I saw this on Statter911. Although similarly titled, it’s different from Tuscaloosa’s “Pull to the Right for Sirens and Light.”

It starts out a little slow, but when “Simulation 2″ was playing, I really laughed out loud.

Enjoy.

This is a very funny music video from Diary of a Mad Firefighter/Plugs and Hoses Records, reposted after a bit of drama. There is nothing offensive or inappropriate in this video, but as usual, it was initially taken down because of concerns from the powers that be.

I absolutely love it when the firefighter walks into the wall in the dark at 2:05.

Enjoy.

Update #1:

Never mind – it was removed again. The powers that be apparently didn’t like the video. They usually don’t like anything, I’ve noticed.

Update #2:

I’ve just received permission to re-post it. Once it made its appearance that very first time, it quickly went viral, and it was hard to keep it from spreading like wildfire.

Update #3:

Since I’m not very hip, I didn’t even know what the original song was until it was pointed out to me. Of course, listening to that song only makes the EMS version so much more brilliant!

I happened across an article stating that the CDC’s statistics show that only 8 percent of ED visits are non-urgent. Now, ask anyone who works anywhere near an ED and s/he will tell you that number is absolutely bogus. Fuck, even the janitor will tell you that 8 percent is horseshit.

Of course, during the ensuing research, if you can call it that, I then came across this letter by Dr. David Stern blasting the methodology used by the American College of Emergency Physicians (ACEP) to obtain the numbers in the “non-urgent” category.

Being the nosy type, I went to the CDC’s website to see what this “non-urgent” business is, and according to them, it’s defined as ED patients who should be seen within “2-24 hours.” Problem is, there is no other category that is defined as “more than 24 hours”* or, similarly, “go home and you’ll get better with time and rest.” In other words, according to the CDC, even the most bullshit of patients should be seen within 24 hours. One must seriously question the meaning of these so-called categories of acuity.

If I, right now, walked up to the ED triage nurse and said I simply wanted to be seen for no particular reason, I’d be told to wait for my name to be called, and according to the CDC, and thus ACEP, I’d be categorized as a patient who should be seen within 2-24 hours. For no particular reason.

Besides, the EDs that I’ve been to do not even use any uniform method of classifying acuity, so how does the CDC even reconcile this basic difference? Details, people. Details.

Basically, if you don’t want to read the links, the story as I understand it is that the ACEP apparently is attempting to derail plans for payors to provide public education on what is and what isn’t an appropriate ED visit by obfuscating facts and statistics. Because, as we all know, ignorance is bliss, and those lazy EDs just aren’t busy enough.

Before finding Dr. Stern’s letter, knowing that 8 percent is unbelievably low for non-urgent ED visits, I thought to myself: What patients did I see during my last rotation at work?

• Chest pain
• S/p witnessed seizure
• ‘Flu-like symptoms
• Pseudoseizure
• Weakness
• Hypoglycemia
• “Infection” s/p hip surgery
• Back pain x 4 days – walked to gurney
• Blueberry up nose, supposedly – can’t find it
• Chronic leg pain
• Small leg laceration
• Multi-patient freeway wreck
• Auto-ped
• Drunk homeless guy
• Homeless guy with chest pain at payphone
• “I’m sick” at 7-Eleven payphone
• Weakness – 4th response in 2 weeks
• Drunk college kid
• Chest pain x 4 years

Don’t get me wrong; I love this work, as do the majority of providers. However, out of these 19 events, without remembering a whole lot of details – why waste brain space remembering most of this junk – I would argue that 12 of them are pretty much silliness, meaning that 63% of these patients are “non-urgent” by my definition and the way most normal providers would define it, NOT the way the CDC defines it.

Granted, this sample size isn’t large, but based on experience, I think it’s fairly representative of the types of patients we come across.

Eight percent, my butt.

*I’m using the 2007 form since the 8 percent ACEP quoted is from 2007.

When are we going to stop using the pain scale? We think it’s stupid. Patients hate it.

For God’s sake, we even named a pain scale.

(For this post, we’re not going to talk about the wussies, for whom everything from a cut finger to a stubbed toe is 10 out of 10 painful. They need no more attention from anyone.)

Some hospitals have made the pain scale “the 5th vital sign,” and, after some cursory research, which really just means that I clicked around, I’m told that this is likely thanks to JCAHO, now called TJC in an attempt to get away from the negative opinions it attracts the same way criminals use aliases. For folks outside of health care, JCAHO is the bureaucracy that believes that such attributes as the locations of trash bins and the number of times per hour the floor is mopped are actually very important in order for hospitals to maintain their accreditations.

(If you can find ONE patient-level provider who does not think JCAHO is absolutely ridiculous, I’m sure all of us would like to meet this person.)

