EMTs Should Not Be Allowed to Decide On Scene Flight Helicopter Use.  

EMTs don’t possess the foundational knowledge in disease process, anatomy, physiology and pathology needed to decide who should and should not be flown by HEMS. I’m not faulting EMTs for this but the fact remains that they simply do not have enough training to know who should and who should not be put in a helicopter.

EMTs should not be allowed to decide on scene flight helicopter use with the current initial educational standards in place. The NHTSA and the NREMT need to increase the educational requirements on this topic. Perhaps they could replace a few hours of the spinal immobilization witchcraft that is obsessed over in EMT programs and talk about things that matter to patients and outcomes; cost–benefit analysis and risk versus benefit decision making, explaining what flights can and cannot do for a patient, financial, patient advocacy and the concept of patient autonomy in medical decision making.

17,000
“No thanks is necessary ma’am, just doing my job.”

Before your BP gets any higher and you round up your pitchforks, most paramedics are not good at this either and they need more training on this topic as well.

There should NOT be a difference in the initial education on this topic between EMT level providers and Paramedic level but unfortunately  there is one. The National Emergency Medical Services Education Standards from the NHTSA (http://www.ems.gov/pdf/811077a.pdf) serve as a blueprint for what EMS courses must teach and there is clearly a difference between EMR/EMT/AEMT and what the Paramedic is taught about who to fly and when.

helicopter educational standards
National Emergency Medical Services Education Standards Page 49

How much time was devoted to this subject in your class? When I took EMT it was a 30 second spiel about “life or limb” and that was it. I looked in a recent (2012) EMT text book to see how much of the text was devoted to information on when to use air medical resources. 3 paragraphs out of a 1284 page book were devoted to this topic. 3 paragraphs about a decision we make that can literally cost someone their home and ruin their life seems a bit light to me.
There needs to be sweeping reform of all EMS education, especially this topic.

If you have read this far I would like to apologize for the somewhat click-baitish nature of this post, but controversy drives people to posts way more than a post titled “NHTSA Needs to Make Sweeping Policy Reforms to Air Medical Resource Utilization Education in Initial EMS Training.”

Dunning – Kruger Effect
Over triage rates of patients sent to the hospital by HEMS ranges between 26% and 60%1,2. Dr Bledsoe et al produced an excellent meta-analysis of this in 2006 and it seems fair to say that the issue has not gotten better in the past 10 years.

EMS loves nothing more than to develop flow charts rules and protocols for things. There have been attempts to streamline who should and should not be transported by a helicopter. The NHTSA has produced a set of guidelines based on the 2011 CDC Guideline for the Field Triage of Injured patients3. The 2011 CDC guidelines are too broad and not specific enough to work unless common sense is applied. While a respiratory rate of >29/minute might be a problem, it might also be due to the fact that the person was just in a traumatic car accident, without clinical correlation the guidelines are worthless.

Primum Non Nocere
The number one cause of bankruptcy in America is medical bills.
Depending on the study or article you read medical bills account for between 17-62% of all
bankruptcies in America. Medical billing is a major cause of bankruptcy and it is not just affecting the uninsured, many of the people forced to file bankruptcy because of medical bills have medical insurance.

The nation’s largest provider of EMS helicopters is Air Methods. A recent NY Times article states the average bill for a flight from Air Methods is around $40,000.  There have been accusations that Air Methods has taken people to court over their bills and even put liens on people’s houses in order to get paid4. EMS needs to make sure that the ends justify the means when utilizing HEMS for a patient.

Patient advocacy needs to be one of the tenants of EMS practice and this has now extended to counseling those with decision making capacity on the financial aspects of their health care choices.

I’m not an idiot, there are some patients that simply need to be put on a helicopter and flown to a major hospital because the choices are A) be dead or B) be alive and bankrupt but this is not a justification for bad decision making; it is not a justification for the what-if game.

It is no longer acceptable to replace poor clinical judgement with an appeal to emotion of “well, at least they are alive to bitch about the bill.” It is also no longer okay to rationalize bad medicine to ourselves and others with another appeal to emotion of “THE LAWYERS” and the ever popular well what if I don’t fly them and they get worse and then I get sued.

You might be saying, “I’m just an EMT and shouldn’t have to make these decisions and wait a second here, the author of this blog post agrees I should not be making these decisions so why is he telling me to figure it out.”

Because I live in reality and know EMTs are going to be tasked with the decision of who goes to the ER by HEMS regardless of what a blogger says on the internet. It does not change the fact that it is not okay to routinely cost patients $40,000 because we as an industry have shit for educational standards.

Here is the thing that no one ever told you in EMT class – your decisions have consequences, mostly for the patients and sometimes for you. If you don’t want that responsibility then look in to another career.

What is a realistic goal then? Educate yourself, read everything you can on this, talk about it with your coworkers, supervisors, protocol writers, and medical directors. Discuss it on internet forums, think of scenarios, and understand what HEMS can and cannot do in your area. Strive to be a provider who uses clinical judgment with a solid educational foundation.

