Battle for the ERs

"The funniest thing I ever heard a nurse say was that Paramedics don't belong in triage. "

I am not anti-nurse, but I would like to explore the subject of Paramedics in the ER. Why do nurses run the ER? What is an ER? Emergency Rooms are used to assess newly arriving patients and determine if they need to be admitted to the hospital, or can be treated and sent home. Emergency Room Doctors are equipped to handle a myriad of diseases and trauma, temporarily, until proper long term care can be established. An ER is not meant to be a long term care facility. The idea is get them in and get them out, or admit them. Everybody knows the saying, "Greet them, Treat them, Street them." What is a nurse? The very definition of nursing is to care for in a long term manner, as in to nurse back to health. That is why you see nurses in Hospice and NURSING HOMES!!! What is a Paramedic? A paramedic was created to provide short term care to sick and injured people until they could be cared for, long term, by a doctor or nurse. They specialize in triage and transport. So I ask again, why are nurses running the ERs?

Paramedics have taken over the role of the house-calling doctor. No, I'm not calling us doctors, but we do go to people's houses and treat what we can while we transport to the hospital. We work under an extension of a Medical Directors license as put forth by the Medical Control Office's Protocols. Where I am from, we do not need to call online medical direction for anything, unless we just need advice. I am seeing more and more Paramedics being utilized in the ERs around here, but only under the descretion of the nurses. They are treated as techs. Nurses cannot intubate, do surgical airways, or many other things that Paramedics can do, so why are we taking a role that limits our abilities? Wouldn't it make more sense to place Paramedics in the nurses place, to work alongside of the ER doctors and actually help them treat and care for the patients seen in the ER? I know nurses do that same thing, but not like a Paramedic would be able to. Regardless of how you feel about Paramedics and nurses, the end result should be to the patients benefit, and by having a person who can intubate and do many other things that a nurse cannot, the patient would definately benefit. I'm not saying that nurses need to leave the hospital, but they should have a bigger role on the floors, where long term care is needed. There is a nursing shortage ater all, that would help alleviate the nursing shortage, as well as the Paramedic shortage. Paramedics working in the ERs would get paid much more than street medics (they traditionally have), which would lure more people to the field. It would be a trickle efect.

So why isn't this going to happen? Nursing Union! They have been here longer, took control of the ER long ago, and won't give it up, even if it means that the patient doesn't get the benefit. I'm not saying there aren't nurses out there that cannot intubate, do sugical airways, and whatever else, but they aren't trained that way. They have to take extra classes and whatnot to get the experience. Paramedics are trained that way from the go, and we specialize in short term medical care, like TRIAGE!! When was the last time a nurse intubated as opposed to a Paramedic? When was the last time nurses were put in charge of Triage at a mass casualty incident? I am sure there will be nurses that say, I have, or I do, or I do all the time. They are the exceptions, not the norm. The only way Paramedics will start to win the Battle for the Ers is with higher education. Everything with us starts with more education. I advise all the medics out there to look into higher education and go get your Baccalaureate.

Paramedics need to look into the ERs and explore what could be.

I mean no malice or harm to any nurses reading this. I am not against nursing, I just don't understand this trend we have going in the ERs. This is just the tip of the ice-burg and I could go on, but I don't want to monopolize the blog. PLease let me know what you think. Thank you

-JZ

Happy Thanksgiving

Happy Thanksgiving everyone!

You did what?? And why??

In following up on the sentiment expressed in the previous post about EMS' "taxi runs," here's one of my stories. I spent a while looking for the PERFECT one, but after realizing I had SO MANY (unfortunately), I decided to just close my eyes, point my finger, and pick THAT one...



We were en route back to the station from the hospital when EOC dispatched us TO OUR STATION for a “walk-in” having an “unknown problem.” If you’re not versed in this, a “walk-in” is just what it says- someone who “walks-in” or “drives up” to the station for “help.” This particular station I was at for that shift seems to have more than it’s fair share of “walk-ins” for some reason. We were only about a mile away when we got the call.

