Robert Vroman, M.Ed., BS NREMT-P

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EMS1 Daily News

More than 2,500 dead in Nepal earthquake

Nepalese dug through the rubble for missing people as aftershocks panicked survivors

NJ technical school to start EMT program with state grant

High school students will have the option to start a career in law enforcement, firefighting and EMS thanks to a $343,902 education grant

Narcotics missing from Ohio fire stations

There is suspicion within the division that a firefighter or paramedic took the drugs, but officials said nothing has been proven

Cop crashes into building after suspected stroke

The police officer was on a routine patrol when he crashed his cruiser into a parked car, then ricocheted into a building

EMS grad starts free CPR program for low-income residents

After receiving a free EMS education, he's paying it forward with a program to teach CPR and first-aid to low-income residents, veterans and active-duty military members

Ambulance 're-mounting' becomes national business

Rather than buy a new unit, operations from across the country ship their old vehicles to East Texas Medical Center, where the box containing the rolling hospital room is installed on a new chassis

Over 1,000 dead as 7.8 quake hits Nepal

The violent quake collapsed houses, leveled centuries-old temples and triggered avalanches in the Himalayas

Wife's intuition saves husband crushed by car

She was at work and had a strong feeling she should go home and check on her husband; she found him pinned under their SUV after it slipped off the jack

Fire chief saves boy choking on gummy bear

The fire chief, who is also a school board member, was at the school for a board meeting when the boy started choking

Quick Clip: Where were you during the Oklahoma City bombing?

Chris Cebollero and Kelly Grayson recall what they were doing when they heard about the incident 20 years ago, and how it relates to terrorism today

EMS1 Topic Articles

More than 2,500 dead in Nepal earthquake

Nepalese dug through the rubble for missing people as aftershocks panicked survivors

NJ technical school to start EMT program with state grant

High school students will have the option to start a career in law enforcement, firefighting and EMS thanks to a $343,902 education grant

Narcotics missing from Ohio fire stations

There is suspicion within the division that a firefighter or paramedic took the drugs, but officials said nothing has been proven

Cop crashes into building after suspected stroke

The police officer was on a routine patrol when he crashed his cruiser into a parked car, then ricocheted into a building

EMS grad starts free CPR program for low-income residents

After receiving a free EMS education, he's paying it forward with a program to teach CPR and first-aid to low-income residents, veterans and active-duty military members

Ambulance 're-mounting' becomes national business

Rather than buy a new unit, operations from across the country ship their old vehicles to East Texas Medical Center, where the box containing the rolling hospital room is installed on a new chassis

Over 1,000 dead as 7.8 quake hits Nepal

The violent quake collapsed houses, leveled centuries-old temples and triggered avalanches in the Himalayas

Wife's intuition saves husband crushed by car

She was at work and had a strong feeling she should go home and check on her husband; she found him pinned under their SUV after it slipped off the jack

Fire chief saves boy choking on gummy bear

The fire chief, who is also a school board member, was at the school for a board meeting when the boy started choking

Quick Clip: Where were you during the Oklahoma City bombing?

Chris Cebollero and Kelly Grayson recall what they were doing when they heard about the incident 20 years ago, and how it relates to terrorism today

EMS1 Columnist Articles

Quick Clip: Where were you during the Oklahoma City bombing?

Download this quick clip on iTunes, SoundCloud or via RSS feed

Chris Cebollero and Kelly Grayson recall where they were when former U.S. soldier Timothy McVeigh packed a rented truck with explosives in a blast that killed 168 people and injured more than 500.

Grayson said he remembers being at work, and seeing the aftermath of the bombing on T.V.

"The survivor guilt hit me really hard," Grayson said. "What really struck me was, dammit, I ought to be there."

The April 19, 1995 attack was the worst homegrown terror attack on American soil. They explore how the incident relates to our perceptions of terrorism, and events that have occurred since.

"Evil does not have a particular face or ethnic origin or anything else." Grayson said. "Timothy McVeigh was as white-bred and middle America as could possible be."

