Questioning the benefits of stroke ambulances seems to be in vogue lately in certain circles. In the interest of self-promotion these individuals love to point out the perceived shortcomings of others. As an EMS leader and agent of change, I feel I need to bring some clarity to this issue. I will outline the many benefits of having a stroke ambulance in your community below. Continue reading “Why you need a stroke ambulance by Chet J. Reilly (guest post)”
With absolute certainty the EMS empty suit proclaims that a college degree will fix all the issues EMS faces both today and in the future. Strangely, many of the proponents of a degree requirement do not even have a college degree themselves. They honestly believe it is a simple equation of supply versus demand. Degrees will cause there to be fewer paramedics and therefore increased demand for paramedics, which will fix everything. Complex problems rarely have simple answers.
Raising the barriers to entry and decreasing the number of paramedics won’t automatically equal higher pay for paramedics, it might just create more bastardized dumbed-down version of paramedic to skirt the regulations- think EMT-Intermediate,* Advanced EMT–Critical Care, Cardiac-EMT, Enhanced EMT, IEMT and all the other alphabet-soup flavors of ALS-lite that exist for communities that can’t or won’t pay for paramedics to be on staff or volunteers that don’t want undertake that much education to help out their community. 
I thought doing quality assurance (QA) at my EMS agency was going to be a simple matter.
I was wrong.
A decade ago the QA person at my agency resigned. Because I was a willing, warm body I got the job. I didn’t get any training on how to do QA, but I also didn’t think I needed any – besides, it was just going to be a matter of reading reports and telling people when they screwed up.
Over the past decade, I have learned many lessons while doing QA; more than a few of them have been about me as a person than how to do quality assurance. Being blinded by ignorance (along with a side of arrogance) I was certain in my approach – treatments could be labeled right or wrong, protocols were followed or they weren’t and providers were either good or bad at their job. If you made a mistake the solution consisted of write-ups, remedial training, and discipline. I made complex flow charts to grade medical errors by the level of harm to the patient. The level of harm dictated the actions that followed. Level 2b yellow was bad but not as bad as a level C3 orange. God help you if you were found guilty of a level 4 red event.
The Dunning-Kruger effect was strong with me. There is nothing simple about doing quality assurance for EMS. From time to time I try to share what I have learned from doing this job. What follows is something that might have been better as two separate posts, or maybe you can view it as a two-for-one deal.
The Outcome Bias
Almost every decision you make is a gamble. Continue reading “The one about the outcome bias.”
I just finished reading Decisive: How to Male Better Choices in Life and Work by Chip and Dan Heath. If you have an interest in making better decisions you should read this book.
The core concept of the book is the WRAP process. In the heat of the moment it can be hard to remember all of this so I made a pocket sized cheat sheet to consult before making some decisions. It is tailored to my needs and some of it may not make sense to you, some of it is a bit abbreviated. You obviously cannot completely avoid some of the biases, but for the sake of brevity I put “avoid” instead of “really try to avoid…”
For example: I am not a morning person, at all. I am cranky until I have ingested about 600mg of caffeine and should probably make as few decisions as possible before 10am. We were having a discussion about our protocols and if we should approach the state to attempt to get a waiver for non critical care certified paramedics to transport patients on levophed on inter-facility transfers. Should we or shouldn’t we ask the state?
I was going back and forth with it internally. No we should just require everyone to get a critical care certification. Maybe we should try for the waiver so that it shares the load among the crew, so yes? No, why should people get to have the standards lowered, they should have to do the work like I did and get an FP-C. Yes, it isn’t rocket science, it is titrating a medication to a BP. No, because then what was the point of me getting a CC cert? No, because it is going to mean we cannot charge the medicare SCT billing rate when they take the transfer. Yes, because we should focus on building people up. I don’t know…
Should we do it or not?
I was still several hundred milligrams short of my therapeutic dose of caffeine when a single neuron somehow fired and I was able to form a cogent thought. I realized I was falling victim to narrow framing and the the trap of “should we or shouldn’t we?” I needed to widen my view and figure out my goals.
The wider view was simply to ask what are we trying to accomplish here? We are trying to get sick patients to the right place in a timely manner. Often the weather shuts down the option of flying and they must go by ground transport for 2-3 hours from the local level IV to a level II or I hospital. It would be tragic to make a patient sit in a ER room or get admitted to a level IV when that is what they do not need. We are trying to get patients to where they should go in a timely manner, does approaching the state about a waiver for non-critical care paramedics to transport vaso-active medications on IFTs align with these goals? I think it does. Can it be done safely with the proper training and education? I would say yes.
