Murphy's EMT laws!
Air goes in and out, blood goes round and round, any variation on this is bad.
Try not to discuss "your day" at the family dinner table.
You may not install a "car catcher" on the front of the ambulance.
The more equipment you see on a EMT's belt, the newer they are.
Examine all chest clutchers first, bleeders next, then the rest of the whiners.
When dealing with citizens, if it felt good saying it, it was wrong.
All bleeding stops... eventually.
You can't cure stupid.
If it's wet and sticky and not yours -- LEAVE IT ALONE !!!
"Riding shotgun" does not mean you shoot the tires of non-yielding vehicles.
If at all possible, avoid any edible item that fire fighters prepare.
EMS is extended periods of boredom, interrupted by moments of sheer terror.
Every emergency has three phases: PANIC... FEAR... REMORSE.
A good tape job will fix almost anything.
Yuppies involved in accidents complain how bumpy the ambulance ride is.
It's not a compliment when Policemen say you're crude, crass & cynical.
The severity of the injury is directly proportional to the weight of the patient.
Turret mounted machine guns usually work better than lights and sirens.
Schedule your days off to avoid working during full phases of the Moon.
There is no such thing as a "textbook case".
You've come to conclude 90% of all drunks are a waste of protoplasm.
Never refer to someone in respiratory distress as a "Smurf".
Automatically multiply by 3 the number of drinks they claim to have had.
Your social skills will be lacking, if all your anecdotes deal with blood.
Assume every female between 6 and 106 is pregnant until proven otherwise.
Get very, very scared when a child is too quiet.
Don't place bets on the glucose level of an unresponsive patient.
You cannot institute a surcharge for unruly or surly patients.
It is not necessary to have a pet name for your cardiac monitor.
As long as stupidity remains epidemic in the US, you have job security.
Don't worry about the gunshot wound as much as dealing with the family.
All emergency calls will wait until you begin to eat, regardless of the time.
Corollary 1:
Fewer accidents would occur if EMS personnel would never eat.
Corollary 2:
Always order food "to go".
Saturday, November 29, 2008
Friday, November 7, 2008
Saving the Air Medical Industry
Saving the Air Medical Industry
* Bryan E. Bledsoe, DO, FACEP
* Another Perspective
* 2008 Nov 6
You would have to live in a cave to not know that the air medical industry is out of control. As of this writing, there have been 14 crashes/incidents resulting in 29 deaths and nine injuries in 2008. (Any time you have to add the phrase "as of this writing" to an article, it usually indicates a bad situation.) Any discussion of the air medical industry evokes an emotional response in the EMS community. But with people dying all too frequently, emotion must be moved to the back of the queue of importance.
I've studied the air medical industry for years. In addition, I've been a flight paramedic and helicopter EMS medical director. I've never claimed to have the solutions to this issue, but I have some ideas.
Helicopter EMS (HEMS) must be dispatched through the local/regional EMS system. All calls for HEMS must go to a centralized dispatch center that will send the closest helicopter regardless of the operator. This would put an end to "helicopter shopping," which has been a factor in several HEMS accidents. This would also stop the practice of calling for another helicopter after another service turned down the flight because of weather concerns.
We need minimum airframe requirements for HEMS. All helicopters should be larger, dual-engine aircraft with full Instrument Flight Rules (IFR) capabilities. All aircraft should have fire-retardant fuel tanks to minimize the chances of post-crash fire.
All helicopters must have two pilots at all times. Most highly developed industrialized nations require dual pilots for safety. Most of us would never get on a commuter airliner that had only one pilot -- but it occurs many times daily in the HEMS industry.
Helicopters should not attempt scene responses after dark. Many of the incidents and crashes have occurred during night operations. Landing a device as complex as a helicopter in an uncontrolled environment, like an emergency scene, is an accident waiting to happen. Many other countries, including Canada, forbid (or strongly discourage) nighttime scene flights.
Helicopters should only attempt interfacility flights at night if both the transferring and receiving hospitals have IFR approaches to their helipads. Several crashes have occurred on approach to hospitals. IFR approaches will make this much safer.
No helicopter crew should attempt a night flight without night vision goggles. I'm not a pilot, but I've been told by many pilots and HEMS crews that night vision goggles have been a significant safety improvement. These must become mandatory.
