RSS

Endings, beginnings and limbo

A couple of days ago I found out that I was in fact accepted into the paramedic program I have been working so hard to get into.  5 days later, after considering where I had been, where I wanted to go and where I am right now, I realized with that single phone call I reached an end, a new beginning and found myself in a sort of limbo.

It isn’t often that a single event can bring about all those paradigm shifts, life tends to reserve such a substantial change in perspective for equally substantial events. I can hear some of you saying it’s just paramedic school man, get over it; and yes, on the most basic of levels, you are right it is “just” paramedic school. Of course when you take into consideration that I have wanted to be a medic for over 20 years now, that I was away from EMS for over 15 years, and that I walked away from owning a successful construction company to return to the field I love, it takes on more meaning, If you factor in that I took a SUBSTANTIAL cut in salary to return to EMS, and that every decision I have made in my professional career over the last two years had led up to that phone call, well you might then begin to understand how important that phone call was to me.

Now I found myself wondering whats next – it’s no longer I want to go to p school this fall, it’s I am going to paramedic school this fall. It’s no longer have to do x,y,z to impress the selection committee, it’s I have to do x,y,z because it’ll make me a better paramedic student and ultimately a better paramedic. The pre-requisite classes are now all officially over and it feels as if this stage is coming to a close. I didn’t get to this stage by myself, it took a lot of support from people who care, it took a gentle kick in the kiester (or two) and someone to believe in me and tell me I could do it.

Now that p-school is no longer something that I am working towards, it is something I will be in. I find that all the anxiety about not getting in has now shifted to “oh my God, I got in… now I have to do more than just talk about it.” The whole new set of challenges, the new base of knowledge, even the physical demands of paramedic school all bring a renewed set of challenges, new obstacles to overcome. A new beginning to an old dream, needless to say, I am more than a little excited about it. So excited I find myself having to stifle the urge to start right this very minute… to not to dive into pharmacology, cardiology and patho phys. Not to say that I won’t prepare and try to get a head start, but I have some time for that still. Hell, I haven’t even received the new student packet yet.

That brings me to now and the “limbo” – school doesn’t start until September – and I can’t say what day in September yet – (see new student packet above) I’ve been so focused on getting in that now that I am in and until it starts I feel sort of lost, like I don’t know what I should be working on. The fun-loving side of my brain says take some time for yourself now – plan a trip up to the mountains and try to get as much “fun” in outside of work as you can because once school starts opportunities for that kind of recreation will be very few and very far between. The practical, professional, driven side of me says start studying now, because I can’t seem to suppress that drive to be the best (frankly, I don’t really want to either).

For the moment I think I will dwell in the satisfaction of a job well done, I will plan a trip to mountains before school starts and I will take a moment (or two) to breathe, before I start the early studying.

Til next time…

 

Posted by on August 2, 2011 in Paramedic School, Personal

Leave a comment

Tags: , , , , , ,

SOAP – Not just for your hindquarters anymore – Conclusion

The original plan was to type out one of these sections daily until I had finished it, BUT thanks to a standby yesterday that went a whole 4 hours longer than it was scheduled for I didn’t get a chance to post yesterday. SO lucky you. You get a double dose of documentation in a single setting… Don’t you feel special 😉

The A section is the place for your assessment of the patients condition, I know over the years we have all been told we don’t diagnose in EMS and that’s true, but it’s also a misconception. You HAVE to form some kind of opinion of what is wrong with the patient, otherwise how do you decide what to do for them? You have an opinion – write it down, the diagnosis box at the hospital will be filled in by the ED doc, and I don’t care how big a rock star you are. He isn’t going to just copy what you write down. Don’t be afraid to form an opinion of what is wrong with the patient or to express that opinion; even if you never say the words your treatment tells everyone what you suspect is wrong.

In the scenario patient we’ve been documenting his injuries are obvious and I would have absolutely no qualm with writing them down as you will see, but what about nana who presents with a medical condition you can’t be quite as sure of? You still will have formed an opinion of what is wrong with her, but you can’t be sure if it’s CVA, A TIA, or is secondary to a previous CVA and she’s just presenting with a case of generalized weakness. Two little letters R/O (rule out) come in extremely handy in these situations. You can list every suspected injury, illness or condition with confidence when preceded by the letters R/O; this is a suggestion to the ED that based on your assessment you believe they should look for ______________.

Generally speaking, that should be sufficient to satisfy even the most ardent defenders of the “we don’t diagnose” argument.

You wouldn’t dream of walking into the ED and in your hand off report telling the doc: Well Doctor Smith, the patient presented with an asymmetric smile, slurred speech and arm drift that occurred suddenly about 30 minutes ago, but I have no idea what’s wrong with her…. You would say she’s suffered a stroke. If you would say it don’t be afraid to write it as well, granted we can’t tell if the patient is having a TIA, or a CVA, but at this point neither can the doc… He needs to see if the symptoms resolve and examine the scans, but if this is a concern for you then list your assessment as: R/O CVA/TIA

Enough of my SOAPbox (pun intended) grandstanding, back to the narrative.