911 breached duty by sending responders to wrong address

Incidents like this, the death of a woman in a house fire, are unfortunate and not at all uncommon. Beyond all of the technology, emergency response systems are still operated by humans and humans make mistakes.

I agree with the attorney for the county, emergency services are not a Constitutional right; arguing a Constitutional right violation seems to be a stretch and, at the end of the day, I don’t think that argument will hold. The more appropriate (in my humble opinion) analysis would be a negligence theory.

Breach of duty to respond

The 911 system has a duty to send resources to the correct location. It is a duty the county accepted when the 911 system was created and citizens were told to call 911 in case of emergency. When the 911 operator sent resources to the wrong address, the duty was breached; that seems pretty clear.

The real legal fight will likely be over whether sending the resources to the wrong address was both the actual and proximate cause of the death. A quick look based only on the news report would strongly suggest that. But for the 911 operator who sent the resources to the wrong place, the death would not have occurred as, how, and when it did, thus the county would be an actual cause of death, which is a legal determination for negligence. But we don’t know this for sure, do we"

Furthermore, under a proper negligence analysis, actual cause is not enough. The plaintiff will have to prove that the death was foreseeable; that there were no unforeseeable, superseding, or intervening factors that caused the death despite the delayed response. For that, there will need to be much more investigation.

Another problem the plaintiff will have to overcome is the fact that the dispatcher told everyone to leave the home and the victim didn’t.

What the flakka is this new drug?

News reports with descriptions of men running naked, performing sex acts on a tree, and fighting with police officers are sure to draw the attention of civilians and EMS providers.

Flakka seems to be the most recent cheap, potent and synthetic drug to emerge in Florida and several other states. As I read about the reports of violent encounters between flakka abusers and emergency responders I am befuddled trying to understand the appeal of the drug’s high.

Flakka is a potent stimulant

Researchers told the Palm Beach Post, a stimulant is the primary component in flakka, which is also known as gravel in other parts of the country. Although, like many street drugs, the ingredients in flakka are not predictable and a dose of flakka may also contain cocaine, methamphetamine and heroin. Flakka, cheaply available and possibly not illegal in many states, can be ingested, inhaled, snorted or injected.

Flakka signs and symptoms

  • Patients that are intoxicated on flakka have been described with these signs and symptoms:
  • Wild and bizarre behavior
  • Partially or fully naked
  • Hallucinations and psychosis
  • Violent behavior and extreme combativeness

Because of these signs and symptoms EMS providers are likely to be asked to respond with law enforcement to assist officers in restraining the patient, to treat injuries secondary to a violent struggle with police officers, or to treat injuries caused by the patient’s own violent, bizarre, and psychotic actions - like the man that impaled himself on a police department security fence.

Flakka patient response with law enforcement

Like any violent patient, EMS providers should have received training to respond as part of a coordinated effort with law enforcement to use physical restraint and then chemical restraint. Training and pre-planning can reduce the risk of injury to the emergency responders, as well as reduce the likelihood of additional injury to the patient/suspect during the restraint attempt.

Ketamine, increasingly administered to severely agitated or violent patients, may be within your scope of practice. Follow your local protocols for ketamine dosing and delivery by intramuscular injection, intranasal atomization, or intravenous injection.

One of the important roles for EMS providers when responding with law enforcement is raising the possibility that the suspect’s violent behavior is due to a medical emergency. And that a medical intervention, chemical restraint, may be the key to halting the violent behavior.

Have you encountered a patient high on flakka" What training, protocols, and tools do you have for restraining and treating violent, psychotic patients"

What are some secrets of sleep that can benefit EMS providers?

1. There is no such thing as too much sleep. If your body thinks you've had enough, it will just wake up.

2. 4 consecutive hours during the night is the minimum requirement for cognitive function. Not good or effective cognitive function, but still. Any less and you may as well be drunk because that is the level of functioning that your brain is at. I know this is true for college-aged students; I'm not positive about other age groups.

