Two weeks ago I wrote about whether arming EMS responders was a good idea.  In the three weeks or so since the original news story was reported, I’ve gotten a lot of feedback in comments, emails and on Twitter and Facebook.  Many other bloggers have also written about this topic (see links below).  One comment in particular, however, stuck out in my mind.  Dustin Cox wrote:

I agree. I think that carrying a gun while on duty could be even more dangerous not only to you but everyone around you. Besides, WE are one of the top trust professions and I feel that if we carried while on duty we would not be trusted anymore because we would look like police whom is not among the most trusted professions. I am an NRA member and support all gun rights including concealed carry (yes I am a carrier), but I believe there is also a time and a place to carry and while I am on duty is not a time.

Dustin brings up a great point:  people trust us.  One of the reasons we are able to treat our patients as effectively as we are is that they are willing to answer our questions about behaviors they wouldn’t likely share with their mothers.  I’ve worked in systems where I’ve worn a badge and I’ve worked in systems where our uniforms closely mimic those of law enforcement.  That comparison frequently put me at a disadvantage that I had to battle back from to earn the trust of a patient.  This period can potentially delay care given certain circumstances.

At the end of the day I, like Dustin, fully support the Second Amendment including the right to concealed carry.  I agree, however, that EMS carrying on duty potentially puts the trust the public places in us at risk.  What do you think?

To read more about this topic among the EMS blogs, check out the links below:

 Should ambulance crews be allowed to carry weapons? – Kelly Grayson

Will Virginia EMT’s Be Granted Right To Carry Firearms? – A Day in the Life of an Ambulance Driver

Concealed Carry for EMS: 2 Questions – Everyday EMS Tips

EMS Providers Carrying Guns – A terrible idea – Life Under the Lights

Surviving the Next Shift – Part I – Rogue Medic

Armed EMS – Reactive or Proactive? – Unwired Medic

The topic of EMS and fire personnel carrying firearms on duty has been covered heavily in both the news and blogosphere lately.  I should preface this post by stating that I absolutely have a bias.  I am a gun owner and I support the rights of individual citizens to keep and bear arms.  I also support the idea of issuing concealed weapons permits to responsible citizens who demonstrate proficiency.  I additionally support the right of business owners to post that they do not wish for concealed weapons to be carried on their property.

With that out of the way, I’m very reluctant to think that “arming EMT’s” is a good idea.  Kelly makes some compelling arguments in the blog post linked above.  I’m not reluctant to support this concept for really any of the reasons he quoted in his article, however.

Do I think that EMS workers will engage in vigilante justice?

No, I don’t.

Do I think that EMS workers will resort to using their firearm rather than trying to talk a patient down or use sedatives?

No, I don’t.

Do I think that a hapless EMS worker will have their firearm taken from them and wind up looking down the barrel of their own weapon?

Likely not, but it’s certainly happened to police officers, so there is a risk, albeit a small one.

So what’s the problem then?

My concern about this emerging trend is that armed EMS workers are not consistent with where our focus should be.  The news article linked above contains a quote that the Fire Chief of German Township, Ohio has had a weapon pulled on him twice in his career.  While not exclusively, most of those type of situations result from a lack of awareness on the part of the responders.  I’ve worked in some of the worst areas in California and haven’t ever had a gun pulled on me.  Without pulling up statistics I’m going to hazard a guess that there is more violent crime in Oakland, CA than German Township, OH.

Most of the firearms training I’ve been a part of has stated something along the lines of “a weapon isn’t any good to you locked up”.  This is certainly true.  A firearm will not accomplish its purpose unloaded and locked away.  Since EMS and fire responders in this case would not be sworn officers, if a call occurred inside a business that had a sign displayed explicitly prohibiting concealed carry or somewhere like a post office, then it doesn’t do those responders much good.  Additionally, after having walked up to the door and realized that they can’t carry inside, they will have to return to their vehicle, secure their firearm and proceed back inside.  If this is a cardiac arrest, sepsis or STEMI patient, this undue delay can have potentially detrimental effects on patient outcome.

Finally, firearms training repeats the tenet: “Be aware of your target and what is around it”.  Responders who should be focused on their patient will not be fully cognizent of their surroundings.  This creates an inherent risk of an accidental or improper discharge.  It is also the reason that many police officers I know elect not to carry off duty when with their children.  If the scene is that borderline, you should/should have called for police support.  I have never once in my career been given grief for falling back or staging because a scene got sketchy.

At the end of the day, I fully support the rights of individuals to conceal carry.  I think that allowing responders to do so, when we have a resource like the police department available, splits the focus away from our patients and has the potential to delay care.  Carry off duty, not on.

Agree? Disagree? Fire away in the comments!