“Yes, we should approach the state about a waiver.
And then I slowly sunk back in to the haze that is my early morning and wondered if I should or should not have another cup of coffee.
Feel free to copy this, mock it, edit it, share it or anything else you might want to do with it.
For every EMS provider that understands what a NNT or P value is, there are ten out there that think backboards save lives and that oxygen is somehow a pain med. For every provider that knows the difference between a Randomized Controlled Trial (RCT) and an observational study, there is an army of providers that believe asystole is an indication for naloxone. Show me an EMS provider who knows about what the AHA means with their proprietary class IIb recommendation (see below if you don’t know) and I will show you a hundred providers who are convinced that oxygen is a lifesaving intervention in a normoxic myocardial infarction patient.
Mary Baker Eddy authored the book of magical Christian Science nonsense, “Science and Health with Key to the Scriptures” in 1875. I find myself consulting a somewhat similar book with some frequency, “EMS Protocols Version 10.” Both books deal with raising the dead and treating the sick and injured and both books are far from being what one could consider science as they rest on a large foundation of anecdotal evidence and appeal from authority.
The 2015 AHA Emergency Cardiovascular Care Guidelines (AKA ACLS) which sort of forms a default standard of care* in our industry are mostly based on opinions and limited data. Shockingly, 46% of the recommendations in the guidelines are drawn from studies with limited data sets and 23% of the recommendations being based on “expert opinion.”
Much of what we do in the name of ACLS either does not work or does not work and might be harmful. Instead of asking if a medication works we have entered some sort of weird “the emperor has no clothes” paradigm. We now have to prove things do NOT work before we stop subjecting patients to out “treatments.” Painting with a broad brush here, for the average patient some of our treatments are about as effective as Reiki.
Some examples of what I mean:
- Amiodarone in cardiac arrest: No better than a placebo in terms of increasing CPC scores.
- Epinephrine in cardiac arrest: Not helpful in cardiac arrest in terms of increasing CPC scores , likely harmful
- Saline in trauma: harmful in large doses
- Backboards: No benefit in terms of immobilization, possibly harmful
- C-collars: No benefit in terms of immobilization, possibly harmful
- Lasix in acute pulmonary edema: No benefit, probably harmful in acute pulmonary edema
- High flow oxygen in the normoxic patient: No benefit, harmful in some patients
- Lights and sirens: Little benefit, high risk.
- TPA ambulances: No benefit (except marketing)
- Lucas devices: No benefit over well performed CPR with adequate rescuers, may be harmful
- Surviving sepsis guidelines (30ml/kg for ALL patients): May be harmful to some (most?) patients
- Some Supraglottic airways in cardiac arrests: No benefit in most cases, may be harmful
And let’s not forget a laundry list of our greatest misses involving things like MAST, high dose epinephrine in cardiac arrests, Therapeutic hypothermia following cardiac arrest, sodium bicarbonate in cardiac arrests, stacked shocks, treating “malignant” PVCs, and whatever else lurked in the drawers of the Plano box that you would give during cardiac arrests. The issue is all of these things made sense at the time; they all seemed like good ideas at the time.
The problem is the trend continues in EMS.
We simply refuse to learn from the past.
In the name of being a “progressive” agency, EMS is yet again engaging in alternative medicine. A small study on anesthetized pigs shows promise in performing heads up CPR and suddenly an EMS agency is being progressive and performing heads up CPR. If the science does not pan out and patients end up getting a treatment that made them worse, please accept our apologies in the name of “progress.”
But what is a bit of human sacrifice when things like marketability and JEMS articles are at stake? All those dead patients are just grist for the mill, casualties in the war against the status quo.
I fully support well done randomized controlled trials in medicine and many of our current practices need to be placed under the magnifying glass of an RCT; but an agency simply rolling out a new unproven, poorly researched treatment and touting their “results” does not equal an RCT. As providers, we have very little skin in the game here, we have all the upside if the new hotness works and we have none of the downside. If the treatment turns out to be causing harm we simply wash our hands of it and talk about it in blog posts like this a few years later. We don’t consider the countless dead we left behind when the next new shiny thing comes our way.
