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Do you realize ?

That we have been granted a unique privilege by society, to enter into individuals most private lives (to share their most intimate thoughts, feelings, emotions and sorrows) it is a rare privilege which we think so little of and teach so little about in our medical schools, yet it is central to everything we do”

– Fisher “Back To Happiness” 1987

Those words resonate with me at the level of my very being. It is something we so often take for granted. I wonder how many of us stop to actually think about it…

Think about what it is like for someone to call 911 – to know that regardless of who shows up, the police officer, the fire fighter, the paramedic – regardless of who it is – they are opening up their entire life; to you… their home, the most sacred aspects of their lives – mostly without limitation because the situation is out of control for them and they need help…

That is what we do everyday, when we go on 911 calls.

There is an awful lot of gravity to that – what an incredibly special a privilege that is.

Speaking only for myself – I am not a very trusting person, I do not welcome strangers into my home – in fact I am VERY thankful the state I live in has a “Make My Day Law” – I feel strongly about that personally…. But when I need help; I’m calling 911 and no matter who shows up it’ll be “by all means, come on in.” All of a sudden everything flips, because I feel out of control in the situation and I ask for help.

It is all of us that are put in the position to help those people – I hope we always remember what a truly special opportunity that is…

It is a delicate line we walk each and every time we put on our uniform. That fine line between EMT or paramedic/patient relationship and public safety.

Where do lines of confidentiality begin, and end… where are we willing to blur them a bit? ARE we willing to blur them at all?

Due to HIPPA laws we are not allowed to tell the police officer how many drinks our “drunk driver” patient admitted to… but in the interest of public safety do we allow the officer to stand at the back door of the rig and listen to the responses our patient gives to our assessment questions? Do we ask the officer to ride along for “our safety” so he can get the information he needs for his investigation and we don’t breach HIPPA laws? Or do we steadfastly protect the privacy of that patient and close the doors of the bus behind us when we get in and tell the officer he can meet us at the hospital and do his investigation there?

What is the right answer to that question… both options are completely legal – and neither is necessarily right or wrong.

What about the call you respond to for chest pain and see a huge pile of cocaine on the coffee table? Does that change the answer, does it influence your judgement?

I’m not talking about the “mandatory reporting” issues those are clear-cut… I’m talking about those calls that fall squarely in the middle of that grey area.

Where do your ethics draw the line between respecting that immense privilege you are granted in being allowed into someones most sacred and private places and the general safety of the public? Have you ever thought about it?

It was suggested that we think about these tough decision type of calls ahead of time, so that we can make a split second decision we can live with when we are called upon to do so.

In theory that sounds like a damn good idea, however, I wonder if that isn’t like playing “Who Wants To Be A Millionaire” on your couch… It’s easy to find the answers when there is no pressure…

When there isn’t $ 1,000,000 on the line and no lifelines left I can right off the top of my head tell you that Dr Ignaz Semmelweiss is the Hungarian obstetrician that required his students to wash their hands in an antiseptic chloride solution before examining patients, and because of that simple task, maternal death rates plunged from a high of 18 percent to a low of nearly 1 percent in 1847. (Our pharmacology instructor is a big fan of “cocktail party trivia”)

I wonder if the memory of that particular nugget of information would come quite so easily with the spotlight shining on me under all the pressure a game show contestant feels…

Is coming up with answers to these difficult ethical questions any different?   Isn’t it easy to know what the right answer for you is sitting there at your desk reading this? Isn’t it easy for me to say “well this is what I would do” hiding behind the blinking cursor of this blog?

I’m not by any means suggesting we should never think about these things… more that, I’m not sure we can answer them with any degree of certainty until it is OUR feet that are being held over the fire.

What do you think?

 

 

Posted by on October 24, 2011 in EMS, Ethics, Paramedic School

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What would you do?

Watch your thoughts, for they become words. Watch your words, for they become actions. Watch your actions, for they become habits. Watch your habits, for they become character. Watch your character, for it becomes your destiny.
— Unknown

 

It never ceases to amaze me when the classes you think you are going to get the absolute least out of, prove to be the ones that make you go home thinking. Ethics class proved to be full of  ”things that make you go hmmmm…”

I went into class fully expecting to be bored out of my gourd, which for paramedic school is not such a bad thing, easy nights are few and far between. Class opened with the instructor saying this would be one of those classes where they weren’t there to give you answers; instead they were hoping we would leave with questions, questions about our own set of values and how we exercise those values in the field.

Whatever let’s just this over with so we can go home” – none of us actually said it, but I know I wasn’t the only one thinking it.