Back in the real world, I must admit I feel like an asshole whenever I ask a patient whose arm fell off what number they would rate their pain. Even if I don’t ask for it – and trust me, most of the times I don’t – the ED will ask for it, not because nurses are blind to human suffering and deaf to all the screaming, but because that’s a box they have to fill out. It’s reached the point of asking for the sake of asking.

It’s quitting time when you preface the question with, “I know this is a stupid question, but…”

The only time I can see it being useful is when it’s used to compare the pain before and after interventions. But, only with reliable patients. Which means, perhaps one patient per week.

For instance, it has some value when we have patients rate chest pain. But, just as I do not typically pay a whole lot of attention to how patients subjectively describe their chest pain, mindful of how most sensations are beyond words and of the deteriorating language ability of the average person thanks to the deteriorating educational standards on this side of the planet, we should remember that asking them to assign their pain a number on a scale of 1 to 10* is just as subjective. And therefore not very reliable.

Now, as a very simple example, imagine for a second you’re having chest pain, and let’s say more likely than not it’s some legitimate badness, because there are sirens and I’m not hiding behind you in the jumpseat, ignoring you and doing paperwork. While you’re trying not to freak the fuck out over the chest pain and silently hoping I don’t have to stick you 4 times because you’re “scared of needles,” I’m making you come up with some random number on a scale of 1 to 10 after every spray of this disgusting, vaguely cherry-like substance that is giving you a raging headache, not to mention the dizziness and the blurry vision that come with it, obscuring the view of your life flashing before your eyes. Even though you’re convinced this is your last day on Earth and you wish you called your mother more often, you spit out a number a few minutes after every spray. How accurate do you think these numbers are?

(By the way, those of you who still push on patients’ chests to see if the pain is worse hoping to “rule out cardiac”: Please stop doing that.)

Besides, wouldn’t you agree that any subjective assessment tool that gets the same result – 10 out of 10 – like 90% of the time is just pretty much useless? (OK, I guess we had to get back to the wussies at some point.)

*Some providers say “on a scale of 1 to 10″ and others say “on a scale of 0 to 10″ – which is it? I submit that, rather intuitively, “0 out of 10″ means no pain. Since the simple fact of having pain typically leads providers to asking for a rating on the pain scale, it would seem that “on a scale of 0 to 10″ is a little redundant, since no patient is going to say “0 out of 10″ after being asked to rate his/her pain after complaining of pain. If s/he does, then s/he is an idiot, and definitely don’t give that asshole any narcotics, unless you want your bosses on your ass. In either case, I don’t really give a shit because the pain scale is stupid. Have I mentioned that already?

“Can you tolerate being bamboozled by your patients from time to time?”

In this discussion, I think there is some context that is a bit lacking that needs to be laid down first. Specifically, what is our starting point?

If you work in a system with conservative pain management, then the concern is you’re not administering enough pain medication to enough patients. Conversely, if you work in a system with liberal pain management, then the concern is which patients you’re giving it to.

While I generally agree with the idea of aggressive pre-hospital pain management, I feel that this seemingly new trend towards very liberal, blanket pain management is just too much. It seems like a classic case of over-correction (of the past practice of very conservative pain management). I’m not referring to the safety issues of the various medications that we could use, although balancing risks (potential adverse events) and benefits (relieving bullshit pain) should always cross a provider’s mind, and I’m not referring to the basic, noble idea of relieving somebody’s pain, but rather, I’m displeased by the inappropriate selection of patients for IV pain medications. It’s almost as if people aren’t even thinking about who they’re administering medications to.

Lost in this rush to medicate everybody are basic techniques that work, such as proper splinting, traction, ice and psychological coaching. People tend to forget to use any of these methods before starting IVs and pushing medications or even after they’ve given the medications. I’m not much into cliches, but “BLS before ALS” isn’t necessarily a bad thing here. Besides, I don’t like seeing crews spend time starting IVs on calls before, say, for instance, properly splinting a fractured leg when even the patient tells them the pain is tolerable; it seems like misplaced priorities.

There are always going to be drug seekers, and there are always going to be people who are truly in pain. Our egos take a hit when they fool us, but it doesn’t really matter because it’s ultimately not really our job to decide who falls into which category. Besides, it’s not our dope.

But, at the same time, in many cases, it’s painfully (unintended pun) clear whether patients are full of shit or not. I do not agree with either extreme – either we act like the candy man and give everyone pain medications or we don’t give anyone anything. If it’s not clear if someone’s seeking or truly in pain, certainly there’s nothing wrong with medicating them.

Coincidentally, ERP had 2 posts not long ago, one after the other, in which he encountered a patient who deserved all the narcotics he could handle and 2 other patients who were so clearly seeking. He also posts about drug seekers quite often, and they’re pretty funny.

Am I, as a transport medic with short contact times, going to give IV pain medications to the lady who calls every day for the same pain? Probably not.

