EMS as a Profession, or a Hobby?

Posted by Patrick Lickiss on Apr 16, 2012 in Current Events, EMS 2.0, General | 3 comments

I’m a touch late to the party on this one, but here it is anyway. Just some quick background: Over at The EMS Patient Perspective a post was put up asking the question: Now That Doctors Specialize in EMS, Shouldn’t We?  This title refers, of course, to the recognition of EMS as a subspecialty by the American Board of Medical Specialties.  The venerable Skip Kirkwood weighed in on the topic and prompted the Rogue Medic to chime in.  Take a moment to check out those posts and come on back.

Now the comment of Skip’s that was quoted in the Rogue Medic post is as follows:

Before we can get to specialize and sub-specialize, we have to have a PROFESSION to begin with.

So what is a profession? One definition is “a calling requiring specialized knowledge and often long and intensive academic preparation.” That, we are emphatically NOT…We have high-school or at best trade school education. We have no distinct body of knowledge. We resist education and entry standards. We are, as a nationwide body (in the U.S.), someplace between a hobby and a trade or vocation. Profession? I wish, but I don’t think so.

Bold statement right?  But is he really that far off base? How many EMS practitioners are multitaskers? How many aspire to be multitaskers?  How many are looking beyond EMS to the next big thing? A good number right?

For that matter, how rigorous are our education standards?  How many people ACTUALLY fail an EMT or paramedic program.  Honestly, we created a system where you basically write your check and get your license.

What about the opposite approach: How many EMS practitioners are content to work in the prehospital arena for the rest of their careers and not include rescue, fire suppression, law enforcement, haz mat, etc. in their job description.  Now think about how you responded to that.  Did you think “I’d never want to be only an EMT/paramedic!”? That’s the problem.  We’ve never thought of EMS as a place we’d want to spend our whole careers.  Like Skip says, we’ve never seen it as a profession ourselves.  Why should we expect other to see us that way.  As said in the original post, we’re the one’s running calls every day, why is it that the physicians overseeing us are specializing in something we don’t take enough pride in to make it a profession?

So this is your call to arms:  EMS Week is fast approaching.  Just to remind you, EMS Week is sponsored by the American College of Emergency Physicians.  Are we sensing a theme here? We don’t care enough about our jobs to host our own appreciation week.  The theme this year is “EMS: More than a job. A calling”.  I propose something a bit different.  Figure out one thing you can do to make EMS more than a job.  Figure out one thing you can do to make EMS a profession.  Take a continuing education class you aren’t required to. Read an article from an actual peer reviewed journal.  Hold your coworkers to higher standards.  Make you sure actually look and act professional when you come into work.  Be proud of your chosen profession.  Seek out those who are doing good things in EMS and get involved.  But don’t continue to treat your career like your hobby.

What do you plan to do to help make EMS a profession?  Let me know in the comments.

Accuracy of Paramedic Broselow Tape Use

Posted by Patrick Lickiss on Apr 12, 2012 in Assessment, General, Research | 4 comments

The medical community has a love-hate relationship with the Broselow tape.  If you ask five providers, regardless of level of training, how accurate the device is, you are bound to get six answers.  The most recent report of the accuracy (or not) of the Broselow tape in estimating the weight of pediatric patients was e-published this month in the journal Prehospital Emergency Care.  Check out the abstract below:

Prehosp Emerg Care. 2012 Mar 23. [Epub ahead of print]

Accuracy of Paramedic Broselow Tape Use in the Prehospital Setting.

Heyming T, Bosson N, Kurobe A, Kaji AH, Gausche-Hill M.

Source

From the Department of Emergency Medicine, Harbor-UCLA Medical Center (TH, NB, AHK, MG-H) , Torrance , California ; St. Joseph’s Medical Center (TH) , Orange , California ; Los Angeles Biomedical Research Institute at Harbor-UCLA (TH, NB, AK, AHK) , Torrance , California ; Department of Medicine, David Geffen School of Medicine at UCLA (NB, AHK) , Los Angeles , California ; and University of California Irvine (AK) , Irvine , California .

Background: The Broselow tape is widely used to rapidly estimate weight and facilitate proper medication dosing in pediatric patients.

Objective: We aimed to determine the accuracy of prehospital use of the Broselow tape.

Methods: We prospectively enrolled a consecutive sample of pediatric patients transported to the emergency department (ED) at Harbor-UCLA Medical Center from February 2008 to January 2009. Eligible subjects arrived via ambulance and were less than 145 cm tall, the upper limit of height for Broselow measurements. Subjects were excluded if they had a medical condition preventing proper measurement (e.g., contractures). Per Los Angeles County protocol, paramedics obtained a Broselow weight on all pediatric patients. The paramedic Broselow weight was compared with the ED Broselow weight and the ED scale weight, which was obtained unless mobilization was contraindicated. Accuracy was determined by assessing Bland-Altman plots and the Pearson correlation coefficient. As part of a sensitivity analysis, multiple imputation was used to account for missing data.

