Sep 242016

My first post in this series I mentioned to be aware of the quiet patient. I’d like to say I learned that lesson that day…but it didn’t happen that way. The call I am writing about in this post is not one I really care to remember, it’s just one that’s stuck around. I know I learned several lessons from it and maybe someone else will too.

On this call I am still an EMT Basic. It was a winter Sunday morning and our call was a motor vehicle crash at nearly the same location as my first post. There were four older ladies on their way to church. The driver had tried to enter the highway and a car coming around the blind corner ended up t-boning them on the passenger side. Decades later the department of transportation would fix this intersection. I have no idea how many people were injured and killed before the change came. I know there were many. I transported my share.emt training

I ended up with two patients in the back of my ambulance and both appeared quite stable.  The patient on a portable stretcher on the bench seat had numerous lacerations. The patient on the gurney had assorted cuts and scrapes, a R lower leg fracture and complaint of pain in her upper R arm. Both patients were conscious and alert and no complaints of trouble breathing. They might have weighed 100 KG combined.

My patient with the leg fracture was dressed in her Sunday best and had on a long puffy warm coat. There was no way to slip the coat off her without causing pain and I felt bad about cutting it and destroying it. I chose to not cut it off. It was a twenty-five minute run to the hospital and I would go back and forth between my patients checking on them.  Like many of their generation they were reluctant to complain about anything. When we were maybe five minutes from the hospital, my patient on the gurney was becoming increasing drowsy and hard to get her to respond to me. When I did get her to respond she would just say she was fine, just tired. By the time she was wheeled into the ED she was unconscious.

I stayed and helped in the ED as they tried to resuscitate her. Such a nice polite older lady who never complained.  I remember staring at her coat when it was removed in the ED. The whole R side was soaked in blood inside but not a spot on the outside. The coat must have weighed several pounds heavier with all the blood it had hidden.

Three things I leaned that day. The first is that patients can move from conversant to quiet in a short period of time. The second thing is to never hesitate to expose something in order to confirm or rule it out as a problem. The last thing is I learned just how much blood can be contained in clothing. Probably explains why I would include a blood loss estimation lab in my trauma classes decades later.

I guess there is some risk in me writing about a bad outcome but I’d rather suffer a little shame than see someone else have to learn these lessons like I did. I’d appreciate hearing about experiences readers may have had.






Sep 202016

VMSQBxqThis is the first in a series on emergency calls that have stuck in my head after all this time. After a couple decades in the field it’s an odd mix of calls and patients I have floating around. Kind of like a screen saver cycling through your favorite photos but in a semi-morbid way. It made me wonder which calls get re-run in other folks heads? Is there a lesson to be shared with the next generation of emergency responders? If I can elicit some interesting comments from this post I’ll keep the series going.

My first EMT call -First some background to set the scene. I had been a member of a volunteer fire department for several years. We did first response medical out of a rusty station wagon with minimal equipment and one wrist watch for taking an accurate pulse between three of us. Keep in mind this was back in the 1970s’ and no I do not recall seeing any dinosaurs. In 1976 the department was able to send us to attend a Basic EMT class.  At the end of class our instructor asked me if I would like to come work for his ambulance service. I’m not sure if I impressed him during class or I was just the first person he asked who said actually said yes. He needed someone to fill in while an employee was on their 2 week vacation. It was just the beginning of summer on the Oregon coast.  My shift started Friday morning and by the time the afternoon weekend traffic was building I was on my way to my first call as an EMT. A head on motor vehicle crash on a nasty corner of the highway coming from Portland about 10 miles from our station. There were only two patients alive after the crash. One who was ejected through the windshield and one quiet patient trapped in the car.  This was back in the day when our ambulance service carried hand extrication tools because fire departments were still mostly wanting to do fires not medical. If you’ve never cut and bulled your way into a car chassis with a K BAR T you’re missing a good workout. Imagine trying to open a 50 gallon drum with a little 25 cent military surplus can opener and you’ll get the idea. My partner assigned me to the conscious ejected patient once we had extricated the trapped patient. My patient was in the roadway and had multiple laceration injuries but the chief complaint was the dislocation of the head of their femur. Pretty simple to package up and manage if you don’t count the loud screaming.