Another disturbing trend that is emerging is that of the “compounding resuscitationist” phenomenon. I agree that standard dose epinephrine either has little meaningful effects or is somewhat harmful. If I were to suffer a cardiac arrest I do not want any epinephrine given to me, and a sort of DNE form (Do Not Epi) might need to be created. I think a drug without any proven benefit and an association with harm should not be given to patients. Unfortunately many people are playing mad scientist and coming up with their own proprietary dosing regimens: adding a milligram to a liter and running it in over 20 minutes, spaced out dosing, giving some random dose of epinephrine, dosing based on etco2, giving only one or two doses, or a number of other alternative dosing regimens. This is not science, it is alternative medicine. It does not clarify anything; it only muddies the waters further.
Should we even discuss the madness that stroke ambulances are? Perhaps that is topic best left to a separate post.
There is a certain satisfaction one may get from being progressive. It feels good, it strokes the ego a bit when you have new information and do things other agencies are not doing. It may even generate some attention for you and your agency, especially if you are good at self-promotion. As long as you continue to employ the confirmation bias and only remember the few times the progressive movement was correct it is easy to continue this dangerous trend. We owe it to the dead to proceed with caution and diligence and avoid the seductive power of progressiveness.
We have entered the next age of medicine and are proud to present the release of EMS 4.0.
While we do offer our regrets regarding the brevity of the prior upgrade, the EMS 3.0 model was not optimized to achieve the cross-platform metrics that stakeholders demanded and will no longer be supported as of last week.
Rest assured that EMS 4.0 is both progressive and allows for enhanced marketability.
It is a bold new era with the release of EMS 4.0, the patented technology allows end-users to break free of the cycle of being needlessly constrained by things such as facts or evidence. Finally free of the burden of proving efficacy, or even any kind of tangible benefits, EMS 4.0 is sure to deliver the results you and your agency need in today’s emerging mobile healthcare solution marketplace. Continue reading “EMS 4.0.”
The bodies were still out there in the streets, covered with makeshift body bags when they asked you to donate to the cause. Less than 18 hours had elapsed since 58 people were murder, and 500+ were injured and when they started the fundraiser.
No, this wasn’t for the victims or their families.
I have sat on this post for 19 days, wondering if I should post it or not. I decided that what I have to say, needs to be said.
I need to be clear here. The zealots have a “if you are not with us, you are against us approach.” I want to preempt the rhetoric that is sure to follow that I am “perpetuating the stigma,” which seems to be the go-to defense when questions arise.
I support mental health initiatives for EMS providers and think people deserve care if they need it. I think every agency must feel responsible for their employee’s physical and mental injuries that occur from the job and even more for preventing these in the first place. I do not support their approach to the issue.
But, Jesus Christ…
It took less than 18 hours before the deaths of 58 people became about us, the rescuers.
For a problem that does not exist yet.
We are told the money is being raised for the mental health issues that the EMS workers who responded to Las Vegas are going to suffer.
Unless the Code Green Campaign has developed clairvoyance this is speculation, perhaps not unreasonable, but still speculation.
The fundraising campaign exposes the assumption that is the foundation of the organization; when EMS responds to these calls some responders will develop mental health problems, some of them may even need inpatient treatment and rehab for substance abuse. The notion that their agencies will not pay for this and will not support their employees is implied as otherwise there would not be a need for this.
If I were a manager for a Las Vegas Fire, Law or EMS service I would be highly offended that an organization thinks I am not going to take care of my employees; that they need to set up a fundraiser to pay for things workers comp should be paying for. And it should be paying for it, just so there is no misunderstanding what I am saying.
Maybe the organizers of the fundraiser have inside info on this and I will have to eat my words, maybe I am overly optimistic about the level of caring and resources that Las Vegas EMS/Fire and Law agencies have at their disposal. If we employ Hanlon’s Razor at best this fundraising is an ill-conceived and insensitive attempt to help. At worst, it is something much different.
A line needs to be drawn in the sand. We need to stop making every tragedy about us. It is not our tragedy. How selfish is it to agree to help (by accepting the job) and within 16 hours of 58 people being shot to start saying that we need some money for us. We chose this field, we chose to help others. We were not drafted, conscripted, or otherwise forced in to some sort of EMS servitude.
We willingly agreed to this. We chose to have front row seats to all the shit that life serves up.
How about we let the families finish burying their dead before we make this about ourselves. Consider holding off on the fundraising until the funerals have finished and let the nation mourn before the diatribes about what the rescuers had to endure that day begins. What the rescuers had to deal with is tragic, but it does not hold a comparison to the thousands of lives that were forever horribly changed that day. Go look at the dead, you owe them that much. Now imagine their families. Tell me again how bad we have it? http://www.latimes.com/nation/la-na-las-vegas-shootings-victims-list-20171002-htmlstory.html
EMS is about serving others, at least to some degree.
