On the Cusp again?

I was part of a brand new movement in medicine. 40 years or so later, I’m trying to make sense of  what it has become. It seems I’ve been subjecting you to standards of an old paradigm that is in its death throes today. Forgive me! But there’s still enough of it left living in today’s EMS culture that it might be useful for us to explore how it effects EMS.

Every day I read a good 100+ posts on EMTlife.com (I’m a Community Leader there) and it is there I get to notice trends and patterns. One of the trends is I keep missing something! I’ve got a MAJOR blind spot, kind of like I’m thinking I’m still in Brooklyn when I’m really in…

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Back in my day, the “idea” of the paramedic program was more complex than just saving a few lives here and there. It was based on a movement by our society to extend the capabilities of modern medicine out into the streets where everyone, no matter the circumstances, would have access to sophisticated pre-hospital emergency care and transportation.

The future I envisioned then included steady advances in technique, internal organization and checks and balances, equal distribution of services to the public, required advanced education, inter-agency cooperation, career paths, adequate compensation, improving working conditions, respect from the community, and comprehensive physical and emotional support for its workers.

Our populace DESERVES the BEST when it comes down to Emergency Intervention. That was the guiding light that got all of us here, don’t you agree? But somewhere along the line something has gone wrong so that now, enough to get by is enough; on EVERYBODY’S end.  What happened?

The “profession” I thought I was getting in to was one where, as our technology and medical knowledge grew, it would be Standard Operating Procedure that those committing their working life to the cause would be able to grow with the profession and be able to make those advances available to the populace. Along with advances in their ability to serve would come acknowledgment and a cycle would begin of hands helping hands.

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So much for adolescent dreams!

That would mean making sure that even if the heavy duty tools and protocols weren’t used much, the medics that showed up to your house had them available, knew how to use them and could if they needed to. The idea was to plug as many holes in a leaky patient as quickly and efficiently as posssible because that was what the public wanted as well; they deserved the best; all of them. What have they gotten?.

What I hear now is a lot of medics questioning their own validity, in a few words, it goes something like this:

We’re learning so many of our advanced procedures don’t do all that much good for long-term recovery, so, really, how much do you need ALS? Why bother having two paramedics on board when the evidence shows that for most of our patients, Load and Go will suffice? Hell, most of our calls are about IFT, what kind of training do we REALLY need?

And for me, a continuing disturbing trend is the one where more and more often medics are claiming that if they found themselves off-duty and in the middle of a medical or traumatic emergency they would refrain from assisting or even identifying themselves as medics for fear of litigation, or the risk of getting harmed in real or fantastically imagined ways.

It almost seems like we’re seeking reasons to minimize our impact on our populace. Why? So we don’t have to invest in our communities? So we don’t have to really educate ourselves? So we really don’t have to take the time to mold this into a real profession? What’s up with that? Why are so many of US beginning to say things like:

Really, if you do a cost-benefit analysis, the paramedic program doesn’t pay! Let’s get by with the minimum service we can get away with.

So, in a thread I started, I asked “What happened and what can YOU do to change this?”

One of the responses was from a soon-to-be physician with a background in EMS, Veneficus. I think his response is worth reprinting here in its entirety with some of my comments. I’d like you to seriously consider some of his points because he enlightened me on what IS rather than what I’d hoped would be. He begins:

Having been involved during the time of the transition, I think that while we still try to save as many as possible, at least I do, using the most sophisticated knowledge and technology available, many things have changed.

Most importantly, we have realized there are things worse than death.

There was a time when we got a pulse back and delivered this person to the ER (not ED, as it was usually a room) if that person sat in a medically induced vegatative state until they either died of pneumonia, sepsis, or a court or family finally pulled the plug, it was a win.

Not because the person might wake up or live again, but we wanted and perhpas as humans needed to prove we could defeat death with science and our will.

We are now realizing how foolish that notion is.

Vene’s opening passage was particularly annoying to me because I so much believed in what I was doing; that every time I brought someone’s pulse and breathing back he or she was a “save!” Even though I suspected I was contributing to filling my community with “Cardiac Cripples” I had no idea how dangerous were the drugs that the best of medicine at the time gave me to use.

Considering that there is NOTHING in the philosophy of EMS that has really changed; namely that we’re still going out after death with a vengeance and using aggressive treatments in the streets to combat it, I still insist 20 years from today you, too, will be lamenting over the total uselessness of what you did back then!  Vene goes on:

Society has changed.

Many of us old folks grew up in a society of helping your neighbor and your neighbor would help you. For no other reason than you were neighbors. A community pooling together to survive and prosper.

Now the US is an “every man for himself” society. Even the very possibility of the common good is considered distasteful and an antithesis to the very values of the US.

It is one thing to risk your life and health for somebody who might watch out for you or your kid. Let you borrow a cup of sugar, or help you in a nonmedical way if you needed.

It is quite something else to take such a risk for a person who would shoot or stab you for “not doing enough” or at least threaten to sue you for all you had. If they outright didn’t just to make the whole event profitable for themsleves or their lawyer.

Everybody’s a stranger is what he’s saying. I have to laugh at my own idiocy! Let’s look at what the U.S. population has done since I’ve been born (1951):

Damn near doubled, hasn’t it? I concede to you all I grew up in an incredibly different world than you’re in. Your life is filled with twice as many people in your space. The way we have been taught to deal is to draw more closely into ourselves. I got it.

I have to remind myself though to be gentle on ME! I continue to live in an insulated, sparsely populated environment (150,000) on an island in the most isolated part of the Earth! I confess; I still live in a bubble and am out of touch!

But still, turning your back on someone who falls down right alongside of you and may be in serious danger? Vene makes a great observation:

Biology has changed.

Over time, new viruses and bacteria have evolved. Being up to your elbows in blood (literally, even surgeons were not using gloves) or putting your lips on a stranger for mouth to mouth meant you were no more likely to get something that you didn’t already have.

But things are different, now you can get diseases that you cannot see or feel but will not only kill you, but degrade your very life to torture doing it.

I honestly hadn’t taken that into consideration. There truly appear to be a lot more “Nasties” around today than there were in my time and that would have to include the people we serve. Vene goes on to say:

At one point, the idea of these responding providers, was a community investment. They collectively paid a little for a service they may need. They valued that piece of mind, insurance, if you will.

The idea of everyone benefitinng was something they were willing to sacrifice for.

