Bypass is stupid

And I don’t mean coronary artery bypass grafts. Those are mildly necessary. And important.

 

In my area, several hospitals are known for going on “bypass” which means they aren’t accepting ambulance patients. Usually, because they are busy. Sometimes, there is a reason for their bypass, such as neuro bypass, which either means they don’t have a working CT scanner, or a neurologist in the hospital. Every once in a while, Little Trauma Center in Capitol City will go on trauma diversion, and all trauma patients will go to Large Trauma Center. That doesn’t usually matter too much, mostly because they are only a few miles apart.

 

Some of the hospitals are known for going on bypass simply because they are busy, and I feel that does a disservice to their patients. Sure, it makes sense to let the EMS crews know that there is a long wait, so the information can be relayed to the patient, who might make the decision to go to a less busy hospital instead. I consider that customer service.

 

But when a hospital tries to refuse a patient because they are busy, that’s just lazy. And that’s poor customer service.

 

Here is an example of a conversation I had a few days ago.

 

“St. Elsewhere Emergency Department, this is nurse Ratched. Can I help you?”

 

“Yeah, this is Roy from Medic 51, I need to call a report.”

 

“Oh, we are on bypass, you need to go to another hospital. It’s going to be a very long wait if you come here.”

 

“That’s fine. This guy has had a pain in his leg for 12 years. I think he can wait a while.”

 

“Well, you really need to go to another hospital. We aren’t accepting ambulance patients right now.”

 

“Okay, are you refusing my patient, or just suggesting I go to another one?”

 

“We aren’t accepting ambulance patients right now.  You need to go somewhere else.”

 

“Okay. Can you give me the name of the physician who is refusing my patient, so I can document it?”

 

“Uh, ummm, uh…”

 

“Yeah, see you in 10 minutes.”

 

I had the pleasure of working with one of the EMS pioneers in my state for several years before he passed away. This was often a topic he liked to talk about while standing in his underwear early in the morning, smoking cigarettes inside the ambulance bay.

 

While his name isn’t important, his message was:

 

“When they turn off that sign that says “Emergency” I will stop bringing them patients. Until then, they can shut the f $$$ up.”

Dear Thief

You stole my stethoscope.


Granted, I left it on the truck over night, so I bear some responsibility for your theft of my stethoscope, but you still stole it.


It was underneath the control panel in the back when I got off the truck, and you were the only one who got anywhere near it over 12 hours. As a matter of fact, your partner that you worked with that night said you were the only one who even got in the back.


Nobody climbed into the back of the ambulance while you were posted, or at a hospital, to steal my stethoscope, and only my stethoscope, leaving the good drugs in the box.


You kind of gave it away when you took off real quick this morning.


My stethoscope is a 27 inch Littman Master Cardiology black edition. My wife gave it to me for Christmas. She also personalized it by purchasing the red binaurals with the grey eartips. So it’s unique. Nobody else has one like it. But you wouldn’t know that, since you are the kind of person who would steal another medic’s stethoscope.


And I took it to a jeweler to have my name engraved on it. Not on the chest piece, but inside. If you don’t know it’s there, you would never look for it.


I am going to catch you with my stethoscope at work, and I am going to take it back.


And then I am going to expose you for the stethoscope thief that you are.


It’s mine, and I want it back.


Sincerely

She was worried about her job, her health, everything. “Hey, God!” she wanted to shout. “Remember me?”


Fat drops of rain spattered against my face. I ducked under an overhang and set down the heavy cat carrier. “Just a few more blocks, Junior, and we’ll be at the vet,” I said, peering in at the stray I’d taken in two months ago. He mewed pitifully.


“I know exactly how you feel,” I said.


So far my year had been dismal. Family disagreements. Reduced shifts at my bookstore job. A move to a dumpy, cheaper apartment, close enough to walk to work and to shops.


Now my boss told me that he would have to cut my hours even further, and word came from the corporate office that I would be losing my health insurance. What would I do if I got sick? I was barely making ends meet as it was. I didn’t think I could take one more blow.


Still, I couldn’t miss Junior’s vet appointment. He would be getting a microchip with my phone number and address injected between his shoulder blades so that people would know who he belonged to should he ever get lost.