I won’t go all Mother Theresa here. I am not going to blow smoke up your ass and talk about how we are always on call or tell you that I would run in to a rain of gunfire to save someone because it is bullshit. I am probably not going to do that. I am no hero and I am going home in the morning after my shift if I have any say in it.
Someone needs to speak up and be the opposition. We are not all one call away from a mental health issue. Sorry, I know that might bother some people, but it needs to be said. If you find yourself preaching resiliency while at the same time saying we are all time bombs, you are full of shit.
You are going to see dead and dying people if you are in EMS. You will see people in pain and suffering. You will see humanity at their absolute god damn worst. You may see many people die in a short period of time. You are signing up for this.
And it is not about you.
You may need to reconcile who you think you are with who you really are. This may not be a skill that the majority of the population possesses; honest self-assessment flies in the face of the Dunning-Kruger effect which has apparently become an epidemic in society.
“Maybe you are wired different, maybe you are more resilient than others, maybe you have better coping skills than others” is what I often hear. Beats me, sure, maybe I am, I have no idea. I don’t know what kind of coping skills you have. I don’t know what kind of bullshit you are dealing with outside of work. What I do know is some jobs require specific mental and physical attributes. Perhaps it is time here to go out on a limb and say that EMS and medicine in general require a certain personality type or at a minimum specific attributes. No, I do not know how to screen for it or if that is even possible.
Life is short, violent and often brutal and has been this way for a majority of human history. Only recently, in the past few decades, have we become insulated from the reality of how life is.
EMS can be draining; it can exert both a mental and physical toll on those who do it, but the bleating of “what about us” while the blood is still in the streets is more than bothersome.
I imagine there will be some images that rescuers saw that day that they wish they could forget. Some providers may indeed get mental health issues from being at work that night and they should get all the assistance they need. If they do not get the help they need I do not think a few dollars thrown their way is the solution; we need to hold peoples feet to the flames here. We need to demand accountability from management and workers comp insurance. We need to demand legislative changes and cultural changes, not a gofundme account that will pay for a few people to get some help or fund the staff trip to talk about awareness.
The goal of an EMS quality assurance program (QA) should be increasing safety, satisfaction, and outcomes for both EMS providers and patients. Unfortunately, many QA programs are not healthy, they are a dysfunctional mess.
Compare your agency’s quality assurance program to the seven signs below and see how you match up. Continue reading “7 SIGNS YOUR AGENCY’S QUALITY ASSURANCE PROGRAM IS A DYSFUNCTIONAL MESS.”
“Tell them we are really sorry and we are going to change our policy, okay?” I say to the RN on the phone. We are now going to have a strict hand washing policy when this sort of thing happens.
Perhaps in the near future, the title of this blog may change to “Mistakes that I made that you should read about so you do not make the same mistakes as I did.”
Continue reading “Fixation Errors: Blame Aunt Jemima.”
In 2007 Elaine Bromiley went in to the hospital for an elective sinus surgery. Thirteen days later she died. If you are unfamiliar with the case, there is a reenactment video of what happened in the OR here. Be forewarned, it is not an easy video to watch.
Recently we discussed the case at work. Providers expressed their disbelief over the events. “I don’t get it. How could that have happened?” was asked. Before doing quality assurance (QA) in EMS for several years I know I could tell you the answer, it is glaringly obvious to anyone with or without any medical knowledge – THEY ARE INCOMPETENT IDIOTS! For good measure I might also throw in some pseudo-intellectual comment about how the definition of insanity is doing the same thing over and over and expecting different results. For the coup de grace I would add they should lose their license to practice medicine.
Doing QA is hard. Sure you can just read reports and dole out sanctions for protocol violations like some sort of EMS SVU. “In the EMS justice system, QA based offenses are considered especially heinous. In the agency, the dedicated QA officers who investigate these vicious felonies are members of an elite squad known as the Special Victims Unit. These are their stories.” Chung-chung. It won’t make your system better or safer, but you can do it. It happens all the time.
To do QA right requires you to either have natural talents in things like emotional intelligence (I don’t) or to learn about yourself and come to some unpleasant realizations, things like you are wrong a lot. Even worse, after doing QA for some time you might come to find the root cause of some of the problems in the agency also involves you. The notion that second ago you were sure the providers were morons and now you are contemplating that you are perhaps a causative factor in the incident can be a bitter pill to swallow.