So we get there and find the fire department sitting in the truck bay with this woman in her 30s. According to her, she had been at home sitting at her computer when she spun around in the chair to get up and became dizzy. Then she threw up…ONE TIME. Now she wants to go to the hospital. Her husband rides in the front of the ambulance with us to the hospital. Know what I did? I took her blood pressure. I took her pulse. I got her O2 sat. I asked her about her medications and allergies. I called the hospital. That was IT. It took me about 3 minutes.

Alright first of all, why do you “need” to go to the hospital because you’ve thrown up ONCE? I’ve spent all day throwing up and feeling lousy, and I didn’t call 911. Never even THOUGHT about doing it. Second of all, if you drove- well actually your husband drove you- from your home to the fire station, WHY couldn’t you just keep on driving to the hospital yourself? I didn’t do anything life-saving for you in the ambulance. I didn’t do ANYTHING for you. A “ride” to the hospital is $400 via our ambulance. Then we charge $8.50 per mile from wherever we pick you up. It’s 15 miles from the fire station we were at to the hospital. You do the math.

The other thing I don’t get- which I didn’t actually think about until later- is what was the point in this woman’s husband riding WITH US? Now someone has to waste the time and gas to come get you both then take you back to get your car and…I just can’t see any point in all this.

Biggest Pet Peeve

No doubt, my biggest pet peeve in EMS is the taxi runs we do. It has been on my mind a lot lately, between the Men's Health article, and some issues we are having at the firehouse. Go to any state in this great union, to any firehouse, and any medic can give you ten examples in the last year of such runs. Why is this such a problem? Ask any child: When do you call for an ambulance? Most likely they will answer: When there is an emergency. Yet, the parents of those kids call for some extremely stupid reasons. If 7-year-olds can figure it out, why not 30-year-olds?

We see abuse of EMS from all walks of life, regardless of race or socio-economic class. Regardless of insurance status. Even regardless of transportation status, and by that I mean the patient is completely ambulatory, stable, not a damn thing wrong, and six family members all with cars are home and able to drive.Over the last few years I have heard many excuses as to why the ambulance was called.
-Going by ambulance will get me seen faster (not true, not true)
-I don't have insurance (this ride isn't free)
-I don't have any other way to get there (OK, I can kind of see that)
-I don't have a regular doctor (huh?)
-Because I want pain meds (I don't think so)
-Because I wanted to (can't argue with that logic)

I have transported stubbed toes, hurt pinkies, and fevers of 99 degrees. I have also transported a 22-year-old who drank one beer and the parents freaked out, a scratched knuckle, and someone who needed inner reflection. I am sure all of you reading have similar stories. I even had a chronic caller, 3 times a day from the same pay phone. He would call and say he was dizzy and he needed to go to the hospital. 3 times a day. I would think that would be an abuse of 911, punishable by law, but PD told us there was nothing they could do. Once, when we were with him, a 3-year-old girl was hit by a car in our district. She had to wait 5 minutes longer for help to arrive. When we explained this to him, his reply was "Oh well. When I call, you have to come." I had no response to that. He had me there.

We educate the public on fire prevention. We educate the public on fire safety. We educate elementary students on E.D.I.T.H., stop, drop, and roll, and stay low and go. We educate on everything fire related. Thanks to all of this public education, fires are down. What about EMS? EMS makes up 85% of FD calls (depending where you live). Why do we not educate on EMS? Sure, we put on CPR and AED classes. But why is it so taboo for us to educate on what is an emergency? When it's OK to use an ambulance? There has to be a solution to this problem. Unfortunately I don't see it coming anytime soon.

Just another day at the office

I've worked in the ER long enough to feel confident in what I do. I can do that 12 lead ECG with my eyes closed, I can get the IV first time and draw blood without bruising my poor unsuspecting patient. I *can* do it. I do do it... and most of all, I enjoy it. Well, at least until the end of last week. I think the universe decided I was getting too big for my boots and knocked me clean out of them.