A:

Tension Pneumothorax

Intra-abdominal bleeding

Hypoglycemia

Fx Left Femur

Scalp Lac 

During our exam we confirmed each of these injuries; I have no problem writing them exactly as I did, if it makes you feel better put an R/O in front of them.

Finally the last section P – procedures – this is the section where you document EVERYTHING you did for the patient. This is one of the sections I see A LOT of people skimp on, I was guilty of it myself until I was set straight by my paramedic partner in an ED lounge one day. He had a valid point and I adopted the things he told me and my reports have never been better because of it.

We are required to obtain consent from our patients before we ever touch them right? DO you document it?

What about how the patient got into the ambulance, or if you fastened all the straps on the cot?

Then there is always how the patient got into the ED… I think you get the drift.

DOCUMENT DOCUMENT DOCUMENT – more than any other THIS is the section lawyers have a field day with, if it isn’t here you DID NOT do it period.

Disclaimer first – the treatments below are based on our local protocols, and any ALS interventions were suggested by one of our paramedics whom I greatly respect… I am a basic so if I botch the dosage or something it’s because I didn’t know any better – (that’s why I’m going to paramedic school next month after all)

P: Consent, assumed control of patient’s C-spine from bystander, primary survey, survey interrupted to perform needle decompression (10g, 2nd intercostal space, midclavicular line, with flutter valve), ventilatory assistance via BVM with reservoir and 15 LPM O2, initial survey resumed, Trauma activation called into St. Injury Trauma Hospital, interview, CMS check, C-collar sized and applied, Pt log rolled onto long spine board and secured with spider straps (back exam performed during log roll), head blocks applied and patients head and blocks secured to board with 2″ tape, CMS check, Patient loaded onto cot using long board by crew, foot of long board raised aprox 6 inches by placing med box under it (Trendelenburg), all 5 straps fastened and side rails raised, patient loaded into back of ambulance by crew, Patient transported emergent to St. Injury Trauma Center, vascular access (bilateral A/C, 14g angio, blood pump), BGL, fluid challenge 20ml/kg started (1600 ml total), vitals, 3 lead cardiac monitor, head to toe survey, 50ml (25 gm)D50 administered via established IV – Right arm, CMS check of Left leg, traction splint applied (to help relieve pain), CMS check of left leg, 12 lead cardiac monitor, vitals, repeat BGL, monitor decompression site for patency, call in consult to S.I.T.H Dr. Bones to administer 2 mcg/kg fentanyl, order received from Dr. Bones 1 mcg/kg fentanyl IV. 80 mg fentanyl IV via established IV in left arm, vitals, CMS check, patient unloaded from ambulance by crew on cot and wheeled into ED – red 1, patient transferred from cot to bed on long board by crew with assistance of SITH staff, hand off report given to trauma team RN, Patient and care transferred to SITH ED staff without incident.

John Q. Rockstar NREMT-P, Ambulance Company

————————————END OF NARRATIVE—————————————

While some of the treatments the patient got may be open for discussion, there is NO question about what was and what was not done for this patient.

So let’s take a look at the narrative from top to bottom start to finish.

 

NARRATIVE

Ambulance 123 and engine 456 dispatched emergent to go fast speedway at 123 any street for an auto-ped MVC

U/A found approx 20 YO M pt lying next to the race track in a semi prone position. Patient’s c-spine is being held by track employee and two other track employees are talking to the patient. Patient’s pants have a large tear in them in the left upper leg region and the left leg is bent at an awkward angle. Blood is visible in the patient’s hair and the patient appears very pale.

S: Pt is a 23 YO M. Patient states he “Can’t breathe” and his “chest and leg hurt”. Patient speaks in one to two word sentences and is confused and disoriented. Patient states that “a car drove right over me!” Patient states he isn’t sure how long ago this occurred.

HEENT: no complaints – pt states he “thinks he feels blood running down his face, but it could be sweat”

Chest: pt C/O pain to left chest – Pt denies having this pain before the collision, breathing/moving makes it hurt worse, pain is described as being sharp and squeezing at the same time, patient denies any radiation, pt rates the pain a 10

Back: no complaints

Abdomen: Pt C/O pain on palpation, patient denies any pain before accident, “you pushing on it” makes it worse, pain is described as dull all over his abdomen with no specific site, patient denies any radiation, patient rates the pain a 6

Pelvis: no complaints

Lower extremities: Pain to Left upper leg, patient denies having any pain before the accident, trying to move it makes it worse, pain is described as sharp and pulsating, patient denies any radiation, and rates the pain as a “12″

Upper extremities: no complaints

Allergy to PCN

Medications: insulin

PMHx: DM 2

Patient does not remember the last time he ate.