Now if you are sick, it is your problem, why should I have to sacrifice to help you? With no promises of a positive outcome?

An interesting point. Our populace is more concerned with their personal well-being than they are concerned that EVERYONE has fair access to services. Coming together to raise everybody is no longer in our ethics. That’s a pretty chilling observation but it might very well be true.  Vene hits another target:

Our understanding of disease has changed.

(some are slower than others to catch on)

We thought people suddenly and unpredicatably suffered from things like heart attacks.

We know now most diseases are neither sudden nor unpredictable.

With the management of chronic disease, including things we used to simply attribute to “getting old” sometimes by the time EMS is called to intervene, the person is well beyond the help of modern medicine.

This reflects my contention that while my job was attacking acute diseases — and not having a whole lot of success with it — yours seems to be management of chronic states until you can get them to the hospitals.  But the same thing that happened to me is happening to you. According to Vene:

We spent money we didn’t have, on things that didn’t help.

We mandated care, even if people could not pay, without setting up a way to make this sustainable.

It not only caused some people/groups to take impossible losses, but it drove up the costs for everyone else.

…and if you start to follow the money, you better get real about the driving forces that power medicine in the U.S. today as well…

We also try to make substantial profits off of other people getting sick. It literally benefits somebody if somebody else is not well.

What a sad truth this is, but is not profit intertwined in every facet of medicine today? How that little word has the power to distort our very intent, and Vene’s conclusion is not all that encouraging.

Finally, we lost sight of what medicine is supposed to be.

A helping hand when things go wrong.

Now we destroy ourselves with our diets and activities and think medicine is simply resetting to the beginning as opposed to help in living with whatever we did.

Like belief in the divine, we now believe in the miracle of medicine. At the very least we want to.

It appears that modern medicine is still in its infancy, it is showing us its limitations and asking us to re-work the way we’re using it. Can you see how EMS can play a part in that re-definition?

 

EBM, Psychotropics, Suicide and You!

By the time you get to the end of this blog, I’m banking that you’ll WANT to follow the link to the video I posted here. But, please, let me prepare you before you jump in. I’m challenging you to THINK!

For those of you who don’t know me, I grew up in Brooklyn in the 1950′s when hospitals were much fewer and far between and doctors made housecalls. There were always extended-family members you could count on to get you through most common illnesses. It was also an age that when it was time to go, you just keeled over and died. None of this lingering shit! When your number was up, something acute would crop up and within days your dead body would be laid out in your own bed in your own bedroom and everyone would file in to pay respects, leaving food for the family on the dining room table on the way out the door.

(Yup, I’m old…I’m the little kid behind the guy who’s thinking, “Oh, Shit, wrong Alternative!”)

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Going to a psychiatrist was something only the very rich did and they didn’t talk about it. Discussion about, and treatment of, mental illness was largely confined to cases of mental retardation, extreme cases of what we call today “developmental disabilities”, or those who exhibited extreme signs of bizarre, antisocial, self- or other-destructive behavior. They were all taken out of society and placed in controlled communities (gated!) together. The rich retreated to their estates.

Everybody else was pretty much left to themselves, living in relative security that only bizarre behavior would expose them to the sanctions of Higher Authorities who would then mandate their treatment. It was a world where everyone had their ups and downs and no alarms went off unless there was a wide variation from the norm. Once you crossed the line into “mental illness”, however, you were X-d out of your place in the mainstream and you were marginalized, if not shunned by your peers. Also, it’s important to remember that most of the “inmates” in those institutions were of the lower class and/or people of color.

There was stigma to having mental illness back then. Today, it has become a big business. Can you see it?

Behind the closed doors of those institutions, which for all intents and purposes were prisons, the inmates were part of Grand Experiments. Many of them involved electricity and/or medications.  Truthfully, we know little about what really went on inside those walls but it’s fair to say that the first “subjects” in the initial “clinical trials” of so-called “therapeutics” for “mental illnesses” were not exactly willing subjects and had zero protection through checks and balances; it was a free-for-all for the experimenters!

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Scary as it seems, it hasn’t changed all that much. As you’ll see in the video, the experimenters just adapted to changing times and their guinea pigs happen to be walking the streets now!

Where things are different today is there are no more “Mental Institutions”. There are lots of people who are suffering mental illnesses but they are “controlled” by medications which means they are kept functional through chemistry. Functional enough to live on their own, anyway, mostly supported by welfare programs. At any rate, they’re amongst us now and they’re part of another Grand Experiment. For far too many of these people, unfortunately, when they run out of meds they end up homeless. This is part and parcel of our work in EMS; tending to their real or imagined needs.

Have you noticed the enormous percentage of our population who are using drugs once reserved for only the most severely afflicted! What do you think? If drugs had not replaced the institutions, would there be that many more institutions to accommodate our mentally ill today? Their numbers are growing fast, aren’t they; why is that?

Could it be the tremendous leap in advertising we’re exposed to through the pharmaceutical industry is contributing to this explosion? Can you see that people are being instructed on symptoms to look for (of mental illness), told what medications might be useful and then instructed to “Ask your doctor!” Just turn on your T.V., listen to your radio, open a magazine or check in with a computer screen of some sort!

Continual, repeated exposure in all media is not about “ask”, it’s about creation of demand; Successful Advertising 101!

The people under treatment for mental illnesses seems to have increased exponentially in proportion to the rest of society. The mentally ill — whom now include the insomniacs, depressed and compulsive — are no longer on the margins, they are quickly becoming the mainstream! Why is that? Are there THAT many more of us who are at wit’s end? What IS mental illness, anyway; where’s the real line?

This video will at the very least, start you thinking about the subject and your patients in a new way. It does a pretty good overview of how they get the medicines they ask for. BTW, I have no vested interest in the video or the group who made or sponsors it. All I’m asking you to do is to examine the systems that influence your ability to serve; be aware and then respond accordingly. This isn’t even a call to action as much as Continuing Education without credits!

The treatments of choice  for as many mental illnesses as we can define are called psychotropics and I don’t have to tell you the percentage of your patients who are on them. How many of your patients are taking more than one, two, or three+ different ones? Did you ever wonder why that’s going on? For you guys and gals who’ve been at this game for the last ten years or so, please, tell us all about the huge difference you’ve seen in their usage!

