168 hours a week

I happened to glance at the paper the other day and noticed a letter written by a reader, responding in agreement to an earlier article, complaining about how in a certain city average public safety salaries were significantly higher than that of other city employees. That really irked me. Never mind, for a second, that the media gets most details wrong usually with lies, half-truths and omissions anyway. Most city services are open for business 40 hours a week, if you’re lucky. Public safety agencies – police, fire, EMS (not to mention hospitals, jails, etc.) – are open all 168 hours a week. That means nights, weekends, holidays, blizzards, etc.

A bit of basic mathematics: 168 hours divided by 40 hours is 4.2.

Roughly speaking, I would expect something that is operating 4.2 times longer to cost quite a bit more. But, that’s thinking that seems to have eluded many folks.

Anyway, I’m sure you’ve heard these silly questions before:

“Is the fire station open at night?”

“Who goes to the calls at night?”

“Do you need training for this type of work?”

“Can I call 911 after hours?”

“Do you sleep at night?”

“Do you go to calls if you’re sleeping?”

Amazingly, it’s the people who seem to have their shit together who ask these questions. Which is kind of funny until you remember that these folks are often asked to vote on issues that directly affect our operations. And then you remember that there are still people wondering about the President’s place of birth. Eventually at some point you start to wonder if Canada is still taking applications for residency.

Serving on the first “death panel”

Continuing along the same lines, I saw an excellent article a few days ago about end-of-life decisions.

These questions appeared trite and inconsequential compared to those I posed to Grace, but by the end of this tedious national debate it was easy for me to imagine that my questioning would quickly be met with suspicion and scorn. I feared that the complete breakdown in civility manifested by our leaders in politics and media would taint the real health-care issues I had to deal with daily.

Most of us in this little world of ours know the importance of these decisions. Unfortunately, most of the people we see at work don’t. The shameless political hysteria surrounding this issue does no one any good. The real point here is – no matter what your decision is – it’s important that SOMEONE talk to you and your family about this at some point in time before someone like me asks if there is a DNR or some form of advance directive. And then you say “no” when you wish there were.

In my experience in my little corner of the world, primary-care physicians who should be doing this have failed spectacularly at this, just like OB/GYNs have failed spectacularly at educating patients about safe sex and birth control. Over the last few years, I’ve grown tired of waiting for them to do it, and any appropriate opportunity I get, I talk to patients and their families. I’m sick of running codes that don’t need to happen. There is no dignity in an unnecessary resuscitation.

Firestorm

I’ve been away from blogging for a while (and you can see the gaps in my archives; most of those posts are still in the draft section), and apparently in my absence a lot of things have been happening, from the emergence of countless elaborate and well-written blogs to new media projects.

Filmmaker Julie Winokur and photographer Ed Kashi made Firestorm, a documentary that follows LAFD’s Station 65 as they navigate this broken health care system, also known, inexplicably, as “the best health care system in the world” to some people. Now, I know this topic gets people all worked up, but I want to emphasize that I don’t write this blog to be political. That being said, whichever party you belong to, if you cannot see that the health care system in the US is broken and/or are unwilling to do anything about it, then I simply cannot agree with you.

Anyway, here’s the trailer:

What’s a condom?

Code 3 for abdominal pain.

An attractive 18-year-old is complaining of suprapubic cramping. Unusual in the ghetto. She is 10 weeks pregnant. Not unusual in the ghetto.

On our way to the hospital, I begin to remember.

“Didn’t we take you to the hospital a few weeks ago?”

“Yeah.”

“For the same thing?”

“Yeah.”

She starts crying.

“I’m tired of this.”

“Well, these things happen, especially with a pregnancy.”

“I know.”

“Do you know who the father is?”

“Yeah. But he doesn’t care.”

“That’s why you have to protect yourself and use condoms. It’s unfair because you’re the girl, but you’re the one who has to deal with this pregnancy and everything that comes with it. You have to think about yourself because boys aren’t going to.”

“What’s a condom?”

So thanks to the unrealistic and unreasonable ideology of groups hostile to birth control and family planning, the most vulnerable can’t even get something as simple as a bit of knowledge about condoms, let alone get them.

Too many babies

Usually, when someone is about to give birth, there is a lot of planning that goes into it. Dry runs to the hospital with family members, tours of the L&D wing, check in with the OB/Gyn doc, etc.