Patient also states he has a headache and some dizziness. Patient denies N/V/D as well as any LOC, but says he isn’t sure about that.

Bystanders give verbal report as follows: patient was walking from the pit area when he was struck by a vehicle traveling at a high rate of speed. Bystanders say that car did in fact drive over the patient saying he collapsed on impact and went under the car. Bystanders add that the patient was unconscious until just prior to our arrival. Bystanders also report that patient has not been moved and that track personnel were to him almost immediately keeping him still and “holding his head”.

O:

INITIAL EXAM

Airway: Open and patent

Breathing: Rapid w/ poor movement

Circulation: rapid radial pulse, minor bleeding from scalp lac, no major bleeding found

Skin: Pale, Cool, diaphoretic, cyanosis noted around lips

LOC: confused and abusive, won’t follow commands

Head: Blood in hair, no active bleeding, no other wounds noted, PERRL

Neck: No DCAP/BTLS noted, possible tracheal deviation to the right, positive JVD

Chest: Contusions noted to left chest, no paradoxical movement, crepitus and tenderness on palpation, breath sounds absent on left

Abdomen: slightly distended, tender to palpation

Pelvis: No DCAP/BTLS – intact and stable

Upper legs: Swelling, tenderness, deformity of left upper leg, normal CMS

Lower legs and arms: no injuries noted

Posterior: No DCAP/BTLS

Initial vitals: 90/50, pulse 150, respirations 36

GCS: 13 (eyes – 4, verbal -4, motor -5)

Sensory and motor function: normal

SECONDARY SURVEY: performed after initial interventions – en route to hospital

Airway: patent

Breathing: improved movement of air, less work to breathe, breath sounds now present on the left although diminished

Circulation: no major bleeding noted

Skin: pale, cool, diaphoretic, cyanosis around lips is improved

Vitals: 100/60, pulse 110, respirations 30

LOC: unchanged

GCS: unchanged

BGL: 40

Head: blood in hair from approx 4″ long scalp lac, no active bleeding, no battle sign or raccoon eyes, no drainage from ears or nose, face is atraumatic, PERRL

Neck: trachea appears more mid-line, JVD is no longer present – No DCAP/BTLS

Chest: unchanged

Abdomen: distension and tenderness are both increased from prior exam

Pelvis: unchanged

Upper extremities: NO DCAP/BTLS, Good CMS function

Lower extremities: Left leg in traction splint – CMS present, right leg no injuries noted

ONGOING EXAM: Performed after secondary interventions

BGL: 80

LOC: Patient is awake and alert, less combative and able to follow commands

GCS: 15

Breathing: movement of air continues to improve

Vitals: 110/70, pulse 110, respirations 30

Skin: unchanged

Neck: trachea remains midline and JVD remains absent

Chest: breath sounds still diminished on the left

Abdomen: distension/tenderness continues to worsen

Distal CMS on Left leg still intact and adequate

A:

Tension Pneumothorax

Intra-abdominal bleeding

Hypoglycemia

Fx Left Femur

Scalp Lac 

P: Consent, assumed control of patient’s C-spine from bystander, primary survey, survey interrupted to perform needle decompression (10g, 2nd intercostal space, midclavicular line, with flutter valve), ventilatory assistance via BVM with reservoir and 15 LPM O2, initial survey resumed, Trauma activation called into St. Injury Trauma Hospital, interview, CMS check, C-collar sized and applied, Pt log rolled onto long spine board and secured with spider straps (back exam performed during log roll), head blocks applied and patients head and blocks secured to board with 2″ tape, CMS check, Patient loaded onto cot using long board by crew, foot of long board raised aprox 6 inches by placing med box under it (Trendelenburg), all 5 straps fastened and side rails raised, patient loaded into back of ambulance by crew, Patient transported emergent to St. Injury Trauma Center, vascular access (bilateral A/C, 14g angio, blood pump), BGL, fluid challenge 20ml/kg started (1600 ml total), vitals, 3 lead cardiac monitor, head to toe survey, 50ml (25 gm)D50 administered via established IV – Right arm, CMS check of Left leg, traction splint applied (to help relieve pain), CMS check of left leg, 12 lead cardiac monitor, vitals, repeat BGL, monitor decompression site for patency, call in consult to S.I.T.H Dr. Bones to administer 2 mcg/kg fentanyl, order received from Dr. Bones 1 mcg/kg fentanyl IV. 80 mg fentanyl IV via established IV in left arm, vitals, CMS check, patient unloaded from ambulance by crew on cot and wheeled into ED – red 1, patient transferred from cot to bed on long board by crew with assistance of SITH staff, hand off report given to trauma team RN, Patient and care transferred to SITH ED staff without incident.