Results: There were 572 subjects enrolled. The median age was 24 months (interquartile range [IQR] 10 to 49 months); 316 (55%) of the subjects were male. The weighted Cohen’s kappa assessing agreement between the paramedic and ED Broselow colors was 0.74 (95% confidence interval [CI] 0.68 to 0.79). The median difference between the paramedic Broselow weight and the scale weight was -0.10 kg (IQR -1.7 to 0.7). The accuracy of the paramedic Broselow weight when compared with the ED scale weight and the ED Broselow weight as defined by Pearson’s correlation coefficient was 0.92 (95% CI 0.90 to 0.93) and 0.97 (95% CI 0.97 to 0.98), respectively. Multiple imputation for missing data did not alter the results.

Conclusion: Paramedic Broselow weight correlates well with scale weight and ED Broselow weight. Paramedics can use the Broselow tape to accurately determine weight for pediatric patients in the prehospital setting.

This appears to be a fairly well designed study.  Comparing paramedic Broselow weights to those obtained both from the hospital scale and the hospital Broselow allows both the technique used by the prehospital providers as well as the accuracy of the tape itself to be analyzed.

Do you routinely use the Broselow in your practice?  Do you have a different technique for estimating the weight of pediatric patients? Any tips or tricks?  Let me know in the comments.

Image via Flickr

Occupational Traumatic Stress in Paramedics

Posted by Patrick Lickiss on Apr 10, 2012 in EMS 2.0, General | 6 comments

Like it or not, we have a stressful job. Some days are worse than others, some calls trigger us in different ways, depending on our perspective. I, for instance, approach pediatric calls very differently since becoming a father.

Think back to when you were in EMT or paramedic school. Chances are are someone spoke to you about the stresses associated with the job we’ve chosen. Chances are you, like me, figured that you could handle it and it wouldn’t affect you. Let me just say that I was wrong and you probably were too. Most of us will experience a period of increased stress at work. It’s a given. The trick is learning how to recognize it and deal with it constructively.

I was contacted the other day by David Whitley a paramedic and the EMS Coordinator for the York Region Critical Incident Stress Management Team in Ontario. David has created a series of videos posted to YouTube with the goal of providing resources for EMS providers to recognize stress before it becomes overwhelming. David hopes to use the power of social media to spread his message and advocate for better education and support for EMS providers. David’s YouTube channel can be found here.

David has three videos up so far with more to come. Take a few moments and watch them here then head over and follow his channel on YouTube. If you find anything in these videos helpful, share them with your friends and coworkers. If you’ve been feeling stressed and overwhelmed at work or at home, don’t hesitate to ask for help, there are a huge number of resources available. If you feel comfortable sharing any of your experiences with the others in the EMS community, I would invite you to do so in the comments.  Thanks.

Image via Flickr

Are More Ambulances the Right Answer?

Posted by Patrick Lickiss on Apr 5, 2012 in Current Events, General | 10 comments

In an unsurprising move, the Los Angeles mayor, Antonio Villaraigosa, announced that he was ordering six more ambulances as one of several steps meant to improve the level of service provided by the Los Angeles Fire Department.  As you may remember, LAFD ran into a few hiccups recently regarding exaggerating response time performance.  This is certainly a good move to make politically but will it ultimately matter?

The response time issue resulted from statisticians using a six minute response time requirement rather than the five minute response time actually required for first response units.  This had nothing to do with transport response or performance.

There is little, if any, evidence supporting the notion that response time affects patient outcomes.  There is also little evidence supporting the idea that more paramedics equate to better patient care.  Finally, the issue at hand has nothing to do with transport unit availability.  Sounds like three strikes against Villaraigosa.  What do you think?  Let me know in the comments.

The Golden Hour in Acute Head Injury

Posted by Patrick Lickiss on Apr 3, 2012 in General, Research, Treatment | 0 comments

The “Golden Hour” is one of those topic in EMS which people feel very strongly about.  Plenty of research exists on both sides of the issue and further studies are released all the time which tend to compound the issue rather than clarify it.  The Golden Hour,  to review, is the time interval said to be linked with survival of a traumatic injury and is measure from the time of injury until the patient receives surgical intervention.  The idea, of course, is that getting a patient to surgery within an hour will improve outcomes.  It is important to note, however, that there a certain subset of trauma patients who have fatal injuries regardless of time to intervention, sometimes it is just your day to go.