3. Sleep converts day to day experience to long term memory.

4. People who have other mental health [issues] usually have inconsistent sleep patterns. I've heard from a UC Berkeley lecture on sleep that your brain converts "negative" memories first. So if you consistently get too little sleep, you're more likely to have a bleaker outlook on life because your more "positive" memories weren't effectively converted to long term storage.

5. One sleep cycle is approximately 90 minutes. After 45 minutes, most people are in deep sleep. If you wake up in the middle of this, you're usually groggy and it takes a while for you to come out of it and wake up fully. The time it takes to come out of it usually aligns with the amount of time left in your sleep cycle.

6. Naps should either be less than 40 minutes OR the full 90. You really don't want to wake up from deep sleep.

7. Something like 40 percent of people aren't natural nappers -meaning they just can't nap. And that's okay! It just means that you need to treasure your night sleep even more and give yourself the time you need.

8. Some people say that napping makes them groggier and more tired before. Here's the science: when you're super sleep deprived, you're running on adrenaline. When you finally sleep a bit, you're rested enough to realize how tired you actually are. It's not the sleep that's making you lazy. You just have a lot of sleep debt.

9. Sleep debt: if you can, sleep without an alarm clock. If you sleep longer than six to 10 hours, you probably have a lot of sleep debt piled up. For example, say you're a person who needs nine hours to function. If you only get eight hours every day for a week, it doesn't seem like much during the day; BUT that's seven hours of sleep debt that's piled up. This is probably where sleeping in on the weekend comes in.

10. You need approximately half an hour of sleep for one hour awake. This ratio is what gives us the eight hours thing: 24 hour day, 16 hours awake, eight hours asleep.

11. If you've payed off all of your sleep debt, you should be able to go to bed and wake up the next morning without an alarm.

12. The exact time length for sleep varies from person to person, so when you're relatively well rested, and have paid off much of your debt, experiment with naps and with night sleep to see how much you actually need.

Lead by example to create an EMS learning culture

By Steven Knight, PhD

In emergency medical services we are in a constant state of learning. But does that mean we have a “learning culture"" For most organizations, the answer would seem to be “yes,” simply due to the sheer number of educational engagements. However, the greatest value of becoming an organization dedicated to continuous improvement will not be realized by the volume of educational sessions alone.

There are multiple definitions of a learning culture or learning organization, but I like a simple version that includes a set of attitudes, values, and practices that support the process of continuous learning. Of course, this learning must be put into practice through continuous inquiry that consistently challenges historical processes and methods. This ability to adapt to new knowledge ensures continuous improvement and organizational agility.

5 questions to measure your agency’s learning culture

To truly build a learning culture, the continuous process of learning must be a part of all levels of the organization. Often, EMS chiefs and CEOs obtain a level of formal education prior to filling those positions and rarely return to the learning mindset. While in some ways they are leading by example because they have an advanced degree, a diploma on the wall does little to demonstrate a dedication to continuous learning and improvement.

Ask these five questions to measure your agency’s commitment to a learning culture:

1. How often does the EMS chief or CEO introduce the new training and then leave as it begins"

Certainly, top administrators cannot afford to attend all of the training opportunities offered by a department, especially in larger agencies that may require many sessions to reach everyone. However, it is important for the chief or CEO to attend the first training and then reference the program and its value as subsequent deliveries are introduced. Ultimately, this embodies the “lead by example” component that is important as you develop a learning culture.

2. Are the learning opportunities and content contributing to organizational and individual improvement"

An organizational learning culture’s greatest value is in the cummulative or synergistic effect of continuous improvement. Through this lens, the content needs to foster organizational and individual improvement that is aligned with the organization’s mission, purpose, vision, and values. Agencies should assess the overall content of the learning opportunities and ensure that mandatory industry training requirements consume as little of the overall delivery as possible.

3. Is continuous inquiry and dialogue encouraged by members at all levels"

In a learning culture, inquiry is a vital component. Again, the greatest strength is the impact of continuously challenging the status quo through efforts to understand or to improve the system. The dialogue is valuable to the organization because the employee asking the questions gains new knowledge and the member answering the questions must have full command of the content area. Gaps in knowledge or sound reasoning are easily identified and should be addressed.