I didn’t even want to think about what I would do without my cats, the one bright spot in my life.


A friend at work had told me about Junior. She knew that I had been looking for a buddy for Prince, a big gray cat that I had adopted from a shelter a few years back.


“I saw a new cat at the park,” she said. “He was hanging out with some feral cats I feed. But he’s friendly. I think he must have been abandoned. Would you consider...”


“I’ll take him,” I said.


I’d barely made introductions before Junior and Prince started grooming each other. Finally something was going right.


My cats gave me a reason to get up in the morning. They needed me. And I needed them. Their antics made me laugh. And they both cuddled next to me in bed at night, their gentle purring a reassurance.

.

Thank you, God, I prayed. We’ll get through this rough patch together, the cats and I.

But now I wondered, worried all over again about my job, my health, everything. I hefted the carrier and trudged on to the vet’s office, trying to ignore the pelting rain.


A vet tech ushered me into an exam room when I got there. I took Junior from his carrier and set him on the table. “He’s a handsome fellow,” the vet tech said.


Not that I had anything to do with Junior’s looks, but I swelled with pride.


The vet tech explained how microchips worked. “With just a quick scan any veterinarian will know that your cat has an owner and will be able to find out how to reach you.”


She took a wand from the counter. “First let’s make sure that he doesn’t already have a chip,” she said. She scanned Junior’s body. “Yep. He has a microchip already.”


“That’s impossible,” I said. “He was abandoned.” “Maybe he got out by mistake,” she said. “Here’s the number for the microchip registry. They’ll be able to tell you who he belongs to.”


But I already know who he belongs to, I thought. Me!


I loaded Junior into the carrier and plodded home in the rain. It was all I could do not to flop down on some bench and have a big cry. But who would even notice? Or care? “Hey, God!” I wanted to shout. “Remember me?”


 

Aurora answered. “I think I might have your cat,” I said.


There was a pause, then a shriek of joy. My whole body sagged. I told her how I’d taken Junior in, how well he was doing.


“I can’t thank you enough for taking such good care of him,” she said. “Isn’t he a wonderful cat? You know he was raised with sled dogs. And he loves being sung to...”


I couldn’t deny it any longer. He was her cat. She loved him as much as I did. I’d been selfish to even think of keeping him. “I could rent a car and drive him down to you,” I heard myself say. “Or put him on a plane.”


“Let me figure it out and get back to you,” she said.


We hung up.


I sat there in my dumpy little apartment, but I felt calm, the stress that had weighed so heavily on me suddenly gone, like it was never even there. I had done the right thing. I had contributed something right to a world where so much seemed wrong.


I could handle this. Everything—my job, the bills, Prince and I—would turn out okay. Hadn’t God sent Junior to me? The perfect antidote to my fear and worries. God would be there for me even after Junior was gone. Junior was a demonstration of grace.


“God, thank you for taking care of me,” I prayed. “I believe you know what’s best for Junior just like you know what’s best for me. Be with him and his owner, wherever their journey might take them...”


The phone rang. I picked up. It was Aurora. Was she calling back with instructions already?


“Hi, Linda,” Aurora said. “I’ve been thinking. You’ve actually had Junior longer than I did. And he’s happy there. I think you should keep him.”

She was worried about her job, her health, everything. “Hey, God!” she wanted to shout. “Remember me?”


For a moment I couldn’t speak. “Thank you,” I finally said. “That’s incredibly sweet of you. I’ll send you pictures. I’ll even sing to him.”


I looked down at Junior, rubbing against my leg, purring, the very sound of grace. Maybe he hadn’t crossed a glacier or fought off hungry wolves, but the journey that had brought him to me seemed no less amazing.

.

Not really a stabbing

The “stabbing” that we sent 12 people to, blaring their sirens and flashing their lights, turns out to be a goofball who poked himself in the top of the hand with a steak knife.


Some college-aged moron was playing the “knife game” while drunk.


I have seen the future, and we are doomed.


Nevertheless, he actually bled a good amount. One of his roommates was kind enough to bandage everything up before the fire department got there, and he did a darned good job of it, too. Like, 4×4 dressing and kling wrapped, and tied in a knot.


The bleeding is controlled, and not a single spot show through the bandage.