And how has your working life become more complicated because the psycho-active drugs your patients use tend to affect multiple aspects of their physiologies? Their “effects” are not limited to psychological ones, and their unstudied and unknown interactions with other drugs can significantly impact the efficacy of your treatments! Who is doing the monitoring here and who is warning us as soon as there is evidence that people are being harmed?

Here’s a good example to chew on. Are you aware of this conclusion drawn from this article Risk of death related to psychotropic drug use in older people during the European 2003 heatwave: a population-based case-control study. (Pub-Med)

Use of any psychotropic drug was associated with a 30% increased risk of death during the heatwave, with a significant dose-response relationship between the number of psychotropic drugs and the risk of death… CONCLUSION: Our findings suggest that a causal relationship may exist between psychotropic drug use during a heatwave and increased risk of death in older people.

Who picks these people up? Has anyone told you that you’re NOT dealing with repercussions of heat-stroke, but with the ameliorating effects of psychotropics? These are things you need to know and unless something changes radically and fast, your workload in areas like this will increase substantially. Why? Because economic forces are at work.

For illustration that something just might be askew here, and to further pique your curiosity, let’s zero in on one aspect of your job where evidence of the effects of our (prescription) drug-oriented culture are painfully obvious; suicide! The video does NOT go into detail about this, but here’s an illustration I’m sure you can relate to.

Are not these calls some of the most personally challenging ones you must deal with?

Let’s face it, there’s something special about attempted and succesful suicides because you’re likely to wonder, “What would it take for me…?” At least two of my former paramedic colleagues found out the answer to that question and acted on it.

?!?!?!

 

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Unfortunately, as you will soon learn, a decision to step across the threshhold into suicide can take a whole lot less than you think. And evidence shows it could be propelled by treatments prescribed to reduce depression and lessen the chance of suicide! This entry is so very much connected with my last blog, By the time you get to a shrink, it’s too late! it’s almost uncanny. And, quite frankly more disturbing than I even imagined!

In fact (since I’ve completely KILLED any notion of brevity here!), you’re reading this because I wanted to double-check my notion that psychiatry today is largely about handing out prescriptions. I simply wanted to learn more about the effects of the psychotropics they dispense.

Now, I have to say please, look at your patients, look at yourself and look at this video and see how easy you, too, could find yourself at rope’s end (literally!) even after getting help! But let’s start here to illustrate how you’re being told you’re trained to intercede on behalf of the deeply disturbed when what you really may be doing is trying to counteract prescription-related effects.

In the article Treatment-induced suicide. Suicidality as a potential effect of psychiatric drugspublished in: Journal of Critical Psychology, Counselling and Psychotherapy (United Kingdom), Vol. 2 (2002), No. 1 (Spring), p. 54 58, Peter Lehmann says:

In 1976 Hans-Joachim Haase of the Psychiatric institution Landeck, Germany, reported that the number of perilous depressive occurrences after a treatment with psychiatric drugs increased at least ten times when compared with before the introduction of psychiatric drugs. The increase of the suicide rate is »alarming and worrying«, said Baerbel Armbruster of the Psychiatric Department of the University of Bonn, Germany, in 1986 in the Nervenarzt – without, nevertheless, alarming the (ex-) users and survivors of psychiatry and their relatives, or even the public.

From what I could gather in internet searches, approximately 50%  of suicides in the U.S. have been under treatment by psychotropics. The question that is being asked is Which came first, the chicken or the egg? The most authoritative study I came across happened in Sweden. In Psychiatric drugs and suicide in Sweden 2007 A report based on data from the National Board of Health and Welfare, it says:

Public reports reveal psychiatric drugs linked to 64% of all suicides in Sweden

This unique report presents data about the preceding psychiatric drug treatment for all persons who committed suicide in Sweden 2007. The conclusion is that a large percentage of the persons who committed suicide had received extensive treatment with psychiatric drugs within a year of and close to the suicide. Public reports reveal psychiatric drugs linked to 64% of all suicides in Sweden.

What IS going on here? I’m sure this is JUST Sweden and it only happened back then five years ago, right? Sorry gang, it’s a TREND that is not going to abate unless a lot of us wake up! That means that everyone else under treatment that didn’t commit suicide didn’t do it because of the drugs, right? What’s missing here, could it be Evidence Based Medicine again? What say you, colleague Rogue? The video clearly explains how this works in psychiatry.

There are forces at play in these statistics that affect almost every day of your working lives and that’s why I’m bringing you to this video. If we are to grow into a true profession we must have a sober view of the forces that affect our patients. This is completely a judge for yourself thing. but at the least, let it inform you.

Let me interject something; There are no Good Guys or Bad Guys here!

This is a phenomenon brought about by countless numbers of people desiring to make a decent living doing decent things. Our capitalistic society offers them all the technology they need to explore possibilities and its systems have been designed to derive profit from the development and sale of what they come up with. There is money in relieving pain and suffering. There is also money in the illusion of relieving pain and suffering.

We’re not quite sophisticated, advanced or civilized enough to anticipate, prevent or correct the collateral damage we cause until too late. Profits are seductive. Human beings are seduction-prone and it slows down our reaction time.

The one thing that has been consistent in the development of our medicine since my days as a child in Brooklyn has been the influence of economics on what drives our dispersal of drugs and therapies to our populace. I have personally been witness to an explosion of technology and treatments in the nineteen-seventies that have mostly been debunked or gone into disuse since. We continually discover that what we have been doing is wrong!

But what I’ve observed is that a lot of this new stuff gets out in to the field through persistent marketing and then, too long after it has been found to be ineffectual or worse, word gets around that something is amiss and it’s pulled.

As long as we correct glitches when we figure out what we’re doing wrong, I’m fine with progress. But we really need to shorten the time between when we discover we’re screwing up and when our patients are relieved from our assaults! All too often, there are economic interests that hold on as long as they can, regardless of the cost to our populace. THIS AFFECTS YOU!

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So with that, I offer you a challenge to better understand the world you’re being asked to work in and some of the things that influence you every day. I came across a well-done and researched video that follows the interelationships between modern psychiatry, medicine, the pharmaceutical industry and the FDA. It helps to explain WHY so much of the work you do centers around working around, if not counteracting the “cures” that are dispensed by medical professionals!

It also reinforces why it might be a good idea to rely on other people, rather than prescriptions, to deal with the personal conflicts that you experience in EMS work.

With that said, let’s Follow the Money! Although the video begins speaking of this as a greed-driven conspiracy, stick with it and you will see that it builds its case one step at a time with things that you can see happening all around you.

