June 2004 Letters

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Mail: EMS, 7626 Densmore Ave.
Van Nuys, CA 91406-2042
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You Do What You Have to Do

I thoroughly enjoyed the November 2003 issue of EMS Magazine. Chris Hendricks’ column (When Force Is Necessary, Customer Care) provided some great information. Some calls require that level of force, while others require a different, more creative approach. I have had many times in my EMS career where patients desperately needed to be seen in the ED but adamantly refused treatment/transport by EMS.

Two instances I had to deal with involved elderly patients who had obviously suffered AMIs. One lady just would not go, even after nearly half an hour of us trying to convince her. We tried everything in the book to no avail. Her son arrived, and I explained the situation to him outside. Naturally, he inquired what to do. I told him that if she were my mom, I’d gently pick her up, put her in the car and take her to the ED. I assured him that we would follow them, and if he had a problem to pull over. The short trip to the ED was uneventful, and his mom recovered after a lengthy stay in the hospital. The bottom line was that we got her there the only way we could. The other call was an elderly gentleman who was just as adamant about not seeking medical care. We tried our best to get him to consent to treatment/transport, without success. Out of desperation, I asked if he would go by car, and surprisingly, he consented. Since this call was a considerable distance from the hospital, I loaded up my oxygen, drug box, and Lifepak and rode in the backseat with him to the ED.

We were met by a wheelchair and my supervisor. He said he’d never seen that trick before and was curious how they would bill for this service, as they had no code for this type of intervention. When we went 10-8, he was still scratching his head.

Sometimes you do what you have to do to get the job done.

A few comments on Mike Smith’s Beyond the Books column, A Question of Balance: He is absolutely right about getting away from the job. All the supermedics out there who sleep, eat and live EMS should heed his advice. Been there, done it. A couple of ways to help you do that: First, turn off that scanner. Second, don’t provide your agency with your personal pager or cell phone numbers. Granted, you usually are required to give them your home phone, but with caller ID you can screen your calls. One tactic I used on occasion when my agency tried to call me in was telling them I’d just had a nice cold beer. No EMS agency in the world can make you come in with ETOH in your system.

Learn to just say no. If you don’t, you will wake up one day with nothing else to give, and maybe a case of PTSD for your troubles.

To Matthew Streger, I say good luck on your new career. Your Back to Basics columns will be missed.

Mike Collins
Greenwood, SC

Selective Agreement

I read the November letter from Dr. Bernard Beckerman, regarding EMS professionals not being selective enough in their spinal immobilizations, with great interest. I agree with Dr. Beckerman: I, too, see too many instances where patients are c-collared and placed onto a board when it is truly unnecessary. We should be evaluating our patients further, and being more detailed in those evaluations, in deciding whether to immobilize.

I find it frustrating, when working with another EMT, to have a patient who is complaining of lower back pain, with a history of back trouble, muscle spasms, etc., no fall having occurred, having only felt a muscle pull while working, and instead of placing that patient in a position of comfort, the partner insists the patient be collared and boarded as a precaution.

I believe in this instance, this is not warranted, causes undue stress on the patient, and takes a considerable amount of time. Remember, these patients are never found in easy positions to deal with. My experience has been that these patients will be found down on the ground, on all fours or in some other awkward position, complaining they can’t move. In instances like this, forcing patients to endure a collar and placement on a long spineboard is time-consuming and unnecessary. Yes, it is better to be safe than sorry, but how many times are we putting our patients through unnecessary discomfort, just because our boss might discipline us?

I certainly agree that any suspected injury should be regarded as a problem, and all necessary precautions should be taken, but if there is no injury or MOI, why put the patient through it? Should we not be questioning and assessing our patients a little further, gathering more SAMPLE and OPQRST information, to make this decision?

And though we might be worried about discipline from our employer, most times, the state’s protocols override the employer’s.