I think the roommate said something about being a boy scout, but he was slurring his words pretty hard. Regardless, I’m not one to remove a bandage just to look at a wound, when the bleeding is already controlled.

Laziness, maybe. Maybe not.

He wants to go to the hospital across the county to be near his mommy. If I were drunk and stabbed myself while playing the knife game on a dare, the last place I would want to be is near my mother. It’s a low-priority call, so Slimm jumps in the back and I drive.


I catch about 20 minutes of a Rush Limbaugh rerun on the way.


At the hospital, after dropping him off, my Slimm is approached by the doctor on staff.

“Hey, did you guys even look at the cut on his hand?”


“No, not really. The bleeding was controlled by the time we got there, and the bandage was already on. We didn’t want to remove the bandage just to look at it.”


I’m hiding around the corner, but within earshot, working on my first cup of coffee.


“Well, you guys should have looked at it. It’s only like, two centimeters long and not very deep. It will probably only take one stitch, but we might be able to glue it.”


“Oh, so you guys can handle it? Or do we need to run him down to the trauma center?”


I choked on that sip of coffee.

Physician vs. Patient vs. Paramedic

Lights and sirens don’t mean faster.

Ambulance 1 is dispatched to a single-car motor vehicle crash, with injuries.


Ambulance 1 arrives on scene a short time later, and finds a car that has overturned several times, with two patients who are both critically injured, and requests a second ambulance, which also arrives fairly quickly.


Patients are packaged and prepared for transport, and ambulance 1 departs the scene with the injured driver at 14:06:31, heading towards the local trauma center non emergency.


The trauma center is 14 miles away from the scene, and the trip consists mainly of a 4-lane divided road with numerous at-grade crossings with traffic lights. The speed limit is 50 miles per hour.


Traffic is average for a weekday at 2 pm.


Ambulance 1 encounters several traffic lights on the way, but experiences no significant delays.


Ambulance 2 departs the scene with the injured passenger at 14:07:12. Ambulance 2 is traveling emergency to the same local trauma center.


Both ambulances radio their reports to the local trauma center, and are assigned trauma rooms, with teams awaiting their arrival.


Less than 1 mile away from the trauma center, Ambulance 1 yields to the right for Ambulance 2, which is still traveling emergency.


Ambulance 2 arrives at the trauma center at 14:22:53.


Ambulance 1 arrives at the trauma center at 14:23:27, while ambulance 2 personnel are unloading their patient.


Ambulance 1 had a cumulative transport time of roughly 17 minutes.


Ambulance 2 had a cumulative transport time of roughly 16 minutes.


Ambulance 2 saved (at most) 2 minutes by traveling with their lights and sirens activated.


Both patients received excellent care in the back of the differing ambulances.


Using the lights and sirens during transport does have it’s indications and contraindications. But those indications are rare.


Driving with lights and sirens does not get you there appreciably faster, and is more dangerous for the driver, the attendant, the patient, and every other driver on the road.


The danger was witnessed first hand by the driver of Ambulance 2, when he witnessed a rear-end collision that was caused by someone who was attempting to yield to the red lights.


Lights don’t save time, and are over-utilized.

“Medic Eighteen, a motor vehicle crash with injuries reported. Possible entrapment.”


“Ten-four. We’re enroute.”


The MDT gives us a location well known for collisions, a windy road which goes around a good-sized lake. This stretch of road is hilly as well, with lanes that were designed for cars traveling much lower than the posted speed limit of 50 miles per hour. It’s fairly rural, with only a few houses, which are all a great distance apart.


It’s about a 15 minute drive from our station.


“Medic Eighteen, State Patrol is on scene, advising one vehicle is a Sheriff Deputy, and a pickup truck.”


I don’t like the sound of this. Neither does my partner.


“Ten-four, we are about seven minutes out.”


We debate calling for a helicopter, since the closest trauma center is easily a 45 minute drive. We decide to wait until we get there. The helicopter base is only a 5 minute flight away from the scene. It’s an area the flight crews know well.


“Eighteen, Trooper advises complaints only on the driver of the truck. Negative injuries on the Deputy.”


“Received. Two out.”


Good thing we decided to wait on the bird.