It’s about 1 1/2 hours, so pop some popcorn and settle in and enjoy the ride!

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By the time you get to a Shrink, it’s too late!

At EMS Office Hours, Jim Hoffman looks at when an EMS provider should seek out psychiatric help to deal with their job experiences. He exhibits the same cultural blindness that permeates EMS and prevents us from becoming a real profession.

It’s not his fault, it’s mine! I was one of the guys that formed the culture in the 1970s by buying in to Johnny and Roy, master technicians but without an ounce of human wonder (or frailty) in their bones. [Read more...]

Evidence-Based Medicine Central!

I’ve attracted Rogue’s bile before by challenging his notions of evidence-based medicine (EBM), so I should know better! But his recent blog gets me thinking, maybe I can help! I’m sure he wants it from me.

I’m on your side this time, Rogue, square business!

Over and over again, I hear Rogue bleating in frustration something like, “We know damn well this (insert drug/therapy/procedure/material/tool, etc. here) we’re using in the field does more harm than good. Evidence-based medicine shows us, see? Here, here and HERE! (How many times do I have to show you?) We’ve known this since (insert year). But here it is (10, 20, 30…insert years) later and we’re STILL using it!”

Just so you know I’m not making this up, in the blog, Rogue, in reference to use of Lasix, puts it this way…

We have seen patients get worse. It is 1985. We are not the first to study this, but emergency medicine and EMS will not really cut back on the use of furosemide for acute CHF until after 2000 – more than a decade and a half.

So I have to ask, What the hell good is evidence-based medicine if nobody listens to the conclusions that it comes to? I honestly don’t hear conclusions getting reached that are acted upon, not in a timely manner, anyhow.  Too many of us Homo-Sapiens are using Cro-Magnon tools and nobody’s saying, “C’mon Boys, Grow up!”

What good is EBM if it takes fifteen years for standards to change so dangerous drugs will be taken off our rigs when most new drugs (many of which will be found equally if not more offensive!) can get out there in less than 7 years? When do we say STOP?

 

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Maybe what’s really wrong is nobody’s saying it for sure and setting limits and boundaries in how long any of the materials under scrutiny are continued to be either examined or used.

We’ve watched Rogue’s blogs as these obscure studies keep showing up — many of which are flawed in execution or concept, i.e. Epinephrine in cardiac arrest — and come to the conclusion that there “just might be” BENEFIT to its use! It seems that no one acts on the dominant studies showing danger. To me, it looks like, with ANY degree of doubt imposed, they wait for more EBM to come in.

At this point I have to ask, and what I hear no one answering is, How much EBM is enough and when is it time to pull the plug?

Lots of people are building data that shows drugs being currently used are ineffectual if not dangerous but nobody’s saying, “Okay, Gang, we have all the info we need. BAN IT!” Maybe taking them completely off the market is too harsh, and after all, isn’t that the bailywick of the FDA? Oh, wait, they just ban stuff when it’s really killing us!

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In practice, however, what I see being presented by Rogue are slews of case studies, over years! that pretty well show there’s enough evidence to remove certain rules, protocols, procedures, therapies or drugs from use in EMS and usage drags on for years more before all systems get on board and stop. One area in EMS for example Pittsburgh, gets the word and discontinues use while in Austin, they’re still using the questionable whatever wholesale years later!

Now, of course, this is going on in all of medicine, but why worry about THEM, let’s worry about us!

What if we gathered a panel of pharmaceutical, medical and field EMS experts and assigned them the task of reviewing material and studies that show the possibility that this or that drug (procedure, etc.) in EMS is ineffectual or harmful to patient outcomes? What if they were assigned to decide, on each drug or procedure, based on scientifically-driven studies, a “threshhold” wherein they are ready to claim, “All the evidence is in that we need to know. This will not be used in EMS from this date forward!” It can even be temporary; contingent on further testing for which they help set the parameters?

Oh, I screwed up. All I’m talking about is an Advisory Board and we’ve got them all over the country, don’t we? But they are not talking to each other. So, there’s no Central Authority and loathe as I am to say it, in this situation we REALLY need one!

Something like an EMS Practices, Procedures and Materials Review Board. But, remember, without any authority to act, it’s just a joke. We have to be willing to accept their learned judgments.

So is there something in place now that we could adapt to these serious needs, or must we create one? We need to identify and empower something already here or create one place we could go to with authority! Not only in its ability to review and advise but in its ability to ENFORCE so that no EMS agency is using the materials in question from a specified date forward.

I see this as a major flaw in our system (U.S.), especially since our technology is relentless and economics shove the marginal into the limelight until someone screams, “Fer Godssakes, that thing damn near killed us!”

 

 

An Exit-Interview for EMS personnel

On EMTlife.com, the question “Why are paramedics paid so little?” is getting looked over like a kid whose Momma is picking lice out of his hair! Since I’m one of the Community Leaders I had to be especially careful about hijacking the topic, and naturally, I have a bit of a twist on the whole thing.

I agree with what seems to be a general connecting thread running through the postings; the reason pay isn’t better is because WE are NOT furthering the profession by organizing better, raising our standards of education, and lobbying for change. We’re not putting in the work, pure and simple. But I think you need to look a bit below the surface to identify the reason for this:

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I keep going back to turnover being the biggest problem with medics not getting decent pay. Our personnel don’t stay with the field long enough to invest in themselves as professionals and into EMS as a profession.

Logically, as is being done in the thread noted and on every other EMS Forum in the Universe (Shameless plug – of which EMTlife is the most active!), much focus goes on pay and what an un-remunerative gig ambulancing is. But I believe the REASON for this has more to do with not enough people sticking around long enough to raise the standards
so they get paid what they deserve.

And why don’t people stick around long enough to make elevation of pay part of the elevation of the profession?

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Because they burnout on the pressures of the work! But I’d have to add another element to my equation here because it’s not only about matters of the head — the incredible illogic of investing every aspect of your life in service to the health and well-being of those of us in need of emergency intervention and being unacknowledged, disrespected and poorly compensated. It’s equally about:

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Heartbreak! These are the human-being-like challenges; the psychological, emotional, moral, psychic and spiritual conflicts that go unresolved and build up until, one day — compounded by the dismal career/economic path and the toll it all takes on your personal relationships, BOOM! You’re outta there!

The systems that most EMS folk are working in are responding to this steady circulation of personnel rather than creating it. At worst, they’re exploiting it.