One of the measurements that many EMS systems use to determine if they are “doing it right” is their survival rate for cardiac arrest patients.  These numbers are broken down in many different ways but the accepted “standard” seems to be witnessed arrest with a shockable rhythm (ventricular fibrillation or ventricular tachycardia).  In other words, the patients with the best possible chance at survival.

One of my current tasks in my system is entering all of our data into the CARES registry so that our patients can be matched with their hospital outcome and our system performance can be tracked for cardiac arrests.  Typical of most quality improvement projects, part of this one involves figuring out how to do what we do better.

Over at MedicSBK, there’s a post entitled “Doing it Better” that looks at precisely this idea.  In this post, Scott contrasts his system with that of Wake County in North Carolina.  I have been lucky enough to hear Brett Myers speak about cardiac arrest care and the approach that his system takes is revolutionary and it works.  By performing CPR only on scene and packaging a patient for transport only after sustained return of circulation, they are locking their crews into focusing on high quality chest compressions.  This, along with defibrillation, is the only treatment that has been PROVEN to help cardiac arrest victims.  I say good for them!

I recently began analyzing the quality of compressions that our crews perform in conjunction with our first response agencies.  A quick Twitter poll leads me to believe that many EMS systems are not performing detailed analysis of this important component of care.  Our findings have mirrored Dr. Myers views on when and where to treat these patients: despite the best efforts of everyone involved, CPR quality suffers during transport and lengthy pauses in CPR are not uncommon.  The conclusion? We should not be transporting under CPR!  Treat these patient where they drop.

I’m lucky in that my crews have the latitude to remain on scene during resuscitation.  We transport very few of our cardiac arrest patients and usually only after regaining pulses.  Thanks to Scott for bringing this up about his system.  I hope that we can all move towards treatment algorithms that closely mimic Wake County and that allow us to provide optimal care in the optimal setting.

What about your system?  Do you routinely transport during CPR?  Do you wait for a certain length of ROSC before transporting? Let me know in the comments.

Unfortunately no, but this story had me going.  Turns out that EMS agencies in Portland, Oregon are going to be studying “whether cardiac arrest drugs help or hinder”.  That headline gave me hope that we were finally studying if all the ACLS drugs benefited or harmed patients when looking at neurological outcomes.  Turns out we’re not.  We’re studying whether Amiodarone, Lidocaine, or a placebo results in better outcomes.  Now don’t get me wrong, this is a step in the right direction.  Now that being said, the article references the fact that research has already shown Amiodarone to be no more effective than a placebo.  But, if memory serves, that study looked at ROSC, not neurologically intact outcome.  That being the case, this study IS moving in the right direction.

My question remains, however, why can’t we do the same study with epinephrine?  On the face of it, this study protocol appears to be one which could be easily transferred to epinephrine.  Using syringes marked only with a barcode so that researcher can later link a certain medication or a placebo to a given patient.  When I started reading the article comments, however, I realized why we can’t study epinephrine.  We haven’t bothered to teach the public.  Heck, we haven’t even bothered to teach the medical community.  Many of the comments, including some from those who identified as medical professionals, launched into tirades about lawsuits resulting from withholding “standard care”.  The fact is, as long as people (both those in the public and the medical community) assume that our “standard” treatments are based on facts, our hands will be tied.  This dedication to tradition for tradition’s sake may be killing our patients.

We are forced to follow outdated modes of treatment because we haven’t taken the time to educate our own communities about what those treatments are based on.  While there will always be a subset of the population unwilling to participate is these types of programs, aggressive public (and medical) education campaigns may help to mitigate some of those issues.  Researchers are offering the public free “No Study” bracelets if they want to opt out. It will be interesting to see, when all things are said and done, how many took them up on that offer and if they have trouble getting an acceptable sample size.

What do you think?  What would be the most effective design for a study looking at the benefit or harm of ACLS drugs?  Should patients or family have to consent for this type of study?  How can we effectively educate the public about why and how we treat them?  Do you work for one of the agencies in this study?  Let me know in the comments.

In a slightly lengthy, but really well done video, Dr Stephen Smith presents a guide for determining a STEMI in patients with a left bundle branch block. Thanks to the Society for Academic Emergency Medicine for making this resource available to the public!

ECG Diagnosis of Acute STEMI-Equivalent in the Presence of Left Bundle Branch Block from Academic Emergency Medicine on Vimeo.

Aren’t you glad you spent 20 minutes watching that? Now go find a STEMI!

In the kitchen that is. Over at JEMS, Guy Haskell has an article about a patient with suicidal ideation who evidently requires no less than 10 fire, police and EMS employees to treat her. The article brings up an interesting question: How many providers do you REALLY need on scene?