Air ambulance operations (rotor wing and fixed wing) need their own rules and regulations within Federal Aviation Administration (FAA) statutes. Currently, HEMS is considered an "Unscheduled Air Taxi" and falls under the airline deregulation act. These criteria are often not appropriate for the HEMS environment.
Allow individual states to require more stringent HEMS regulations than those required by the FAA. Currently, states have absolutely no authority to regulate HEMS. The State of Tennessee tried, only to be sued by a HEMS operator. The federal judge ruled that HEMS regulation is purely a federal issue. Whatever happened to the Tenth Amendment to the U.S. Constitution? Also, we need to consider requiring a "certificate of need" prior to an HEMS operator placing a new aircraft.
Usage protocols for trauma must be significantly and immediately changed. Mechanism of injury criteria needs to be removed or minimized as an indicator for HEMS usage. The American College of Surgeons (ACS) should immediately revise its Trauma Center usage criteria (on which much of the helicopter usage criteria are based). I call upon my colleagues at the ACS to act on this immediately -- please give up the dogma and make these criteria evidence-based. And, while I'm casting stones, how come the two professional organizations I belong to, the American College of Emergency Physicians (ACEP) and the National Association of EMS Physicians (NAEMSP), have remained quiet on this crisis? Come on, guys -- your silence is deafening.
Weather minimums for HEMS operations must be stricter. Bad weather and night operations appear to be significant factors in several crashes. Sometimes, pressure from management (and occasionally medical personnel with a sick patient) will push pilots to take risks. Pilots must never know anything about a patient's condition when making weather-related decisions.
Medical flight crew members must have limited work periods and mandatory rest periods as pilots do. Why would we rest pilots but work HEMS medical crews to death? The medical decisions they make are just as critical as the aviation decisions made by the pilots. This might also help prevent untoward incidents, like leaving electrical cables connected during takeoff, aircraft doors open or rotors tethered, and might help reduce rotor strike accidents.
All requests for interfacility transport must first be evaluated by an independent physician for necessity before a helicopter is launched. Even the public recognizes that many of the recent HEMS crashes occurred while transporting patients who could just as well have gone by ground. When a call for an interfacility transfer is received, it should be evaluated medically; the EMS communications center, based on independent physician review, could then determine whether to dispatch a helicopter or ground CCT unit. The transferring physicians and hospitals have shown they're incapable or unwilling to determine the proper usage of HEMS for interfacility transfer.
All HEMS transports, both scene and interfacility transports, should have 100% quality review for appropriate usage. Because HEMS is a very expensive and dangerous endeavor, it should have 100% post-usage review just like we would expect with other high-risk procedures, such as endotracheal intubation and surgical airways.
HEMS "subscription plans" must be outlawed. HEMS subscription programs are nothing but a marketing tool that plays to the entitlement mentality that exists in our country. People with subscriptions believe that, because they wrote a check for a membership, they're entitled to HEMS transport, even for minor injuries and illnesses. This serves to promote inappropriate usage and risk.
The FAA must act -- and act now. Almost two years ago, the National Transportation Safety Board (NTSB) issued recommendations to the FAA to enhance HEMS safety. To date, the FAA has done nothing. Finally, after the recent spurt of crashes, they decided to have "hearings" in 2009.
I call upon every member of the EMS community to communicate their concerns about the HEMS industry to their senators, congressional representatives and local officials. I call upon my physician colleagues -- especially intensivists, emergency physicians and trauma surgeons -- to do the same.
The HEMS crews who are needlessly dying are our friends and colleagues. Their lives and their contributions to the EMS system are too important to allow the current system to continue unimpeded. It is time to stop the carnage!
* More articles by Dr. Bryan Bledsoe
*
*
Bryan E. Bledsoe
Dr. Bledsoe is an emergency physician in Texas. He can be contacted at bbledsoe@earthlink.net. Bledsoe also leads the Street Medicine Society, a group of physicians who got their start as EMS professionals. If you're a physician (MD, DO or equivalent) and have been involved in prehospital care, consider joining the SMS.
Learn more from Bryan Bledsoe at the EMS Today Conference & Expo, March 24–28 in Baltimore.