What I learned on that call – A loud, swearing, screaming or crying patient is better than a quiet patient. I was impressed with how painful a dislocation like this was. It was a twenty minute run to the closest hospital equipped to handle trauma patients.  I learned that pain meds help but brute force was the key to reducing the dislocation in this case.  Once that femur popped back in place the pain meds kicked in and they were snoring and happy as can be. The quiet patient did not fare so well. They never really complained and did not survive long. Over the ensuing years I had had my share of quiet patients. My advice for the new medical person would be suspicious of a patient wanting to rest when the situation is telling you they should be climbing the walls.

I’d like to hear about your first patient and what lesson you can pass down to the new generation.


Sep 122016

The Centers for Medicare & Medicaid Services (CMS) has published the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers rule. Tipping the scales at 651 pages there is no doubt it is a federal document.  I was thinking what would have happened if my mom gave me a rule 651 pages long….I would still be grounded.

In reading through the estimated hours predicted for various facilities to develop the required documents it makes me question what the intent of the rule really is. I have no doubt organizations will come up with written documentation to meet the rule so they are in compliance. I also have little doubt that the documents produced in many cases will not actually enhance preparedness in the community.


This chart outlines the FEMA recommended process to follow in developing a plan (also listed in the rule as a helpful reference). If we compare the chart with the anticipated body of planning work to accomplish to meet the new rule it does not really match up well.

On the other hand I would look at this as an opportunity to boil the 651 pages down to what is necessary and more importantly what makes sense in enhancing preparedness of an organization among the whole community. In my experience there is an inverse relationship between the thickness of an organization’s (state and federal government included) plans, policies and procedures and their ability to actually implement them. It is possible to over plan and that should be avoided. In the CMS rule they point out four core elements to focus on. They are:Fire in Stairwell

  • Risk Assessment and Emergency Planning
  • Policies and Procedures
  • Communication Plan
  • Training and Testing

Over the years one of the most common reasons I heard why emergency preparedness programs were disliked in healthcare facilities is that the training and exercises were so disruptive of daily operations. No one objected to one poor soul writing a plan to make them “compliant”, but the issues started when the author actually tried to implement change and ensure competency. The reality is that a well designed preparedness program and sound understanding of the Hospital Incident Command System (HICS) can actually simplify life within your organization. Both on a day to day basis and when emergencies arise.  My suggested keys to building a successful program are:

  • Implementable Planning – Boiler-plate plans are going to be popping up and tempting many organizations to make them “CMS compliant” yet they are seldom a good fit for any facility. Many consulting firms love them because they are easy to develop and therefore profitable to sell. They may allow you to check the box necessary to meet a grant deliverable but they will most likely fail in a real event.  Developing plans that actually work may take more up front effort but make your life much easier in managing the event.  Keep in mind after an event you will be judged based on your plans, polices and procedures and training records.  If you can’t actually accomplish something you’ve documented in your plan you are setting yourself up for misery and liability.
  • Practical Training – I consider education to be a key factor in how people will perform under stress. Canned courses are like boiler-plate plans. Usually longer than they need to be and a good portion of the content is is irrelevant to your organization or performance expectations. I am often accused during my courses of making people think.  It’s not rocket science stuff. I simply give them material which is relevant to their current situation, aligns with organizational expectations and is focused on need to know material.
  • Realistic Exercising – Properly designed and facilitated, exercising is where we can evaluate the results of our planning and training components. Part of exercising is the evaluation component and developing a Plan of Improvement. These findings go into the next evolution of planning and training effort. Exercising without incorporating what we have learned is a waste of effort and resources. For additional information on ideas for a good exercise program click on the link.

While the intent of the ruling is to raise the bar of emergency preparedness in individual facilities, the final outcome should be a better prepared community.  You may be able to find assistance from other members of the healthcare or emergency management organizations in your area. Regardless of the route you take to meet the ruling, internal work effort, other community partner agencies or a consultant, make sure your preparedness program passes this common sense test.

  • If a predictable event(contained in your Hazard Vulnerability Analysis) occurs, does your staff understand their role in ensuring the safety of all staff, clients and visitors?  This includes staff on campus as well as working at remote locations.
  • Does your organization utilize the HICS to manage events and trained staff have demonstrated competency in its use? If efficiency in operations and effectiveness in outcomes is desired, spend time learning how to use the HICS and not just spell it out.
  • Has your organization developed sufficient documentation (plans, polices, procedures, initial Incident Action Plans) for staff to understand how they will provide for the continuity of patient care in emergencies? This may require coordination with other community partners as necessary and appropriate.
  • Is organizational leadership 100% engaged in the preparedness process?

I would love to hear from organizations and how they are intending to proceed in order to meet the intent of the rule.