Now, in the poor parts of town, why go through all that trouble when you can just pack your bags and call 911 when you – correctly or incorrectly – think that you’re about to go into labor? Unlike your baby-daddy, the medics will get you to the hospital. The medics will get you to the right floor within the hospital. Besides, the medics don’t require cash on the spot like cabs and buses do. And when you get there, the staff will call your doctor for you. You don’t need to do anything at all. All you need to do is, after the baby is born, call 911 when it spits up milk. But that’s another story.

We issue driving licenses and still, look how many problems, inappropriate behavior and illegal activities are associated with them. It’s only logical that getting pregnant is regulated on some level. There are always a bunch of people who are against abortion for whatever reason, so why not restrict pregnancy? Fines and community service make a lot of sense, and they can partially offset all the money that is spent on all these unnecessary pregnancies and child care issues and all of their associated financial implications.

Resistance

A longtime medic told this story about resistance to change in the fire departments. In 1983 he was to teach the first EMT class at a fire department, then at the beginning of the process of training every firefighter to at least this basic level of care. At the time, firefighters were only trained, medically, to the first responder level, which is akin to first “don’t move the patient and wait for help” aid.

An EMT class is about 120 hours long. Nothing brutal. And they got paid to be there. Overtime. But firefighters resent medical responses, and even to this day old feelings die hard.

The medic introduced himself, and asked if anybody had any questions.

“Yeah, why the fuck do we gotta be here?”

The union got the class canceled 3 days later.

Can’t swing a dead cat…

USA today had an article dated May 21, 2006 on paramedics, well, too many paramedics… A new study found that survival rates for out-of-hospital cardiac arrest were higher in cities with fewer paramedics per capita. This mirrors USA Today’s findings, first published in their special report, “Six Minutes to Live or Die,” in 2003, that called into question the national trend of putting firefighter-paramedics on fire companies.

The reason, at least the one stated publicly, that fire apparatus are carrying paramedics is to decrease the response time for paramedics in medical emergencies. Fire stations are everywhere, and it’s extremely impressive on paper to have ALS capabilities in less than 4 minutes on every medical call. In cardiac arrests, especially ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), it is absolutely essential to have a defibrillator on scene within 4-6 minutes for the patient to have any chance of meaningful survival with limited disability.

However, the majority of 911 calls for medical assistance are not cardiac arrests; instead they are for such minor medical problems as cut fingers, ‘flu-like symptoms, homeless alcoholics, baby spitting up, etc. This is not to discount such requests, but certainly an ALS engine response and an ALS ambulance response is a bit of a waste of resources, like arresting, without evidence, a teenager who wasn’t driving for a hit-and-run that no one saw. In tiered systems, calls deemed to be not life-threatening are handled by BLS units, simply because there is no need for ALS personnel who can be better used on more serious calls. In other words, save the paramedics for the good stuff. Paramedics would be thrilled to be able to avoid calls that any taxi can take care of.

Now, some have suggested that the use of paramedics on fire apparatus is motivated by self-interest. Fire departments have – along with powerful unions and excellent public relations machinery – big budgets. But years of public education, prevention and enforcement, coupled with modern construction techniques and strict building safety codes, have so dramatically reduced the number of fires that fire departments don’t have much to do these days. Simply put, in order to justify their budgets, they respond to medical calls to bump up their call volume, which, for the reasons stated above, isn’t necessarily a bad thing, especially in VF/VT arrests. Fully 70-80% of a typical fire department’s responses are for medical assistance, and the other 20-30% are not all for working fires.

The other problem with ALS fire apparatus is more subtle and wasn’t easily envisioned before it actually happened. In some regions, a paramedic license increases enormously one’s chance of getting through the ultra-competitive firefighter recruitment process, so some of these paramedics may not have the right motivation to begin with. Also, many  firefighters are firefighters because they want to respond to fires, not medicals. As a result, some firefighters view medicals as something they’re forced to do by their management, and we all know what happens when you have to do something you don’t want do. This is a source of tension between ambulance crews and ALS fire crews. (I personally don’t care as long as everyone’s nice to each other.) Add to this the longstanding fact that EMS is extremely trying on your patience most of the time anyway, and sometimes quality goes straight out the window.

Back to cardiac arrests and having so many paramedics that you can’t swing a dead cat without hitting one on medicals… The defibrillator needs to be available within 4-6 minutes of the onset of cardiac arrest, but it doesn’t have to come with a paramedic. So why not have BLS fire apparatus (and their very short response times) equipped with defibrillators respond to cardiac arrests, followed by an ALS ambulance? As it turns out, the EMS systems with the best survival rates do exactly this, and they have been doing it way before these specials and studies were produced.