Air Goes In and Out

One of the forums I frequent recently had a poster ask a question about the mechanics of breathing, so I made the following based on a model that was used in a grad school physiology lecture. However,  that model was a professionally manufactured model.  Hopefully it’ll give new providers that “Aha” moment when covering respiratory physiology. On a quick technical note, the last two ribs (11 and 12) move in a “caliper motion,” which is simply out and in, unlike pump handle or bucket handle ribs.

How to make the model.

Posted in Physiology | Tagged , , , , , | Leave a comment

Why proofreading and grammar is important.

For anyone who is having trouble getting a provider or student to use appropriate grammar when writing reports, just show them the following.

(Original artist is unknown)

The mental image of Stripper Stalin alone should be enough of a mental image to spur good grammar from anyone.

Posted in Clinical EMS, Documentation, Humor | Leave a comment

Independent Judgement

In case you haven’t heard yet, California is working towards officially introducing (pdf) (underlined is new legislation. Some of it is cleaning up a mess left from moving EMT-II to AEMT) Advanced Practice Paramedics and Critical Care Paramedics as state levels. While scanning over the proposed legislation, the following line from the proposed Critical Care Paramedic scope of practice struck me as odd.

“1. perform digital and nasotracheal intubation;” -pg 11

Wait, shouldn’t the scope of practice (albeit the basic scope of practice for all paramedics) be “intubation?” If paramedicine is a profession, shouldn’t paramedics be entrusted with the independent judgement to determine, based on their education, training, experience, available tools, and their assessment of the patient, how specifically they intubate? If a paramedic believes that the totality situation calls for digital intubation or a gum bougie or any of the other method instead of or supplemental to direct laryngoscopy, shouldn’t that be the imperative of the professional paramedic? Furthermore, provided standard concerns are met like maintaining oxygenation, isn’t the goal of putting an appropriately sized tube into the slightly larger (and correct) tube, and the ensuing confirmation, more important than how that is achieved?

Could some of the issues with paramedics intubating be, in part, because the wrong tools are being used? If you only have a hammer, then everything is a nail. That’s fine, provided you’re dealing with nails or wooden pegs. However when you get to screws, sure a hammer may work, but why not use a screw driver?

Why is the skill of direct laryngoscopy more important and sacred than the intervention of intubation when other skills can achieve the same goal? Furthermore, if paramedics cannot be trusted to pick the correct mechanical skill when providing the intervention of intubation, what does that say about paramedics, and why are paramedics not fighting back?

On a side note, I’m sure I’ll have more than one person think I’m a complete idiot for this, and the ensuing implication about EMS’s current status between technical trade and profession. Feel free to call me an idiot in the comment section (or email, but the comment section lets you drive the discussion), I don’t mind and without discussion nothing changes. My only request is that you take a minute to call me an idiot, take a second minute to explain why I’m an idiot.

Posted in Clinical EMS, EMS Levels, EMS Operations, EMS: A Profession | Tagged , , , , , , , | 9 Comments

In the News: EMS vs Press

The first video is from July and came to my attention though Statter911 (the comment section includes responses from the camera man). The second video came to my attention today through the JEMS Facebook page, and neither paints EMS is a good light.

First, I agree that access to active scenes needs to be controlled, and preferably with some sort of barrier. Similarly, I agree that fire, EMS, and the police have a responsibility to ensure that non-responders are not in dangerous areas and are not interfering with the response. Finally, I agree that EMS has a duty to protect a patient’s privacy, albeit done by the crew taking positive action on their part, not by restricting what people in public can film.

Having said that, requesting the press to leave a scene needs to be done carefully unless they are actively interfering with care or in a truly dangerous location, and force is an option of last resort. From what I can see, neither is the case in either of these cases, and before anyone starts talking about hazmat in the second video, how many other people are walking around in street clothes? Claiming scene safety is rather hard to justify with so many other people wearing no protective equipment in the immediate area.

Similarly, interfering with the scene is dubious, especially with no boundary tape up. Simply being on film is not interference. Someone getting upset and being distracted because someone an appropriate distance away is filming is not being interfered with. If you can’t handle the pressures of a job done in public, and relatively often done in situations of public interest (in contrast to most other careers), emergency services is the wrong set of careers to be involved with.

More importantly, unless it is a matter of object life or death for the camera man, it is simply not worth the fight with someone who is not interfering with the scene. Regardless of the ultimate judgment of either of the above cases, the EMS provider and service loses. It’s a lot like crossing a busy street at an unprotected cross walk without looking both ways. Sure, the cars should stop for a pedestrian in the cross walk, but when the car going 30 mph runs into the pedestrian, the pedestrian loses.  Similarly, while the EMS provider may be “right” in his or her ability to control access to a reasonable area around an incident, the damage done by making the 4, 5, 6, and 11 o’clock news, Statter911, and the JEMS Facebook page simply isn’t worth a physical battle in the vast majority of cases.

However, there are generally plenty of options that should be run through before coming to blows with reporters.

