Paramedics who “hid” broke law, Canada inquest told

TORONTO — Two Toronto EMS paramedics who waited for police and delayed attending to a 911 call about a man who collapsed of a heart attack were breaking provincial law, an inquest was told Thursday.

Instead of hiding around the corner, out of sight of James Hearst’s downtown Alexander St. building, the paramedics should have attended and assessed the scene, said Rick Brady, a health ministry investigator.

By not doing so, Trevor Cornwell and Hayley Rothwell-Cusack contravened the Ontario Ambulance Act, he testified.

The act requires that paramedics who decide to withhold or delay patient care must “go to the scene, see it, make an assessment: Does the environment appear to be safe? Can I get out of my vehicle?” he said.

I’ll assume, for the sake of argument that Mr. Brady’s interpretation of the law is correct. If that’s the case, then the law is stupid. If there was a report of people shooting at each other, would the law require the paramedics to respond to the scene and make an assessment? Are the ambulances in Toronto bullet proof?

The inquest has been told the paramedics decided to “stage” or wait for police. An EMS dispatcher classified the 911 call as “unknown trouble” and put the code “HBD” (“had been drinking”) into the system because the original caller said the man had fallen on his face and looked like he “might be drunk.”

While I am sometimes critical of dispatchers, the truth is that for the most part they are doing their job blindly. They are relying on untrained people, some of whom are in a panic, some of whom are frankly just stupid, to decypher what is going on at a location where they can not see the patient or the surroundings. Cell phone calls are even more difficult because the person may not be at the scene, may have just driven by, may not want to “get involved”.

Lawyer Jordan Goldblatt, representing the paramedics’ union, questioned why Brady did not interview key EMS staff on duty that night…

Good point. A thorough investigation would include statements in writing from the participants and maybe even direct interviews by the investigators.

Goldblatt also contends that supervisors were negligent in monitoring the actions of the dispatchers and paramedics.

“I would have to agree that no one seemed to be paying attention to this,” said Brady, adding he had no reasons to question those people during his investigation.

No, wouldn’t want to talk to the people actually responsible for supervising the system. Nope, nothing to be gathered there. Why, it might even show that the paramedics were acting prudentely based on what they knew and that the supervisors dropped that ball. Even worse, it might show that the supervisors weren’t at fault and that it was upper management who failed to establish proper procedures.

That. Just. Will. Not. Do.

Let alone suggest that the law that the paramedics “broke” might in fact be broken itself.

After all, there are phoney-baloney jobs to be protected.

Harumph!

Far easier to go for the low hanging fruit and blame the paramedics.

A very busy and productive several days at EMS Today in Baltimore. The down side here is that when I had Internet access I was too tired or busy to do much other than skim email. When I had energy and time I didn’t have Internet access.

I’ll post a bit including some comments on goings on, including this foolishness,

Paramedics who “hid” broke law, Canada inquest told

The comment is that the “experts” who are criticizing the action of the paramedics should be flogged, tar and feathered, and then ridden out of town on a rail. Even though it’s Canada, which with apologies to my friends and readers in Canada, is full of stupid laws designed to make the lives of everyone harder, this is really stupid. Sort of like that politician down here in the US who criticized paramedics for not risking their lives on a call. I’ll include the reference to that in my full post.

More to come after food, a shower, and some sleep.

Dispatched for a “Cardiac Disorder”. One of about 500 a week that we go to 495 of which turn out to be not cardiac disorders. Some aren’t even in parts of the body near the heart. It’s just easier for the dispatchers to do it that way, so that’s what they do. On the way to the call we look at the comments on the screen. 38 male, pacemaker firing.

“Uh, isn’t that what it’s supposed to do?”

“Well, maybe it’s a demand pacemaker.”

“But how would you know if that was kicking in?”

“Well, maybe it’s an overdrive pacemaker for SVT.”

“Or maybe the dispatcher doesn’t know the difference between a pacemaker and a defibrillator.”