By not looking at it squarely and putting into place systems of support for their personnel, they are, in a sense, taking advantage of the situation and in my opinion, compounding the pressures on our society by using workers until they burn out and sending many of them as walking wounded back into the streets.

Oddly enough, the damage they go back to their lives with is usually not the kind that active ambulance workers transport a lot. I’m not saying EMS creates its own customers, but what appears to be true is a lot of ex-medics have real challenges in regaining the personal and career equilibrium they lost over the years they were in the field.

The truth is, MOST people can’t handle this work, but lots want to try!

You get so many coming in who shortly down the road (within about five years) silently admit to themselves that the pressure they’re putting themselves under just ain’t worth it. When it becomes time to gather the numbers to move the profession forward, they just aren’t strong enough for a MOVEMENT to gain traction.

Unless we make this a Movement, nothing is going to move!

As you can see, I’m working on spiffing up my blogs with graphics. I’m also working on keeping them shorter which is like asking me to not speak with my hands, so it’s failing! In the searching images for “turnover” I found this:

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If someone has done this simple thing in EMS I’d sure as hell like to know about it!

What an incredibly simple concept; Ask the medics who leave WHY they’re leaving. Why depend on my guesswork? Let’s get some Evidence-based stuff going! (Do you like that one coming from me, Rogue?)

One of the problems we face is that, for the most part, our higher-ups aren’t talking to us. WE are the last ones to be asked of our personal experiences in the field and why we are leaving it in droves. Any business knows that employee-retention is good business and worth investing in to assure future viability. That is, any business that doesn’t depend on high turnover to keep financially stable.  Unfortunately, that is the EMS business model.

And that’s what we have going here. It’s a kind of “We really DON’T want to know” sort of thing. I think it’s something we need to get really clear on; all of us. To date, I don’t think we’ve really figured out that it might be a good idea to actually TALK to our medics as they go out the door. Those of us left are just guessing!

So as a start, I’d like to advocate for ONE SIMPLE THING:

An anonymous EXIT-INTERVIEW FORM, standardized and sent to every medic who leaves an EMS service. The forms would be mailed to a central address (not mine!) for tabulation. Off the top of my head, let’s start with something like this:

Please take a couple of minutes to answer a few questions. We are doing a survey of individuals who are choosing to leave Emergency Medical Services. We are seeking to identify common factors amongst personnel that can be addressed in the future to help the profession become more stable.

EMT            Paramedic           1st Responder              LEO            Fire             Other_____

Years in EMS   <1  1  2  3  4  5  6  7  8  9  10  11  12+

State:

Urban   Rural   Mixed

Medical only     Medical/Fire     Private      Municipal      Hospital     Volunteer    Other

Volume of calls   High      Medium       Low

Please rate each of the following according to its weight of importance in your choice to leave EMS. A rating of 1 would indicate a reason of no great importance while a rating of 10 would indicate a reason extremely important to you.

pay

benefits

hours

schedules

policies

travel distance

condition of physical facilities

equipment maintenance

partnering

overtime- lack of

overtime- excess

workload- high

workload- low

supervision

upper management

union/representation

absence of career ladder

absence of raises

stagnant/absent/reduced benefits

business scrutiny

politics:         company         municipal             county            state

professional scrutiny

physical safety

BELOW CATEGORIES, please rate        Work Related        Non-work related

physical injury

medical condition

medication use

substance abuse

problems at home

relationship with children

relationship with significant other

relationship with extended family

emotional health

moral conflicts

psychic issues

spiritual conflicts

anger issues

Please rate each of these statements on a 1 – 10 basis, 1 being least true for you and 10 being most true.

I am burned out           physically___  emotionally___  morally___ politically ___

other (specify)_____

There is no future in EMS

My interpersonal relationships are suffering too much as the result of my job

I’ve lost my compassion       Personally               Professionally

Patient care has become a burden

I’m tired of the business/system/political fight

Now, of the strongest responses above, please choose ten and list them below from most important (10) to least important (1) in your decision making to leave EMS.

10)

9)

8)

7)

6)

5)

4)

3)

2)

1)

We also invite you to submit up to 200 words any comments you would like to offer to either clarify your reasoning for leaving EMS or suggestions for other factors we may have missed.

Thank you for your time and we wish you the best for your future!

 

I don’t think there’s a Forum for burned-out EMS medics yet. I suppose somebody ought to start one, but by the time they get there, who the hell wants to talk about this stuff, anyhow? But that would be the perfect place to post this.

This isn’t at all the point I started with, but right now, all over the internet everyone in EMS is talking about the instability of the industry and why so many people are transients in it. Maybe it’s time for us to REALLY find out!

Who has some ideas, time and connections to help carry this further?

(P.S. We’ve been infiltrated by a Smiley; I never invited it in, the little Gremlin showed up on his own!)

 

 

 

 

 

 

 

Synchronized (to kill) cardioversion!

Christopher, a paramedic on Blogspot offers us (hopefully!) a highly unusual scenario. It’s a great illustration of what could be following protocol over focusing on the patient. In the first, you treat whatever aberration you can find (because you can!), in the other, you treat what’s really there. Here’s his start:

 

EMS was dispatched for a 62 year old male with an altered mental status. Upon their arrival they found the patient to be non-communicative, responsive to verbal stimuli, in moderate respiratory distress, with pale, diaphoretic skin, and weakly palpable radial pulses. The patient was placed on the monitor during their initial assessment:

 

The FULL BLOG is HERE and because it has such great EKGs that I won’t duplicate, I suggest reviewing
it completely before you read on. Read it as if you were the ER Doctor on duty. Take your time, I’ll wait!

 

(Walks to refrigerator, gets Dead Guy Ale.)

 

Granted, this presentation may not have been complete, but in that respect I have to make a point. All we have to go on is what is presented to us. If we’re offered a scenario for our review it would make sense to present it as thoroughly as if
it were being presented to a doctor to get orders (or a lawyer for that matter!).

 

Having said that let me share my initial impressions, based on the information offered.

 

First, I’m not clear on WHY the cardioversion? Is it because his heart is galloping and showing a slow but steady drop in BP? Is it because the heart is going SO fast (for the patient) that it is suspected that it will give out or be further compromised (based on his history)? None of that is evident in this narrative. What was the clear, clinical reason.

