Since I closed down my daily blog I have been trying to increase the number of posts to Street Watch, which I have always thought of as my weekly blog. I am hoping to post at least three or four times a week. Since I will not always be able to write the type of extended life of a paramedic story I like best, I am going to also try to do posts a variety of post types, including research, news story type updates, and a general miscellaneous type post which I will try to do tonight. I am going to try to respond to comments more.
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I rode today with another paramedic and her preceptee. I had called in looking for a shift, and hers was open. They didn’t tell me she had a preceptee with her. That was all right. I just drove, and let them do the calls. The preceptee is a bright articulate young man, who I think will be an excellent medic. We had no real challenging calls, but I could see he had a good head and common sense. We were in one of the newer ambulance, where the emergency lights are in the ceiling above you head. Supposedly, you just reach up and hit emergency master and they all light up. We got a call to intercept with a basic car that needed a medic, so I looked up, hit the emergency master and off we went. I drove a little faster than normal because I wanted to be able to hit the intercept point before the other ambulance, which was already enroute passed it. We made it fine. Later, the driver of the other ambulance mentioned I had had my siren on, but no lights. I guess, whoever was in the car before me had turned the individual emergency lights off, so you had to not only hit the emergency master, you had to then hit each of the lights. D’ooh! Oh, well.
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Consider the following merely an idea brewing in my head, a troublesome unformed idea:
The other day I had an interesting talk with an EMT, who used to work in the dispatch center, which is located in another city from us. He works the road, but still keeps his feet in various dispatch centers. While like many road people, I find dispatchers annoying and easy to blame, they do have their side to tell. While I may suspect them of sending me on a priority one for something I don't think should be lights and sirens only because they want to clear their screens( by getting us to the call quicker to get us to the hospital sooner, and clear for the next call sooner) there may in fact be more to it.
We used to have dispatch right in our same building, and we all knew and saw each other everyday, and the dispatchers often knew the streets better than we did, so for the most part we got along. For the most part, they were good to us, we were good to them. It was also in the days before EMD, when dispatchers could use their common sense in selecting how to send us to the call. Now, we hire non-medically trained people to EMD the calls, which I understand is what the EMD company prefers so that the call takers won’t deviate from the algorithm. The ambulance company I guess gets a better insurance rate as long as they stick to the algorithm – the EMD company will defend them in court. The problem is, the dispatchers, whose hands I guess are tired by the call-takers work (And the call-takers side may simply be we're just doing our jobs as we have been trained), end up sending us priority one all the time for difficulty breathings simply because the patient is not breathing normally, but there is no context. Maybe they are COPDers and this is their baseline, and their problem today is a skin tear. Maybe they have had pneumonia for a few days and the doctor has finally decided to send them in for hydration and antibiotics. An glaring example the other day we were sent priority one for difficulty breathing only to find the call was for a psych who was breathing rapidly because she was agitated because the nurse wouldn’t let her watch the show she wanted on the common TV. We found her with a cigarette in her mouth. I could go on. The calls are all appropriate per EMD, but inappropriate for a lights and sirens response per common sense.
I am a big fan of Bryan Bledsoe, an EMS physciaian and writer, who has made a name for himself, among other things exploding EMS myths. I believe I heard him once and another time read him making a reference to their being no science behind EMD – nothing that provided that it in fact made a difference in a measurable way. I eagerly wait for him or someone else to truly tackle the topic. In the meantime a few days ago I was browsing around on a site called Pub Med where you can look up research articles and I found some very recent ones, which I will write about soon in more detail, which showed how poorly many of the calls correlate to the EMD protocols they are assigned by the dispatcher. For instance, something like only 26% of calls given the chest pain protocol, are actually cardiac related, and I read another that I believe said only 1 out of 18 cardiac-related calls is a true MI. I seem to remember reading something that in many cases random chance did a better job of picking the appropriate response than EMD (I hope this isn’t so). Now, keep in mind these numbers are just out of my memory now, and I promise a deeper look into them. The bottom line tonight for me is that while we may all think of EMD as motherhood and apple pie, and may it protect us from liability, it may also not be doing the patients much good and may be putting us in harm’s way.
I’m going to look into this further, and promise to post my findings here, as well as the relevant research. I may in fact be wrong, but I also may be right.
Earlier today we were sent on a priority one by a town police department for a psych and arrived to find the man in handcuffs with about seven cops surrounding him, and the man was quite calm. While this call was not EMDed it came as a request from an officer, I would argue that our going lights and sirens did not contribute to saving anyone’s life and may in fact have endangered someone’s – ours and the public’s.