A study was released recently for Injury looking at what might be a grey area in the argument about the Golden Hour: severe head injury.  Let’s take a look at the abstract:

Injury. 2012 Feb 13. [Epub ahead of print]

Redefining the golden hour for severe head injury in an urban setting: The effect of prehospital arrival times on patient outcomes.

Dinh MM, Bein K, Roncal S, Byrne CM, Petchell J, Brennan J.

Royal Prince Alfred Hospital, Trauma Office level 10, Missenden Road, Camperdown, NSW 2050, Australia.

BACKGROUND: In patients with severe head injuries, transportation to a trauma centre within the “golden hour” are important markers of trauma system effectiveness but evidence regarding impacts on patient outcomes is limited.

OBJECTIVE: To determine the effect of patient arrival within the golden hour on patient outcomes.

METHODS: A retrospective cohort of adult patients with severe head injuries (head AIS≥3) arriving within 24h of injury was identified using the trauma registry from 2000 to 2011. Survival analysis was used to determine the effect of patient arrival time on overall mortality. Study outcomes were in hospital mortality and survival to hospital discharge without requiring transfer for ongoing rehabilitation or nursing home care.

RESULTS: There was a significant association with mortality with each incremental minute of patient arrival (HR 1.002, 95%CI 1.001-1.004, p=0.001). There was however no survival benefit observed for patients arriving within 60min of injury time (HR 0.77, 95%CI 0.50-1.18, p=0.22) but an apparent benefit for those presenting within 2h of injury time (HR 0.31, 95%CI 0.15-0.66, p=0.002). Patient arrival within 60min of injury time was associated with increased odds of survival to hospital discharge without requiring ongoing rehabilitation (OR 1.78, 95%CI 1.14-2.79, p=0.01).

CONCLUSION: A survival benefit exists in patients arriving earlier to hospital after severe head injury but the benefit may extend beyond the golden hour. There was evidence of improved functional outcomes in patients arriving within 60min of injury time.

So what’s your take? First of all, let me say that I am pleased to see more researchers looking at patients who are surviving illness and injury AND retaining functionality.  Simply surviving a head injury or cardiac arrest but being unable to function at all should not be considered a success of medicine.  The patient who survived AND did not require ongoing rehabilitation were counted an analyzed.

Second, this is looking at an urban trauma system.  Given the prevalence of research and teaching institutions in urban centers, this type of research tends to be focused there.  I am in an urban system so this is useful for me, but it would be nice to see more research targeted at rural trauma patients.

Third, the results are fairly interesting.  Patients appear to be more likely to survive if treated within the first two hours.  They are more likely, however, to be discharged functionally intact if treated within the first 60 minutes.  Sounds like the “Golden Hour” may work here.  There was, though, no benefit associated with treatment before 60 minutes.

So what does this all mean?  Clearly, severe head injury patients are time sensitive.  For the purposes of this study, however, that only means that they are seen within one hour of their time of injury.  There is no noted benefit to being seen before then.  Perhaps these patients fall into the growing category of those who do not require “lights and sirens” transport.  If these patients are maintaining an airway and vital signs, maybe we can forgo the risk of running code into the hospital?  What do you think?  Let me know in the comments.

Differential Diagnosis: 62 year old Female – Fall

Posted by Patrick Lickiss on Mar 29, 2012 in Assessment, General, Treatment | 1 comment

You are dispatched Code 2 (no lights and sirens) to a report an elderly female who fell on the steps of the library. It rained recently and has been cold out. There have been several slip-and-falls responded to around the city this morning.

As you pull up on scene, you find that your patient is still leaning up against the steps and has been covered with a blanket by a bystander. The patient tracks you visually when you walk up and appears to be in obvious pain. Witnesses report that the patient was walking down the ice-covered steps and fell. Both the patient and bystanders state that she did not have a loss of consciousness nor did she strike her head.

As you begin to assess the patient, she reports that she only has pain to her right knee. She denies feeling dizzy or weak before the fall. She has a history of hypertension and is currently taking Atenolol. She reports an allergy to aspirin. Enlisting the help of bystanders, you move the patient to the gurney and into the ambulance out of the cold. You now have an opportunity to directly visualize her knee:

Yes, I know it's a picture of a man's knee...

There is obvious deformity to the knee joint and swelling to the back of the knee.  The patient has good circulation, sensory and motor distal to the injury site.  She is in significant pain.

What are your potential differential diagnoses?  What is your treatment?  What hospital services do you anticipate that she will need?  Anything else?

Image via MedScape