“Um, could be.”

We arrive in due course to see one of the BLS guys coming out for the heavy duty stair chair. Uh-uh. That’s never a good sign.

We walk into a well kept pretty messy apartment, which at least is on the first floor. We find our patient who is, uh, large. Very large. My guess is 400 pounds and I really should get a job guessing heights and weights at carnivals. I was about 10 pounds off, which isn’t bad.

“What’s happening this morning sir?”

“My defibrillator keeps firing.” To prove his point our patient let out a huge scream and levitated off the bed. Which to my amazement didn’t collapse into splinters.

“I see.”

“I was in for them to adjust it a couple of weeks ago and OWWWW – there’s something wrong with it.”

“I guess there is.”

The BLS guys had put the patient on O2, which wasn’t going to help but probably wasn’t going to hurt. Besides it looked like we were doing something while we got ready to do something. If you know what I mean and I think you do.
We also got a blood pressure, respiratory rate, and some history. The blood pressure was high, which was expected, the respiratory rate was a bit fast, but nothing worrisome. The history was as good as the patient could give, but wasn’t all that helpful. The list of meds contained no surprises. The medication surprises came later on, at the hospital.

While all that was going on I put the leads on and turned on the monitor, which showed us this,

“Hmmm.”

At which point things went, as Law Dog says, “Sideways”. But just a bit.

Those jumpy bits in the strip are where the defibrillator fired. While the doctors will tell the patient that the might feel a bit of discomfort if the AICD discharges, the truth is it hurts like hell. At least every patient that I’ve ever transported who has had his or her AICD discharge tells me. I think in this case, the AICD fired about 10 times in all.

I should mention that there were some shocks in this sequences that were not recorded on paper. While continuously recording “Arrhythmia Andy’s” performance would have been educational, it would have killed many trees and spotted owls. Nor was I always quite fast enough on the Print button to get all of the interesting rhythms. At one point it seemed that the monitor was defibrillating Atrial Fibrillation, but I didn’t think that’s what it was doing. In fact I was pretty sure that machine was shocking sinus tachycardia some of the time. Which certainly was not the way it was supposed to be.

Here is an example of what seemed to be sinus tachycardia, but clearly wasn’t. In this case it wasn’t being shocked, but you get the point.

“What do you think we should do?”, I asked my partner.

“Versed.” was the answer. I was pretty sure he meant for the patient.

Good plan, and since it was slightly outside of our protocols, or so I thought, we got on the radio and consulted medical control. Who OKed the Versed mainly because the doctor on the radio had no idea what our protocols are. I think my partner could have asked to cut the patient in half to count the rings and the doctor would have said yes.

While my partner was on the radio, I started the IV. If you’re in EMS you know what happened. I penetrated the skin, got a nice flash as the stylet pierced the vein, and then the defibrillator discharged and the patient levitated off the bed. Fortunately the IV stayed in and I was able to advance the catheter and then secure everything in place. Then we gave the Versed. Which I think mostly made us feel better, because it didn’t seem to help the patient all that much.

Now came the hardest part of the call. Which was getting the patient out of the house and into the ambulance. Fortunately the four of us were able to get him into the chair and down the mercifully short front porch steps without difficulty. Well, without MUCH difficulty, because a 390 pound patient always presents some obstacles.

In the ambulance, we got everything sort of settled in and started off to the hospital. We gave more Versed, but things seemed to be getting worse, not better.

That doesn’t look very much like sinus tachycardia, does it? My thinking was that we were dealing with Atrial Fibrillation. Interestingly, defibrillators are placed for Atrial Fibrillation, they are placed for people with Ventricular Tachycardia. Which, as I mentioned, wasn’t what was going on here.

And the patient kept getting worse. By now we, or at least I, had decided that maybe it wasn’t a defibrillator problem. After all, even at 38 a patient with as many problems as this guy has is a ripe candidate for developing all sorts of bad conditions. And so I got a brilliant idea. He still had plenty of blood pressure, his rate was taking off, he was feeling worse, his rhythm was irregularly irregular. It had to be Atrial Fibrillation, right? Now what do we do?