The guy who falls asleep on the gurney after complaining of 20/10 pain? Probably not.

The patient against whom EDs have restraining orders because of drug-seeking behavior? Probably not.

“Where the fuck is my fucking dilaudid?” Probably not.

The patient calling from a ED lobby complaining of whatever pain wanting to go to a different hospital? Probably not.

The patient who doesn’t even want medications, even if a bone is sticking out of their body? Probably not.

The patient with a broken finger or an ankle sprain? Probably not.

Menstrual cramps? Probably not.

Toothache? Probably not.

These are just hasty examples, so don’t anyone get all literal on me.

Besides, in these parts, EDs are often way too busy and many ambulance patients are sent to the lobby. EDs absolutely hate it when you bring them someone they want to put in the lobby appropriately but can’t because you’ve inappropriately medicated them, especially when they are already scrambling to find beds for legitimate patients who have been waiting in the lobby. Right or wrong – I’m all for a smooth transition. If that means helping to maintain the actual-sicker-people-first order at the ED, if that means trying to be more in tune with what the EDs want so I don’t have to wait with the patient for a bed for an hour or two and instead be available again in the system for the greater good, i.e. overall system status, then I will do exactly that. It’s a trade-off. Nothing is perfect. In a perfect world, everyone gets everything they want. But this is an imperfect world, and when there are no units available, you do what you can. It’s almost like a mini-MCI in your daily routine, spread out over a larger area and a longer timeframe.

Fundamentally, it’s no different than the concerns about liability The Happy Medic and EMS 2.0 folks raise:

Imagine I take Erma Fishbiscuit in because her dial a nurse told her to call 911 to arrange her colonoscopy.  Erma demands transport and I am bound by law to oblige her, regardless of her lack of need of an ALS ambulance.  We take her because of a perceived liability, that if we don’t take her and she sues us we will not like it one bit.

5 minutes after getting Erma loaded up a code 3 CPR in progress comes in next door to Erma and a 6 month old child dies before ALS can arrive on scene.  Are we liable for not having more ambulances?  Which liability is greater?  Which liability makes national headlines?

Or:

“Your honor, we had no ambulances because Mr Johnson’s neighbor made us take her in for a sore throat.”

Let’s say I cater to the patient’s demands for pain medications, even though it’s totally silly (and we can name countless examples), because only the patient’s opinion and perception of pain matter, as some people have suggested. (Since when do we provide patient care based solely on whatever other people tell us?) We wait a long period of time for a bed, unable to respond to other calls for service, when without pain medications, this patient could have easily and safely (and deservedly) gone to the lobby. Multiply this by whatever number you want representing other units in the system, because, let’s face facts, some type of “complaint of pain” is frequently one of the most common category of response. I just don’t see blindly medicating everyone as being responsible.

Spending time transporting the sore throat and as a result being late to the VF code is not really all that different from spending time sitting in triage and being late to the VF code. Since the ED staff routinely asks for our input when deciding who goes to the lobby, I’m unwilling to handicap them by making a lobby patient into a room patient because of IV access and medications.

There are also folks out there who say we can’t be 100% correct in sorting out the bullshit, so we shouldn’t be judging at all, in case we miss a legitimate patient, and we should instead be indiscriminately handing out pain medications like candy. I don’t agree with that at all. Following that logic, we’d be:

• Giving Albuterol to anxiety/hypervents because we might miss bronchospasm.
• Putting everyone in C-spine, never mind that it’s probably one of the 2 remaining bastions of old wives’ tales in patient management.
• Bringing all chest pains to cath labs because we might miss a STEMI, especially given the low sensitivity of most algorithms.
• Bringing all ALOCs to stroke centers because we might miss a hot stroke. (If you think cath labs and stroke centers don’t mind false activations, think again.)
• Giving D50 to all ALOCs even without hypoglycemia. (Wait, didn’t we do this 20 years ago… oh, right…)
• Let’s not even mention trauma centers.

Since missing any of the aforementioned conditions is actually more serious than missing a true candidate for pain medications, I would say that a few patients who didn’t get any pain medications when they could have used some isn’t the end of the world as some folks have suggested. In other words, I’ll readily accept responsibility for not going to the cath lab when I should have, but I’ll be less willing to take the blame for not administering pain medications when I could have. Yes, it’s easy to say when I’m not the one in pain – and I have experienced pain (while sucking it up big time) – but medicine by nature is never 100% and it’s not going to change. I would prefer that I be 100% correct, but that’s not going to happen.

I feel that anyone with half a brain can reliably and consistently figure out who is truly in pain and uncomfortable and who is not. We should emphasize thinking before we do something.

Providence Fire Department’s Lt. Michael Morse, who wrote the book Rescuing Providence, has a sequel, Night and Day, scheduled for release in the fall of 2011.

Go leave a comment on his post.