4. Do the best ideas rise to the top regardless of the rank from which they originate"

In a quality organizational learning culture, the idea is far more important than the rank or position of the individual who suggested it. Ideas should be embraced and vetted with a process for evaluation and feedback. This is difficult at times, especially in paramilitary organizations. In a learning culture, the inquiry or idea should be fully addressed in a comprehensive and transparent manner so that both the individual and the organization have an opportunity for growth. In a learning organization, our paramilitary rank structures should have little negative influence over the flow of ideas.

5. Is failure accepted as part of the continuous improvement process"

This is a challenge, especially in emergency services. In many respects, our culture promotes a “no failure” work environment. While we must maintain high-quality reliable skill sets for our EMS service delivery, we must also simultaneously support failure at the organizational level. This duality is difficult and organizations cannot allow the intolerance of failure in the field to influence the culture of inquiry and improvement. A learning organization allows new ideas to be tested and failure is one of the acceptable outcomes. Of course, pilot programs are the preferred choice for testing new ideas and processes so that the organizational mission maintains its integrity during the continuous improvement process. Finally, failures are embraced and utilized as an opportunity for growth as ideas are continuously refined and new knowledge is created and reintroduced into the organization.

Make a commitment to learning culture

One of the best ways we can lead by example is to put our money where our mouth is. When faced with budget reductions, many leaders’ first cuts are to the travel, training and educational incentive programs. Typically, these line items do not add up to significant savings, but have a significantly negative impact on the health and well being of the organization. Decreasing educational components is counterproductive to a learning culture and shows that organizational priorities do not include improvement and education.

To establish that an organization values learning and that its future success depends on continuous learning and improvement, you must lead by example and never stop seeking out more education and opportunities for yourself and your colleagues.

It is not atypical for a leader to have spent years “acquiring” all of the degrees and certifications necessary to obtain the leadership position. However, this “trophy case” does little to establish an organizational learning culture because these educational milestones no longer contribute to growth. Obviously, I am a proponent for higher education, but the value is the continuous application of knowledge in a process of personal, professional, and organizational growth.

This is critical not just to demonstrate the importance of continuous learning, but also because EMS is a constantly evolving field. Leaders who fail to learn will soon find themselves losing the respect of an agency whose members realize they are part of a stagnant organization, and not one adapting to new information or best practices.

Similarly, leading by example leaves executives vulnerable to failure. Under the veil of continuous improvement, leaders must be willing to take calculated risks to test ideas and seek new knowledge. Essential to this process is the reality that not all ideas will be wholly successful.

The most difficult part is that these “failures” should be transparent and public for two reasons. First, through leading by example, the CEO or EMS Chief can communicate to the organization that the agency and leadership is committed to new inquiry and continuous improvement and that failure is not demonized. The freedom to fail removes the greatest barriers to growth. Second, the new knowledge must be reintroduced to the organization so members do not only learn from their own experiences, but also have the benefit of learning from all organizational efforts.

About the Author

Dr. Steve Knight, a Fitch & Associates consultant, brings more than 25 years of fire and EMS experience to the firm. He served for nearly 17 years as assistant fire chief for the City of St. Petersburg, Fla. He is a subject matter expert for the National Fire Academy and also held a similar position at the Center for Public Safety Excellence (CPSE), a nonprofit corporation that serves as the governing body for the organizations that offer accreditation, education, and credentialing services to the first responder and fire service industries.

Knight has also served as team leader and assessor for the Commission on Fire Accreditation International and has held multiple faculty appointments in Fire Science and EMS. Prior to coming to Fitch, he served as senior manager of a consulting team within the Center for Public Safety Management.

Rare study exploring health of 9/11 EMS responders is remarkable

One could read this article and come to the quick conclusion that, why yes, EMS providers who worked alongside firefighters and law enforcement in the hours and days after 9/11 experienced the same poor health outcomes. One could then conclude that a study like this would be relatively unremarkable. But it’s not, for a variety of reasons.