My partner looked at me and I suggested “Diltiazem.”

He agreed and I mixed up and drew the correct dose for a patient this size. Which was at the maximum for a patient of his substantial size.

Have you ever watched The Three Stooges? I have. A lot.

In one short, Moe comes up with one of his typical brilliant ideas. Larry and Curly start to do whatever it is they have to do in order to get the plan off the ground. The camera closes in on Moe and he says,

“It was my idea, but I don’t think much of it.”

Which is how I felt about the Diltiazem. I just had the feeling that it wouldn’t help and might hurt. Which I mentioned to my partner. Who said that he thought we should give it. I said that we should give the hospital a call and see what they thought. One thing about this partner is that when he gets an idea in his head, it takes a crow bar and an act of Congress to get it out. So, back and forth we went. And forth and back for that matter.

At which point the patient decided to entertain us by throwing another rarely seen, at least by me, rhythm our way.

So the monitor/defibrillator/pacer/toaster oven shocked the patient out of Atrial Tac (and yes it is almost at 300 beats per minute) into something else. Only it wasn’t entirely clear what something else was. Damn. Now the patient was feeling worse, getting really diaphoretic, and looking like crap. I gave up the idea of giving the Diltiazem just as we backed into the hospital.

Where we were greeted by an empty triage area. Well, empty except for the two ambulance crews and the triage nurse.

“Uh, where’s the trauma team.”

“Oh, do you think we need them?”

“Yeah, we thought that was made clear on the radio.”

“You called on the radio?”

I looked and around and we were in the correct hospital. At least to the extent it was the hospital to which the patient had said he wanted to go. I don’t know if it was correct in that it would give the patient the best care, but that’s the patient’s decision in this case.

So, we proceeded into the resuscitation room and the trauma team kind of wandered in. We gave the story, I printed out a 15 foot long Code Summary, and then stood back to watch. At first the doctors wanted to give Diltiazem. Then they thought maybe Amiodarone because it had to be Ventricular Fibrillation. Then, they looked again and it wasn’t Ventricular Fibrillation. So, they decided to give more Versed. And Fentanyl. If nothing else, the patient would be sleepy. “Resting comfortably” as they say.

Then they brought up his old chart. History of Ventricular Tachycardia. Did have a defibrillator. Had been in recently for an “adjustment”. Meds included Metoprolol. Is known to be none compliant with medications.

Ding! You are now free to control your heart rate.

Yes sir, the medications work a lot better when you actually, you know, take them.

So, they gave him some Metoprolol IV and his heart rate dropped down to a reasonable rate.

It turns out that there was a problem with his AICD and he was non compliant with his medications. The combination meant that his AICD was seeing what was his normal underlying Atrial Fibrillation, interpreting it as Ventricular Tachycardia and shocking it. He was admitted so that cardiology could correct whatever was wrong with his AICD in the morning.

My life would be so much easier if patients would read the text books. Oh, and take their medications. It’s almost like medications are designed to fix specific problems and that taking them might make the patient better.

It probably wouldn’t hurt if he lost a couple of hundred pounds too.

Not my call, but I heard about afterwards.

A unit was dispatched to an address for a serious burn call.

The comments in CAD were,

“Patient was smoking and dropped the cigarette down the hole for her Tracheostomy”.

That would in fact be a serious burn, but fortune was kind and the unit was cancelled.

Why were they cancelled?

“Caller states that patient coughed the cigarette back up and is OK now.”

Really folks, this is why I will never write a book. No one would believe I wasn’t making this shit up.

If the FDA could make a TV commercial with a person smoking through their tracheostomy hole (which I think they’ve done), then dropping the cigarette in the hole and COUGHING IT BACK UP, then the tobacco companies would be out of business in about a week.

My only question was if the “patient” finished the cigarette or lit up a new one?

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.