INSIDE LOOK AT LIFE AS AN EMT

 

I recently participated in a project to describe the daily routine of an EMT to help people considering a career in EMS.  The final product was published this week on the website below.

INSIDE LOOK AT LIFE AS AN EMT

Here is an excerpt:

5:30 AM:

I punch in and checkout my equipment, my house bag which contains my medications, IV and airway supplies, my heart monitor, and then the equipment on the ambulance shelves, while my partner checks the ambulance to see that the siren and emergency lights are working and that we have plenty oxygen to make it through the shift. He also checks the oil and engine fluids.

Then, we sign on with our dispatcher and already there is a 911 call for us. No time for coffee. A 68-year-old woman has been vomiting all night. I feel her forehead she is burning up. Her tongue is also dry and cratered. I give her Zofran for her nausea and IV fluid for her dehydration. We transport her to the hospital.

6:23 AM:

I am writing my PCR (Patient Care Report) on my laptop computer in the hospital EMS room when my pager goes off “Can you clear for a Priority One?” We head out lights and sirens for the report of a person unresponsive in a car. Before we can get there, we are cancelled. It turns out the person was merely sleeping. Dispatch has another call for us. A motor vehicle crash by the highway entrance ramp. Both drivers are out of the car inspecting the damage, which is minor. One driver has arm pain, but refuses to go by ambulance to the hospital. We have him sign a refusal of care, and then clear the scene.

7:04 AM:

Report of another person not responsive. A woman stands by the front door and we can see she is crying as she flags us down....

To read the rest, Click here

Draft ILCOR Advanced Airway Recommendations: Banning Paramedic Intubation-What System will be the First?

 

The Consensus on Science with Treatment Recommendations (CoSTR) from the International Liaison Committee on Resuscitation (ILCOR), the group that forms the basis for the AHA ACLS guidelines, has released a new draft guideline on Advanced Airway Management During Adult Cardiac Arrest.  The guideline is available for public comment until April 2, 2019.

Advanced Airway Management During Adult Cardiac Arrest

The recommended guideline takes into account the latest literature, including The Pragmatic and AIRWAYS-2 trials:

Pragmatic Airway Management in Out-of-Hospital Cardiac Arrest

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest A Randomized Clinical Trial

Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome The AIRWAYS-2 Randomized Clinical Trial

Here areILCOR's the key draft recommendations:

Treatment Recommendations

• We suggest using bag-mask ventilation or an advanced airway strategy during CPR for adult cardiac arrest in any setting .
• If an advanced airway is used, we suggest a supraglottic airway for adults with out-of-hospital cardiac arrest in settings with a low tracheal intubation success.
• If an advanced airway is used, we suggest a supraglottic airway or tracheal intubation for adults with out-of-hospital cardiac arrest in settings with a high tracheal intubation success rate.

While they do not specifically define what low versus high intubation rates are, they write the following:

We have not provided a precise value or range of values for low and high intubation success rate, nor an agreed definition. Studies have used different definitions of tracheal intubation success. Using the individual study definitions, we considered the Wang and Benger RCTs (Benger 2018 779, Wang 2018 769) as having a low tracheal intubation success rate (51.6% and 69.8% respectively) and the Jabre study (Jabre 2018 779) as having a high success rate (97.9%).

In other words, if your service has an intubation success rate of 69.8% or less, then you are should be using a supraglottic airway instead of tracheal intubation.

(Intubation success should not judged on whether or not the patient eventually comes in with an ET tube place (after multiple attempts), but your rate per attempted laryngoscopy.)

When I began as a medic in 1993, ET was the standard for prehospital care.  We did not even carry supraglottic (backup) airways.  Today supraglottic airways, and even bag value mask, are considered acceptable alternatives.   As research continues to show that tracheal intubation does not lead to improved outcomes and may lead to worse, medical directors are going to start pulling intubation from their medics’s arsenal.  To date, I am not aware of any who have done so.  What system will be the first?

 

Moral Injury

 Check out this powerful You-tube video

https://www.youtube.com/watch?v=L_1PNZdHq6Q&feature=youtu.be

When I see another provider who is burned out, my reaction has always been:

"Get another job.  You have no business doing this kind of work."

Until I saw this video, I never really considered the concept of moral injury.

If a fellow paramedic hurts his back lifting or wrestling with a patient, I would never thing to say, "Get another job.  You don't belong in this work work anymore."

Companies take great precautions to make our work physically safe.  There have been great innovations in stretcher design (when I started we used a two man dead lift), stair chairs, safety nets, and driver safety systems.  And while most services have employee assistance programs, I can't think of any preventative measure routinely taken in EMS to prevent moral burnout.  Long shifts, holdovers, too few cars on the road, 911s holding, order-ins.

Meat in the seat.

There is always a new hiring class to pick up the fallen stethoscopes and take their places on the front lines. 

It is hard to change things overnight.

I am glad there seems to be an awakening ahead.

 

An Underappreciated Attribute

There are many qualities I appreciate in a BLS partner (Our system pairs either each paramedic with an EMT.)  These are my ideal attributes:

1. Strong, can lift.
2. Solid EMT.
3. Knows where they are going.
4. Pleasant disposition.

Over the years I have worked with partners who are missing some of these.  I have learned to work them.

If a partner can’t lift, I make use of first responders.

If a partner is not a good EMT, I never rely on them.

If a partner doesn’t know where they are going, I can direct them because I know the roads.

But if a partner isn’t pleasant, there is nothing I can do suffer. 

All

 

I’m on scene of an overdose. A fifty year old man in an unkempt apartment went unresponsive after sniffing two bags of heroin. His neighbor found him, giving him 4 mgs of Naloxone IN, and then called us. The man is alert and oriented by our arrival and does not wish to go to the hospital. The neighbor says he will watch the man. He still has another Naloxone in case the man goes out again. He says he gets his Naloxone from the local harm reduction agency.

