I received an email from a friend of mine who is an EMS supervisor over across the Atlantic in Great Britain,

The gray mafia here have decided that in their relentless aim of blaming Ems for Amy infection in hospitals, that we should only be allowed to wear gloves that come out of packets.

They do not have to be sterile or individually wrapped, but they cannot be in a pocket or belt pouch.

While this may work in a lot of environments, I am concerned that it will encourage some staff to put gloves on when they get the call, and keep them on until they are back in the truck.

Personally I will often use several pairs of gloves on a call. I don’t like having the same pair on for any length of time.

On one of my previous trips across the pond I saw a supplier that did a small pack that was designed to hang on a belt. It had four or five pairs of gloves in.

Does anyone know who they were made by? Any good?

I couldn’t help him with the glove problem, but it certainly started me thinking. For almost as long as I’ve been in EMS, nurses have been trying to blame EMS for giving patients infections. They seem to not understand that it’s a dirty world out there. They also don’t seem to understand that the purpose of the gloves we wear is to protect US from the PATIENT, not the other way around. The patient is the one with the medical problem, not us. At least that’s a good presumption.

On my ambulance there are several boxes of gloves in various sizes. There are N95 masks, surgical masks, eye shields, some Tyvek apron things, and lot of disinfectants. All of those serve to protect me from exposure to the yucky things that patients already have.

We talk about sterility in EMS, but it’s more myth than fact. Very clean is an achievable goal, but sterility isn’t. IV insertions are about as close as we come and I’m always leery when hospital staff tells us about the rate of infection from out of hospital IV placement. They cite studies, but can never seem to come up with one when asked. Or they’ll say, “It’s an internal study and we can’t release the data.” Right.

Intubation? Not sterile.

One little fact that seems to escape a lot of in hospital people, is that trauma patients aren’t sterile either. You’d think that they would know that because one of the first things that happens to trauma patients when they come in is that they get IV antibiotics. Lot’s of IV antibiotics.

I haven’t done a peer reviewed, double blind, IRB approved study, but I’d be willing to bet that bad guys don’t sterilize their bullets or knives before they go out to shoot or stab anyone. Nor does the city sterilize the street before pedestrians get run over.

If the Gray Mafia in Great Britain are looking to find and fix the source of patient infections in hospitals, maybe they should look in the hospitals instead of coming up with dumb ideas about gloves in ambulances.

Up to 1,200 patients died unnecessarily because of appalling care

Labour’s obsession with targets and box ticking blamed for scandal

Patients were ‘routinely neglected’ at hospital

Report calls for FOURTH investigation into scandal

I think more than having EMS crews use gloves in pouches is in order here.

Related to me by a guy on the day shift.

They responded to a report of a rollover with entrapment.

Oooo, exciting, the bad one, big time trauma, right?

Think again.

They responded to find the vehicle on it’s roof, driver still strapped into her seat, upside down.

Talking on her cell phone.

Not injured of course.

Especially if I could hook it up to certain dispatchers. But I digress.

The Race to Build a Real Star Trek Tricorder

The X Prize Foundation has set up multimillion-dollar rewards for lunar landers and ultra-high-mileage cars. Its next contest is straight out of sci-fi: The X Prize is asking scientists to envision and build the equivalent of Star Trek’s medical tricorder, a device that can remotely diagnose any malady in patients.

“Healthcare today certainly falls far short of the vision portrayed in Star Trek,” Paul Jacobs, the head of Qualcomm, says.

That’s probably because Star Trek was set in the 23rd century and this is the early 21st century. We’re way ahead of where a lot of people thought we would be at this point in time. Me included.

But Kalmar, a neuroscience Ph.D., says she can imagine something as simple and ubiquitous as a camera making other measurements to serve as a proxy for a brain scan. For example, gauging reaction time or eye movement could indirectly gauge brain activity or help to diagnose illness.

I’m sure she’s smart, but does she have her own TV show. You know, like Dr. Mayim Bialik? Sorry, I’m digressing again.