John Q. Rockstar NREMT-P, Ambulance Company

————————————END OF NARRATIVE—————————————

After reading through it top to bottom, do you have any question as to why this guy is in the ambulance, what is wrong with him, or how you intervened to try to help? Can you say the same thing about the last narrative you wrote?

Til next time…..

 

 

Posted by on August 1, 2011 in documetation, EMS, legal, Paramedic School

Leave a comment

Tags: , , , , , , , , ,

SOAP – Not just for your hindquarters anymore

One of the many things has changed over the years is the standardization of the narrative, early in my career a timeline story narrative was the norm, one gigantic block of information that you had to read from beginning to end. These days there are two preferred versions of the narrative – C.H.A.R.T. or S.O.A.P. I have heard conflicting versions of which of these is the “preferred” version to use, you know the one that will eventually be the be all and end all of narratives – at least until it changes (again).

My personal preference is SOAP, it works for me (after I was dragged kicking and screaming into the 21st century and forced to choose one or the other). So I am going to go into detail about SOAP over the next few days breaking it down into pieces that are easily manageable.

A frequent complaint I hear from people about SOAP is that they get confused about what information goes into each section, this is understandable until you get a feel for this type of narrative and how it works, but it’s actually quite simple. Everything your patient or a bystander says goes into S- put another way – everything you could learn about your patient if your eyes were closed belongs in the subjective section. Everything you see on exam belongs in the objective section – this is the place for reporting the findings of your actual examination of the patient. The A is assessment and is the place for you to record your “differential diagnosis” of the patient, while much has been said over the years about how important it is NOT to diagnose your patient in the EMS setting there is a way to convey what you think is wrong with your patient AND not write an actual diagnosis – we’ll get to that when we breakdown the A section in detail. Lastly, there is the P or procedures section… and A LOT more information goes here than you would think at first thought, I’ll go over some of the things you should have in there to help make that section of the narrative bulletproof.

Let’s get started shall we

This is totally fictional patient that I have taken from a testing scenario – so there is no concern about any potential HIPPA violations (honest chief)

I am not going to give you any of the call information as it came in, what the patient’s MOI is, or what injuries this scenario contains… because IF I document it properly – you should get all of those questions answered by the time I finish this narrative.

I always start my narrative with the dispatch information and what we found on arrival before beginning my SOAP narrative. Actual narrative will be bolded – comments will remain in normal font.

NARRATIVE

Ambulance 123 and engine 456 dispatched emergent to go fast speedway at 123 any street for an auto-ped MVC

U/A found approx 20 YO M pt lying next to the race track in a semi prone position. Patient’s c-spine is being held by track employee and two other track employees are talking to the patient. Patient’s pants have a large tear in them in the left upper leg region and the left leg is bent at an awkward angle. Blood is visible in the patient’s hair and the patient appears very pale.

At this point we have documented everything we know before getting out of the ambulance, we have defined the MOI, the approximate age of the patient, how we found them and given the general impression we formed – this guy is “sick”

Now that we have done all that it’s time to dive to into what the patient tells us when we approach.

S: Pt is a 23 YO M. Patient states he “Can’t breathe” and his “chest and leg hurt”. Patient speaks in one to two word sentences and is confused and disoriented. Patient states that “a car drove right over me!” Patient states he isn’t sure how long ago this occurred.

HEENT: no complaints – pt states he “thinks he feels blood running down his face, but it could be sweat”

Chest: pt C/O pain to left chest – Pt denies having this pain before the collision, breathing/moving makes it hurt worse, pain is described as being sharp and squeezing at the same time, patient denies any radiation, pt rates the pain a 10

Back: no complaints

Abdomen: Pt C/O pain on palpation, patient denies any pain before accident, “you pushing on it” makes it worse, pain is described as dull all over his abdomen with no specific site, patient denies any radiation, patient rates the pain a 6

Pelvis: no complaints

Lower extremities: Pain to Left upper leg, patient denies having any pain before the accident, trying to move it makes it worse, pain is described as sharp and pulsating, patient denies any radiation, and rates the pain as a “12”

Upper extremities: no complaints

Allergy to PCN

Medications: insulin

PMHx: DM 2

Patient does not remember the last time he ate.

Patient also states he has a headache and some dizziness. Patient denies N/V/D as well as any LOC, but says he isn’t sure about that.

Bystanders give verbal report as follows: patient was walking from the pit area when he was struck by a vehicle traveling at a high rate of speed. Bystanders say that car did in fact drive over the patient saying he collapsed on impact and went under the car. Bystanders add that the patient was unconscious until just prior to our arrival. Bystanders also report that patient has not been moved and that track personnel were to him almost immediately keeping him still and “holding his head”.