1. A study of EMS workers

It is in fact a study about EMS workers. Very few have been done to date. This study’s conclusions support the notion that EMS providers are exposed to similar hazards other public safety personnel face. It might seem obvious to those of us in the business, but it’s still earthshaking for others who believe EMS is a stepchild service.

2. Comparison of study group and control group

The study has tighter controls over those who were at the site - the study group - and compared them to EMS providers who were not present - the control group. Since the two groups were more similar to each other, any differences could be more correlated to 9/11. (Note that I didn’t say “attributed” - but common sense might help fill in the gap.)

3. We need to know more

The study points out how little we know about the long-term effects of such a catastrophic incident that was the World Trade Center attack. It’s urgent that this group, as well as the other groups of affected emergency workers continue to be studied for the next several decades. Of course, what we do with the information is even more critical. RaHow can we minimize, or outright avoid, such major consequences of the job"

4. EMS providers deserve better PPE

The diseases these EMS workers face can be directly linked to insufficient, and ineffective protective personal equipment that existed then. Many rescuers stopped using air purifying masks, since they became so clogged with airborne debris so quickly, as to be rendered useless. I’m not sure whether any work has been done to improve these and other devices that were designed for one level of protection, but not the conditions as severe as 9/11. WE deserve better designed protective equipment.

5. Make the funding for long-term care permanent

Last, there is federal legislation to make permanent the relief bill that has helped many public safety providers recover the best they can from the effects of 9/11 and provide relief to the survivors of those who have succumbed to their related diseases. Despite the cost of the program, it needs to be made permanent. As this study shows, the long term health effects of 9/11 and the cost of providing medical care, support and relief are still largely unknown. To eliminate the funding would be to sever a lifeline many will need for the remainder of their lives. Let’s hope that compassion, not politics, prevail.

Good EMS documentation and the ability to get paid

We provided an ambulance transport, what do you mean insurance won’t pay"

We hear this question a lot - from patients, paramedics and municipal representatives who may not always appreciate or understand the nuances of ambulance billing and reimbursement. Unlike some other types of healthcare providers, where the mere provision of a service, such as an emergency department visit, administering a vaccine, filling a prescription, or even a well-patient check-up, often warrants reimbursement, ambulance reimbursement is not so cut and dry.

In order for most ambulance transports to ultimately be paid by insurance, including commercial, Medicare, or Medicaid, the transport must be considered “medically necessary.” Generally speaking, this is a subjective standard, with different definitions for different payers. Here are some examples of these three payment standards, but keep in mind that state laws may also play a role in determining whether reimbursement is warranted.

1. Prudent layperson (commercial)

Many state commercial insurance laws, or even contracts between an ambulance service and a commercial insurer, impose a “prudent layperson” standard to define when emergency ambulance transports will ultimately be deemed payable. A common theme in this prudent layperson standard is looking at “someone of average knowledge of health and medicine,” and whether such a “prudent person might anticipate serious impairment to his or her health in an emergency situation.”

This ultimately means: would an average person think this was an emergency" Would the condition warrant calling an ambulance in the particular situation, or would a prudent layperson seek alternative forms of transport, when placed in the exact same medical situation"

Thus, a stubbed toe probably doesn’t warrant an ambulance, but a cardiac event likely would. While obvious in some situations, there are many gray areas where the need for an ambulance is highly subjective. Therefore, the ultimate need for the ambulance may depend on the quality of the documentation on the patient care report, which further explains the patient’s complaint, relevant findings, and treatments provided to the patient.

2. Federal law (Medicare)

From a Medicare perspective, 42 CFR § 410.40(d) states:

"Medical necessity requirements – (1) General rule. Medicare covers ambulance services, including fixed wing and rotary wing ambulance services, only if they are furnished to a beneficiary whose medical condition is such that other means of transport are contraindicated. The beneficiary’s condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary."