  • Approach the videographer is a professional manner. Make them your ally. Politely state your concerns, request compliance, and offer alternatives. As with dealing with everyone else a, “Hi, I’m concerned about my patient’s privacy, would you be willing to blur the patient’s face prior to broadcasting the video?” works better than “Stop filming!”
  • A “Would you mind filming from over there that’s out of our way?” works better than, “I told you to stop filming.”
  • If worse comes to worse and you have to ‘make’ a videographer leave, then take a lesson from Major League Baseball umpires in how to diffuse and walk someone away.  If you have enough people to send someone over to eject the videographer, then you have enough people to do it in a manner that won’t end up on the 11 o’clock Action News broadcast.
  • While I’m all for a ‘stay and play’ mindset for the vast majority of patients, if worse comes to worse on an EMS scene, move the patient to the ambulance. You have to do it eventually and the ambulance comes with a built-in perimeter.
  • Finally, if you absolutely have no other option but to lay hands on a reporter, engage the police first.

Above all else, when dealing with someone who can tell a story to millions of people, choose your battles wisely. If the story is going to be about the providers, let it be about your medical care, not your fight with the man with the camera.

Posted in EMS Operations, In the News | Tagged , , , , | 1 Comment

EMS Expo: Wrapup

Friday; wrap up day with another set of great sessions. My only scheduling complaint (besides having so many good sessions overlapping, making for some hard decisions over the 3 day expo), is the entire 2 sessions, lunch/exhibit hall break, 1 session, go home. Unfortunately, I made the decision to leave during lunch, which was ultimately a bad decision since my route home was blocked with a brush fire. Personally, I’d rather have all three sessions together or a late start, 1 session, lunch, 2 sessions. C’est la vie.

My first session of the day ultimately should have been a capstone presentation. Justin Schorr (of The Happy Medic fame) presentation on infiltrating command was a perfect wrap up for the expo. With so many of the sessions revolving around the cutting edge or inevitable evolution of EMS, what good is the information if it never reaches the people who can affect change? More importantly, why can’t (and ultimately why aren’t) you, the individual provider, the agent of change? Research new protocol options or changes. Offer to help set up or run that new program. Become the service expert in some aspect, and then utilize that knowledge and respect to help bring about change. Ultimately the front line providers and supervisors underestimates the power they have if only they were willing to roll up his sleeves and get their hands dirty.

My next session was the Gathering of Eagles conference, which was another great roundup of the current controversies and direction of research in EMS. One of the nicest features of this was how open the session was run. Essentially the discussion was open to what the attendees wanted to discuss. However, like a lot of the research talks, it boils down to a lot of what we do lacks evidence (lack of evidence isn’t the same as evidence of harm), and a lot of interventions might not matter whether it was initiated prehospitally or at the ED. However, EMS is also pushing the EDs to implement new interventions.

On the exhibit hall front, there was a few products that stood out. To be honest, I’m not really big on having the newest shiny toy. I’ll take a standardized patient and proper clinical rotations over a $50k simulator, give me switches instead of touch screens in the ambulance, and I honestly don’t care about portable suctions provided they, well, suck (and don’t get me started on the backboards). However a few products did stand out.

SynDaver Labs

Probably the booth that wowed me the most was the SynDaver booth. Requiring a good foundation in anatomy and physiology is one of my pet peeves, and ideally the anatomy course would be a gross anatomy course. For a variety of reasons, cadaver labs aren’t the easiest to get into. This is where the SynDaver comes into play as an anatomy simulator. There’s a difference between being able to feel, cut, and see actual organs and simply reading about them in a book, including the so-called “Dead Body Book.” To that end, I think that the SynDaver products fills the gap between an anatomy atlas and a cadaver lab rather well.

Ferno Mondial

Technically, this wasn’t a booth but the gurney from one of the ambulance manufacturer displays. There’s some sort beautiful simplicity that comes with combining a pole stretcher with an ambulance gurney. Going off of appearances (this is one of the few toys that I wouldn’t mind having a chance to truly play with), it looks like it gives crews a better choice and access to tools need to move patients over either rough terrain or tight spaces. It’s a better option than, say, putting a transfer flat (another under utilized piece of equipment) under the gurney mattress.

As a final note, thinking back to the topics and the conversations, one thing I’m thankful for is the topics, the bluntness, and the level of discussion maintained during the conference. As a veteran of EMS discussion sites online over the past several years (before the rise of EMS 2.0, JEMS Connect, or the EMS Blog-o-sphere), I know the hot button topics. I know which comments will bring out frothing hatred not because the message is wrong or because the poster is “trolling,” but because of how personal some people take EMS. So to hear one of the presenters state that EMS in the United States is still trying to recover from the harm of the 1993 EMT-B curriculum was shocking. Not because it was news to me. Not because I disagree, either on an intellectual level or a personal level as an EMT, but because I know what sort of fire can come with comments like that. It was shocking to finally be with a group of people who have a similar view-point and who are largely dissatisfied with the current general direction of EMS and are doing their best, in their own way, to help put EMS on the right track.

Posted in EMS World Expo 2011, Equipment | Tagged , , , , , | 1 Comment