 

Here’s what was said:

 

Given the presence of a WCT with hemodynamic instability the patient was prepped for synchronized cardioversion. Combo-pads were placed anterio-laterally, the Sync button was pressed, and sync markers were noted with each QRS complex.

The patient was then synchronized cardioverted at 100J biphasic:

 

He said a BP could not be obtained. There was no report of changes in the patient. Could this have been a stable tachycardia? If not, please, give me some hard evidence to go on. All I read was that “WCT with hemodynamic
instability” was the rationale
for doing what turned into essentially a fatally-synchronized cardioversion.

 

I don’t get it.

 

What was happening with the patient? How could the medic (my read is that Christopher is presenting some other medic’s case) tell the patient’s circulation was getting bad enough to warrant such extreme intervention?

 

Any sort of cardioversion at any dosage of Joules on a conscious patient is an extreme measure because you’re likely going to stop the heart. It’s done “in hopes” that the heart will pick up and reorganize itself properly and resume its normal rhythm. That does not always happen in tachycardia. Even if the shock has no ill effect on the rhythm (the tachycardia stays the same), you run the risk of further compromising the patient by adding the stressor of the cardioversion.

Basically, if you commit to doing a synchronized cardioversion you have to accept you may be turning someone live into someone dead. And remember, that can be true with casual observers as well!

 

 

I really don’t see the evidence in the narrative for such drastic intervention. Even properly applied sychronized cardioversion has the high possibility of failure, and in this case, failure means V-fib and we’re not the ones who decide if it will convert itself or if another defib will restore a functional rhythm.

 

Of course, I’m coming from a place where I had to pull teeth to get orders back in the Stone Age!

 

Regardless, this case/presentation calls for the very clear documentation of a need for intervention. At the very least, this deserves a medical review, and perhaps Christopher is on that team. Hopefully, he’ll ask the same questions as me!

 

But the thing I didn’t see emphasized was that this case screams for exploratory surgery of that infernal MACHINE, a major review of that model and how it is applied and how people are trained to use it! What I SAW was sychronized cardioversion NEVER should have been tagged to Lead II. How did that happen? Who programs the machine to link itself to one Lead over another for synchronized cardioversion? (I plead ignorance.)

 

But that doesn’t matter because, as Christopher said, sync markers were noted with each QRS complex.”

 

Whoa there! If the medic could see the markers for synchronized cardioversion on the screen/printout, why on God’s Earth couldn’t he/she figure out something was wrong?

 

Give me a break, THREE markers on each complex? How much more of a yellow flag could there be?

 

I’m not all that sure that our machines have progressed so far that we can transfer all our Blind Faith to them. Do you still trust your GPS to NOT lead you on to the Railroad tracks? How about a little bit of checks, balances and discernment here!

 

These are our tools, NOT our Directors.

 

Performance-based compensation and EMS

Back at the ranch, EMTlife.com, one of my fellow Community Leaders asked our community members what they thought about performance-based  compensation for medics. His query really got me going!

It is becoming more and more popular for public school systems to base teacher compensation on performance. It used to be that if your students did well on the standardized test one received a bonus. The bonuses are long gone and NC teachers haven’t received a raise in years, but this year a teacher’s continued employment is based on his or her students’ scores on standardized tests.

How would you feel about performance based compensation in EMS? Would it help weed out the poor providers? Would providers pursue additional education to better maintain their skills?

The whole thread is HERE.

First of all, how do you compare a teacher to an ambulance medic? The way I see it, one shapes lives and the other saves lives. Perhaps that is my biggest objection to the whole idea of performance evaluation in the first place for either job description. What a true teacher or a true medic does is make a difference!

How do you evaluate that and what do you pay for it? The truth of the matter is, when it comes to shaping or saving lives  it’s the things you don’t see, the things you can’t document, that really matter and deserve recognition.

(As a slight digression, on tour the other day I had a few teachers from the same school district. One of their schools hit 100% on their standardized tests two years ago. Last year, they did the same. There was NO improvement, so none of the teachers in that school got raises. Gee, sounds like that system works!)

Reward or upward mobility for compliance with company and/or system policies and the like make perfect sense to me but in EMS it is IMPOSSIBLE to accurately and fairly assess “performance” in rendering care.

There’s no “standardized” metric that can measure it. That’s what we do; we render care and the most valuable things we do are never rewarded because for the most part, they go unseen. The things that are visible may never accurately reflect how effectively we are performing for our patients. All they reflect is how we perform for our companies or systems, and quite frankly, that is not what is most important.

Here are a few illustrations of problems inherent in determining performance criteria for the compensation of medics.

Anyone with a few years of experience under their belts knows that calls, successes and failures come in “runs”. Some weeks you do nothing but strokes, others trauma and still others, just move-ups. Sometimes you go through stretches where every patient you have has veins nobody could hit, not even with a 50 gauge needle!

That means that you’d have to have some sort of a mathematical formula to deal with the probabilities that a few calls gone bad were just the by-product of the odds. Or were they due to poor performance on the part of the medic? There are simply times when everybody dies on you. Performance, when evaluated during those times is going to look bad. Do you see any reason your future economic stability should be determined by that?

The same would hold true with successes. Sometimes, nothing you do can kill them! Do you see you or any of your co-workers as immune from the fickle finger of fate?

But to me, even more critical is all the things that would NOT be evaluated in the review of someone’s performance in the field; all of those moments where the medic invests that little bit more to ensure the comfort and welfare of his or her patients, the safety of people and co-workers on the scene, and all the bad situations successfully avoided. All those moments when the medic renders professional care that makes a difference.

Being a good ambulance medic is about sending out ripples in a pond, not about hitting the bullseye.

Remember, “performance” is something you track and the only information you have available to you is on records reviewed by someone who wasn’t there; wasn’t in the skin of the medic on duty or in the experience of the patient.

Rather than weeding out poor providors, I could see performance evaluation-based compensation as discouraging excellent providors. Those who focus on the visible — the volume, the documentation, the time schedules –  get rewarded; those who focus on affecting their patients favorably – contributing to their ability and willingness to begin healing — are ignored. There’s no one who can evaluate those kinds of contributions other than the medic or patient him/herself.

“Patient satisfaction surveys” were suggested, yet the goal could easily become a succesful survey rather than a succesful outcome, couldn’t it?

Sorry for being the cynical ass that I am but really, if performance evaluations were to become part of EMS, the education that it would produce would be more about medics schooling themselves on how to get better and better performance evaluations!