You are going to over triage patients and fly them, it is a fact and this is preferable to under triage but when you follow up on the patient you flew from scene (you do follow up on them right?) and find out they had only minor injuries and did not benefit from a flight don’t dismiss it, embrace it, look at your decision making pathway. Keep track of your rate of over and under triage. When you screw up sit there with those feelings and wonder if you are a shitty EMS provider, feel bad about yourself and your judgment for a bit. This is what good EMS providers do.

Bad EMS providers simply say some bullshit about lawyers, MOI, better safe than sorry, x-ray vision or some other non-sense and never internalize this lesson and grow from them.

Good EMS providers scrutinize their judgments and feel bad when they make a mistake. Feel bad about it for a while and then move on, realizing this is the path to becoming a better provider.

  1. Smith HL, Sidwell RA. Trauma patients over-triaged to helicopter transport in an established Midwestern state trauma system. J Rural Health. 2013;29(2):132-9.
  2.  Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’keefe MF. Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis. J Trauma. 2006;60(6):1257-65.
  3. http://www.nytimes.com/2015/05/06/business/rescued-by-an-air-ambulance-but-stunned-at-the-sky-high-bill.html?_r=0
  1. https://www.ems.gov/ficems/june2012/Draft%20Manuscript%20for%20HEMS%20Evidence-based%20Guideline.pdf
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ECG Lead v4R: The Streetlight Effect.

“…And then I would throw down and do v4R to check for right sided involvement.”

dextrocardia
EMS providers love cautionary tales. Remember how we used to put a cervical collar on everyone and strap them to a backboard because “what if they have a c-spine injury?” Lead V4r is becoming the new cervical collar. It might be somewhat useful in a limited set of patients but it is often done out of fear of missing a right sided infarct or for reasons like “because so and so said to do it on all patients.” And just like c-collars v4r is probably not needed most of the time we use it. V4r is an example of the streetlight effect.

The streetlight effect is observational bias of looking for answers where it is easiest to look for answers. The name is derived from an old joke:

 

Late at night, a police officer finds a drunk [sic] man crawling around on his hands and knees under a streetlight. The drunk man tells the officer he’s looking for his wallet. When the officer asks if he’s sure this is where he dropped the wallet, the man replies that he thinks he more likely dropped it across the street. Then why are you looking over here? The befuddled officer asks. Because the light’s better here, explains the drunk man. [1]

When to do v4r:

  1. Is there an inferior wall STEMI and you are considering giving nitro? Is the inferior wall STEMI patient significantly bradycardic or tachycardic? Then don’t worry about v4R since you are not going to give nitro anyway. Is the inferior wall STEMI patient hypotensive? Then forget v4r because nitro is not indicated, you need to worry about fluids and perhaps something like an inotrope. If there is an inferior wall MI and the blood pressure is acceptable for nitrates then take a look at v4r.
  2. Are there ECG changes that suggest something might be going on and you should check out the right side? I’m talking nonspecific or non-diagnostic changes like ST segment depression or elevation, T wave inversions, etc.
  3. Did the patient get hit in the right side of the chest and you are looking for signs of a right ventricular cardiac contusion? It seems that at least one study has been done on this and the results of looking at v4r to see if there was a right sided cardiac contusion were not diagnostically helpful. [2]
  4. You have a patient with dextrocardia.

That is it. No one else is really going to benefit from a right sided ECG. The pneumonia patient at the nursing home who has a normal 12 lead doesn’t need you to throw down and put more stickers on her chest. Focus on what matters, focus on what will change your treatments and the outcomes for your patients.

Are You a Closer?

A…B…C…
This is the second article in series for new EMS providers.

I precept several new EMS providers a year and the biggest issue I see in new EMS providers is they aren’t able tot close the deal.

What do I mean by close the deal?

always be closing

If you don’t know what I mean by close, go watch the 10 minutes of Glengary Glen Ross where Alec Baldwin delivers his speech. [NSFW language: Coffee is for closers]

New EMS providers are usually able to get through the SAMPLE and OPQRST part with a patient fairly well and then things come to a screeching halt. Once the assessment and history gathering are done there is an awkward silence as they look to the preceptor for direction. They don’t close the deal.
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At the risk of oversimplifying things, in the end you have two outcomes of a 911 call:

  1. The patient goes to the hospital with you.
  2. The patient does not go to the hospital with you.

Sometimes it is obvious what the choice is, other times patients are unsure what they should do.

Our job as EMS providers is (should be?) to inform and educate patients so they can make a health care decision that is right for them. What follows seems like common sense but I think you would be surprised how many newer EMS providers find this to be a stumbling block.

If the patient is not sure of they want to go to the ER, do your assessment, gain enough information to counsel them. Once you have decided that you feel a patient should go to the hospital by ambulance or that they don’t need an ambulance if they don’t want one*, don’t turn to the preceptor and look for direction, just take the ball and run with it.