This means the patient could not be transported by any lesser means, including wheelchair van, private vehicle, taxi, or bus. Medical necessity can sometimes be a difficult standard to meet, and whether or not medical necessity is met is the focus of the vast majority of today’s Medicare audits. Medicare auditors look to whether the documentation on the Patient Care Report demonstrates that other forms of transport are contraindicated.

3. State law (Medicaid)

Many state Medicaid programs outline unique and specific definitions that define whether the Medicare program will pay for ambulance transports. For instance, the Pennsylvania Medicaid regulation (at 55 Pa. Code § 1245.52) specifically states that Medicaid covers ambulance services only when medically necessary, including conditions such as patient incapacitation due to injury or illness; serious internal or head injuries; the need for restraints or oxygen and other limited conditions.

State Medicaid standards are often more specific than federal law, by describing actual conditions that can establish the need for an ambulance, though even these standards are subject to debate. Complete and accurate document of conditions, interventions, and/or procedures are necessary in order to satisfy this standard.

Good documentation is good patient care

Good documentation not only plays an important role in patient care, as discussed in a previous article , but reimbursement as well.In fact, is critical to substantiate the need for ambulance transport in the first place.

Today, we see more and more insurance audits where the payers probe more deeply into the supporting documentation upon which payment will be based. In these audits, when there are inconsistencies, incomplete records or when the documentation fails to support the need for ambulance, auditors are quick to deny coverage and demand repayment of their claims.

Just because an ambulance transport took place, there is proof of such a transport, and two crewmembers participated in the transport is not enough to assure reimbursement. The documentation must support using the ambulance, as opposed to other forms of transport, in order for most payers to make payment. Similarly, just because the patient may require transport to a hospital does not always mean transport by ambulance is the most appropriate form of transport, or that ambulance transport is payable.

The ultimate need for patient transport and need for patient transport by ambulance are two different things. The need for transport does not always make the ambulance transport payable.

Even though the three different types of payer standards as outlined above may be slightly different, the common theme is the importance of the crew documentation to satisfy the criteria as outlined. To satisfy those criteria, it is critical for ambulance crews to report sufficient information to meet the “medical necessity” requirements, no matter the payer. Even the most serious complaint, or dispatched condition, will not meet reimbursement requirements if not adequately supported by documentation.

Thorough documentation is critical, no matter the payer, and the following information becomes critical towards satisfying the payment standards:

  • Dispatched/reported condition or complaint
  • Patient condition on scene
  • Treatments/services rendered, with patient response
  • Objective report of the patient’s appearance and/or mental status

While this is not an exhaustive list, it is this specific information that suggests that other forms of transport would not have been possible and that the reasonable person would also call for, and expect, an ambulance transport. Therefore, next time you might question why a particular transport was not paid, ask first what about the documentation supported medical necessity to warrant such payment. Unfortunately, simply performing an ambulance service does not warrant payment.

EMS Syndrome: The chronic disease of EMS

The disease struck again. A productive conversation with an EMS executive about the future of his organization suddenly ended when his cell phone vibrated and he started thumb-poking the screen.

“Sorry man,” he said with a grave look on his face. “I just got to take care of this.”

And just like that, the conversation was over as he hurried away to deal with an urgent budget matter related to a threat from the fire department.

During my years of working with EMS organizations and leaders I’ve become convinced that the industry is afflicted with a chronic and debilitating disease. Merriam Webster describes disease as “a problem that a person, group, organization, or society has and cannot stop.”

EMS certainly has such a problem. I call it EMS Syndrome.

The major symptoms of EMS Syndrome are:

  • being stuck in busyness
  • jumping from crisis to crisis to put out fires
  • experiencing chronic shortages of time, imagination, creativity and innovation
  • feeling victimized by circumstances beyond our control
  • avoiding deep reflection and planning about the future
  • failing to have a vision and provide leadership on critical issues
  • sticking Band-Aids on problems instead of solving them

The impact of EMS Syndrome is devastating. Our growth is stunted, potential is thwarted and our standing in the larger community is dwarfed.

Lest I sound pompous, I know this syndrome well because I have often been afflicted by it. I have failed to plan. I have bounced from project to project. And often, I have been led by circumstances and events, rather than leading them.