The lecture proceeded as expected for a while, the definition of ethics, ethics vs. morals, etc.

Then an interesting “case” was presented.

A foreign “dignitary” was brought into the hospital via ambulance – the hospital was rather busy as you would expect from an urban  level 1 facility, but tonight was exceptionally busy… the dignitary was placed into one of the rooms in the old ER which is now used as the psych ER. The room was perhaps not the cleanest in the hospital, nor was it the newest, it was however fully stocked and equipped with all the necessary equipment.

The nicer rooms in the ED were all filled with “regular people”, homeless folks, the drunk that passed out in front of 7 – 11, junior who fell and broke his arm etc.

The dignitary received the top-level of care and was treated as any other person would have been.

After their release the dignitary filed a complaint about their treatment they received and about being put into the sub standard room.

Then the questions started…  Was it OK to put that dignitary into a sub optimal room instead of homeless Joe? Should that person, based on who they are or what they do receive “special treatment”? Was the complaint justified?

Of course, all of us reacted the same way you probably just did; “Damn spoiled brat politicians” Why should they have gotten a nicer room, or faster care, or any other special treatment. We were all convinced we would have done the same thing the ambulance crew in question did, and the same thing the nursing staff did when the assigned the room…

All of a sudden though what was black and white a moment ago became cloudy and grey with a single question….

What if the dignitary had instead been a police officer, a firefighter or one of your fellow paramedics who was hurt in the line of duty? What if it had been your partner? What if it had been you?

All of a sudden we all were faced with having to admit that each and every one of us (in my class) carry some level of double standard, because we all had to acknowledge that we would have expected DEMANDED better treatment if it had been one of our “brethren”

Where do we draw the line? What is the right answer? What would I have done?

Another case was presented… You are en route to the hospital with a patient suffering from symptomatic V -tach… You call the doc for a med order and to your surprise it’s your medical director who answers… You present your finding and tell the doc your plan; he denies your request to deliver an amiodarone drip and tells you instead to push 1 mg Atropine. Stunned by such an order you request confirmation, and he confirms 1 mg Atropine IV push.

What do you do?

I haven’t had my pharmacology classes yet, but even I know that if you follow the doctor’s order, you will likely kill this patient.

I pride myself on my integrity, my patient advocacy, and my absolute commitment to endeavor to do no harm… My answer was immediate and loud – I give the amiodarone drip to help my patient and I deal with the doc’s fury later…

It’s the RIGHT answer if you ask me, but then the student sitting next to me said ” I totally see what you are saying and I agree that that is probably what you SHOULD do… but how much will that help you when the medical direction gets you fired and your certification pulled, and you are standing in front of the supermarket holding out a can hoping for donations to feed your family”

I paused and considered what he had… Would that change my actions? Would the prospect of losing my chosen career after so much hard work force me to change my mind?

I like to think the answer is no… At least I will know I didn’t sell my soul to make a doc happy and potentially kill someone in the process… But it’s easy to answer that sitting here typing, much different than rolling down the road hot 3 minutes out from that very same doc, holding a patients life in the balance.

All of a sudden this stuff isn’t quite so boring, nor is it quite so cut and dry.

I’m not a huge country music fan, but Aaron Tippin sings a song called “You’ve Got To Stand For Something” there’s a line in the song that says ….

“… Whatever you do today, you’ll have to sleep with tonight…”

I guess it never really hit me much until after that class how true that was…

What would you do my friends?

 

Posted by on October 21, 2011 in EMS, EMT, Ethics, Paramedic School

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Target Fixation

Target fixation is defined by Webster’s dictionary as: a process by which the brain is focused so intently on an observed object that awareness of other obstacles or hazards can diminish. Also, in an avoidance scenario, the observer can become so fixated on the target that the observer will end up colliding with the object [1]

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The term seems to have originated from World War II fighter pilots, who spoke of a tendency to want to fly into targets during a strafing or bombing run, focusing so intently on their target everything else faded from consciousness.

That’s really interesting, but how in the world does that relate to EMS? Replace an observed object with patient and you’ll see where I am going with this.

We as providers are called to bad scenes, to violent crimes, to people’s home courts – not all of those people will be happy to see us. Sometimes, we get so fixated on the sick patient that we forget about everything else in the surroundings… I wrote about a time when this happened to me here

Wait a minute we are the good guys/gals why would anyone want to hurt us?