Not that I don’t have faith in you, it’s just this human nature thing! What incentive does improved compensation due to favorable performance evaluations provide? I believe it becomes the goal of improving your compensation BY winning the game of getting a good performance review.

Don’t get me wrong, I’m all for playing games, just keep my relationship with my patients’s welfare and the mysteries of life and death out of it!

 

 

 

 

“Overhaul” my Tushie!

Back in the 1960′s there was a tremendous debate afloat; the U.S. government wanted to get involved in the healthcare business. Ostensibly the plan was devised to protect Senior citizens from devastating medical costs, but it morphed in to a complete revolution in the health care industry and a sea-change in how we look at health.

The doctors at the time were especially horrified by the prospects of Medicare. Through government involvement in the payment system they were certain that they’d get screwed, essentially being shifted from professionals who set their own fees to technicians who are paid based on fees set by people who have no idea of what the work entails; beaureaucrats!

Somehow, the Docs got over the trauma. In fact, I recall a cartoon in The New Yorker magazine some time around 1970, that went something like this (couldn’t find the original):

“And to think, I opposed Medicare!”      (Photo credit)

But here, in today’s News:

America’s historic health care overhaul, derided by Republicans as intrusive,
costly “Obamacare,” narrowly survived an election-year battle at the Supreme
Court Thursday with the improbable help of conservative Chief Justice John
Roberts.

Read the whole article here.

The whole thing that really rankles me about this is all the rhetoric about this being an overhaul of the healthcare SYSTEM! Both sides have characterized it as such.  It is not. It is about how the money flows and this plan is designed to keep the money flowing into the pockets of the people who have dominated the healthcare business since Medicare started to gain traction.

Is there any doubt in your mind that healthcare (in the U.S. today) is almost completely defined by intervention and damn near totally neglects prevention? Good health provides profit for society and that appears to have become secondary to the profits of corporations. Obamacare is as much about preserving the status quo as it is about having more people become dependent on it.

The very thing that needs to be faced squarely is just how much of the money spent in the “delivery” of  healthcare truly needs to be spent and how much of what we pay is lining the pockets of the businessmen/women of medicine instead of relieving pain and suffering? If you ask me, unintentional as it may be, the business of medicine prolongs the agony of living and dying. 

Without claiming expertise, I can still attest to having been witness to trends that developed right around the time that Medicare came into effect (1965). Both professional and business forces came together to make sure that once the government got involved in the business of medicine, every ounce of leverage would be used to make sure every available penny would be squeezed from it.

Obamacare simply tweaks the source of payment a bit. It does nothing to place limits, boundaries and restraints on how medicine is delivered and what is paid for. It’s the same old medicine; the same old outrageously costly medicine that will bog down ANY system that supports it.

As I recall it, the big fearful switch into Medicare was all about “reimbursement”. The government would now develop lists of procedures and acceptable medications, attach a price to each and that would be what the doctor would get, period. For the various pharmaceutical and medical equipment manufacturers, in my opinion, it increased their need to create more and more useable products and procedures. Remember, I’m not talking effective, just useable (until proven dangerous, that is!). In a sense, the way to pull doctors out of the clutches of the government was to develop more and more weapons for them to use, producing a plethora of billable items thereby having Medicare support their upward economic mobility.

Medicine became driven by technology and the actual needs of the individual patient lessened in importance.

This strengthened the power of the Food and Drug Administration, kind of a payback to the government for putting up with the hassle; after all, isn’t government all about the distribution of power? In part because of the extravagant costs of bringing new, government-approved goods to market, this significantly moved the economic power structure and dominance of  various medically-related industries into the hands of a few, select, mega-corporations.

Oh, I suppose in the beginning most of these companies had products they believed in that were sure to make a difference, but the corporation is beholden to its shareholders and that easily affects the overall mission; often twisting it if not in theory and intent, in execution. Let’s put it this way as an example. The pharmaceutical industry gets the lion’s share of its financial compensation for creating, testing (clinical trials) and distributing new drugs, most of which (long-term) end up failing. Money gets heaped on them to “try”, without any penalties whatsoever for failing. The end result is them having access to waves of guinea pigs circulating through the system, literally and figuratively “consumers”. We used to call them “patients”!

Medicine has become complex, gimmick-ridden and overdosed with medications and procedures that maintain the function of life but do little to enhance its quality. And that is the reason no one can afford it and no one wants to pay. Somehow, the converstation has turned away from the real issue and gotten fixated on partisan politics.  As the debate will for sure continue, keep in mind that it’s not about reforming healthcare at all; it’s about making sure that the current system continues to be paid.

And as usual, no matter who wins, the lawyers come out ahead!

Titanic Questions!

If you haven’t read this Blog by SALTYMEDIC  please do so. It is terrific! There’s something very primal about it, as if you’re looking into a forest while a Native points out all this stuff that you weren’t even seeing! It’s important that people at all levels of growth and development within EMS read this. Mostly because there are too few in the industry who are able to maintain that level of love and respect for the work for as long as she has, let alone see the depth of the experience.

What a crappy thing to say, especially at the close of National EMS Week, but I’d guess that about 80% of the medics working in the streets today view EMS through different eyes, or are in it for completely different reasons than she. As evidence I present the incredibly high percentage of medics who prove to be tourists and end up just pulling in to this port for a little while!

(Source)

First of all, SALTYMEDIC makes it clear that EMS – or more specifically the idea that you could actually change lives for the better by your actions in such an immediate way — was her first love. Believe me, I completely understand the disease! I haven’t been certified (as a paramedic, anyhow!) since 1985, yet, I can honestly say that a good third of my life since has been dedicated to exploring themes to which I was introduced in the back of an ambulance. This stuff is mesmerizingly rich!

FNGs need to hear more of that balance because the culture bends toward pummeling them with “reality”, which is usually from a burnt out’s perspective. (It’s important we disabuse the new ones of any Romantic Notions right away because our lives depend on it, right?) FOGs need to read this to be reminded of the feeling that they most likely had at one time. Call it “fascination” at least, but I would hope everyone in the field at sometime experienced a heart-directed desire to get involved! Hopefully, they’ll start start asking themselves how they’ve been missing the boat lately and want to get back on.

Well, maybe not the one above in the illustration, but can you see the metaphor? I betcha most medics leave EMS because they percieve themselves on some form of a sinking ship; in their view, they will for sure drown if they stay aboard!