Without going in to enormous amounts of detail, towards the end of my shift, we had a 30 something year old lady come to us with chest pain. She had a significant family history (both parents died of MIs before 40) and her ECG showed huge ST elevation. Oh and before I forget - she was 38 weeks pregnant... and she coded.

So, skipping over the gory bits (for my sanity as well as yours), there was a very quick and dirty c-section in the ER, not an OR with dad watching. Mom didn't make it but the baby is going to leave the NICU tomorrow morning.

I didn't know that pregnancy increases the risk of the patient aspirating and that I needed to apply cricoid pressure. I didn't know that my hand position for chest compressions should be moved up the sternum or that the uterus needed to be displaced. I didn't know, I didn't know, I didn't know...

I've learned a lot from it and in that respect, I'm grateful for the experience. I just wish I hadn't been left feeling like I've failed... but I guess thats the price you pay for for all the great stuff being in medicine gives you the chance to take part in.

Party Paramedics

Just got my JEMS email, and in there was this fascinating article about "party medics" and the concept of having EMS staff on hand at college parties.

Party Paramedics

One has to wonder, though, what kind of message it sends.

Does it simply accept that "college kids will be college kids" and offer a measure of protection for that mentality or does it show a level of acceptance for potentially illegal behavior?

Working part time for a small university's Public Safety department, I've seen the best and the worst of college students, and their choices. We very recently created our own EMS club, and are in the tentative stages of trying to figure out what roles they can play on our campus, without major liability on the university's part.

Does this university's insurance policy cover the "party medics"? Are they affiliated with the school itself? How are they funded?

And does anyone else see this as a lawsuit waiting to happen?

Advice Anyone?

Hello everyone. I was recently laid off from my job due to a budget cut. There, I was a Security Guard/EMT, but if you ask me, I was more of a secretary than anything else lol. I thankfully found a new job, but this time as a paid EMT. I'm a member of a volunteer first aid squad in my town but to go from volunteer to paid, well that's just a HUGE jump, at least in my eyes.

I joined the squad in my town a couple of years ago for reasons I'm not even sure of. Our squad, along with many other volunteer squads were struggling and dying for EMT's, so taking the EMT course was just kind of the next step. I wish I had some meaningful reason as to why I became an EMT but sorry guys, I don't.

Although I did well in the class and passed everything with flying colors, to this day I swear up and down that I shouldn't have even passed any of the tests and even the state test. My new job obviously will entail answering emergency calls and I feel like I'm no where near ready. I try to answer as many calls with my squad and even sign up for more than one duty crew night a week. Sometimes up to four. I feel like the effort is defiantly there but the lack of call volume and certainly the lack of confidence defiantly doesn't help my situation.

I will hopefully be starting at my new job next month and will have to either get over my fears and suck it up or be jobless. I know this blog was originally started has a place for EMS workers to tell their stories but I come to this blog looking for advice. With that.. advice anyone?

(Yes, I did do a similar post a month or so ago.. but did I mention I REALLY need advice?)

Meltdown

Protecting its citizens from harm is the noblest of government functions, the very core of a successful republic. Providing that protection is the purpose of organizing and maintaining our government. But who do we turn to when our fellow citizens turn against us?

A pregnant female with a toothache called 911 from a housing project at six AM. She had been up all night, unable to sleep. An advanced life support vehicle was sent to her home and took her to the emergency room. Innocent enough, one of hundreds of EMS calls fielded by the Providence Fire Department every day. Most rational persons would have a difficult time defining the majority of these calls “emergencies.” Had the Emergency Medical Technicians refused to transport her, instead of being commended for using common sense and reason, would be reprimanded for failing to address the needs of the patient. It matters not that an entire section of the city was left unprotected during the time this patient was transported; time when true emergencies could, and often do happen. The patient was catered to, no complaint filed, and the department’s goal of “covering your ass” was met.