J. Isajewicz
via e-mail

Old Tool, New Use

I’ve read Mike Smith’s Beyond the Books column on spinal immobilization (Safety Nets, May 2003) and Dr. Beckerman’s response to it (Letters, November 2003). Just like a coin, there are two sides to the issue, and both made great points.

There is another option for COPD patients that I think has been overlooked: For patients who have breathing problems but complain of back pain after a fall from a standing position, I have used the trusty but dusty XP-I or KED. Protecting the spine while letting the patient sit up calms them down tremendously. Maybe it’s time we reexamine this old piece of equipment and see if it has new uses in the world of selective immobilization.

Marie R. Blevins, EMT-P I/C
via e-mail

Stroke Envy

I just finished reading December’s Vital Signs item on the upcoming trial of magnesium for early treatment of stroke (Los Angeles Medics to Play Key Role in Stroke Therapy Trial) and couldn’t help but feel envious and frustrated—envious that other EMS systems are considered for such trials, and frustrated because here in the northeast region of Pennsylvania, our MICUs don’t even carry magnesium. Oh, yes, it is in our refractory v-fib protocol, along with bretylium and procainamide, neither of which we carry. RSI? Forget about it! To quote our own regional medical director, “It will never happen. I don’t trust any paramedics.” How fortunate for the people of these L.A. communities that will benefit from this potential lifesaving advance!

I’m not only venting here; I do have a question. Does L.A. County EMS have any hypertension protocol? That’s another intervention we lack. I could never understand why we’re even dispatched to hypertensive crises, when we can’t do anything about them! I guess once the patient blows a vessel, then maybe we can breathe for him/her. I thought prevention was our business.

Thanks for the space. I’m anxious to learn the results of this very promising study. Please keep us informed.

Norman Heinz, EMT-P
Northeast Region, PA
via e-mail

That Study Sounds Familiar…

I read your January issue and enjoyed it greatly. I wish to comment on Gene Gandy’s article, Three Cardinal Sins in Airway Management.

The last paragraph on the second page of this article states, “Cadaver studies have shown that properly placed endotracheal tubes move up and down with flexion or extension of the neck.” The accompanying footnote attributes this finding to Yap, et al, via a study published in 1994.

The next sentence then states that the Yap article is the reason for the AHA’s current Emergency Cardiac Care recommendation to place a cervical collar on all intubated patients. But the Yap article dealt with intubated patients (that is, living patients) in an operating room who were scheduled for elective surgery. It did not deal with cadavers, and it made no specific recommendation to prevent ETT movement. This article also did not specifically deal with displacement of the ETT in an intubated patient, and certainly not an intubated EMS patient. Yap, et al were researching a prediction of ETT tip location and the ETT tip distance from the carina in the process of moving various patients’ heads in various positions in the OR.

To my knowledge, there are not any cadaver-based ETT displacement studies or articles in any available literature except for my June 1998 article in another EMS journal. I began research in this area in 1996 and published on this topic twice in 1997 in preparation for the published cadaver article. I am told the second half of this article is to be published this spring.

Incidently, in the same issue there was an article by Piendl and Price that studied, in response to my 1997 “letters,” this ETT displacement issue and concluded that my theory about ETT displacement was correct, and my preventive recommendations were, in fact, sound.

If Gandy or the editors of EMS are aware of any other ETT displacement studies—ER, OR or especially EMS, cadaver or otherwise—that are available for my edification, please advise. Additionally, I do not know why AHA/ECC is making the c-collar recommendation for all intubated patients, but I would be surprised if it was due to the Yap article alone.

I obviously believe this issue to be a crucial one—we are talking about the security of the A of the ABCs. More research is needed in this most important area.

Paul A. Matera, MD, EMT-P
Chair/founder, Street Medicine Society

Gene Gandy replies: Thank you for your comments and the clarifications of the literature you provided. I apologize for failing to mention your work in the article.-I should have given you credit, and would have if my research had located the articles you mention.