We arrive on scene just as the volunteer firefighters arrive from the other side of the accident. Lots of pretty colored lights bounce off the damp pavement and leafless trees.


We see serious damage to both cars. It appears that the pickup truck crossed the center line in the middle of the curve, and struck the rear driver’s side door of the Sheriff cruiser. The Deputy must have swerved slightly to avoid the collision, and luckily so. He certainly avoided serious injury.


Colored plastic and engine fluids are scattered and smeared all over the pavement.


The driver of the truck is walking around, talking with the State Trooper on scene.


I approach the Deputy, still standing beside his cruiser, and notice the airbag on his side deployed.


“Y’okay, buddy?”


“Yeah, I’m just a little shook up, but I’m alright. Go ahead and get your form out, I’m not going to the hospital.”


It’s always good when they know the routine.


I peer into the cruiser, to assess the steering wheel and windshield. And I see it. In the passenger seat.


3 large boxes from the local doughnut shop. The box on top is open, 2 doughnuts conspicuously missing. Then I see the smashed, half eaten, grape jelly doughnut on the dash, just underneath the light bar.


“Hungry this morning?” I ask with a smile.


“I swear, I was buying them for the guys this morning. We are going to the range to qualify with our pistols, I swear!”


“Sure thing” I say as I reach in to grab a glazed bit of deliciousness. I’m hungry myself, and haven’t had breakfast yet either.


“Man, I’m never going to hear the end of this, am I?”


Nope. Not at all.

Writing Patient Assessment Notes in the Field

How do you write notes in the field? Do you use scraps of paper, a smartphone app, or a tablet PCR?


A new EMT asked me for ideas for tracking the patient assessment details they learned during the patient assessment. I have used a variety of methods.


1. Paper notepad. My favorite has always been the pocket-size paper note pads handed out as a promo item from the local flight service. The pad easily fits in my pocket. The pre-printed fields remind me to capture essential information. I can write additional details on the back of the page. Most importantly if I leave the whole pad sitting on the desk in the hospital EMS office or on the action desk of the ambulance it’s not a big deal.


2. Waterproof pad. I have also used the Rite in the Rain EMS Notebook. I like the fact that as the name says this is a waterpoof and durable paper. It is also a perfect pocket-size for the front pocket of my uniform short. The fields for writing patient information are small so I need to be deliberate about what I write and how I write (quality).


3. Smartphone app. I have not used a smartphone app for tracking patient vital signs and documenting other information, but I know they exist. Everyday EMS Tips review of the EMS Tracker App.


4. Patient care report. When I used a hand written patient care report I would write information into the fields as I worked through the patient assessment. I have not used an electronic PCR that flowed well enough to document information in the PCR as I did the assessment. Instead I write on a paper pad and then transpose to the ePCR after the call is over.

5 Tips for Patient Assessment Scenario Debriefing

Scenarios allow students to see injuries and illness within the context of the patient assessment. They also allow students to practice applying treatments. The final phase of any scenario is the debrief. The instructor’s role is to review what happened and begin the process of transferring the lessons learned from the performance phase to future training or actual incidents. If you are an EMS educator follow these Everyday EMS Tips for debriefing:

 

1) Don’t attempt to debrief every component of the scenario. Focus discussion on the components most important to the scenario objectives .


2) Ask questions to stimulate discussion about the objectives while avoiding statements that judge performance.


3) Make sure to ask what went well. It is often more difficult for instructors and students to talk about successes.


4) Ask specific questions to specific people. All students need to be ready for giving hand-off reports. Specific questions – i.e. “What were your patient’s initial assessment problems?” — prepares the student for the work environment.


5) Use questions that teach and elicit new information. If every group assessed a respiratory distress patient, each student reporting during the debriefing should add new information to the debrief.

5 Stethoscope Tips

I can’t think of a single piece of equipment more closely connected with the medical profession than the stethoscope. Can you? The stethoscope is more than 200 years old and its basic design has barely changed in the last 150 years. Read my recent Everyday EMS Tips column at EMS1.com for more on the stethoscope.


Meanwhile, follow these Everyday EMS Tips for stethoscope use and care:

1. Having trouble hearing? Make sure the ear pieces are pointed towards your nose. This is the direction of your ear canals.