In 2005 NAEMT cited assault as the leading cause of injury to EMS providers accounting for 52% of all line of duty injuries. [2]

We all joke and make jazz hands saying BSI/Scene safe during our testing, but I seriously wonder how many of us forget that the world isn’t such a nice place sometimes, and we, fellow providers, are often on the front lines of that nastiness.

In that same study NAEMT found that only 21%of us expressed our safety as our primary concern. [2] That says a lot about the people who dedicate their lives to helping others, but it also shows how vulnerable we often are.

Let’s look at a couple less than obvious scenes, any of these sound familiar to you:

You respond to a street party for a DK (local term for intoxicated party) with a head lac – I know it’s a stretch to imagine such a call… Your “windshield survey” reveals of crowd of about 100 people in the street – many of them jumping up and down and waving their arms – you exit the vehicle and hear several people yelling in your direction “damn, it took you guys 15 minutes to get here – what the hell…” Undaunted,  you make your way to the patient – he has a baseball sized egg in the middle of his forehead complete with a 5 or so inch lac – your evaluation of the patient reveals he has an alcohol like odor on his breath, and he is not orientated to anything but self… he has to go to the hospital because you legally can’t leave him here – he adamantly refuses – and when he realizes his refusals are falling on deaf ears – he resorts to screaming – “OW YOU ARE HURTING ME ” the crowd wasn’t on your side to begin with and now they are all squarely focused on you and what you are doing to their friend… More screams “I’M NOT GOING ANYWHERE WITH YOU MOTHERF***ERS – YOU CAN’T MAKE ME GO” Somewhere in the crowd a lone voice says loud enough for you to hear it “They can’t do that – we gotta stop this”

That one might have made your spidey medic-sense tingle – how bout this one

You respond to an abdominal pain call for a 68 YO F – U/A you find a nice home, in a nice neighborhood, the house is well-lit and there is a family member standing in the open door waiting for you. You grab your gear and head for the door, as you enter, a gorgeous yellow lab nudges you wanting to be pet – you look at the family member in the doorway and the individual says “oh that’s just Ole Yeller, he doesn’t bite”, with a smile you reach down pat the pooches head and continue in to your patient. She is pale, cool diaphoretic and on her nightdress is the faintest hint of coffee ground emesis… you go to work

As you palpate the woman’s abdomen she lets out a pain induced cry – from the corner of the room Cujo Ole Yeller,  the gorgeous yellow lab you pet on your way in, hears her cry and springs into action to protect his master from the people hurting her.

Neither of those is a scene you would necessarily “stage” for – maybe the first one depending on your system. For the first one I would expect PD on scene, does that mean that violence can’t happen? Are two EMS providers and a couple of officers enough to “handle” the crowd?

The second call could easily be just you and your partner.

Did you anticipate the outcomes? Did you recognize the risks? Did you prepare for them?

As responders we tend to fall into 1 of 4 categories with regards to our street medicine – I suggest we also fall into these same categories with our scene safety assessments

  1. Unconsciously incompetent – we don’t even know what we don’t know – sadly ALOT of providers fall into this category
  2. Consciously incompetent – holy crap I don’t shit, how the hell did I ever get out of school – (Step 1 to becoming an awesome provider)
  3. Consciously competent – I have a clue and if I focus really hard on what I’m doing I can pull it off – (There is a REAL danger of target fixation here)
  4. Unconsciously competent – It’s all second nature to me – it just happens and I don’t have to think about it much

How does one advance from one stage to the other – Practice and experience, time and exposure. This is the same way we can get good at recognizing hidden threats on scene.

How many of us do any or all of the following:

  1. Strategic parking on arrival
  2. A scene report from the passenger seat – fire is GREAT at this
  3. Scanning the windows of the house/vehicle as we approach
  4. Take the wheels/cot over land through the yard approaching at a diagonal instead of up the walk
  5. Identify the last shred of cover we can hide behind if we need to – from that point forward you are in no man’s land
  6. Is there a crowd, pet, “bad actor” on scene
  7. Are people running in the opposite direction you are going
  8. Do you pull up lights and sirens blaring, or are you discreet and shut down a couple blocks away – leaving only the running lights on as you arrive
  9. Do you search your patients before you get in the box with them? If so do you take their belongings or remove them from easy access?
  10. Do you ask – who else is here when you arrive at a house
  11. Do you stand in front of the door when you knock
  12. Do you identify the way out and position yourself with unobstructed access to that route
  13. Do you walk around the rig instead of between it and the car with the slumped over driver in it?
  14. Do you approach a vehicle like the one above from the passenger side?
  15. Do you stand in front of the elevator doors waiting for them to open, maybe even chatting with your partner (Bad guys often have to leave via the same route we enter)

Just a few examples of things we can and should do on calls. Some of them are controversial sure – (I would LOVE to debate some of them if you disagree) ALL of them will help you get home safely at the end of the shift.