That doesn’t make SALTYMEDIC wierd. To me, it means something is missing for the others and that’s a shame.  I 100% agree; EMS is an incredibly enriching human experience to be a part of! 90% of this game is all about how you interpret the things you witness and the attitude you choose to hold on to. Too many medics seem to prefer their own Black Clouds as company over other human beings.

Listen to this passage. That’s right; read it out loud, because it’s pure poetry!

I see EMS as a living, breathing entity. 

It has a heart, an intelligence, and a soul.  It lives within me.

The heart of EMS is comprised of its people who together

provide an unlimited well from which compassion and comfort flow

 for human suffering.

The intelligence or brain of EMS is the vast amount of experiential knowledge

and skill that healers acquire and share

through desired and undesired lessons and experiences.

The soul of EMS is comprised of the collection of wisdom and emotional intelligence

earned by EMS professionals who witness first hand

the trials and tributes of life.

(Please, please PLEASE make sure you read her whole piece! Thanks.)

This is a beautiful vision of a profession aware of itself. This is a vision of a profession whose participants honor each other

because they intimately understand the territory that EMS is and how it can impact EVERY aspect of a practitioner’s life.

Each concept had a word or two that jumped out at me. First was “unlimited well” in reference to compassion. Next was “share” in reference to desired and undesired experiences. Third was “collection” in reference to witnessing the trials and tributes of life. In order for these things to be able to happen universally within EMS, the culture has to change. Medics have to start talking to each other about the things that SALTYMEDIC speaks of as if they mattered. Medics need to seek the Silver Linings.

Dammit, SALTYMEDIC, I honestly wish what you spoke about was what’s really happening, but we’re not quite there.

But you know what? We are a BIG STEP CLOSER, because you are!

Many thanks!

Caller ID please!

“EMS. More than a job. A Calling.” Are you sick and tired of hearing that yet? Whoever thought that slugline up doesn’t understand the culture of EMS. Or maybe in a sadistic way, he or she is spot on! Let’s look at some definitions:

Definition of CALLING from the Merriam Webster On-line Dictionary

1: a strong inner impulse toward a particular course of action especially when accompanied by conviction of divine influence (my emphasis)

2: the vocation or profession in which one customarily engages

3: the characteristic cry of a female cat in heat; also: the period of heat

Examples of CALLING

a. He had always felt a calling to help others.

b. He experienced a calling to enter the priesthood.

When it comes to EMS, Definition #3 has more of the raw image we’re used to projecting:

(picture credit)

We handle the nitty-gritty so you don’t have to! How perfect is it though? Everyone else freaks out when the cat starts screaming, they call 9-1-1, we show up and dismiss it all with “Don’t get so bent out of shape, that’s no Baby! Ain’t you ever heard a cat in heat, Lady?!”

Definition #2 has all the punch of noodles with no sauce. In the context of this years’ slugline, it has no significance because it’s a casual connection. If I told you I had a calling to work in a Toll Booth, would you buy into it? No, our “calling” is something that means we are fulfilling a much greater purpose and asked to carry a much heavier burden than everyone else.

When you speak of EMS and a calling in the same context, you’re pretty much talking Definition #1. This is something that goes a little bit beyond liking one day on and two days off for a work schedule. The reason for doing it (“especially when accompanied by conviction of divine influence”) is not so much a “want to” as a “have-to” because going AGAINST it is going against, at the very least, your most driving inner-convictions and at worst your very Creator!

GOD? In EMS? We’re Scientists and Technicians, aren’t we? We’re driven by the physical challenges, we didn’t come here to be Priests. We came to fix bodies, not raise the dead! Oh, wait a minute, we DID come to raise the dead. In fact, before we showed up pretty much the ONLY ones who raised the dead on the streets were Holyfolk!

Look at what Wikipedia has to say:

Calvinists distinguished two callings: a general calling to serve God and a particular calling to engage in some employment by which one’s usefulness is determined.

Once again the question arises, “usefullness is determined” by Whom? Maybe 15% of the medics out there will publically declare that they, indeed, experienced the proverbial bolt of lightning hurled by their concept of a Higher Power that propelled them into the (not-quite) profession, but who is anybody kidding when it comes to the rest? Those who personally acknowledge their connection usually keep it all in the closet. God forbid you’d give God or the Supernatural credit for anything when it comes to “Evidence-based medicine” our stock in trade, or so Rogue says (in the Comments).

But here, and as evidenced by the NYFD poster, we come to your door as agents of…what? Heaven, God, Fate? That Fireman may as well be the Hand of God! It ain’t just us, we have to be much bigger than that, don’t we?

Well we sure do because our reward is not here on Earth!

And that’s the part that sickens me! As TOTWTYTR aptly puts it, EMS week is an annual exercise  where our keepers whip out some tokens of appreciation. Kelly Grayson hits the nail on the head when he places as #1 on the Top 10 ways to celebrate the last EMS Week ever a beautiful commentary on our expendability.

So here we are, dearest citizenry, at your doorstep because a Higher Power called us to be there. We’re still not educated to the degree of our responsibilities, but with God on our side, who needs to be? We do not have access to appropriate receiving facilities, we only have one, the Emergency Room and that will bankrupt you. Our systems are designed based on the fact that we are expendable troops who are fighting a Holy War against an invincible enemy. There are incredibly many of us who are called in this way!

If you’re lucky, our Cookbook Protocol will work. This is part of our vow of Obedience. There just aren’t too many places in this Heaven for those who question. God sent us here to do our best with Man’s limited knowledge (Let HIM take the weight!). We’re glad that tipping us for saving your life is not an option because that would violate our vow of Poverty.  Making rent is an aspiration and our children will be burdened with debt because we cannot afford to put them through college. About one in one-hundred of us will have the option to collect retirement from our employers. In the end, we’ll be more crippled than the general population, probably end up in the SNF’s we detest, and our final prayers will be that our pain and suffering will pay off next time around.

The only thing we’re missing is a vow of Chastity. I suppose if we had to do that, too, you’d be carrying your sick, wounded and dead in wheelbarrows to the hospital all by yourselves!

If this continues to be the calling that EMS is, then my advice for the next generation is don’t answer your cellphone!

But, remember, this is just US talkin’.

 So there’s no doubt about where my heart’s at,

here’s my contribution to EMS Week

via an Interview on a Nationally Syndicated Radio Show,

(click) THIS WEEK IN AMERICA, with Ric Bratton.

Enjoy!