At this point we have conveyed all of the information we got from dispatch, conveyed how we found the patient, what prior aid if any was administered as well as all of the pertinent information we gathered verbally from our patient AND bystanderswe have completed the O, P, Q, R, S, T for each complaint as well as the SAMPLE history.

Now obviously we didn’t gather all of this information prior to leaving the scene, but since this isn’t a chronological report is does not matter when we got the info, just that we obtained it at some point.

Our objective assessment would come next, but that’s tomorrow’s post

Til Then…

 

Posted by on July 29, 2011 in documetation, EMS, legal, Paramedic School

Leave a comment

Tags: , , , ,

Documentation – Why bother?

During a conversation with one of the EMT students I had this week, the subject of documentation came up, it was bound to happen that they would find out about what many of us consider the absolute worst part of the job. It was only a matter of time before that “dirty little secret” came to light.

Speaking strictly for myself, documentation is the one skill I don’t ever want to “practice” – it seems so trivial to us in the grand scheme of things, that many of us are inclined to say things like “I didn’t take this job to be a billing specialist,” or some other equally inappropriate comment like “what difference will my documentation make to whether this patient lives or dies?” It’s not so much that we mind having to take the time to write stuff down, it’s just that it’s dull, boring and when not viewed in the light of how important it actually is,  it can be seen as a waste of time.

Documentation mostly gets a bad rap – we’ve all heard the line “if you didn’t write it down it didn’t happen”, many of us have likely heard something along the lines of  “oh sure make me write it down so it can be used against me later, “or perhaps you’ve gotten the call from the billing office that says “we can’t bill this trip because you didn’t document……”

It doesn’t have to be that way folks, let’s take a look at why documentation is so important and answer/address some of the common misconceptions we all too often have about it. Properly appreciating the value of good documentation can be had when we take the time to understand all the things those “seemingly meaningless” documents are actually used for.

From our standpoint as providers, the most important aspect of the patient care report (PCR) is that it is a clinical document that follows your patient through their hospital stay. It allows later providers to experience the event their patient is being treated for from the beginning to the present. Let’s put that in a context we can relate to:

  • How many times have you been able to get an accurate history of your patient at a nursing home? How frustrated do you get when you are unable to establish a “normal” baseline for your patient? Is that facial droop normal, how about the slurred speech and left-sided weakness? Ummm I don’t know they aren’t my patient, or I’m not the normal nurse over here – I’m just covering and I have never had this patient before ….

Speaking only for myself – I know what I think about the care that patient is getting or the level of professionalism of the caretaker I just spoke to. Do YOU want to be seen in that same light when some provider down the line tries to decipher your PCR and can’t get any information from it? I know I don’t want people to think about me or the care I provided to my patient that way.

Just as poor documentation that is missing important information says your care was sloppy and that you were not thorough in your treatment, professional documentation that is thorough implies that your care was as well. You can be the best provider in the world, but if your documentation looks as if it was done by a kindergartener, it will be ASSUMED that the care you provided was also performed at that level.

I know we all think our reports are totally ignored by ED staff but in actuality, they are carefully reviewed and incorporated into the patients chart.

Additionally, the documentation you write every day is what is reviewed when the effectiveness of our systems is critiqued. Studies on pre-hospital interventions are based largely on what we write in those reports, statistics, effectiveness of treatments even compliance with federal, state and local laws all are based on the documentation we provide.

The information you document in a PCR may not make a difference in whether or not that particular patient lives or dies – BUT it may make a difference in whether a patient you treat down the line does…  QA/QI processes are based almost solely on our documentation, and those sessions help determine how effective and appropriate our care was. QA/QI can be “painful” – espicially when it is your call under review. These sessions, in my experience, are generally not used as witch hunts where management goes looking for someone to blame for a negative outcome; instead, when used properly they are used to teach providers how to more effectively treat their patients in the future, maybe as a result of this process – local protocols are adjusted to allow us to better serve those who depend on us.

Of course you knew it was coming, any discussion of documentation would be incomplete without a discussion of the medical-legal aspects of what we write down, but we only ever see the downside of this. Instead of viewing your PCR’s as something to be used against you, I suggest you see them as your blue tights with the red S on the chest, your armor if you will. Thorough documentation is not something we should fear should a case go to court, instead knowing your treatment was solid, your decisions sound and your patient well cared for AND that you covered all the bases and documented all of that should alleviate that concern for you. Yes, we have all heard cases where pre hospital providers have been sued and some even where they lost, BUT those cases are due to POOR documentation.

We live an extremely litigious society, people will sue for anything they perceive as a payday for them, it’s a sad fact of the world we live in (and one of the reasons health care reforms will never achieve the desired results – sorry that’s another post). Instead of looking at your documentation as the weapon some ambulance chasing shark is going to use to surgically separate you and your retirement savings, view it is the shield that will stand up to the most rigorous of slimy lawyer assaults. You’ve heard it said if you didn’t write it down you didn’t do it… so counter that by simply writing it down. Civil suits usually start with a PCR being reviewed by some expert, their opinion of your REPORT (not your care) is often the deciding factor in whether or not a case progresses – a well-organized professional report will imply well-organized professional care and more often than not, will nip a suit against you in the bud.

