A Comment on Arming EMS

Posted by Patrick Lickiss on Oct 3, 2012 in Current Events, General | 0 comments

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

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

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

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

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

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

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

Concealed Carry for EMS: 2 Questions – Everyday EMS Tips

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

Surviving the Next Shift – Part I – Rogue Medic

Armed EMS – Reactive or Proactive? – Unwired Medic

Should EMS Providers Be Carrying Guns on the Job?

Posted by Patrick Lickiss on Sep 19, 2012 in Current Events, General | 5 comments

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

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

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

No, I don’t.

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

No, I don’t.

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

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

So what’s the problem then?

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

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

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

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

Agree? Disagree? Fire away in the comments!

Medic SBK Looks at Cardiac Arrest Care

Posted by Patrick Lickiss on Sep 14, 2012 in EMS 2.0, General, Research | 0 comments

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

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

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

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

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

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

Christmas in July?

Posted by Patrick Lickiss on Jul 25, 2012 in Current Events, General, Legal, Research | 0 comments

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

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

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

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

Video teaches recognition of Acute STEMI in the presence of LBBB

Posted by Patrick Lickiss on Jul 18, 2012 in General | 0 comments

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

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

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

Does your call have too many cooks?

Posted by Patrick Lickiss on Jul 11, 2012 in Current Events, EMS 2.0, General, Politics | 1 comment

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

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

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

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

Carbon Monoxide Symptoms Caught on Tape

Posted by Patrick Lickiss on Jul 4, 2012 in Assessment, General, Treatment | 2 comments

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

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

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