Our EMS System is in chaos, patients are allowed to call and request transportation to the hospital for any reason whatsoever and an advanced life support vehicle will be sent, damn the cost to the taxpayer. Most responsible people wouldn’t dream of tying up a valuable resource because they needed a ride or wanted to get into the emergency room faster. Responsible citizens are being bullied by the minority who think government is at their beck and call.

Is this society’s problem? Is there a law that protects the rest of us from such unscrupulous drains on our resources? No, there is not. Perhaps it is time to consider the possibility. We pay for a service. That service is rendered useless when it is unavailable. The CYA policy is an insult to those providing EMS service, and those who founded this country and the generations who fought and died for our independence. The time has come for us to learn how to say no!

For years the 911 system has been overburdened with calls for non-emergency reasons. Because of fear of litigation anybody who calls for assistance for any reason will get help at their door within minutes; unless all resources are otherwise utilized. In that event, the people requesting transportation will have to wait a little longer. Some people die waiting, and that is the result of ineffective leadership. It happens. It could happen to any one of us.

In Providence, there is a severe shortage of advanced life support vehicles. Or is there? Six rescue units handle approximately thirty-thousand calls for emergency medical aid each year, and the number is growing. The need for additional resources is well known, and blatantly ignored by the Mayor’s office and the Fire Department administration. But is this crisis truly a crisis? Or is it merely the personification of a much larger problem plaguing our society, the insistence of many Americans to have government cater to their every whim? When will we have had enough, and simply say, NO MORE!

Because of the very real fear that a responsible person may not call for help in time of crisis we as a society are catering to an unscrupulous bunch who will exploit any option that is available. A mentality exists where government services represent an unlimited pie waiting be devoured, and only a fool would hesitate to get their piece. Our generosity can only be exploited if we allow it. We need to close the drain before the pool is empty! It is time for responsible citizens take our country back. As long as people are willing to give, the long line of takers begins to form. It is our nature to lend a helping hand to those truly in need. There is a limit. It is only natural to have the giving spirit replaced with bitterness.
Going along to get along is no longer an option. It is time to take a long, hard look at our policies and recognize that one of our greatest strengths, our generosity, is also our biggest weakness.

Some Days Are Good

As with life, in this job you have to take the bad with the good. The first call we had this morning was routine. Man fell down, woman gets scared and calls 911 thinking he's having a CVA (Stroke). We arrive and find that he just tripped and all is well but still want to go to the ER just in case.

About an hour after that, we get a call for the unknown medical call. Now nine times out of 10 these calls turn out to be nothing. Just a tag that the dispatcher gives a run when they don't know what the complaint is. We arrived on scene and was greeted by the PD officer who reported that our patient was in bed and breathing shallow. As we proceeded towards the bedroom, I asked the daughter when the last time anyone saw her was. She replied that the checked on her a few times last night but didn't see her until about 30 minutes ago. At that point she wasn't responding to anyone.

Hearing that, we increased our pace to the bedroom. We soon found our patient. We found her doing very little actually. No shallow breathing, no heartbeat, no response to pain. Her lifeless body cold to the touch. Giving my partner a look, we asked the family to leave and informed dispatch to send an ALS intercept our way.

Once the family left the room the CPR began. I have always thought that the most effective scene for a heart disease commercial would be to show an actual CPR scene. The indignity, the blood, the sound of cracking sternums not to mention the far off stare that the patient has. Yes, all of this would definitely open a few eyes because it wasn't like it seemed on TV.

With ALS enroute, the patient packaged and the D-fib advising no shock, we carried our patient outside. Passed the waiting family, passed the eyes of the curious onlookers who had begun to congregate. Out onto the stretcher and into the bus.

After ALS set up and was ready to go, we proceeded to the ER. But during the trip, something happened. Something that very rarely happened. After the third Epi was on board, a heartbeat could be felt! No that can't be right?! Her age, the history of heart disease and the fact that she was just in the ER yesterday for chest pain all pointed to her not making it.

Yet here is was, a pulse! Soon the monitor confirmed it, she had a rhythm! The rest of the trip was spent maintaining her airway and respiratory rate. Turning her over to the ER staff with a heartbeat was really a great feeling.