The cop on scene shakes his head and says, “They’ll give out Naloxone for free, but kids have to pay $800 for an Epi-pen.”

This is an argument I hear quite often. "They’ll give a drug addict free Naloxone, but my wife, who is a school teacher, has to pay $1000 for her Epi-pen.”

What is the implication behind the officer’s remark. Is this man’s life less worth saving then a kindergartner who mistakenly eats a cookie with nuts in it?

Last year over 70,000 Americans died of accidental overdoses. Only about 150 people die a year from fatal food anaphylaxis.  3,000 die from any type of anaphylaxis.* Each of these deaths were preventable. Were the 70,000 who died of overdose all scumbags who willfully chose to become addicts? Were those  Americans who died of anaphylaxis all a higher class of citizen?

"Well, the junkies made a choice to use illegal drugs," an EMT says.

In EMS we talk all the time about the lack of respect we get as a profession. What makes us professional?

Is it the 120 hours of the EMT class we took? Or even the 2,000 hours paramedics get?

Is it how spick and span our uniforms are? How shiny our badges?

Or is it the way we treat our patients? The compassion in our hearts that recognizes the humanity of all our people no matter their circumstance?

Recently a local fire department in its annual CPR lifesaver awards ceremony, chose not to honor its members who had saved overdose victims from cardiac arrest, alongside those who had achieved ROSC in victims of heart attack or other “medical” cause.

There is too much hatred in the world. There is no place for it in EMS.

We should never pit patients against each other.

We should embrace programs like community Naloxone in the same way we should embrace efforts to hold pharmaceutical companies responsible for price-gouging families for the costs of Epi-pens.

We should teach people how to properly use Naloxone with the same fervor that we should teach people how to properly use epinephrine.

***

*In many cases people die of anaphylaxis not from absence of epinephrine, but from failure of medical professionals and/or families to administer it.

When Should I Use Epinephrine? Why Am I Afraid of it?

The Proper Use of Epinephrine for Anaphylaxis

EMT Administration of IM Epinephrine via Syringe

 

Connecticut, following the leads of states such as New York, has just expanded the scope of practice for EMTs to include injecting medications. This means instead of carrying two $600 Epi-pens, EMTs can now draw up 0.3 mg of epi from a $5 vial and administer it to a patient suffering a severe allergic or anaphylactic reaction.  Services who wish to provide this alternative need authorization from their sponsor hospital, but all EMTs in the state will be taught the skill as part of their regular training.

Here’s a link to Connecticut's training program:

EMT Administration of IM Epinephrine via Syringe

Background

Unfortunately, the rising cost of the injectors and their short expiration periods create a significant financial burden on the EMS agencies. King County Washington EMS system, which uses the “Check and Inject” program, estimates they have saved $335,000 annually by switching to a syringe method. According to a recent survey, 13 states have training programs to allow BLS to inject epinephrine and 7 others are considering it. 

Basic Life Support Access to Injectable Epinephrine across the United States

Evidence/Value of Safety of BLS Syringe Injection

“EMTs successfully implemented the manual “Check and Inject” program for severe allergic reactions and anaphylaxis in a manner that typically agreed with physician review and without any overt identified safety issues..”

- “SYRINGE ADMINISTRATION OF EPINEPHRINE BY EMERGENCY MEDICAL
TECHNICIANS FOR ANAPHYLAXIS.” Prehospital Emergency Care; January 15, 2018, Published Online (1-7)

Syringe Administration of Epinephrine by Emergency Medical Technicians for Anaphylaxis

“Based on the results of a State Emergency Medical Advisory Committee (SEMAC) demonstration project, the New York State Emergency Medical Service Advisory Council (SEMSCO) approved Syringe Epinephrine for Emergency Medical Technicians (Check & Inject NY) at the September 14, 2016 meeting. The project established that EMTs, with the appropriate training may administer the proper dose of epinephrine for a patient experiencing a severe anaphylactic reaction using a specific 1cc syringe. Additionally, the project realized a significant cost saving over maintaining epinephrine auto-injectors.”

- Bureau of Emergency Medical Services and Trauma Systems POLICY STATEMENT 17-06, May 24, 2017

I am all for this program.  Some have argued that this is a skill that should be reserved for paramedics, but to me, it is a skill easily taught.  EMTs can administer this drug safely in life-threatening situations and the cost savings can be used to improve other aspects of the EMS system.

How We Feel Versus What Dispatch Hears

 It has been busy at work lately and the crews have been getting pounded.  An EMT posted this video (found on the internet) on our employee Facebook page.  I laugh every time I think of it.  If you have never worked commercial EMS in a high volume system, you might not appreciate it.  I can only say, over thirty years, I have witnessed similar scenes hundreds of times with scores of partners.

https://www.facebook.com/savageparamedics/videos/406029299966649/

Here's a link to an interesting article about working conditions in commercial EMS:

Can EMTs, paramedics catch a break?

Connecticut Overdose Deaths 2018

 The official death numbers for 2018 are out from the Connecticut Medical Examiner's office.

Connecticut Accidental Drug Intoxication Deaths

1017 people died in Connecticut of accidental overdoses, down 21 from 2017.  This is the first decline (albeit minor) after six years of escalation.

746 people died in Connecticut due to the presence of Fentanyl, up 71 from 2017.

Still  much work to go before we can rest.

***

Here's a town by town breakdowns of deaths by residence and deaths by overdose location.  95 of the fatal overdoses occurred in Hartford.

CT Drug Overdose Deaths Town-By-Town In 2018