dr-exmedic.com

Today I leave for EMS on the Hill Day, which is tomorrow.  I will try to post some updates if anything interesting happens (and a summary blog post if nothing does).  If you’re feeling motivated enough to write your Senator or member of Congress a letter about an EMS issue, today would be the day, and fax it to them–that way, they’ll have plenty of supporting constituent letters when we show up at their offices.

The unfortunate thing about global commerce is that company names that aren’t problematic in, say, German, can become offensive or silly in other languages.  Would you buy from Assmann Electronics?

Over my EMS career, I’ve only had extensive experience with 2 tripsheet programs.  One was programmed poorly and quite buggy; the other was clearly designed for flight nurses, not ground paramedics.  However, both of them would at least produce a report that would give useful data to someone reading it.

In PA, electronic documentation is the law, and few places in this side of the state use handheld computing to any degree, so it’s rare to get a tripsheet on a patient while they’re still in the ED.  Nevertheless, I’ve occasionally referred to EMS documentation on my floor rotations, so tripsheets aren’t entirely worthless–unless they look like this:

Looking down, some of it looks fairly intuitive–when area A is assessed as “Patent” and B gets “Normal Respirations,” this starts to look like the standard ABCs–until you get to C, which get the remark “Neuro Intact.”  And what, pray tell, is area U?  Granted, it’s pretty easy to figure out that this is a basically benign exam (although I seem to remember a bruise or abrasion on this gentleman’s face; it’s tough to tell without my admission H&P in front of me as I admitted him at the beginning of April), but if there were an abnormality, would it be obvious where it was to the casual reader?

I understand that at trial, or back at the station, there’s a key that you can pull out to put these things together.  But to those of us without the magic decoder ring, it’s a total mystery.   How this program meets Pennsylvania standards, I’ll never know.

(Incidentally, I hit the offending agency’s website to let them know that their current program is horrible, but they don’t list an email address or have a comment submission form on their website.)

Just a note:  for those of you who didn’t already know this (and I know there are at least 2 of you), if a patient tells you he had TB ten years ago and has had clear chest X-rays every 6 months since, he doesn’t have TB.  Since he doesn’t have TB, you don’t need to wear your N-95 masks, and you most certainly don’t need to call ahead to the hospital and ask for an isolation room, which will invariably have someone in it when you ask, setting off a flurry of activity as we try to move the patient who doesn’t need a negative pressure room to make way for…a different patient who doesn’t need a negative pressure room.

So for future reference, if you ask about medical problems and someone says they have/had TB, make sure you clarify whether they have TB right now or not.

I don’t know how much things have improved in more than a decade, but my paramedic text (circa 1997) has exactly 2 references to sepsis or septic shock in its index.  One is a single sentence (not totally correct, though not totally incorrect either, emphasis in original):  ”Septic shock, for example, is caused by the release of an endotoxin from several Gram-negative bacteria.”  The other reference leads to a full page of information, half of it bullet points…in the “Pediatric Medical Emergencies” section.  There is not a single direct reference to adult sepsis in the entire book.  In addition, I’ve not seen any paramedic agencies with sepsis protocols, although they undoubtedly exist.

Recent research might someday change this.  A recent small study looked at just 52 ambulance-delivered patients with severe sepsis; just under half got fluids.  (In case you’re wondering how it took 2 years to get just 52 study patients, the study only looked at patients with severe sepsis–963–then cut out those not brought in by ambulance–down to 216–and further cut out those who didn’t receive “early goal-directed therapy” (EGDT).  Of those final 76, 4 had no EMS tripsheets (!), and 20 were brought in by BLS ambulance, and couldn’t properly be studied for comparison.)

Important bit of information for background purposes:  EGDT is a bundle of treatments intended to be performed early in the patient’s hospital course, with specific treatment goals in mind including blood pressure, central venous pressure, and central venous O2 saturation.

While the numbers were too small to achieve statistical significance, patients receiving prehospital fluid tended to be more likely to achieve these goals within 6 hours of arrival; the data were strongest for the BP goal.  This is despite the fluid group having an average initial SBP 20 points lower, both on-scene and on arrival at the ED.  (Appropriately, then, the apparently sicker fluid group had a higher mortality–but again, not a statisically significant number.)

So is it appropriate for an EMS agency to develop sepsis protocols?  Certainly.  Is it going to help anybody?  Well, this isn’t proof, but a very suggestive hint that it just might.

Bonus links:  the Surviving Sepsis campaign.  A model state protocol I intend to submit to PA.

For those of you bored at work and stationed on a street corner somewhere, with only a Crackberry or other mobile phone to access this series of tubes, I’ve thrown up a plugin to make my blog a mobile-friendly site.  It should automatically detect that you’re using a phone rather than a desktop.

The definitive guide to being a prehospital medical director is probably the 4-part series put out by the NAEMSP, although ACEP’s guide is probably a close second (plus cheaper and more portable to boot).  However, if you really felt that the government needed to duplicate what’s already been done, how would you arrange it?  Would you put it under EMS’ traditional federal home, the NHTSA?  Perhaps coordinate with NAEMSP to be the lead organization?

No, of course not.  Instead, you’d put it under the Department of Homeland Security, because that’s where the US Fire Administration ended up.  Instead of getting a physician group to take charge of a document meant for physicians, you’d toss this responsibility to the International (!) Association of Fire Chiefs.

Disclaimer:  Despite these misgivings, I’ve agreed to be on the committee that puts this document together…as the NAEMT’s representative.  I hope they have NAEMSP and ACEP reps on the committee–I wouldn’t expect much buy-in from physician groups without it.

This year’s EMS Week theme is “Anytime. Anywhere. We’ll be there.”  Just in case you were interested and hadn’t noticed.

There is a whole string of riddles that ask “How do you hide a hundred-dollar bill from” a particular type of physician.  There’s pretty much the whole array of them here, but what I can’t seem to find right now is a discussion on some board somewhere about the proper answer regarding an ED doc.  The best answer of the group, I thought, was:  ”Stuff it in a tie.”  However, I think I’ve come up with something better (although of course someone has probably beaten me to it).

Q:  How do you hide a $100 bill from an ED doc?  A:  Anywhere out of plain sight–it’s not like they have the attention span to look for it.

It drives me nuts to see the wrong conclusions taken from fairly simple data.  The latest example is in the popular press, which seems to universally believe that talking on the cell phone while driving is a huge evil.  (I’m not convinced it’s safe, but thus far, I remain unconvinced that it’s any worse than talking to the person next to you, eating, shaving, applying makeup, reading paperbacks, or any of the other distracting things I see other drivers doing, or have done myself.)  Note the lede to this story:

A very small percentage of the population can safely drive while talking on their cell phones, but chances are high that you’re not one of these “supertaskers.”

So what data brings the reporter to the conclusion that so few people can “safely drive” while doing complicated math problems?  Well, during simulated drives during a cell phone conversation

It took [drivers] 20 percent longer to hit the brakes when needed, and following distances increased 30 percent

So if you’re on the phone and allow more following distance because you know your reaction time is worse, that’s somehow “unsafe”?  To me, that’s a brilliant example of how people can adapt to what they’re doing, not a cause for alarm.

Keep in mind too that they were asking people do do math over the phone, not chat about the weather and what to pick up at the store–but that’s the fault of the study asking a non-real-world question, not the fault of the reporter.