Indeed, Misczynski says, many if not most of the technologies and sensors that you might envision being in a tricorder already exist, but nobody has really thought about combining them before, which is why he’s excited about the contest. “Medicine is a bunch of silos,” he says. “The cardiologist wouldn’t even think of talking to a pulmonologist.”

And of course NO ONE will shake hands with a Proctologist. There is one place where all of these devices would come in handy. Well, one in the hospital and the other one being…

EMS.

Not only would an all in one device like this, especially one that is completely none invasive, be helpful in emergency situations, but if something like EMS 2.0 ever gets off the ground this would help our futuristic primary care paramedics to treat their patients.

The $10 Million dollar prize is very nice and will spur research, but if the military takes an interest, there will be a lot more money for R&D. After all remote diagnosis has huge potential for the battleground. In fact there is a lot of research going on in the military right now for what they call telemedicine

So, the end result of this X-Prize may not be Dr. McCoy’s medical tricorder. But Bartholomew says the tie-in with Star Trekmakes more sense than you might think. “Any futuristic story is inspirational—creating stories and technology breakthroughs can be surprisingly similar. Its power and draw is something that people can understand,” she says. “Ultimately, we’ll change what people think is possible.”

I received an email from a younger friend of mine who is a paramedic. He’s  been expanding his EMS horizons and is writing for his state’s EMS magazine.  Here is his email,

So, I've been writing a con-ed article for the state's EMS magazine about
airway assessment.  The state employees who edit the magazine aren't EMS
certified, so they sent the article to some paramedics they knew to review  it.

The paramedics complained that the article covered things they didn't know
about.  Isn't that the point of continuing education?

Oh, what a naive young man he is. Doesn’t he know that EMS continuing education is supposed to consist of continuing to repeat the same old material, often with bad and outdated information? What could possibly make him think that anyone in EMS would want to learn something new? It’s not like medical science ever advances or that new techniques are discovered or that old theories are proven to be wrong and must be discarded. No, it’s well established the medicine, particularly EMS, is tried and true and there can be no new material to be learned.

Why, if we followed his lecture, paramedic refreshers might not consist of repeating the same lectures that were given during paramedic school. How are tired paramedics supposed to get any sleep during class if lecturers insist on abandoning the tired old droning lecture, lame ancient jokes and all, and replacing that with NEW material. Why, this could lead to people having to pay attention. Hell, they might even learn something that they can use to treat patients more effectively.

That. Will. Just. Not. Do.

I understand those paramedics criticism, I wholeheartedly support their insistence on not improving their minds or learning anything new.

Next thing you know, people like my young friend will insist that we have some scientific basis of administering the treatments we do.

Someone is just not clear on the concept of continuing education. I’m just not sure who it is.

We all have them and I probably have more than most people because I’ve been around longer than most people in EMS. I suppose I could call it “Stuff that makes me cranky.” but we don’t have that much time.

Hospital notifications. Two peeves. One, people who spend way too much time on the radio. All the hospital needs, and generally wants, is to know what resources they need to muster for your patient. PMH, Meds, Allergies, shoe size, astrological sign, favorite color, and such can wait until after you get to the hospital. After about 30-45 seconds, the nurse who is taking the report has lost interest and mostly stopped listening. Keep it short.

Hospitals that want notifications on all transports. Really, it’s an emergency department, you shouldn’t have to be told when an ankle sprain is coming in. A radio notification should be reserved for when you have an acute patient coming in or if there are some weird circumstances you need to get weird circumstance resources ready for. If the ED staff is going to have to announce the hospital equivalent of “Air raid, Pearl Harbor. This is no drill.”, then you have a right to expect a notification. If it’s an 900 year old nursing home patient coming in for his eighth G tube change of the month, you should be able to deal with that without the crew calling in for a reservation.

Finally, I guess this makes three, if a crew calls in and says that they need the resuscitation room, get the room ready. Telling them that you’ll assess the patient at triage and make that decision is just asking for a crew to walk in with a cardiac arrest sans courtesy call just to see what your assessment will be. Just saying.