2. If the patient’s arm or chest is bloody or contaminated put the bell of the stethoscope in a rubber glove.


3. When not using your stethoscope keep it around your neck or in a pocket.


4. Disinfect your stethoscope regularly. Just like you wash your hands after patient contact you should wash your stethoscope after every patient contact.


5. Don’t press the bell to firmly against the patient’s skin when auscultating a blood pressure. Most times all that is needed is a light touch.

TeresahRN says ...

Bypass is stupid

And I don’t mean coronary artery bypass grafts. Those are mildly necessary. And important.

 

In my area, several hospitals are known for going on “bypass” which means they aren’t accepting ambulance patients. Usually, because they are busy. Sometimes, there is a reason for their bypass, such as neuro bypass, which either means they don’t have a working CT scanner, or a neurologist in the hospital. Every once in a while, Little Trauma Center in Capitol City will go on trauma diversion, and all trauma patients will go to Large Trauma Center. That doesn’t usually matter too much, mostly because they are only a few miles apart.

 

Some of the hospitals are known for going on bypass simply because they are busy, and I feel that does a disservice to their patients. Sure, it makes sense to let the EMS crews know that there is a long wait, so the information can be relayed to the patient, who might make the decision to go to a less busy hospital instead. I consider that customer service.

 

But when a hospital tries to refuse a patient because they are busy, that’s just lazy. And that’s poor customer service.

 

Here is an example of a conversation I had a few days ago.

 

“St. Elsewhere Emergency Department, this is nurse Ratched. Can I help you?”

 

“Yeah, this is Roy from Medic 51, I need to call a report.”

 

“Oh, we are on bypass, you need to go to another hospital. It’s going to be a very long wait if you come here.”

 

“That’s fine. This guy has had a pain in his leg for 12 years. I think he can wait a while.”

 

“Well, you really need to go to another hospital. We aren’t accepting ambulance patients right now.”

 

“Okay, are you refusing my patient, or just suggesting I go to another one?”

 

“We aren’t accepting ambulance patients right now.  You need to go somewhere else.”

 

“Okay. Can you give me the name of the physician who is refusing my patient, so I can document it?”

 

“Uh, ummm, uh…”

 

“Yeah, see you in 10 minutes.”

 

I had the pleasure of working with one of the EMS pioneers in my state for several years before he passed away. This was often a topic he liked to talk about while standing in his underwear early in the morning, smoking cigarettes inside the ambulance bay.

 

While his name isn’t important, his message was:

 

“When they turn off that sign that says “Emergency” I will stop bringing them patients. Until then, they can shut the f $$$ up.”

 

Can't say I agree with this. I can only speak for my ED, but when we go on divert (and it takes an act of God to allow it) it's generally because we are overloaded, have around 30 in Triage, all beds full and several crews waiting in the hall. It's not laziness...it's when we get to the point where we feel it's unsafe to continue to accept additional pts whom we cannot properly care for.  Divert gives us a chance to dig out and move pts out. Our EMS services can override it if the pt has any relationship with the hospital...and they do. We're far and away the busiest ED in the city...waiting for our new Trauma Center to open next year. Trying to grow to meet the needs. 37 beds now at current pace to see 99,000 this fiscal year.

 

The EMS roundtable: Expert insights on medical simulation

Experts offer their opinions on the technology available to medics

As simulation continues to become a greater part of EMS education and training, we sit down with several subject matter experts to discuss some of the issues and predict what the future might hold. In addition, check out our in-depth report on simulation in EMS.

 

1. In education and training we toss around a variety of phrases to describe some of the manikin-based training that we do to keep EMS providers for job readiness. Terms like "scenarios," "low fidelity simulation" and "high fidelity simulation" are sometimes confusing. From your perspective, just what is "simulation" and how does it differ from traditional, scenario-based training?

Scenario-based training and simulation are one in the same.  Simulation is part of a learner-centric teaching strategy. It provides an immersive experience where learners may practice without risk of personal failure or harming patients.

 

When implementing simulation training, one should understand that technology is a supporting cast member, not the star. The star is the healthcare provider learning how to safely manage complex patient problems.