Having gone from a system that had up to 6 medics on every medical call (and more on traumas) to a system that only has two from the ambulance (and many calls get no first responders), I’m not sure that there is an easy answer. Predictably, the comments section of article devolves into an argument for or against ALS fire/ALS first response/public vs. private EMS/whatever else we want to argue about. That’s unfortunate because I think Haskell raises a legitimate concern. Driving emergency vehicles is dangerous. Driving them with lights and sirens is more dangerous. And not just to us but to the public as a whole. Putting everyone at risk under the guise of “first doing no harm” is ridiculous. We owe it to ourselves and our public to find a better way.

Medical priority dispatching does go a long way towards reducing the number of vehicles running code around the city, but I don’t think it goes far enough. Why not have units (first response or transport, I don’t think it matters) treat and release more patients? Why not only call a transport unit if the patient actually NEEDS transport? What about alternate destinations by alternate means? Say, for instance, your patient has suicidal ideations but has not made an attempt and is cooperative? Couldn’t you use a single responder to take that patient directly to the psychiatric facility? The vehicle would, of course, have to have a screen and door handles removed and what not, but I don’t see a reason why that couldn’t work. Suddenly, Haskell’s patient has one, maybe two, personnel on scene rather than 10. Cost savings and improved safety, all in one package.

Obviously this is the ideal. Some areas are moving towards such a model, but there is a long way to go. What about you? What do your ideal system look like? Totally ignore tradition for a moment and forget the way things have always been done. Design the perfect medical response and share it with the rest of us.

There’s an interesting video that has been making the rounds on the Internet that provides a first hand account of what it’s like to suffer from carbon monoxide poisoning. The backstory is that the driver (patient) is a recreational racer who is driving a mid-engine vehicle. His car has a carbon monoxide leak which is filling up the passenger compartment with the products of combustion (CO and soot among others). He has conveniently been videotaping his race. Over time, you can start to see his level of confusion increase and his coordination become delayed. He starts to exhibit rambling speech. Additionally, you can see the buildup of soot on the glass of his roof. Important to note is that for a large portion of time after he claims not to remember, he still appears conscious. Check out the video for yourself:

If you read through the comments on YouTube (something I try not to do often) you’ll see that there is a lot of criticism reserved for the response crew. While that may be a valid conversation to have I think it’s more important to focus on the driver’s presentation. Most recreational racing leagues use volunteers (some with little or no training) to work as safety staff. Many of these leagues also discourage doing damage to drivers’ vehicles (like breaking out a window). Cut them a little slack.

Have you ever run a CO poisoning call? How did the patient present? What was their outcome?

EMS seems to have a “technological imperative” when it comes to our allotted “monkey skills”.  The day they put a new toy on your rig is the day you suddenly find a need for it.  Venous access is no exception.  Now granted, starting IVs is not a new addition to the EMS scope of practice, we’ve been doing that for years.  And the ability to start them isn’t the only driving factor.  Crews that I’ve spoken to often reference the appreciation of the hospital staff for starting an IV.  Other crews reference complaints by the hospital staff that an IV wasn’t started.  Call it a healthy mix of availability and peer pressure.

In a 2011 article published in the Journal of Vascular Access (did you know there was one of those?) authors review a cohort of patients transported to a single emergency room and evaluate whether IVs were actually used after they were placed.  Here’s the abstract:

J Vasc Access. 2011 Jul-Sep;12(3):193-9. doi: 10.5301/JVA.2010.5967.
Indication and usage of peripheral venous catheters inserted in adult patients during emergency care.
Göransson KE, Johansson E.
Department of Emergency Medicine, Karolinska University Hospital Solna, Stockholm, Sweden. katarina.goransson@karolinska.se
PURPOSE: The aim of this study was to identify the underlying decisions taken regarding the insertion of prehospital peripheral venous catheters in adult patients and, additionally, to ascertain peripheral venous catheter insertion rate and explore prehospital and hospital (within 24 hours of insertion) pharmaceutical treatment via peripheral venous catheters.
METHOD: This cross-sectional study gathered data through a study-specific questionnaire and patient record auditing. We distributed a study-specific questionnaire to be completed by ambulance crews, and carried out patient record auditing for 345 patients (median age 64 years, range 18-97 years) arriving at the emergency department at a Swedish level-1 trauma center in October 2008.
RESULTS: Of 135 patients (39%) arriving at the emergency department with a peripheral venous catheter, 94 (70%) had received the device because the ambulance crews intended to use it for intravenous therapeutics (of which analgesics, intravenous fluids, and psycholeptics were most frequently used). In 30 patients (22%), the prehospital inserted device was not used by the ambulance crews or at hospital within 24 hours. The corresponding rate of unused peripheral venous catheters inserted in patients after arrival at the hospital was 35%.
CONCLUSIONS: We found that the main reason for the ambulance staff to insert a peripheral venous catheter in a prehospital setting was that they intended to use the device. Further, the rate of unused peripheral venous catheters was lower among prehospital peripheral venous catheters than hospital.