But I have also made EMS Syndrome a subject of study. I believe its pathology is rooted in the nature of the EMS business and comes from the following causes.

Living in a reactive paradigm

It should be no surprise that EMS leaders often live in crisis mode. Reactivity is in our DNA. When tones sound we jump. When things get bad we mobilize. When blood pressure drops we spring into action. There is a certain addictive satisfaction in reacting, and after a while we start looking for opportunities for more reaction.

Over time it is easy to get stuck in the reactive paradigm. Everything becomes a crisis and busyness is the only way we know how to live. Consequently, we don’t slow down. We don’t plan. The idea of taking our team away from the daily chaos for reflection and planning seems impossible and unnecessary.

A focus on symptom management

EMS is expert at recognizing and managing symptoms. We handle what is right in front of us, and we’re good at it. But because our time with patients is short, we don’t invest in root cause analysis. Instead, we are good at Band-Aids and it shows in big industry issues.

Consider the fee for transport reimbursement system. The symptom is well known. Reimbursement does not cover costs in many systems. So we look for ways to Band-Aid the system and make it work. Currently lots of resources are being put into lobbying to make Medicare extenders permanent. But there are virtually no resources or efforts being put into understanding and changing the root cause – a flawed system that is based on wrong assumptions.

Adaptation to scarcity rather than abundance

EMS developed in poverty. Look at the historical development of most local systems and we find shortages of funding, workers, recognition and community support. An infusion of federal funding in the 1970s was intended to help the infant industry develop appropriately and sustainably. But that funding was ripped away during the 1980 fever to balance the federal budget and, in many respects, the industry continues to live below the poverty line.

Knowing how to react, we have learned to cobble things together, wait in line for soup and tighten the belt. But like people who grew up during the Great Depression we spend our time saving string and clipping coupons instead of living from a perspective of abundance. We view the world through the lenses of scarcity and it shows in our unwillingness to imagine big positive change.

Mentality of isolation and protectionism

Perhaps because of this sense of scarcity we remain preoccupied with clutching onto what we have and are chronically suspicious of “the other” in our industry. I’m still amazed at all the suspicion and fear - fear of the fire service, fear of AMR, fear of the agency next door, fear of the helicopter service in the next town. This fear leaves us fractured, voiceless and impotent as we isolate and try to protect what is ours.

Is there a cure for EMS Syndrome"

I’m not sure EMS Syndrome is curable. But my experience and observations suggest we can mitigate its grip on us.

As with most behavior-related diseases the first move toward mitigation is bringing more awareness to the presence of the disease in our lives and organizations. Some key questions to see if you are infected are:

  • Is my day leading me, or am I leading my day"
  • Am I only fully engaged when in crisis mode"
  • Am I addressing the symptoms or addressing the cause"
  • Would those who love me agree that my life is balanced"

Second, we need to engage in practices that slow us down. Both personally and organizationally we need time away from the chaos to reflect, plan and nurture internal strengths. We need to schedule such time every day.

Organizationally, we need regular time for our leaders to decompress, reflect, dream and plan. Retreats should be a regular activity.

Finally, we need to spend time with influencers that are accustomed to viewing the world from a perspective of abundance. For me this means: spending relaxing time in nature settings where there is an abundance of beauty and life; reading and re-reading materials like Covey’s Seven Habits, Coelho’s The Alchemist, and Pink’s Drive: The Surprising Truth about What Motivates Us; and watching inspiring TED talks by presenters like Peter Diamandis, Elizabeth Gilbert and Simon Sinek.

Clinical solution: Shortness of breath at a soccer game

The initial patient size-up

When assessing a patient suffering from respiratory distress, one of the first items of interest is the patient’s work of breathing. When first visualizing the patient to check for level of responsiveness, also try to determine how much difficulty the patient is having moving air. Is he positioning his body in a certain way" Is he pursing (squeezing) his lips together" Is he using other muscles to assist in breathing" What does his skin color look like"

In general, patients exhibiting these signs of distress are experiencing difficulty breathing. Finding a patient leaned over with his elbows on his knees is called “tripod position.” While there is not much in the way of research to indicate the physiologic mechanism for tripod position, it is nevertheless a frequent observational finding in shortness of breath patients.