So here is the deal, I want to put all these things in a pot:
EMS
Evidence-based medicine
Research
Ambulance personnel
Ambulance Companies
Ambulance crashes
Unions
OSHA
Dispatchers
Police and fire requests for ambulance to their scenes
The public in their cars
The public who is sick
EMD
Lights and sirens policies
Safety equipment
First responders
Whatever else I think of
Mix it all up and see if I can come up with a statement about responding lights and sirens that is true.
Here's an abstract from one of the studies that just came out:
1: Acad Emerg Med. 2006 Sep;13(9):954-60. Epub 2006 Aug 7. Links
Comparison of the medical priority dispatch system to an out-of-hospital patient acuity score.Feldman MJ, Verbeek PR, Lyons DG, Chad SJ, Craig AM, Schwartz B.
Sunnybrook-Osler Center for Prehospital Care, 10 Carlson Court, Suite 640, Toronto, Ontario, Canada. mfeldman@socpc.ca
BACKGROUND: Although the Medical Priority Dispatch System (MPDS) is widely used by emergency medical services (EMS) dispatchers to determine dispatch priority, there is little evidence that it reflects patient acuity. The Canadian Triage and Acuity Scale (CTAS) is a standard patient acuity scale widely used by Canadian emergency departments and EMS systems to prioritize patient care requirements. OBJECTIVES: To determine the relationship between MPDS dispatch priority and out-of-hospital CTAS. METHODS: All emergency calls on a large urban EMS communications database for a one-year period were obtained. Duplicate calls, nonemergency transfers, and canceled calls were excluded. Sensitivity and specificity to detect high-acuity illness, as well as positive predictive value (PPV) and negative predictive value (NPV), were calculated for all protocols. RESULTS: Of 197,882 calls, 102,582 met inclusion criteria. The overall sensitivity of MPDS was 68.2% (95% confidence interval [CI] = 67.8% to 68.5%), with a specificity of 66.2% (95% CI = 65.7% to 66.7%). The most sensitive protocol for detecting high acuity of illness was the breathing-problem protocol, with a sensitivity of 100.0% (95% CI = 99.9% to 100.0%), whereas the most specific protocol was the one for psychiatric problems, with a specificity of 98.1% (95% CI = 97.5% to 98.7%). The cardiac-arrest protocol had the highest PPV (92.6%, 95% CI = 90.3% to 94.3%), whereas the convulsions protocol had the highest NPV (85.9%, 95% CI = 84.5% to 87.2%). The best-performing protocol overall was the cardiac-arrest protocol, and the protocol with the overall poorest performance was the one for unknown problems. Sixteen of the 32 protocols performed no better than chance alone at identifying high-acuity patients. CONCLUSIONS: The Medical Priority Dispatch System exhibits at least moderate sensitivity and specificity for detecting high acuity of illness or injury. This performance analysis may be used to identify target protocols for future improvements.
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Speaking of lights and sirens and ambulance crashes, I was disappointed with the final episode of SAVED. In the end, the medic takes the ambulance lights and sirens to see his girl hoping to catch her before she can leave town with the man she doesn’t love. He is distracted to find his partner in the back who has possibly ODed due to domestic unhappiness. He runs the red light and they are t-boned by a semi-truck.
Now despite all the inaccuracies and quibbles here and there seen though a medic’s eyes, I still really enjoyed the season, and hope it gets renewed. In the end, I think it does raise our profile in the public eye, conveys some of the feeling of what it is like to be a medic, and portrays us as carrying, and at times, heroic people. For TV, that’s doing well. And frankly we need all the help we can, so I send them out a nod of appreciation.
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Here's a story about an interesting study that shows there is no correlation between pain and vital signs.
Correlating Self-Reported Pain and Vital Signs
Here are his concluding remarks:
I have also heard health-care providers say, "Well, he can't be in much pain because he isn't even tachycardic." This study is a milestone in my book to the fact that every patient's pain is theirs and theirs alone. We have created so many myths and personal biases regarding pain that it gets in the way of caring for our patients. Our traditional teaching has been so ingrained in us with these myths that when we don't see the expected changes in vital signs, we assume the patient is simply not in as much pain as they profess.
It may be true that if your patient is tachycardic, tachypneic or hypertensive that it could be a reflection of his or her degree of pain. This is useful when you have the stoic patient who refuses to confess how much it hurts. However, the converse is not true, as it was eloquently demonstrated in this study.
Remember: Our job is not to keep the patients from becoming junkies. It's to provide compassionate care and relieve pain and suffering. Leave the prejudice to someone less enlightened than you.
