about talking to patients--which is a lot harder than you'd think. I was allowed to do patient assessments, gather history, and function as a BLS member of the team. Both of my partners were great guys, and extremely knowledgeable to boot. The lieutenant I rode with was actually the most senior member of the service, unfortunately I feel like I could have done more to take advantage of his wealth of information and learn more from him. But it was day one, and I'm still acclimating myself to the experience. The next shift, I'll be more prepared for and I already have a list of questions to ask in mind.

As I continue through early field internship, I'll be sure to share with you my thoughts, experiences, and findings. Today, however, I'd like to talk about something else; something we all must deal with, and something that I, as I've delved deeper into the realm of EMS, have had to adjust my habits to maintain:

Professionalism.

Yeah, I know. We've heard this from day one of EMT-B and it hasn't stopped since. But are we doing as much as we can and should to maintain a professional air about our profession? First of all, where does professionalism begin? When we put on our uniforms? When we step foot outside of our homes? When we arrive on scene? I believe (as I know others do as well) that professionalism never ends, that it is something we must maintain constantly and vigilantly throughout our lives; from the very first time we step foot into an EMT class.

Every EMT and paramedic, as we all know, represents the rest of us. They first represent themselves, then their agency, then the entirety of EMS. We shall all be judged by our brothers and sisters within the profession. Yet it seems that far too often we begin to forget that--I know I have. How many of you have said something amongst a group of friends, or on a blog or on Facebook, that in retrospect is not a statement you would want to be associated with a member of our profession? I remember last semester during a progress report with my professor, he mentioned that there were some things I said on my Facebook that weren't entirely appropriate. I went home that evening and went through all of my old posts and, after some careful consideration, deleted all of the ones that I decided were not befitting of a member of EMS.

We all did and said things before we entered EMS that, looking back, we wish we could take back. Even amongst ourselves, we must be careful about what we do and say because, though we may think that we're safe among our peers, they are in fact the ones that will judge us most critically--because they know what does and does not make a good EMT and paramedic. Now, I'm not saying that we can't have our little dark humor, I think that's quite possibly necessary just to survive this job emotionally; but other kinds of jokes, those not meant to help us vent our frustrations but only express our own prejudices and sensibilities, are those that we must critically assess and question: "Is this becoming of an EMS professional?"

Professionalism is something we must always uphold, because we don't stop becoming EMTs and paramedics just because we punch out and go home. We are always representatives of our agencies and our profession, and our patients will remember us as the rude, unkempt, cursing guy they saw the other day at the grocery store; and they will remember us as the polite, well dressed, articulate gentlemen and ladies as well. Our non-EMS friends and family will remember us as we are not on the clock, but off it; and they will judge all EMS personnel they interact with later on down the line by how we present ourselves among them.

In conclusion, today I encourage you all to reassess your level of professionalism in your day to day life; at work and at home. Are there things you could change to improve your own image and the image of EMS? Have you already reached that point where you subconsciously remain in uniform in your speech and behavior even when you're off the clock? If so, great! What about your colleagues? Are there things they do and say that you would not want to be associated with? Become a positive role model for yourself and for them, and don't be afraid to stop them and say "Hey, let's not talk that way--we're paramedics, after all." And if you're like me, and you know you've still got a little ways to go, look for situations today where you can work to improve your professional image.

EMS has been plagued with the belief by others that we are not true professionals, and the truth is that there are pockets of professionalism within our little community as well as pockets of unprofessionalism. So let's do what we can to eliminate those pockets of unprofessionalism, and accept the challenge to prove to ourselves, our colleagues in healthcare, and our communities that we are professionals in every aspect of our lives.

Before and After - The Gold Standard pt. 1

One thing I've been curious about throughout the entirety of paramedic school so far is how much my perceptions of medicine will change from the beginning of the program to the end. So to keep track of some of those changes in my opinion (or lack thereof, as the case may be), I'm going to do a before and after post on certain topics that I feel are most subject to change.

The topic of this one: intubation.

Before we start, let me tell you a little bit about my experience with intubation. My first experience with airway management was during our OR rotations about a month ago, and it included bagging, LMA insertion, and endotracheal intubation. So far I've successfully intubated twenty-two patients without any incidences of esophageal or right main-stem intubation. I've never tubed a critical patient, or one outside of the OR. So my experience is pretty limited.