* Bryan E. Bledsoe, DO, FACEP
* Another Perspective
* 2008 Nov 6
You would have to live in a cave to not know that the air medical industry is out of control. As of this writing, there have been 14 crashes/incidents resulting in 29 deaths and nine injuries in 2008. (Any time you have to add the phrase "as of this writing" to an article, it usually indicates a bad situation.) Any discussion of the air medical industry evokes an emotional response in the EMS community. But with people dying all too frequently, emotion must be moved to the back of the queue of importance.
I've studied the air medical industry for years. In addition, I've been a flight paramedic and helicopter EMS medical director. I've never claimed to have the solutions to this issue, but I have some ideas.
Helicopter EMS (HEMS) must be dispatched through the local/regional EMS system. All calls for HEMS must go to a centralized dispatch center that will send the closest helicopter regardless of the operator. This would put an end to "helicopter shopping," which has been a factor in several HEMS accidents. This would also stop the practice of calling for another helicopter after another service turned down the flight because of weather concerns.
We need minimum airframe requirements for HEMS. All helicopters should be larger, dual-engine aircraft with full Instrument Flight Rules (IFR) capabilities. All aircraft should have fire-retardant fuel tanks to minimize the chances of post-crash fire.
All helicopters must have two pilots at all times. Most highly developed industrialized nations require dual pilots for safety. Most of us would never get on a commuter airliner that had only one pilot -- but it occurs many times daily in the HEMS industry.
Helicopters should not attempt scene responses after dark. Many of the incidents and crashes have occurred during night operations. Landing a device as complex as a helicopter in an uncontrolled environment, like an emergency scene, is an accident waiting to happen. Many other countries, including Canada, forbid (or strongly discourage) nighttime scene flights.
Helicopters should only attempt interfacility flights at night if both the transferring and receiving hospitals have IFR approaches to their helipads. Several crashes have occurred on approach to hospitals. IFR approaches will make this much safer.
No helicopter crew should attempt a night flight without night vision goggles. I'm not a pilot, but I've been told by many pilots and HEMS crews that night vision goggles have been a significant safety improvement. These must become mandatory.
Air ambulance operations (rotor wing and fixed wing) need their own rules and regulations within Federal Aviation Administration (FAA) statutes. Currently, HEMS is considered an "Unscheduled Air Taxi" and falls under the airline deregulation act. These criteria are often not appropriate for the HEMS environment.
Allow individual states to require more stringent HEMS regulations than those required by the FAA. Currently, states have absolutely no authority to regulate HEMS. The State of Tennessee tried, only to be sued by a HEMS operator. The federal judge ruled that HEMS regulation is purely a federal issue. Whatever happened to the Tenth Amendment to the U.S. Constitution? Also, we need to consider requiring a "certificate of need" prior to an HEMS operator placing a new aircraft.
Usage protocols for trauma must be significantly and immediately changed. Mechanism of injury criteria needs to be removed or minimized as an indicator for HEMS usage. The American College of Surgeons (ACS) should immediately revise its Trauma Center usage criteria (on which much of the helicopter usage criteria are based). I call upon my colleagues at the ACS to act on this immediately -- please give up the dogma and make these criteria evidence-based. And, while I'm casting stones, how come the two professional organizations I belong to, the American College of Emergency Physicians (ACEP) and the National Association of EMS Physicians (NAEMSP), have remained quiet on this crisis? Come on, guys -- your silence is deafening.
Weather minimums for HEMS operations must be stricter. Bad weather and night operations appear to be significant factors in several crashes. Sometimes, pressure from management (and occasionally medical personnel with a sick patient) will push pilots to take risks. Pilots must never know anything about a patient's condition when making weather-related decisions.
Medical flight crew members must have limited work periods and mandatory rest periods as pilots do. Why would we rest pilots but work HEMS medical crews to death? The medical decisions they make are just as critical as the aviation decisions made by the pilots. This might also help prevent untoward incidents, like leaving electrical cables connected during takeoff, aircraft doors open or rotors tethered, and might help reduce rotor strike accidents.