Now on to my pre-hospital, ahem, colleagues, especially at the BLS level.

A “tight Asthmatic” is one who is making no or minimal breath sounds. The patient that is wheezy like a calliope, speaking on the phone to her BFF, and barely inhaling any of the life giving nebulizer mist is not “tight”. At least not in the lung department. A noisy patient has what we in EMS call a “musical” wheeze precisely because they are moving enough air to make noise. They probably still need a nebulizer and might, just might, need ALS, but they are not tight.

A 20 year old college student who has had too much to drink is drunk. Their mental status change is due to ETOH, not hypoglycemia. Put the glucometer away, because they do not have ALTERED MENTAL STATUS, they are shit faced. The only exception to this is if the patient happens to be a Type I diabetic, then it’s possible that they have a dual condition. Still, that’s pretty rare. The “epidemic” of diabetes is Type II diabetes and it’s mostly among older people, not younger college students. By the way, when I went to college, I could hold my booze. Another failing of the younger generation.

A patient with a supine blood pressure of 80/P is not someone who you want to sit up to “see if they are postural”. Take my word for it, they are. Put them on oxygen, monitor their airway, call for ALS, and start figuring out how you are going to get them to the ambulance. Again, take my word for it, they ARE going to the hospital. Oh, forget the stair chair, because they are going out of the house flat or as flat as we can get them. Backboard, scoop stretcher (a versatile device for extricating patients), or some other form of stretcher is the ticket. If they must go in a chair, turn the chair around so that when you go down stairs, they are head lower than feet. And for the love of God, wrap them in nice warm blankets, even in the summer. Remember being cold is part of shock because of the shut down of peripheral circulation to supplement central circulation. Day Five of EMT school as I recall. Unless you slept through that lesson the firs time and every refresher since.

Use some common sense with Oxygen. There is nothing, I repeat nothing, in the protocols that says all patients need a non rebreather if they get Oxygen. Nor is there anything that says that the regulator has to be set to 15 liters per minute. The correct way to set the regulator is so that the bag slightly deflates on inhalation. It does not have to be constantly inflated like the Goodyear Friggin’ Blimp. Frankly I think that most patients will do better on a nasal cannula set to 3 or 4 liters. I kid not when I say that Oxygen is over rated and over used in EMS. There’s no science that says it helps in most cases and some that says it hurts. I know that they don’t teach EMTs that stuff in school, but you can look it up for yourself. If you only know what you learned in EMT school, you’d best find a new line of work, this one doesn’t suit you so well. When ever you do use a non rebreather remember that you have to be more vigilant monitoring the airway. When a patient vomits into a mask the tend to have some of that vomit go back into their airway with disastrous results. In that case you’ve not only not helped the patient, you’ve done demonstrable and considerable harm to them. A sure fire way to get into the Journal of Iatrogenic Medicine.

Finally, if you find yourself with a patient that is much more ill than the geniuses in dispatch were able to figure out and you can get to the hospital before ALS can get to you and the patient follow this simple advice. Go to the hospital. There is plenty of ALS there, at least in theory. If you are sitting on scene, with your thumbs up your ass, you aren’t helping the patient.

That’s enough grumping for now.

I found this article New ambulance design: Making responses fit for the 21st century at the EMS1.com website and was excited to read it. Well, until I read it, that is.

What I found was a bunch of “advances” that are all pretty much common on North American ambulances and have been for years. I won’t quote the entire article, you should read it yourself, but I will quote some parts and add my own pithy comments.

‘Nobody, until now, has stood back and looked at the design of an ambulance with what it has to do now, where you’ve got paramedics that are trained to diagnose. They don’t just have to take people straight to A&E; they carry quite sophisticated drugs with them, they prescribe and administer and they can actually discharge people on scene.’

Except that 60% of the time, they do have to take people to the hospital. Which is why ambulances are designed to do just that.

The first rather radical step in terms of research was for members of the Hamlyn design team to ride with an ambulance crew on full 12-hour shifts around London.

