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Reality Check

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As usual, the EMS blogosphere has found itself in yet another little tiff. This time Timothy Clemans and Medic22 are in a bit of disagreement about proper use of ALS, among other things.

Timothy seems to believe that ALS skills are wasted on patients that are not in risk of losing life or limb. While Medic22′s way of responding to him might be over the top, I can TOTALLY understand how and why that would happen. See here and here. We all take this pretty damn seriously, so I understand the frustration.

Because I agree with Medic22′s thought process on this, I thought I would chime in a little bit.

If it was up to me I would eliminate prehospital ALS except in cases where ALS care prevents the need for hospital/clinic care and in cases where evidence demonstrates that ALS saves lives. That said, Medic 22 did bring up an excellent point about prehospital pain management.

Is it really that simple? Simply put, I’m out of a job. All of us are. In a systemsign-realitycheck with 11,000 calls a year, we’d be able to pay one medic. Thats it. After the sob story of me being unemployed is over, we’ll address the real issue: why is it that you have to be dying to get compassionate, adequate, respectful care?

If you are sick or injured, but not dying, Timothy is saying that you should only get a taxi ride to the hospital(where you will wait in triage for an hour(or more) and then wait for a nurse to complete an assessment, then a doctor, then maybe get your treatment started).

Are there ALS skills that need to be reviewed? Absolutely, but until you have had to sit in a truck with patients puking their brains out(on your new, shiny boots) you will not understand the validity of our skills that are in between taxi driver and super hero. Pushing Zofran for that nausea not only helped to relieve the discomfort for that patient, it also helped prevent them from further dehydrating themselves (or like a patient a week ago… going into vfib every time she puked… Seriously).

Managing pain in patients is one of the best skill sets we offer(and either the most avoided due to paperwork or most abused by patients).  Allowing grandma some comfort for the 15 mile ride through my Wintry Mid-Western city riddled with potholes and ice chunks is the least I can do after she allowed my whiny ass to stay alive all this time.

I can’t agree more with you! I have been battling this topic for 7 years to no avail. At one point we had our agency MD on board yet the other program MDs in the county voted against it! Again, “nobody ever died of pain” was just one reason. Another was/is the potential abuse issue, especially with fentanyl compounded by the fear ketamine could be stolen off the trucks by youngsters for their Rave parties. Subsequently, our patients receive a proper induction via etomidate but very infrequently the administration of diazepam and morphine post intubation (only a few of us religiously use the agents). What you end up with is a patient who doesn’t remember undergoing paralysis and intubation but wakes up being paralyzed and intubated on a bumpy ride to the hospital.

All this says is that local MDs have zero faith in their medics. If you can’t secure your narcotics, you have no business being in this business. There are dozens of ways to secure them. This is simply an excuse for someone who is afraid to allow their medics the ability to treat.

Medic 22 a dehydrated girl with a low BP and tachycardia needs a line and a fluid blous. That’s ALS. Not an emergency… but something that a paramedic can, and SHOULD do.
Me: what’s the benefit of the prehospital als in that case? if it doesn’t save a life or shorten hospital stay what’s the point
Medic 22: It’s GOOD PATIENT CARE. Its what competent, caring prehospital care providers do.

If the care by paramedics could prevent the need for hospital then I’m all for it. Unfortunately in the case wouldn’t you just be delaying hospital care and doing something just to do it?

First of all, you are assuming we are delaying care. Like I said before:

My scene time consists of a brief primary assessment, possibly a 12 lead and loading the patient where I begin the rest of my treatment–unless the patient absolutely needs other interventions prior to departure. That being said, when I am 15 minutes away from the hospital with someone puking(and further dehydrating themselves) or someone who has moderate wheezes, why shouldn’t I begin treating them?

Again…. It seems that you assume there is some abundance of Life or Limb calls in EMS. Honestly, those exciting calls just don’t come all that much. What we get a lot of is sick baby boomers, indigents, drunks, and people who don’t know any better. Does that mean we shouldn’t treat them while we can?

It is our job to treat patients, and as long as I have time in the back of my truck, I am going to do everything I can to make them more comfortable, happier, and healthier–if at all possible.

Posted by medicTHREE on March 9, 2010 • Filed under: Blogroll, Protocol, ems-health-safety, ems-topics, medic, patient-management, training-development • Tagged:

False Hope.