Growth is hard and to be honest not all that fun. It kind of sucks, actually.
Going back to the Elaine Bromiley case it is easy to be the judge, jury and executioner when we view the events that occurred with the benefit of hindsight.
The thing is if you were to present the scenario in the Bromiley case to anyone of the people that were there in there that day in the form of a question, “your patient is circling the drain, the 02 sats are in the shitter, should you keep trying to intubate?”I guarantee every single person would say “hell no!” But the truth is the people in the OR that day may never have even considered there were other choices. There probably was no choice presented in their minds. The only solution they could think of was “get the tube.” Or maybe they did have choice but the best solution from their perspective was to “get the tube.” Perhaps they though in another five seconds that tube would go through the cords and the disaster would be averted, certainly better to spend another five seconds in the airway than to cut the neck and scar this woman, right?
But they could not know that. Only with hindsight can we tell them that it would not be just another 5 seconds to get the tube. If we had the foresight to say you are never going to get the tube I assure you no one would still be mucking around in a person’s airway when their spo2 is south of 40%.
It is easy to watch the Bromiley video and believe your inner monologue, “IDIOTS.” It is harder to look at things from the provider’s perspective. It takes self-restraint to not jump to conclusion. It is very hard to look at things from their perspective and try and understand what they thought was going on then and why they made the choices they did that day. I think this is referred to as empathy.
From the outside perspective watching a fixation error unfold is a baffling ordeal, it boggles the mind how people could do what they are doing.
Fixation errors are very real. I made one once. After you experience one the world is different. You will be left with lingering doubts about your skill as a clinician. Are you a shit paramedic? How the hell did that happen in the first place? From the calm of your kitchen typing away on your computer it seems almost impossible to understand what occurred that day. You know the facts, you know what happened, but the why of it is much more elusive. Like some half remembered drunken evening you have bits and pieces of went on. What led you astray that night was not just one thing, and you know this. You know the holes of the Swiss cheese lined up just right to set the trap and you took the bait. Hook, line and sinker.
Given enough time, you can begin to understand exactly what did happen. Given enough time, you can be okay with a lot of things. You can begin to understand how others can get lulled down the same shitty path. There are few things in life as seductive as just taking one more “quick look” in your patient’s airway when you know at that moment that an ET tube is the solution to all your problems.
I think there is another component to the issue of fixation. Failure. There is a subtle sense of failure when you place a supra-glottic airway after you could not get the ET tube in, especially in a patient you paralyzed. But you do it. You put that supra-glottic device in, because that is what is needed, that is what is right and correct and should happen, has to happen, but it still stings. It still feels like failure.
But the goal was never intubation, was it? The goal was managing the airway. Or was it? It seems when every cardiac arrest is tried by a jury of our peers the burning question is “did you get the tube?” or “Who got the tube?”
Of course, talking about this is probably going to be frowned upon be some. We are supposed to be bigger than this when it comes to ego and our own biases and patients.
On the other hand, preventable medical errors may be the third leading cause of death in the USA. Maybe it is time we start looking at some human related factors.
Let’s have the uncomfortable talk about how our cognitive biases, ego, and sense of pride might be playing in to killing a bunch of people. If you do not think this is a huge problem in EMS, I would refer you to the post about the ET tube petition. Right next to ET tubes on the NASEMSO document was a call for the removal of PEEP. Now, the thing is there is not a ton of evidence about EMS ET tubes, and what evidence there is paints the practice in a questionable light, but PEEP on the other hand seems to be pretty soundly based in science and evidence. Out of the save intubation crowd there was virtually no science or data or evidence given, only anecdote and an appeal to emotions.
Where was the petition to keep PEEP? There wasn’t one.
- Number of people who signed the petition to keep intubation in the paramedic scope: 26,476.
- Number of people who signed the petition to keep PEEP in the paramedic scope: What petition?
You can ask yourself why no one cared about the PEEP issue but I suspect you know the answer, you have known it all along. We, as an industry, have some weird emotional attachment to intubation; it has somehow become an integral part of our identity as a paramedic. This is not to say that intubation does not have a place in EMS, I think it does, but I think it might be time to start the conversation about why we are so god damned emotionally invested in intubation. Myself included.
How did our value as a paramedic come to rely on a 30cm piece of plastic tubing? How does self-worth hinge on shoe-horning a two dollar piece of plastic several inches in to a patient? I do not know.