All requests for interfacility transport must first be evaluated by an independent physician for necessity before a helicopter is launched. Even the public recognizes that many of the recent HEMS crashes occurred while transporting patients who could just as well have gone by ground. When a call for an interfacility transfer is received, it should be evaluated medically; the EMS communications center, based on independent physician review, could then determine whether to dispatch a helicopter or ground CCT unit. The transferring physicians and hospitals have shown they're incapable or unwilling to determine the proper usage of HEMS for interfacility transfer.
All HEMS transports, both scene and interfacility transports, should have 100% quality review for appropriate usage. Because HEMS is a very expensive and dangerous endeavor, it should have 100% post-usage review just like we would expect with other high-risk procedures, such as endotracheal intubation and surgical airways.
HEMS "subscription plans" must be outlawed. HEMS subscription programs are nothing but a marketing tool that plays to the entitlement mentality that exists in our country. People with subscriptions believe that, because they wrote a check for a membership, they're entitled to HEMS transport, even for minor injuries and illnesses. This serves to promote inappropriate usage and risk.
The FAA must act -- and act now. Almost two years ago, the National Transportation Safety Board (NTSB) issued recommendations to the FAA to enhance HEMS safety. To date, the FAA has done nothing. Finally, after the recent spurt of crashes, they decided to have "hearings" in 2009.
I call upon every member of the EMS community to communicate their concerns about the HEMS industry to their senators, congressional representatives and local officials. I call upon my physician colleagues -- especially intensivists, emergency physicians and trauma surgeons -- to do the same.
The HEMS crews who are needlessly dying are our friends and colleagues. Their lives and their contributions to the EMS system are too important to allow the current system to continue unimpeded. It is time to stop the carnage!
* More articles by Dr. Bryan Bledsoe
*
*
Bryan E. Bledsoe
Dr. Bledsoe is an emergency physician in Texas. He can be contacted at bbledsoe@earthlink.net. Bledsoe also leads the Street Medicine Society, a group of physicians who got their start as EMS professionals. If you're a physician (MD, DO or equivalent) and have been involved in prehospital care, consider joining the SMS.
Learn more from Bryan Bledsoe at the EMS Today Conference & Expo, March 24–28 in Baltimore.
Sunday, October 12, 2008
“Altitude Related Hypoxia”
“Altitude Related Hypoxia”
By:
While studying for the Flight Instructor Rotorcraft Helicopter (FHR) exam, one of the questions posed to the candidate was the following; (Let’s see if you not only get it right, but understand)
During a climb to 18,000 feet, the percentage of oxygen in the atmosphere:
- Remains the same.
- Increases.
- Decreases.
The Aeronautical Information Manual, paragraph
This is the textbook answer and rationale that the Federal Aviation Administration (FAA) poses to our fellow Pilots; however, as a Flight Paramedic and national lecturer on the topic for the last 10 years, I wanted to expound on this topic a little more in depth.
Although I am also a Commercial rated Helicopter Pilot and Instrument Instructor (IGI), the majority of my experience has focused entirely on the air medical side of the operation, managing and working with several Part 135, CAMTS Accredited (Commission of Accreditation of Air Medical Programs) HEMS programs.
The theory of the question above can be explained by a gas law called
Now, why is this important to us, as Pilots? “I am the PIC, I will let the medical folks worry about this…I do not fly high enough to worry about this…”
This gas law explains why one gets hypoxic at altitudes, which is why it is mandated to provide oxygen to all persons at altitudes above 15,000 ft MSL. Hypoxia has several types, which we will briefly go over in this article.
They are:
- Hypoxic Hypoxia
- Hypemic Hypoxia
- Histotoxic Hypoxia
- Stagnant Hypoxia
Hypoxic Hypoxia is an altitude related hypoxia, caused by a decrease in Barometric Pressure and lapse rate as we climb. It is true, there is roughly 21% oxygen on the ground as we breathe and as we climb in altitude; let’s just say to 35,000 feet…, it is still the same 21% oxygen. The problem is that the oxygen molecules are now farther apart because of the decrease in Barometric pressure.
Hypemic Hypoxia is almost as it sounds. Hypemic almost sounds like Anemia. And we know what Anemia is; it is a lack of circulating red blood cells (hemoglobin) that carry the oxygen around the circulatory system to the vital organs of the heart, lungs, brain, kidneys, etc. Hypemic Hypoxia can be from severe blood loss, or anemia itself.