I like to try and stay fluid in my opinions, because medicine is certainly NOT a static profession to work in, and perhaps by the time I'm done with field internship and the program in general my views on endotracheal intubation will change. Above all else, I hope that wherever I stand, I always do what's right for my patient and not necessarily what's right for me.

Before
As of right now, I am a proponent of prehospital intubation. This is a controversial topic in the field of EMS, as numerous studies are out now that show a lack of correlation between prehospital intubation and increased survival to discharge rates. I won't bore you with a list of studies, but you can find tons of them online with little difficulty that range from advocating eliminating prehospital endotracheal intubation all together, to limiting it to medical patients only, to studies that actually seem to support it in the right hands. The unfortunate thing about such scientific studies is that a lot of the results are often very situational; was the intubating paramedic experienced in intubation? what was the patient's mortality to begin with? and so on and so forth.

Is intubation appropriate for all patients? No, not at all. Are there patients that DO benefit from prehospital intubation? Yes! Any paramedic can give you his anecdote of the patient he or she tubed that they saw three months later at the grocery store alive and talking. Furthermore, the current research seems to suggest that medical non-arrest patients DO benefit from intubation. The biggest determining factor seems to be experience and method of intubation. A recent study released on JEMS showed that paramedics in the prehospital setting interrupted chest compressions during CPR for far too long during intubation. Now, we can take that as a call to eliminate prehospital intubation all together, or we can address the problem itself and correct it by not interrupting compressions during intubation. Would that make a difference? Theoretically, yes. If the problem with intubation during CPR is that paramedics are interrupting CPR for too long to tube the patient, then the easy solution is to simply not interrupt CPR during the procedure. That is the gold standard of intubation during arrest for many services, including the one I work for.

Another question that I've unfortunately been unable to get a very solid response to is whether or not endotracheal intubation is appropriate in ANY setting outside of the OR. If anyone's been able to find out mortality rates for patients intubated in the ER, please share them with me. I have a feeling that if it's bad in the prehospital setting, it's probably bad in the ER as well. Because of the critical nature of both of our patients, the setting is generally the same; however unlike the ER, we in EMS may not necessarily have quite as many hands available to assist as they do. The other factor is the educational level of the providers involved. We all know how difficult it can be to get experience in the OR intubating patients, especially when you're competing against CRNA and medical students, so if the evidence shows that if a paramedic is not capable of intubating due to lack of experience, the solution then becomes additional education.

The move towards blind-insertion airways is quickly gaining momentum, and while I can find no fault inherent in the procedure itself, I have to ask whether we're making any more of a difference in using a combitube over an endotracheal tube when the patient will in fact be endotracheally intubated upon arrival to the ER. If emergent endotracheal intubation is inherently bad in and of itself, regardless of factors such as experience level of the provider or location, then why is it practiced anywhere outside of the OR? It seems to me that, if it's bad in an emergent patient outside of the hospital, it would also be bad for an emergent patient inside the ER as well. In which case, perhaps all of us in the realm of emergency medicine should be switching to dual-lumen airways. I haven't been able to find a study that addressed this, but I'd be interested to know what kind of complications and airway damage result from being intubated with a combitube, followed shortly thereafter by having the tube pulled and an endotracheal tube placed.

In conclusion, there are tremendous hurdles ahead of EMS that we must address to increase our ability to care for our patients safely and adequately, one of them being endotracheal intubation. Right now, it is considered the gold standard of airway management. Unlike bagging, you isolate the trachea and prevent gastric distention, and unlike dual-lumen airways it is still the number one choice in the ER, and in the hands of an experienced and knowledgeable paramedic, can be safely performed in the prehospital setting. Time will tell whether the procedure should be held off on all together in all emergency patients, but until then, I maintain the stance that if done correctly and at the right time, it is no more dangerous than inserting a blind-airway device. Does every patient need to be tubed? No, of course not. Should arrest patients be tubed at all? Maybe not. For now, it is the gold standard of airway management. Like all things in medicine, however, it is just a tool that aids us now; in the future, our descendants may laugh at the idea of inserting ANY kind of tube into a patient's mouth to assist ventilations, just as we laugh at our ancestors' notion of the four humors.

Above all else, in the midst of such controversy regarding prehospital airway management, I hope that none of us come to the conclusion that we, as paramedics, are defined by our ability to do any one procedure. We are defined as the highest level providers of emergency medical care in the prehospital arena, and that is the standard we should meet: to provide the highest level of care possible to our patients. If the highest level of care no longer includes intubation, then by eliminating it we live up to our definition.