Now in this game, CPR saves are a few and far between. Some days you get them and some you don't. It's yet another cold hard lesson of life. But today we actually did it! We actually saved a life. It wasn't a drunk frequent flier or a BS taxi ride to the hospital. We actually made a difference in someone's life!

Yes, these moments are truly a few and far between. So when they come, enjoy them, learn from them, for they won't last forever.

Wait

She stripped off the non-rebreather, reached deep, turned her head my way and coughed. Not a polite little clear your throat cough, rather a full on clean out the lungs job. I looked out the rear window of the rescue and focused on the car that was tailing us. Her boyfriend.

"Cover your mouth!"

Years of training and experience reduced to scolding a petulant patient with the audacity to call 911 for a free ride to the hospital. What possesses people to call? Do they think they will "get in faster?"

I walked her past the ambulance triage, through the treatment area and into the waiting room.

Cough in my truck? Not today.

It's Nice to Hear Thank You

Well, it's been some time since I have posted. After doing some reflecting today I have realized that I'm slowly getting the confidence needed to be an EMT. I will never ever have total confidence in what I do, but that is how I am. I think what is most important is I'm learning things everyday and no longer afraid to jump in that passenger seat on the rig. There are times where I'll beg another EMT to take the call, but if you were to ask members at my squad, I think they'd say I'm not as bad as I used to be. It's going to take time, but I'm glad that I'm slowly making the changes needed.

The other night, we took an elderly female to the hospital. She had fallen a couple days prior to calling, but the pain finally got to the point that she thought it was wise to go to the hospital. I have taken her to the hospital before, but she did not remember me. To make a long story short, we got her to the ER. Just waiting on the ER RN to give us a bed for her, I stood next to the cot just talking to her. She grabbed my hand and told me I was a sweet girl and she gave me credit for doing what I do. I just smiled and said thank you. I think if more patient's were like this sweet old lady the world would be a better place. Some people don't understand how hard things are, especially for Volunteer Squads. Every now and than it's nice to be thanked for what we do.

A tiny bit late for Halloween, but here's an EMS Spooky Story for you!

The patient is a well known man. So is his wife. If I told you what they were well known as, you would know who they were, and that would violate HIPPA. So I won't tell you. But suffice it to say, it involves events of the supernatural kind.

I'm home responding, and the rest of the crew comes from headquarters. It's dark as all get out, and a very weird feeling washes over me. My "spidey sense" is tingling. "Very bad!!!!!" vibes slam me as I walk down the dark driveway. Something is very wrong in this house. The feelings make me turn around, head back to my car, and wait for PD or the rest of my crew. I'm not going in there alone.

He's at a GSC of 8, post CVA a number of years ago. She's been taking care of him at home since then. Diaphoretic, pale, and obviously not well, we begin to load him onto the stretcher. I run out for a blanket, and the cop says to me "You know who these people are, right?"

Nope. No idea. Never heard of them. But in fear of looking totally clueless, I say "oh yeah, but I treat all my patients the same" and carry on.

Still with the bad feeling in my chest. There is a mist that night, and it comes in waves...is there someone over there???...I'm spooked, and run back inside very quickly, glancing over my shoulder a few times. But no one follows me. There is no one there.

We load him up, and start transporting. He begins seizing, and we meet up with our intercepting medic just in time. His fever is raging, he's very ill....we aren't sure if he's going to make it through the night.

As we head to the hospital, the bad feeling is gone, I decide I'm just sleep deprived or something.

We go immediately inside, we've been assigned a room already during our patch. But the wife needs to register him.

She registers him under a pseudonym, and the desk clerk doesn't bat an eye. He must have been here before.