Suppose it does progress further… suppose you are called to the stand to testify, how many calls do you run a day? Now multiply the number of calls/day by the number of shifts you work in say a year… can you still remember the details of all of those cases? Your PCR needs to have enough information to help you remember the call and the patient – go to whoever stores your PCR’s at the service where you work/volunteer and ask them to pull one of your PCR’s from a past call say a week, a month even a year ago – can you remember that call based on what you wrote in your report? If the answer is no you aren’t documenting accurately or completely enough to make yourself bulletproof… NOW is the time to fix that not when your retirement fund is on the line.

Billing – it is an unfortunate fact that ambulance services for the most part are businesses and as such they need to make money. Your PCR needs to document accurately what you did for the patient and why. Not only so that the company can make a buck, but more importantly so your patient isn’t unnecessarily billed for a higher level of care then they received or needed. If you run a paramedic/EMT car if the patient only needed BLS then they should only be billed for BLS, but you may need to justify that decision down the line, you can’t do that without proper documentation. It’s a pain in the ass and the single question that I absolutely HATE asking my patients “Mrs. Jones, can you tell me do you have insurance, and if so can you please provide me with the necessary information?” It makes me feel like crap and I hate asking… BUT recently I have begun to see this in another light as well. If I take the 2 minutes to get Mrs. Jones insurance information – how much hassle and headache am I saving HER down the line by having the bill sent directly to her insurance company? How much easier have I made dealing with the financial burden our services can cause by taking that simple step and documenting it. I look at it as an extension of patient care, and when I explain to my patients that I’m asking to save them the headache of sorting it out later, they are usually grateful that I asked, and that makes me feel a little better about asking.

The bottom line with billing… no it isn’t why any of us got into this line of work, BUT it is what KEEPS us in this line of work. Yes, there are services out there that do not bill (oh how I envy those of you that work for them) but for most of us, continued employment depends on continued operations and that my fellow provider is largely related to billing.

Luckily, documentation is a skill – it can be taught, practiced an improved and that will be what we’ll discuss the next few days.

Til next time…

 

Posted by on July 28, 2011 in documetation, EMS, legal

Leave a comment

Tags: , , , , , ,

Reminders

6 hours to go until the end of my set, it’s been 42 pretty busy hours, not quite stand up, but close. I should be laying down and trying to get a little rest before the tones drop again, but I was reminded about some pretty important stuff on two specific calls this 48 and we can all always use a little reminder every now and again, so I thought I would share them while the biggest safety concern you have is burning your retinas from staring at the computer screen.

Everyone who has ever taken an EMT exam of any kind is all too familiar with the way practicals work and the ritual we all do at the beginning of each one… walk in the room, do your best jazz hands for the proctor while uttering the words – BSI is the scene safe… they are drilled into our heads from day one of EMT class and reinforced every time we go on a call that sets off our spidey sense. We say them so often that they become some sort of absurd joke by the end of classes. Relegated to the back of our mind where all the stuff we have repeated ad nauseam lives, that’s where it’s supposed to be so you don’t have to think about it. Every once in a while I realize I have gotten too comfortable in my role and I take something like scene safety for granted.

What about you? What about those calls where the spidey sense isn’t tingling, the calls that are seemingly innocuous? I mean if you are ever going to get caught with your pants down it isn’t going to be in a rough and tumble neighborhood at 0300 in a dark lit alley – just typing that set off all kinds of warning bells. If you are going to have a problem it’s more likely going to be on a brightly lit street in the middle of the day for a seemingly benign call.

I had two reminders over this set of the importance of scene safety – one I handled very well – in fact I was the person that deemed the scene unsafe and made the “good call” to get PD in and US out… Turned out there was no threat on that call. The other one I didn’t handle nearly as well, and while nothing happened it could have gone WAY bad.  Let’s look at both and pick apart what went right and what went wrong… maybe you’ll see yourself in my actions and come away with a valuable reminder.

Call number 1

Dispatch information: call came in from a medical alarm company, unknown problem with Fire Dept.