Expect the unexpected.

For most of us when we evaluate a patient we start with the worst possible thing that could be wrong with the patient – Chest pain calls are MI’s until proven otherwise, man down calls are full arrests until proven otherwise – then we begin to rule those life threats out through our assessment and questioning until we arrive at an accurate picture of what is wrong with our patient.

Why is our scene size up any different? Shouldn’t every call start out by ruling out all the life threats – to YOU?

 

 

 

 

1 – http://www.websters-online-dictionary.org/definitions/Target+fixation

2 – http://www.ems1.com/ems-products/press-releases/16033-NAEMT-Finds-High-EMS-Injury-Rate/

 

 

Posted by on October 6, 2011 in EMS, EMT, Scene Safety, Warning bells

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The Pride Defense

Now that I’ve had ampule opportunity to digest my heaping portion of syllabus salad with boot camp dressing (And So It Begins…), it’s high time we take the swan dive off the high board and find out just what it is I have gotten myself into. With blind enthusiasm, I lept; landing with a thud and a huge splash in medical legal issues class.

Medico-Legal class – what else can I say. Yes, it is dull, it is boring, and it is necessary. It turns out I had prejudged the class though… this one was about to get interesting

My twisted sense of humor grew fond of the instructor (a lawyer-paramedic) telling us “unless you want your policy and procedure manual and that big ole binder with our protocols in it reconstituted in suppository form by some slimy lawyer, you will…” It would be remained funny if he hadn’t said it so often. I had a similar fascination with recto-cranial impaction for awhile so I get the draw.

After the standard misfeasance, malfeasance, abandonment, HIPPA, Good Samaritan laws, etc. Something came over him and he changed from the boring legal guy into a genuine caring paramedic.

“Look I know this stuff sucks, but it is important” Now that we have talked about the required DOT stuff let me give you MY medico-legal class. The stodgy lawyer guy was gone, as were the bad jokes and the lawyer “smell” that permeates the room sometimes when you there is an ambulance chaser attorney in the room.

There before us was a medic who genuinely cared about us as students, about his patients and EMS in general. “I’ve been doing this a long time ladies and gents, and it all comes down to three things. Three little rules that will ALWAYS have you on the right side of any encounter or treatment you render. 3 little rules that will ensure you are delivering the highest quality patient care that you each are individually capable of, and yes for those of you that worry about such things, 3 little rules that will cover your ass.

“Get out your pens and something to write with – THIS is important. In this line of work it isn’t a question of if you get sued, it’s a question of when, and in addition to making you a better medic, these 3 rules will make you as bulletproof as a medic can be. Ready…”

1 – Do what is in the best interest of your patient (this of course should be our guiding principle always)

2 – Do what your medical director would want you to do (sometimes harder to know than what is in your patient’s best interest – depending on your particular medical director and service – this one could be a sticky wicket for some of you out there.)

3- Do what you would be proud to defend. (WOW… I have never heard it put so simply and so brilliantly before.)

“Do those three things and your patients will get the treatment they need, your service will get the medic they deserve and YOU ladies and gentleman will be able to sleep at night and hold your head high when you tell people you are a Paramedic. Have a good night.”

The moment was lost on some, as they eagerly picked up their books and bolted, or began to discuss what bar they were going to meet at for beers after class. For a few of us though, we just sat there in stunned silence – jaws agape.

I felt like I had just been given the meaning of life…

Let’s be honest, if all of us could just do number three ALL the time, how much simpler would our lives as EMS providers be. Would we even need rule number 1 or 2 if we could always do 3?

Call me an idealist (you’d be right), but think about all the negative news stories you have ever heard about EMS, EMTs, Paramedics, ambulance services – public and private – How many of those stories would simply dissolve into nothingness if the individuals involved had followed rule number 3?

Do what you would be proud to defend – it’s so simple yet so eloquent.

It should be easy to remember, not most of the time, not for 98% of the calls – but for EVERY single call we run – including the “drunk” at 3 am that swears that telephone pole jumped into the road, 95 YO nana who fell down and just wants help back up when all you want to do is sleep, AND the emergent response to 7-11 – you know the one the “man down” call that proves to be a convenience store attendant is tired of looking at the homeless guy sleeping outside so he calls 911 and says “man down”.