I knew about your study, but for some reason was not able to find a citation to the article when I was doing my research.-I was quite frustrated by not being able to find what I remembered as being the definitive study results in the literature.-But none of my Medline searches turned up the article, so I began to doubt my memory.

I then attempted to find an article that had been cited by the AHA in its c-collar recommendation for intubated patients.-That was frustrating also, and the only thing I could find that was even close was the Yap article.-I was not comfortable with that, but the deadline was at hand, and I allowed myself to go with that against my better judgment.-I should have trusted my gut.

As you probably gained from my Three Cardinal Sins article,-I feel this is a pressing issue, especially in light of studies that have cast some doubts upon the abilities of prehospital medics to intubate correctly.-I currently am involved as an expert witness in a case that turns upon a tube misplacement with catastrophic results, so I want to do everything possible to educate our folks about the pitfalls of airway management and show them how to minimize those errors.

I very much appreciate your work and your influence on prehospital medicine.

Worth Waking Up For

I am writing in response to Mike Smith’s January Beyond the Books column, At Least Say Thanks. I have had incidents similar to the one he describes. Even after being a medic for 18 years, it’s not a nice thing to go through. Nevertheless, I did learn a few things from it. We may think it is too much for the patient to answer the same questions the first on-scene medic has asked. But we do this for a reason, and that is to check the status of our patient’s level of consciousness from time to time.

Something else that may help is not to ask for something in return for our help, such as a “thank you,” because this is not what we’re there for. We’re doing this work to help make a difference in a person’s condition. There have been times I wished someone would tell me they appreciated what I did, but the more I thought about it, I realized that this wasn’t really what I wanted. I just wanted to make sure my patient’s condition improved.

Nothing feels better than to know you have made a difference in a person’s life. You could say they have been given a second chance thanks to you. This is worth waking up for every day.

Steve Hannah, NREMT-P
via e-mail

Mike Smith, MICP, replies: I appreciate your comments. I agree with your position on the reasking of questions as part of the assessment of mentation. However, I just don’t think we need to ask all 15 or 20 over again because we either didn’t listen to the handoff report or, worse yet, didn’t even get it. In either case, it only serves to frustrate the patient, and for those patients with breathing difficulties, it makes them work that much harder to breathe and talk at the same time. Thanks for taking the time to write and share your thoughts.

Fit Parade

Regarding your new supplement, Fit for Life in EMS: I am an LPN who works in occupational health at a chemical plant. Our plant has a 140-member fire brigade. We are currently in the process of developing a wellness program for those members, as they are aging, and we have seen increased injuries due to that. I am also a paramedic firefighter on this brigade, and the company I work for is sponsoring me to become an ACE-certified fitness trainer.

I am looking forward to the articles in your publication to assist me in developing better wellness for both myself (I am now 50) and the rest of my firefighters. Is this an area you would like me to keep you updated on as we progress?

Keep covering this issue—we all need it. Too many of us care for others but not ourselves.

Kathleen C. Barton
Mechanicville, NY

The editor replies: We welcome updates about your company and submissions from any reader who would like to share stories or discuss issues surrounding their quest for enhanced fitness/wellness.

Fighting to Get Fit

I have been a long-time advocate of getting EMS folks in shape. We have, on our rescue squad alone, many overweight people, and I have seen people on other squads who weigh in at 200 lbs+.

There are no health clubs available in the small community I live in, apart from Curves. I have tried many times to contact Curves to set up some sort of deal for our squad members. Our local medical clinic also has a state-of-the-art physical therapy room, and I have tried to set something up there, but without success. I am now working on putting on a yoga class in our squad building. I think an excellent idea would be to offer discount memberships at the “Y” or other nationally known health clubs.

Barbara Tobison
EMT/Administrative Assistant
Crivitz Rescue Squad

The editor replies: We are currently contacting a variety of national health clubs to see if we can help establish a discount-membership plan for EMS providers.