Histotoxic Hypoxia sounds like Histology, whereas “Histo” means poisons or toxins. This does not necessarily mean someone is doing or taking drugs, which it can though. It can be alcohol, sleeping aids the night before, anti-histamines (Which increases oxygen metabolism, and subsequently can pose dangers with
Stagnant Hypoxia is resultant from poor cardiac output, Cardiogenic Shock (Heart Transplant patients) blood pooling, stagnating blood, pulling excessive G-forces, or can even be the position the patient is loaded in the helicopter. If we fly a head injury patient, and we were to theoretically place them, feet facing forward on a stretcher…as the aircraft departs nose down entering Effective Translational Lift, we are pulling G-forces that may be unnoticed to the crew, but the effects of blood rushing to the head of the patient can be fatal, as the increases in Intracranial Pressure (ICP) causes no blood flow to the patient brain, which results in a permanent damage, usually recognized by stroke like symptoms.
Another commonly confused gas law is Boyle’s Gas Law. Boyle’s gas law is directly related to this above scenario as well. Think about putting a balloon in the back seat of an aircraft. As we climb or ascend, the balloon will expand. As we descend, the balloon will contract or get smaller. This gas law is a direct relationship of Barometric Pressure and expansion of gases. Whether it is a balloon we are talking about, or a patients chest tube drainage system, IV fluids and drip rates, Head Bleed, or collapsed lung (Pneumothorax). The resultant effects are the same; as we climb, gases expand and as we descend, gases contract. An easy way of remembering this is to relate Boyle’s with Balloon.
Henry’s Gas Law deals with expansion of gases from solution, as pressure is reduced. What happens if we have a can of soda that was shook up and we opened it? By shaking the can, we increased pressure inside the can and when the pressure is reduced, we have expansion of gases as well as gases coming OUT OF solution. This is an important detail as there is a very well known condition in dive related injuries termed “The Bends.”
So; in closing, let’s end with one more question from the FAA’s Rotorcraft Helicopter Instructor question test bank, and see if we understand this better now.
What physical change would most likely occur to occupants of an unpressurized aircraft flying above 15,000 feet without supplemental oxygen?
- Gases trapped in the body contract and prevent nitrogen from escaping the bloodstream.
- A blue coloration of the lips and fingernails develop along with tunnel vision.
- The pressure in the middle ear becomes less than the atmospheric pressure in the cabin.
Did we get the correct answer of #2? Let’s try one more.
Hypoxia is the result of
- Excessive nitrogen in the bloodstream.
- Decreasing amount of oxygen as your altitude increases.
- Reduced barometric pressures at altitude.
Answer #3.
In future articles, we will discuss diving after flying and vice versa. Transporting patients that have dive related injuries and the proper means of doing so. We have plans on addressing weather related issues surrounding transport of ill or injured patients, and many others.
In closing; stay safe, stay diligent, always check with an Aviation Medical Examiner or Flight Surgeon about any prescriptions we may be taking, and never forget that if it does not feel right, than it probably isn’t.
Saturday, October 4, 2008
Need a Degree?
We all could use the paper, but don't have time to sit in class 3 or 4 days a week and listen to inane chatterings from some prof who last experience the Real World was somewhere around the time Chris Columbus was setting sail. To the Rescue: CLEP and DANTES, along with several other exam sets. I am in the process right now--I just completed 6 college credit hours by taking a quite easy 1 1/2 hour exam. It is fully accredited, and will transfer anywhere. You can complete Associates and / or Bachelor's degrees COMPLETELY by testing out. Obviously, you can't do this with all degrees, but a lot of science, IT, and business programs are included. More on this in the future, but here are some resources for you:
BA in 4 weeks
Degree Forums
BA in 4 weeks
Degree Forums
Tuesday, September 23, 2008
Introduction
I am constantly researching and finding different EMS education items, and thought I would start to Blog it all to share with my fellow prehospital providers. If you run across anything EMS Education related that you would like thrown up on the blog, please email it to me and I'll get it up.
Thanks for looking!
Thanks for looking!
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