I can’t speak for anybody but me, but I know I would not be proud to have to defend every single action I have ever taken on a call. How about you? Can you look at yourself in the mirror and say that you have honestly given every patient you have ever encountered your best?

If you can say that, then either you are deluding yourself, or your best might need a little work. For those who will say I have given every single patient, every single time nothing but the absolute best I had to offer and are neither delusional nor incompetent – where do I put in my application, I would be honored to work with such an legend partner  EMS God.

For the rest of us human EMS providers, I learned something when I was in the Corps that has stuck with me to this very day “If it feels good to do or to say – you probably shouldn’t” Following this mantra has extracted me from more than one situation that could have turned out much worse then it did. I have used it in both personal and professional life; it wasn’t until sitting in a classroom full of bored paramedic students that it hit me. My mantra was indeed sound, but it didn’t go quite far enough, particularly when dealing with someone who very well may be having the worst day of their lives.

Pride is defined as “feeling pleasure or satisfaction over something regarded as highly honorable or creditable to oneself” (1)

As I continue the journey toward the glittery disco patch, the first standard of care that I intend to change from my days as a basic is to try to remember to always ask myself  “Would I be proud to defend what I am about to do ?”

Now that is a gold standard to try and live up to.

(1)    http://dictionary.reference.com/browse/proud

 

Posted by on October 1, 2011 in compassion, EMS, EMS 2.0, EMT, legal, Paramedic School, Personal

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19 hours in 29 to go…

I’ll apologize ahead of time for this post as it may make little sense to anyone but me, and after a few hours of sleep, I may not even know what I was trying to say. Today was simply put one of those EMS days where everything is stacked against you from the beginning. We’ve all had them so I’m pretty sure you know what I mean.

My day started with me oversleeping, something I never do, I woke up 5 minutes past the time I needed to leave for my 48 hour shift in an outlying station… an hours drive from the house  on a good day minimum. With an “OH SHIT!!!” I flew out of bed and grabbed my phone to call my partner and let him know I was running late.

Luckily, I prepared my bag and gear ahead of time. 7 minutes later with a full mug of coffee in one hand, a duffel, sleeping bag and pillow in the other I ran out to the truck and hit the road. Being a “professional driver” I firmly planted my foot in the carburetor doing 90-95 all the way to work cursing myself between sips of morning go-go juice. I arrived only 10 minutes late which was pretty damn impressive to me, but drove me nuts all the same… I am not one of those EMT’s who shows up late EVER. I prefer to be early and actually thoroughly check out my rig for my own peace of mind… SO now I am late AND i have no peace of mind that my rig is stocked as it should be. Then I find we have an EMT student third rider – which normally I really enjoy, but knowing I just was the example to this impressionable young lady of exactly the type of  provider I get so pissed at that didn’t help my day any either.

Then the EMS Gods wreaked their vengeance on us, the tones went off NON stop all day… several times we were called out before actually clearing the hospital. SO much for students being “white clouds” or so I thought at the time. The calls today have been mentally challenging medical calls all of them except the last one anyway. I swear syncopal episodes were on sale at the dispatch shack today. Each call was an investigation, a series of asking questions, not just questions but the right questions to figure out why our otherwise completely healthy patient is lying on the floor with a bump on the head. After 10 hours our student left and then all hell really broke loose, we didn’t see the station at all for the next 7 hours – considering that the average transport time here is about 7 minutes – well you get the picture.

So now here I sit, bone weary, mentally spent a little drop of drool cascading down from the corner of my lip 19 hours into a 48… and after the day I had today all I can think is…

How lucky I am to do what I do. Yes, it was a tough day, challenging in every way shape and form. It was both mentally and physically exhausting and yet I still told every single patient I met today that it was my pleasure to be allowed the privilege of taking care of them in their time of need. I don’t need nor want their thanks… I want them to focus on getting well. For me its enough to know that someone needed help today bad enough to pick up the phone and call 911 – My partner and I answered… and together we made what could easily have been the worst day in that person’s life better just by being there and by showing them we cared. Who can ask for better rewards than that?

The drool on my chin is slowly inching towards the keyboard…and my pillow and sleeping bag are starting to bellow for me. Hopefully tomorrow will be a better day – fewer people who need us, more people enjoying their lives – but if the call should come in… 2124 will be there and it will be our pleasure to have the honor of taking care of the person on the other end of the phone.

Till tomorrow – well technically later today – stay safe out there

PS Thank God for spell check 😉

 

Posted by on July 26, 2011 in EMS, Personal

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