Pursed lip breathing is another clinical finding often seen in cases of dyspnea. By breathing through tightly closed lips, a patient is able to increase the amount of pressure in the lungs which can have a “splinting” effect, allowing the air passages to remain open throughout the breathing cycle. Patients with chronic inflammation in the lungs may breathe through pursed lips regularly so an understanding of the patient's baseline is important when looking for acute changes.

The term “accessory muscle use” refers to the use of muscles other than the diaphragm to aid in breathing. Ordinarily the diaphragm, a strong, flat muscle separating the thoracic and abdominal cavities, contracts during inspiration, creating negative pressure in the thoracic cavity and causing the lungs to pull air in from the outside environment. In patients experiencing respiratory difficulty, muscles in the neck and between the ribs assist in moving the chest wall to create more negative pressure in an attempt to normalize breathing. This will often be seen as “retraction” or pulling back of the spaces above the collarbones and between the ribs.

Finally, skin signs are an important indication of a patient’s respiratory status. Cyanosis, or skin with a bluish tint, may indicate that a patient is not receiving enough oxygen. The finding of cyanosis in the core of the body, central cyanosis, such as the lips is often a more significant finding than that of cyanosis in the extremities, peripheral cyanosis, such as the nail beds of the hands or feet. Cyanosis results when hemoglobin in the blood without oxygen bound to it circulates close to the surface of the skin and appears blue in contrast to the red of well-oxygenated blood.

Lung sound auscultation

In addition to the basic visual presentation of the patient assessment, lung sounds can provide insight into the cause of a patient’s difficulty breathing. Proficiency at assessing lung sounds is a skill requiring regular practice to learn and maintain competency. As a general rule, lung sounds should be listened to at the same location on both sides of the body before moving to the next location so that a given lung field or lobe can be compared on both sides. In cases of pneumonia or a lower airway obstruction, there may be different lung sounds at the same location on different sides of the body.

It is important to note that not being able to hear lung sounds is not the same as a patient having clear lung sounds. As such, it is important to get in the habit of listening to lung sounds on stable, healthy patients so that you are more likely to notice when a patient does not have clear, “normal” lung sounds.

In the case of Sam from the scenario, your partner stated “I can’t hear anything.” In a patient experiencing significant difficulty breathing or work of breathing, based on a visual assessment, this should be a red flag. In Sam’s case, it is highly likely that your partner cannot hear lung sounds because the patient is not able to effectively move air in order to produce lung sounds.

Assessment and treatment of the soccer player

You noted previously that Sam is having a difficult time breathing and appears lethargic. Since his coach does not know his medical history you tell Sam that you will need to ask him some questions, but rather than try to speak you want him to nod “yes” or “no.” While your partner puts the patient on oxygen, you ask if Sam has ever experienced breathing problems like this before. He nods “yes.” You ask if he has any allergies, he shakes his head “no.” You ask if he has asthma and he nods “yes.” You ask if he takes medication like an inhaler and he nods “yes.” You tell Sam that you are going to start him on a longer term version of his rescue inhaler and ask your partner to administer an albuterol nebulizer via mask.

As you continue with your assessment, you notice that Sam’s respiratory rate has gradually slowed down and he is sitting up straighter. When you listen to his lung sounds you hear wheezing throughout his lungs. His follow-up pulse oximetry reading is 95 percent and he is able to answer your questions four to five words at a time. You recommend to Sam and his coach that he be transported to the emergency department and they both agree. You plan to contact Sam's parents by telephone during transport to the hospital.

Comfort after the death of a patient

Man Made Angel

I've been thinking about this piece for a long time. It was a concept suggested to me by a fellow emergency worker. We try our best at our jobs, but sometimes it's just not good enough. When we're spent and empty it's okay to receive help from where ever it may be.


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