When I finish my internship, I will write part 2 of this Before and After, and let you all know how my views have changed (or stayed the same) with a little more experience under my belt.

I Solemnly Swear to Uphold the Code of Ethics

Today in class, we had a special guest! A representative of the EMS service through which the majority of our class will be doing their field internship. He spoke with us a little bit about the dangers of blogging, and how much trouble a paramedic (or paramedic student) can get into if they're not careful about what they say.

Before I started this blog, I asked two people for their advice on it: our program director, and a lab assistant who's had some experience in EMS blogging. Having heard a lot about the dangers of blogging, I was initially hesitant to risk it myself, but after some self-deliberation, I finally decided that it was worth the risk.

Why is it worth the risk? Because EMS grows through interaction. After seeing all of the positive interaction taking place in the EMS 2.0 movement, especially with bloggers such as Mark Glencorse of the U.K. and Justin Schorr of San Francisco, I realized that THIS is vital to EMS. Just like EMS conferences, seminars, and continuing education, by sharing our experiences, thoughts and ideas, we help the entirety of EMS to grow and improve. Thanks to the internet, paramedics and EMTs can now communicate with one another on broader spectrum than ever before. This is the future of EMS, and I want to be part of it.

Even so, we mustn't ever forget what Hippocrates, the father of medicine, first preached over two thousand years ago:

"All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal."

There you have it. Right there, straight from the father of medicine, spelling it right out for all generations to remember: Do not reveal that which ought not be spread abroad." It's a simple message, but one that can make the difference between a paramedic and an ex-paramedic.

So we've got the nice, clear-cut meat and potatoes message--just what we no-nonsense EMS personnel like--but let's go against our nature and complicate things a bit. Just a bit, I promise. Here is a slightly expanded, slightly updated version of that same message, designed specifically for bloggers by the Healthcare Blogger Code of Ethics (http://medbloggercode.com/). It was designed to give bloggers a clear set of guidelines they can show employers, patients and others about the nature of medical blogging.


1. Clear representation of perspective – readers must understand the training and overall perspective of the author of a blog. Certainly bloggers can have opinions on subjects outside of their training, and these opinions may be true, but readers must have a place to look on a blog to get an idea of where this author is coming from. This also encompasses the idea of the distinction between advertisement and content. This does not preclude anonymous blogging, but it asks that even anonymous bloggers share the
professional perspective from which they are blogging.

2. Confidentiality – Bloggers must respect the nature of the relationship between patient and medical professionals and the clear need for confidentiality. All discussions of patients must be done in a way in which patients’ identity cannot be inferred. A patient’s name can only be revealed in a way that is in keeping with the laws that govern that practice (HIPPA, Informed Consent).

3. Commercial Disclosure – the presence or absence of commercial ties of the author must be made clear for the readers. If the author is using their blog to pitch a product, it must be clear that they are doing that. Any ties to device manufacturer and/or pharmaceutical company ties must be clearly stated.

4. Reliability of Information – citing sources when appropriate and changing inaccuracies when they are pointed out
Courtesy – Bloggers should not engage in personal attacks, nor should they allow their commenters to do so. Debate and discussion of ideas is one of the major purposes of blogging. While the ideas people hold should be criticized and even confronted, the overall purpose is a discussion of ideas, not those who hold ideas.


In conclusion, if you have a blog, great! Make the most of it, and take advantage of that incredible opportunity to share your story with other EMS professionals across the globe. Just make sure that you don't forget the very first lesson taught in every EMS courses: be safe.


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BSI, the scene is safe.

9 Months Into the Program...

Things I have learned in paramedic school so far:

1.) Live tissue intubation is NOTHING like on a mannequin.
2.) A preoxygenated patient in an OR can go FOREVER without oxygen.
3.) Math is not as painful as it seems... really!
4.) Sit CHF patients up... or your lab assistants may have them code on you because you let the fluid in their lungs turn them hypoxic.
5.) Sticking your fellow classmates with IV needles in class is okay... the bigger the gauge the better.
6.) When you bring a grill to class for a cookout, make sure the coals are no longer hot before you throw it into the back of your truck.
7.) Watch your back... and your wallet. Classmates may be sneakier than you expect.
8.) An ET tube makes a great replacement trachea for CPR dummies whose tracheas have been broken.
9.) It's not a car accident, it's a crashy-smashy on the superslab.
10.) The goo. Learn it, love it, live it.