Great news – in his latest EMS directive, Happy Medic has just announced the addition of a new medication, Realitee (Worldnotwhatyouthinkatall HCL), to the list of supplies that we carry.

It will nicely complement the other medication he approved for use several months back – the Maan Pill (Maanitoll).

Happy Medic, can you come be my EMS Supreme Chief Overlord (EMSSCO)?

This website has gone pink for October.

I was going to list some web resources for breast cancer, but decided against it since it’s difficult to sort out what organization has what ulterior motive. So, instead, I’m just turning the website pink (without ribbons) to remind you to think about breast cancer, which, like many other diseases, has been linked to environmental pollution and chemicals used in everyday products.

I recently came across a thread discussing whether a strip was VT or SVT with aberrancy. Never mind that a wide-complex tachycardia is VT unless you can prove otherwise. Just about everyone in that thread was all too happy to call it SVT using a bunch of really questionable criteria that don’t even apply. (Tom – I feel your frustration.)

In this thread, at some point, someone said, “Treat the patient, not the monitor.”

There is no doubt that that is a useful saying in EMS. However, in this particular case, it seems an odd statement to make when the discussion is specifically about the EKG itself. Of course we’re looking at the monitor. (Or, rather, at the tracing on paper.)

Furthermore, what is it exactly that looks different on the patient – other than the monitor – that would determine if it’s VT or SVT? Do patients with VT look different from patients with SVT in a very specific way other than what’s on the monitor? Is there a pathognomonic sign for either one?

Aren’t there VTs – usually the more unstable of the two – that are stable?

Aren’t there SVTs – usually the more stable of the two – that are unstable?

So, how do you look at a patient for the EKG tiebreaker in this case? It doesn’t make much sense.

I don’t come across very many law-abiding citizens who say the cops are harassing them.

Anyway, I just couldn’t resist after seeing this absolutely funny post titled “Why do cops get to harass people?” on Motorcop:

Recently, the Chula Vista Police Department ran an e-mail forum (a question and answer exchange) with the topic being, “Community Policing.”

One of the civilian email participants posed the following question: “I would like to know how it is possible for police officers to continually harass people and get away with it?”

From the “other side” (the law enforcement side) Sgt. Bennett, obviously a cop with a sense of humor replied:

“First of all, let me tell you this…it’s not easy. In Chula Vista , we average one cop for every 600 people. Only about 60% of those cops are on general duty (or what you might refer to as “patrol”) where we do most of our harassing.

The rest are in non-harassing departments that do not allow them contact with the day to day innocents. And at any given moment, only one-fifth of the 60% patrollers are on duty and available for harassing people while the rest are off duty. So roughly, one cop is responsible for harassing about 5,000 residents.

When you toss in the commercial business, and tourist locations that attract people from other areas, sometimes you have a situation where a single cop is responsible for harassing 10,000 or more people a day.

Now, your average ten-hour shift runs 36,000 seconds long. This gives a cop one second to harass a person, and then only three-fourths of a second to eat a donut AND then find a new person to harass. This is not an easy task. To be honest, most cops are not up to this challenge day in and day out. It is just too tiring. What we do is utilize some tools to help us narrow down those people which we can realistically harass.

The tools available to us are as follows:

PHONE: People will call us up and point out things that cause us to focus on a person for special harassment. “My neighbor is beating his wife” is a code phrase used often. This means we’ll come out and give somebody some special harassment.

Another popular one is, “There’s a guy breaking into a house.” The harassment team is then put into action.

CARS: We have special cops assigned to harass people who drive. They like to harass the drivers of fast cars, cars with no insurance or no driver’s licenses and the like. It’s lots of fun when you pick them out of traffic for nothing more obvious than running a red light. Sometimes you get to really heap the harassment on when you find they have drugs in the car, they are drunk, or have an outstanding warrant on file.

RUNNERS: Some people take off running just at the sight of a police officer. Nothing is quite as satisfying as running after them like a beagle on the scent of a bunny. When you catch them you can harass them for hours.

STATUTES: When we don’t have PHONES or CARS and have nothing better to do, there are actually books that give us ideas for reasons to harass folks. They are called “Statutes”; Criminal Codes, Motor Vehicle Codes, etc… They all spell out all sorts of things for which you can really mess with people.

After you read the statute, you can just drive around for awhile until you find someone violating one of these listed offenses and harass them. Just last week I saw a guy trying to steal a car. Well, there’s this book we have that says that’s not allowed. That meant I got permission to harass this guy. It is a really cool system that we have set up, and it works pretty well.

We seem to have a never-ending supply of folks to harass. And we get away with it. Why? Because for the good citizens who pay the tab, we try to keep the streets safe for them, and they pay us to “harass” some people.

Next time you are in my town, give me the old “single finger wave.” That’s another one of those codes. It means, “You can harass me.” It’s one of our favorites.