She is done, she has requested a priest from the clerk, who is calling one for her. She wants to get to her husband, and the rest of my crew is still moving him from the stretcher to his bed. I've gone to write the run form. There's a digital lock on the door to the main ED area. All the local EMT's have the code, and the staff can hit a buzzer to release the lock to allow people in and out as needed. She is standing at the door, and no one is there to let her in. She glances around surreptitiously, checking to see if anyone is watching her. I'm getting up, to go help her out and wondering what she is doing. Suddenly she waves her hand in front of the lock, the light changes, and she opens the door.

She didn't put in a code, and there were no staff members at the desk to let her in. I don't know what she did to that lock, but somehow she made it open.

FREAKY!!!!!

And that bad feeling at the house? Apparently they keep a collection of their work in the house. All I'm going to say about that is, after this call, I believe in ghosts. And I'm not walking into that house alone ever.

Hope you had a Happy Halloween!!!!

Doctor...Doctor!!

My first run this morning reminded me of how different things are in other parts of the world. Which is good that I'm reminded of this because I'm trapped here in the "Garden State".

We're dispatched to a local hotel, on the other side of town, for the 55 year old female who fell down seven steps. As we approached the facility, I made a jocular comment to my partner about the hotel sign advertising their "Fall Special". Sorry EMS humor.

I directed the rig to the rear of the building and as I turned the wheel to round the corner, we were greeted by several tour buses and a sea of tourists from the Orient. PD walked over to us and reported that our patient was a male and upstairs. He had apparently fallen, incurring a bump on his forehead and a possibly broken wrist. I said that dispatch informed us we had a female patient. To that the officer just laughed and said, "I don't think so."

Climbing the stairs, we soon walked into the hotel's welcome area that was populated with about the same amount of tourists that were waiting outside. We then found our patient, a 76 year old, sitting in a chair, arm resting on a table propped up by a towel. A small golf ball sized bump was beginning to form on his forehead. As I knelt down, the only member of their party that spoke the King's English approached. He informed me that SHE had fallen, hurting her arm and head. After asking the patient the usual questions, through my newly found translator, I surmised that her wrist would need an x-ray for a complete diagnosis. I offered to split the appendage and then transport her to the ER.

The group then exploded into a sea of chatter, I guess it was a group decision. Rising to my feet as the think tank processed the data that I had just given them, I bumped into a new fellow that was standing way too close to me. As I turned to greet him, he began pointing at his eyes and mumbling "fix, fix."

Having a three year old, I could notice conjunctivitis from a mile away. I turned to the translator and pointed to my new patient. He told me not to worry about him, that he had been complaining about his eyes for the last two days. I explained that he would need to see a doctor before the whole group came down with it. The translator than asked me why I didn't just give him the medication he needed. Taking a second to respond, Mr Pinkeye rubbed his eyes, and walked out of the room.

Turning my attention back the my original male/female patient, the translator informed me that the patient really wanted to go to Washington DC and if we could, set the arm and then splint it. Now once helping an orthopedic doc set a wrist once, I smiled a bit, running through the steps that I remembered. But then remembering my lack of x-rays and knowledge, I informed them that we would splint the wrist and transport the patient to the ER. The group began to shake their heads in a negative fashion and I was informed again that she really wanted to see DC.

Taking a deep breath and explaining one last time that we could only splint and transport because an x-ray would be needed for a proper diagnoses.

"But you don't understand, we are here to see Washington DC."

At this rate, I was ready to note that as her chief complaint. The translator then asked if we could just splint the arm and leave her be. To that I said if we treat we have to transport. By now, we had been joined by a curious by standard, who had begun fashioning a makeshift splint for our patient.

I asked the translator what was going on and he informed me, you guessed it, that she really wanted to go to DC and this guy was some kind of doctor where they were from. He was going to build a splint and get her ready to travel. Shaking my head, my partner began getting the appropriate information so that our patient could sign off on our release for treatment and transport.

I began packing up our equipment when the officer approached. He told me that I was to walk out the door first because I had gloves on and Mr Pinkeye grabbed the handle after rubbing his eyes. Laughing a bit, I pulled out an alcohol prep pad and cleaned the handle down before we all left.

What can I say, you can't make this stuff up.