Oooo, radical. 12 whole hours to see what paramedics do, so now they are experts in ambulance design.

Part of the solution was a ‘working wall’ that had all the equipment readily available, including five universal treatment packs containing consumables for commonly occurring call-outs – namely wound dressings, airways and oxygen, maternity, burns and cannulation. ‘So that it almost jumps to you rather than going to a cupboard and finding your way,’ Fusari said.

Does he mean to say that ambulances in England don’t have jump kits, primary bags, airway bags, or whatever they might be called? On each call do the medics have to go to the “cupboard” and scoop up an armload of equipment and supplies? One of the very first things I had to do when I first started working on an ambulance full time over 30 years ago was to buy my own jump kit. I could fill it with supplies issued by my agency, and the agency even had issued kits I could use if I wanted to. Only no one wanted to because they were so lame. They weren’t made to be useful, they were made to comply with state regulations.

By creating a leaner internal environment, the team was able to free up space and move the patient trolley bed into the middle for 360° access. In current ambulances, the trolley is clamped to the right-hand side of the wall, making it difficult for paramedics to work on the left-hand side of the patient.

Another modification was to include a moulded composite interior with just two components, creating a single seam in the middle, complete with curved, flushed surfaces for shelves and cupboards. This was intended to help with infection control.

This isn’t a bad idea, but two pieces is. Inevitably, something will crack and need to be replaced. With the current design with all those panels and screws, if a panel breaks, it can be replaced. A modular design will require half of the interior to be replaced. Seems like a waste to me.

The overhead monitor above the patient trolley folds down and carries all the functionality of a Lifepak 15 device, including a defibrillator and a monitor for oxygen saturation and blood pressure. The monitor also has a video link to the receiving hospital doctor or expert consultants for complex cases.

So, the patient has to be dragged out to the ambulance to be attached to the cardiac monitor? In the late 1970s when the LifePak 5 was introduced paramedics finally had a lightweight cardiac monitor/defibrillator that could be easily brought to the patient’s side. Ever since then the trend has been to make equipment more capable and keep the portability factor constant. The industry hasn’t always succeeded, but the trend has held in general. With this innovation we are faced with bringing the patient to the ambulance to see what their heart is doing or duplicating equipment by having a fixed monitor AND a portable monitor. That not only sounds inefficient, it sounds expensive. And impractical.

The link to the hospital doctor or expert consultant has been tried and isn’t really practical. Emergency Departments, at least around here, are way too busy for doctors to stop what they are doing for a video conference. Nor do I see them making decisions without having the patient in front of them and being able to examine them.

Of course the UK system might be totally different.

Meanwhile, the driver’s console includes satellite navigation as well as the option to see what’s going on in the back.

Satellite navigation = GPS box. Which most of the ambulance services around here have had for 5 or more years. Cameras in the back? The driver should be keeping his eyes on the road, not the patient compartment. No mention of a back up camera, which seems to becoming more or less standard on ambulances in the US.

Finally, there is a handheld digital tablet for administration and entering patient reports. Data from the central monitor is automatically uploaded to it.

Been there, done that, got the stylus. Really, this technology has been around since the early 1990s, although it’s improved dramatically in the past 10 years. I can upload ECG data into my patient care report and then upload that to a central server for billing, case review, court testimony, and complaint investigation. It is not, as a friend of mine says, rocket surgery.

It seems that what the designers have done here is not create a new ambulance, but have tried to transform it into a primary care vehicle. Here are things I don’t see in the not very well done video or the artist renditions in the referenced article. Back boards, splints, scoop stretcher, stair chair. Do ambulances in England now have those devices? Every one of those devices is designed to facilitate treating and moving an injured person to the ambulance and thence to the hospital. An absence of any reference to them reinforces my thought that this isn’t an ambulance, but a primary care delivery vehicle that will secondarily transport patients to the hospital.

That this is hailed as a 21st Century design has me baffled. There is little new here, little that is not already in common use in many ambulance services. There is also little that is going to make the daily work life of EMTs and paramedics any easier than it is now.