 

Scenarios, or simulations, reproduce real-life experiences. The best designed simulations are focused on situations with well-defined goals – Resuscitate a patient with uncontrollable external hemorrhage; Provide effective ventilation and oxygenation for an apneic patient; Perform quality CPR according to current guidelines.

 

 

 I use simulation even more broadly to describe any type of patient assessment and treatment practice. Simulation can use students in the role of patients, as well as other trained and untrained actors pretending to be patients.

 

Simulation, like many things, exists on a continuum. On the low end of the continuum a student might simply pretend or act to be unresponsive so another student can assess for respirations and signs of circulation. On the high end a computer-programmed, high fidelity manikin can be the unresponsive student.

 

 

 Simulation is the act of simulating an experience. This can be done using scenarios where providers are role-playing, where we as educators provide information to help facilitate the progression of a skills training experience, or during a developed immersive educational drill.  The confusion lies in what the terms actually mean.

 

Scenarios exist in everything we do. It is a matter of how much fidelity we would like to inject into the experience. The biggest difference between traditional and scenario-based training is the level of complexity and fidelity involved in the implementation of the experience.

 

Traditional involves case discussions with no role-playing. Simply put, the student and the educator discuss how to treat the patient. Scenario-based training has the student actually performing the skills necessary to manage the simulated patient. The simulated patient can be a low fidelity manikin or a high fidelity human patient simulator. The key is they are actually treating the simulated patient.

 

 

3. If you have any words of advice for the instructor who is new to simulation training, what would they be?



My words of advice for new simulation instructors are "think differently." Think about how you want EMTs and paramedics to perform in the field then design learning sessions that focus on the desired behavior. Be very clear on what you want people to do differently after training.


Also, think about how you will help to maintain the provider's competence – current research shows that knowledge and skills sharply deteriorate after training. Frequent, small doses of refresher training are much superior to the prevalent bi-annual approach.


Rehearsal, or deliberate practice, is an ongoing activity meant to maintain and improve competence. Providing complex healthcare could be improved with ongoing training, coaching and feedback.



Work towards becoming a facilitator, not a technician. Facilitate simulations that honor a student's time, knowledge and experience. Deliver scenarios that are reality based rather than once in a lifetime oddballs. Guide students towards success rather than failure. Do a lot of background research on the topic of simulation before moving into this exciting area of training.



Be patient! It is important for the educator to know what he/she hopes to accomplish using simulation training. If you are looking to teach task-based skills, buy a task trainer.


If you are looking to grow a current or future EMS provider using high-paced complex scenarios that create lifelike situations, use a simulator. The educator must think through what they are looking to accomplish, how that can be accomplished, and identify gaps that exist in the current training program that will be may be fixed with simulation.


You have to be patient and make the time to develop a great simulation experience. But, with patience comes great rewards!


 

5. Where do you see simulation training in 10 years?



I envision a much greater emphasis on highly immersive learning. EMS providers will learn about patient problems on smart devices then practice decision-making in interactive game-like environments.


Educators will function more like coaches – helping to improve learning and performance. Continued evolution of technology will enable the simulation of a wider variety of patient presentations. All of these innovations will come from EMS organizations' increased expectations to improve quality with greater efficiency.



In the future, simulation will be less reliant on an actual manikin placed before students on a bed or cot. Instead, simulated patients, with countless complaints, signs, and symptoms, will appear before students on a screen like a smartphone or tablet. Maybe, 3-D projection will be a reality in 10 years.


Simulation will also transition from a focus on emergent conditions, like chest pain, cardiac arrest, and heart failure, to non-emergent conditions that paramedics are increasingly called upon to assess and treat.


Scenarios might be focused towards the care provided by community paramedics, behavioral emergency encounters, or even coaching a patient's medication compliance.



The integration of simulation has exploded in just the last five years. We are beginning to see simulation training take new forms to include video games and 3-D immersive environments.


With current research leaning towards the use of video games to help identify knowledge deficits, we will soon see programs changing how they deliver education.


Over the next 10 years, I see video games playing an integral role in helping us identify areas we need to focus education and then helping us deliver it. I see simulation training growing to include a 3-D immersive environment that will allow us to replicate any situation without having to worry about a provider’s safety. There is so much out there, it is an amazing time to see the industry explode.