Arrival: we were first unit on scene, middle of the afternoon, nice neighborhood – on approach I notice blinds in all the windows are closed except the window next to the front door where they are pulled up. Approaching the front door I notice a keybox hanging from the knob – which is common here when the patient has a medical alarm. I motion for our EMT third rider student to stand behind me on the side if the door and knock loudly announcing our presence, this is repeated a couple of times. After the third try I tell my partner (and the student) I’m going to walk around the house. I start by looking in the window, and while the house has been totally silent I peered through the open blinds and lying on the bed not 3 feet from where I was standing was a hunting rifle, there were no sheets on the bed no other furniture visible and no patient or other occupant that I could see. I relayed the information to my partner who immediately radioed in for PD. He and our student headed for the ambulance while I quickly scanned the yard. Nothing was seen in the yard, so I headed for the bus… EMT student safely inside the ambulance my partner and I in the road behind the ambulance with it between us and the house. We are on the phone with dispatch when the engine arrives… I quickly run down what we’ve found while my partner gets the information on where the key is located from dispatch. He tells me that there is a key under the brick next to the air conditioner… I now have 4 fire fighters on scene to watch windows so I decide to go investigate the key location… there is a brick, there is no key. While turning from there to head back out I must have caught something out of the corner of my eye or heard a faint cry because something compelled me to walk to the back gate and peer through the side that opens and when I did I found our patient lets just call her nanna lying on the ground with her leg shortened and externally rotated.

RIGHT ACTIONS: we parked in a safe location, our approach was solid, our attempt at contact was from a protected position next to the door, I noticed the “threat” identified it to my partner and the student and we all headed for the bus to wait for the calvary to arrive. We investigated again when we had more eyes and ultimately found the patient

WRONG ACTIONS: We didn’t actually leave the scene, we waited in the street. We didn’t actually wait for the calvary to arrive… PD is who should have ultimately found that patient  – not me.

The thing that bothered me about that call was that nanna was crying out for us from the back porch but we didn’t hear her and she laid there suffering for longer than she should have because of that rifle I saw. Do I fault myself for that absolutely not, I know pulling back was the right call but it still bothered me on some level.

Call 2 ~ (the next day)

Dispatch: 90 F with pneumonia

Arrival: Again first on scene – well-lit middle of the day apartment complex that looks like it could have been a hotel at one point. Fairly good neighborhood, although the appearance of the building is rather run down. I park the rig in the parking lot and notice an elderly couple sitting about 25 feet away waving at me on my side of the rig. I glance back over my shoulder and see my partner is heading to the back of the bus for our gear and to fetch our student rider, I start over toward the couple I see sitting there one is a slender male mid 60’s the other is a small female sitting in a wheelchair slightly slumped over. I approach the couple assuming the lady n the chair is the patient. When I get to them the male says its my mom she’s got pneumonia, she’s been real sleepy and feverish since last night, and he starts to walk toward the apartment – I follow. Upon entering I notice a male to my right asleep on the couch head toward the door, his back covered with more “bumps” then I can count, the place is run down and unkept but by far not the worst place I’ve ever seen across the room to my left is a hospital bed with a frail old woman lying in it and my first thought was “OH SHOT” this lady is way sick. I jump right in… she’s breathing and she’s breathing FAST I can hear and see that without even thinking about it so I begin trying to rouse her, verbal – nothing – sternal rub and yelling she opens her eyes, great making a mental note of “V” I grab her wrist as I hear a commotion behind me… It’s my partner, I never turn I just say I need to O2 bag and the monitor, and I go back to assessing… The engine arrives and more commotion behind me I glance back quickly as I am getting the capnography cannula plugged in to the monitor to see two fire fighters carrying the lady who was in the wheelchair when I got there out, My partner is asking is anyone else here sick? and the paramedic on the rig leans into me as I am hooking up the monitor and says there is hep-c, aids, and c-diff in this house as she hands me a cavi wipe and a pair of gloves… I turn care over to the firefighters long enough to wipe my hands get the gloves on and position the cot… My partner (who is the medic) has now assumed care and when I turn around I see the guy on the couch is not there anymore… After an emergent trip to the hospital and safely delivering our patient – I say to the student I made three critical mistakes on that call – can you tell me what they were…

RIGHT ACTIONS: I immediately realised this patient was very sick and was going to require ALS and I took charge of the patient and her care until my partner was able to do so.

WRONG ACTIONS: First I got out of the rig without gloves, assuming I was still going to be talking when my partner got there and handed em to me. Second I left the rig empty-handed – I walked over to who I thought was the patient with no gear or equipment, third when I saw how sick the patient was I lost track of everything else but her.

I found out after the call that my partner (who has worked at this outlying station for a few years) has had several calls to this address and more than once the male sleeping on the couch has had to be “escorted away” in cuffs for becoming threatening to personnel. It took a minute to get him “out of the way”-  my partner had also assumed those were our patients and momentarily had a sense of oh my god where did my partner go. Because I jumped right in I didn’t accurately communicate my findings to my partner (did I mention HE is the paramedic?) the delay to definitive care for the patient was miniscule maybe 20 seconds BUT my partner was playing catch up because HE had to get the scene secured after I ignored it… I knew this was going to be a hot return before he even had a chance to ask me what we had.  Fortunately for all of us myself especially – I would have never been able to live with my negligence causing a fellow responder injury – nothing happened, but there was a mountain of POTENTIALLY unsafe circumstances.