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As EMS providers, we have a very limited scope of tools to help our patients. We are obligated to follow our protocols and treat was is evident from our assessment. This means your assessment is likely the most powerful tool you have in providing medical care. Ironically our most powerful tool, communication, is often completely forgotten by EMS providers.

The hardest part about our job is being honest with patients and their families. Often times we are present in end of life situations. These are difficult in controlled atmospheres–let alone the seemingly claustrophobic nature of EMS scenes. When a patient is dying we need to be honest with them and their loved ones. We need not be brutally honest, but most certainly we can not allow false hope.

False hope is a natural defense mechanism in the grieving process. Denial. Even as EMS providers we sometimes hold on to false hope in difficult calls to get by–but this is neither practical nor healthy in the end. Allowing and providing for false hope will create more shock when reality strikes. Death is a natural process–not always a pleasant process–but natural none the less.

As providers it is our duty to assist our patients and their families in understanding the reality of their situation. Does this mean saying “you’re going to die”? Not at all. But it does mean being clear that the patient is very ill, and you are doing all you can but 1) they need higher level of care 2) they may not make it to that higher level.

Does this make the process of dying easier? Absolutely not. For patients and their loved ones knowing their impending doom can be equally troubling. But it is still our duty to be truthful with our patients. Where I believe this honesty to provide an important relief to EMS is in the all to difficult cease or withholding of resuscitation talk we find ourselves in during these types of calls. Being honest with a patient and their family gives them more time, possibly only seconds, for reality to sink in.

When termination of resuscitation becomes part of the discussion, patients families are often unprepared. Giving them the truthful answers to questions about the reality of the condition of their loved ones will certainly help them to make the decisions to terminate care when necessary.

How do you handle these difficult moments in patient communication?

Posted by medicTHREE on December 11, 2009 • Filed under: Coping, ems-topics, medic, patient-management • Tagged:

Cause…

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I couldn’t have said it any better, I’ll just Let EPIJUNKY do it for me.

We should all follow her lead. I think this is really what we should focus EMS 2.0 on. If we can’t stand up for our patients, what business do we have THINKING for them…

Posted by medicTHREE on October 28, 2009 • Filed under: administration-leadership, ems-health-safety, ems-topics, medic, patient-management

Unspoken

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Often times on a call, it is what ISN’T said that is most important. As paramedics we are trained to ask a set of questions necessary for assessing our patients, but more often than not, we know the important answers. We know when our patients are sick. We know when they hurt. We know when they can’t breathe. Those things are usually obvious.

The hardest thing we often know without a word spoken… we know when our patients are ready to die. The look–or lack there of–in their eyes, their posture, their sound–they all tell the tale all too well.

no_evilThe trouble is that we are trained to prolong life. Little about our training prepares us for letting allowing watching someone die. We are trained to do everything possible to prolong life–whether that is what the patient wants or what is best for them. We are trained to give drugs, artificially ventilate, pace, defibrillate, and otherwise interfere in the dying process. We are not trained to let people die.

So what do we do when the ultimate time comes? Outside of a DNR most systems won’t allow you to cease rescussitation. My system takes the word of a family member very seriously–outside of suspicious circumstances, we honor the wishes of an immediate family member. We also take the time to educate them on what will happen either way. I find it important to make sure someone knows that even if we get them to the hospital alive, they very well might never wake up.

My job isn’t as cut and dry as most think. I rarely save lives. Most of what I do has little to do with medicine or emergencies. Most of my night is spent dodging drunks or other frequent fliers. In the last 6 weeks my partner and I had 4 or 5 really “exciting” calls. Maybe I’m sick/twisted/strange/gross, but the exciting calls are the ones that make you go “aw shit…”. Most of the time we are running call after call of No Ambulance Needed or PD to Transport. But every so often we actually run a “real” call. Every so often we come across a sick patient.

Every so often that patient has already made up their mind that theypain can’t fight anymore. Who are we to decide otherwise? Does what we do make a difference other than to prolong a life of pain and discomfort? Are we doing harm in interjecting in what is the obvious end of the dying process? Are we causing pain? Obviously we are bound by our protocols/guidelines. Obviously we are bound as medical professionals to follow the medical standard. But at what point are we doing MORE harm?

Posted by medicTHREE on October 26, 2009 • Filed under: Coping, Heart Strings, ems-topics, medic, patient-management