Trust me, if we see you making a dangerous decision we will intervene. Summarize your findings to the patient, tell them your plan and ask them to act upon it, let them be involved in the decision making and close that deal.
 “I think you should go to the hospital with us, does that sound okay?”

 “Here is what I would like to propose, I would like to start an IV, give you some medication for pain, let that marinate for a moment to kick in and then take you to the hospital, how does that sound?”

In non-injury accidents I will often tell the patient, “We are not finding any injuries and everything looks okay, however the safest course of action would be to go to the ER and get checked out and we are happy to take you. Do you want to go to the hospital with us?”

You may have no idea what is going on with the patient that is okay. While EMS does diagnose, we do not diagnose every patient every time. I often tell patients I am not sure what is causing their issues and that is why they should go to the ER to get a much more thorough evaluation.

“I’m not sure why you are having chest pain but  I do think you should go to the ER, where they can do things like lab work and imaging and you can be checked out by a doctor. Does that feel like an okay plan to you?”

You may think that telling patients you are unsure about their diagnosis is going to undermine their confidence in you, it will not. In fact it will have the opposite effect making  them trust you more so long as you are confident in your delivery . Honest communication is the cornerstone in building rapport.

Don’t stop until you close the deal. Either you close them and they go with you in the ambulance or they close you and say they do not want to go with you to the ER.

*Please note I am not advocating for EMS initiated refusals here. Use common sense and be a patient advocate.  If a patient has toe pain from gout and they understand the risk of not going to the ER by ambulance then I am fine with that. If a patient has a huge STEMI and chest pain but doesn’t want to go to the ER I am going to really try to get them to go to the ER.

12 Lead ECG and the New Paramedic: Reducing the Germane Load.

numbers scene

What follows is hopefully the first in series of tips for new paramedics.

New EMS providers face a tremendous cognitive load when they attempt to look at the fine details of an ECG on a scene while listening to a patient and ensuring good scene management. I have witnessed many new paramedics apparently hypnotized by the ECG as they stare at a 12 lead mumbling to themselves and losing sight of what is going on with the patient and the rest of the responders.

My advice for new paramedics, when looking at an ECG on a conscious adult patient take a ten second look and then move on.

Look at the ECG and ask yourself the following:

  • Is the rate less than 50?
  • Is the rate greater than 130?
  • Are there ST segment issues that are clearly ischemia or infarction?
  • Are there giant T-waves or other changes that point to hyperkalemia?

If the answer to all of the above questions is no, then put the ECG down for now and move on to other things, the problem is not likely related to cardiac issues that you can quickly discern from an ECG.

A heart rate between 50 and 130 in an adult is not a rate related problem. It does not matter what the rhythm is, provided all the beats are perfusing, don’t waste time on the rhythm diagnosis initially if it takes you more than ten seconds.

Don’t spend time counting out small boxes, looking at axis, looking for zebras, and mumbling to yourself while marching out PR intervals and trying to remember the criteria for Sgarbossa’s criteria. Get every other thing taken care that needs to be done, starting IV’s, giving aspirin, pain management, talking to your patient and re-assuring them, thinking about your plan of action and getting them loaded on the gurney.

“What about if it is an AIVR rhythm at a rate of 55?”
It doesn’t matter, it is not the problem.

“What if it is an AV block at a rate of 52?”
It doesn’t matter, it is not the problem.

“What if it is atrial fibrillation at a rate of 120 – 130 beats per minute?”
What if it is? What are you going to do about it? It doesn’t matter, it is not the problem and it doesn’t need to be fixed, but it is possibly a symptom of something else like sepsis, dehydration, DKA, etc.

This is not to discouraging ECG expertise in any way. Experienced paramedics should strive to be experts at ECG interpretation. A new paramedic simply cannot be an ECG expert.

The ECG expert recognizes patterns unconsciously, they simply look at an ecg and because they have unconscious competence and pattern recognition they can tell what it is, at least most of the time.

After you have seen enough ECG’s you will simply recognize the patterns of things like LVH, LBBB, AV blocks, LAHB, atrial fibrillation, sodium channel blocker OD’s, etc with a cursory glance.  But it is important to understand the ECG expert gains this ability only after looking at thousands of ECG’s, counting out small boxes thousands of times, calculating the axis thousands of times and frankly being wrong numerous times in the past.

If you possess the knowledge to formulate a differential diagnosis that includes things an ecg can help rule in or rule out (TCA OD, channelopathies, Wellen’s syndrome, etc) then use the ECG right then and there. This is a much different mindset however than having a patient and you are not sure why they are ill so you do a 12 lead looking for clues. In the first scenario you are looking to confirm a hypothesis, in the second one you are simply ruling things out as the cause, or hoping to find a clue as to what is going on.

Once you have the patient comfortable and have all the needed interventions done then it is time to go over the ECG with a fine tooth comb and look for the subtle findings, count boxes, calculate axis and make sure you did not miss anything.