Did the call from the day before affect my judgement, maybe a little but I wont make excuses. I made a mistake. My over confidence in myself and my underestimation of how serious a call this would be is what I blame it on.Fortunately, I was able to not only remind myself of things that should come second nature, but I was able to turn it into a teaching moment for a new EMT and hopefully, she will have learned from my mistake.

Comfort on scene and in your abilities in a good thing  – until you get complacent – as I’m sure one of my Marine Corps drill instructors said over and over – complacency will get you killed son.

I got caught with my pants down today, I’m sharing it with all of you in the hopes that my mistake will help prevent you from getting too comfortable in your EMT skin and getting caught with yours down as well.

Til next time…

 

 

 

 

Posted by on July 27, 2011 in EMS, Scene Safety

Leave a comment

Tags: , , ,

We’ve come a long way – with OH SO FAR to go… Part 1

I suppose I should preface this post with a few things before diving into the meat of it. As someone who was away from EMS for almost 20 years the changes in focus and scope of practice have been glaringly obvious. I suppose you could compare my perspective to that of  the grandmother who only sees your kids once a year. She raves about how they’ve grown since she last saw them, while you silently wonder if it’s time to take granny to the “wrinkle ranch” as she has surely lost her ability to reason; the kids look exactly the same to you as they always have. Sadly, much like that grandmother also sees how values aren’t what they once were, I too wonder if we haven’t “evolved” in our role so much that we forgot what it means to be an EMS provider.

Because I try to always find the bright side in everything, I’ll start with how much EMS has grown. I work in Colorado which is a pretty progressive state in terms of EMS, from my understanding the scope for a basic here far exceeds what is allowed in other states, I point that out because my scope may be different then that of a basic working somewhere else. Having gone through EMT school twice (damn I never should have let that cert expire) it became clear to me that the “focus” of a basic’s education has shifted from trauma to medical which is a great thing… trauma is easy, medical requires some investigation. The days of “stay and play” at least to the extent they used to be emphasized are long gone – replaced with the correct assumption that the most important thing we can do as pre-hospital providers is deliver our patients to definitive care – preferably with a pulse.

AED’s were bursting onto the scene when I got my first cert, and required a separate 24 hour-long class, AND a separate cert. after successful completion you were an EMT-D. The difference between professional rescuer CPR and lay person was the professional was also taught two person and pediatric/infant CPR. MAST pants are no longer a required skills basics are tested on, replaced by a tool that is more useful to us a glucometer. On my first go round, basics could give O2, ipecac, activated charcoal and oral glucose – period.  Ipecac has been removed (as has activated charcoal from our system though still taught). Basic’s can now give aspirin, assist with Nitro, assist with MDI’s, and epi-pens. In Colorado with an IV cert basic’s can also administer D-50 and naloxone, our protocols even allow basic’s to administer albuterol nebs (as a call in). In Colorado basic’s can also take an EKG class, and become certified in EKG, (a useless skill for us other than knowing how to place leads for our paramedic partners (but that’s another story as well) Oxygen delivery has been simplified – we had the nasal cannula, simple mask, partial rebreather and non rebreather to remember flow rates for as well as oxygen percentage delivered by each, these days it’s the nasal cannula, and non rebreather, and if you can remember hi flow O’s for everybody you can pass the test (pointing out how it is not how it should be…. so don’t shoot the messenger)

Oxygen tanks were steel, and the stretcher had to be lowered all the way to ground before you and you partner lifted it from the ground to the back of the rig.

Speaking of partners when I took my very first EMT job doing IFT’s in NY – my partner was a driver, no not a pointed stab at the first responder, he was literally a driver, he didn’t even have a CPR card. In fact, I remember coming up on a MVC and sending him back to the bus for 4X4’s and he asked what those were. :O. While I could be mistaken, I don’t think this occurs anymore, I know here in Colorado it is prohibited by Rule 500.

Getting that first job required no more than a valid certificate, a CPR card and a pulse. Once I got that job, it was there’s your shirt, there’s your driver and your bus, go to work. These days testing – both written and skill – are conducted prior to hiring, then there’s the interview process, followed by an academy, and then a field internship where you are again tested on your specific knowledge of the system you are working in.

For a profession in its infancy I’d say that’s pretty significant change over 20 years… Most of those things can be viewed in a positive light by most providers, although there are folks out there who will dispute basic’s administering fluids, starting IV’s and “interpreting” strips, and some of their arguments are more than just medics being pissed we are playing with their toys.

Sadly, all of the changes haven’t been quite so positive… that’s tomorrow’s post.

Stay tuned

 

 

 

Posted by on July 23, 2011 in EMS, EMS 2.0

2 Comments

Tags: , , ,