The results pretty well speak for themselves.  It should be noted that this analysis only took place at one hospital.  I also know that compared to my system, 39% of patients receiving an IV is relatively low.  The important thing to remember is that an IV is an invasive procedure.  Simply starting one because you can or because “someone might use it later” may not be the best thing for your patient.  Every IV increases the risk for healthcare-acquired infections.

What about you?  Do you routinely start prophylactic IVs?  Why or why not?  Let me know in the comments.

One of the hallmarks of advanced paramedic programs and really the future of EMS in general is the ability of providers to determine if a patient NEEDS to go to the emergency department.  If the goal of such programs is to reduce the utilization of ED resources, field practitioners must be able to safely determine if alternate transport or non transport is appropriate.

Approximately a year ago, the National Association of EMS Physicians (NAEMSP) issued a position statement on this topic and determined that:
• There may be potential for EMS providers to avert unnecessary emergency department
visits by providing a medical assessment to determine whether patients can safely be
managed without emergency transport to an acute care facility.
• While evidence supports determination of necessity of transport to acute care facilities
by EMS providers in certain select situations, in general evidence is currently lacking to
establish that EMS providers can universally make determinations about necessity of
transport.
• Prior to adoption of EMS provider initiated non-transport programs, there should be
evidence in the peer-reviewed literature that demonstrates that EMS initiated nontransport for the specific situation is a safe practice.
• A prerequisite to EMS provider decision to not transport requires at minimum:
additional education for the providers, a quality improvement process, and stringent
physician oversight.
The entire document can be viewed here (PDF).

I appreciate a few aspect of this position statement.  First, the NAEMSP acknowledges that EMS plays a pivotal role in the reduction of utilization of ED resources for non-acute patients.  Second, the position paper calls for evidence-based standards and adequate training and oversight when developing such programs.  In the current state of EMS, however, there is little incentive to develop non-transport guidelines as there is no reimbursement for patients that are not transported.

In another position paper published at the same time, the NAEMSP addresses issues surrounding reimbursement:
• When callers access 9-1-1 (or a similar emergency call center) requesting emergency
medical response, third party payers—including federal and state programs, their agents,
and private insurers—should provide fair and reasonable reimbursement for those
services.
• Retrospective determination that a transport was not medically necessary should not
result in denial of payment. Payment for 9-1-1 emergency response should be based on
the prudent layperson standard.
• When EMS systems that possess adequate educational, medical direction and quality
improvement resources choose to implement EMS-initiated non-transport policies
(including, but not limited to, treat and release protocols, termination of resuscitation or
on-site care for mass gatherings), third party payers should consider the relative cost
savings associated with providing on-scene care without subsequent transport, and
provide fair and reasonable reimbursement for those services
The entire document can be viewed here (PDF).

Note, in particular, the last bullet point. A system that takes the effort to building an appropriate non-transport program should be reimbursed fairly.  Makes good sense to me.

The resource document for both of these position statements can be found here (PDF).

So what do you think?  How close are we to researching the ability of paramedics to make a determination not to transport?  Are there cases where we can do this already?  Does your system get reimbursed for non-transports?  Let me know in the comments.

Community health departments have a variety of resources for patients suffering from chronic disease.  It may be that you know about some of these resources in your own community.  If not, I recommend that you reach out to the Department of Public Health so that you or your agency can compile a list for patients.  Doing so can increase the general health of the community but can also connect patients to these resources before they suffer lasting consequences.  Often, patient who do not utilize their primary care physician are not adequately screened for diseases like hypertension or diabetes.  If these patient utilize the 911 system, EMS practitioners have an opportunity to perform these screenings.

A study out of King County in Washington published earlier this year looked at the ability of EMS to identify patients at risk for uncontrolled hypertension.  The study can be found here (PDF).

It is important to note that this was a feasibility study only.  The researchers were looking at whether it was possible to develop a program in which first responders identified at risk patients.  This study did not look at outcomes or improvement in health.  That said, the results were interesting.  Survey respondents seemed interested in the program with 82% stating that they would be comfortable having their blood pressure screened at a local fire station.  The next obvious step is to implement a program and track a population for changes.  Compliance with medication, reduced ED visits and improved overall blood pressure could be outcomes to consider.

Does your agency perform health screenings outside of calls?  Do you have a list of health and social resources you can provide on scene?  What has the response from patients been?  Let me know in the comments.