In a meeting Thursday night held by the City of Springfield’s EMS Commission, the five commissioners voted unanimously to recommend American Medical Response to handle the 9-1-1 contract in their city for the next five years.  Last night I posted on my personal Facebook page that this decision was a “. . . much deserved and expected victory” for the staff at AMR Springfield, and now that I look back on it, and look back on the decision, I do not feel that statement fully

A Springfield truck with the skyline in the background.

describes the impact of the EMS Commission’s recommendation to the city.

The real winners in this situation are the citizens on Springfield because they are getting the best care that they possibly could by having the paramedics and EMTs of AMR Springfield to respond to their emergencies.  AMR has had the opportunity to be in the lime light a few times in the past couple of years with the tornado of 2011 and the gas explosion of 2012 to name just a few, and while those calls were very high profile and visible, they barely make up a chapter in the story of AMR Springfield.

The things that are really important are the things that happen every day.  It is not the multitude of trucks that I had sitting in our staging area on Worthington St that night, it was the other ambulances that were out still answering the “routine” emergencies that made the difference.  It was not just our crews going to door to door with State PD and Springfield Fire in the Island Pond Road area of the city after the tornado hit that deserve more recognition, it was also the other crews parked up on the other side of the debris field ready to pick up any emergencies on the north end of our City.

Heroic things happen every day in every city across the country and Springfield is no exception to this.  It is the medics who recognize that STEMI on a 12-Lead and call an early heart alert because that is what their training has taught them to do that matter.  It is the EMTs that are able not only to recognize what calls need a paramedic to respond with them but also their ability to recognize the calls that they can handle, especially when things are getting busy to make sure that there is a crew out there to grab the next call that comes in.

If I could give one piece of advice to those who are still up in Springfield, it would be this: Always believe in yourself and remember what your mission really is.  Always remember that what matters is the care that goes on in the streets.  Always strive to learn something new every time you step on the truck, and always make sure that you do the best that you can for every patient you come across, not matter how serious or how minor their emergency might be.

Take a bow, AMR.  You deserve your moment in the spotlight.  Let’s make this a great 5 years!

It is a great feeling to be accepted to present back in the state that I so recently left where I spent the first twelve years of my paramedic career.  The title of my presentation is “The Solution is Pollution: Using Capnography to Guide Your Treatment.”  Exciting, huh?

Are you in or around Massachusetts?  Come out and take some great classes given by a number of great speakers.  Want to contribute in your own way?  Take a look at the advertising and exhibitor packages that are being offered.  The committee that puts this conference together each year is doing a great job conference is growing exponentially every year.  If you ask me, I would say that the Massachusetts EMS Conference is well on its way to becoming the premier EMS Conference in New England.  It is great to be part of it as a presenter this year.

Interested in attending?  Click here!  Be sure to check out the Exclusive Facebook Pre-Sale

Do you want to be an exhibitor or sponsor?  Click here!

There was a rather serious traffic accident on the highway that ran next to our town.  Due to a shortage of daytime crews, just like many other days, our squad was called upon to respond.  The patient was a middle aged male with shortness of breath, and belly pain.  Since he required extrication, the decision was made to fly him to the trauma center rather than drive him.

From what I was told then, and can better comprehend now, he was hypotensive and had a significant amount of internal bleeding.  As with any other trauma patient in a similar condition, he got two large bore IV’s, and a boat load of fluid as he was transported by medivac to our regional trauma center.  The area of New Jersey where I was raised was very small, and through the grapevine, word came down that after his arrival at the trauma center he had passed away.

We were told that due to the patient’s religious beliefs he refused a blood transfusion.  Because of his depleted volume and the seriousness of his internal injuries, without the assistance of blood products the trauma team was unable to save him.

The reaction from some of my fellow EMT’s was one of sadness and anger.  Many could not understand how this man could possibly put his religious beliefs and his expectations in the afterlife above that of the life that they had worked so hard to try and save that late August afternoon.  But that is what he wanted, and the trauma center was willing to honor and respect it.

A few weeks later my squad held an in-service in which they had someone of the same religion come in and answer questions about the how’s and why’s of this man’s beliefs, and why he decided to do what he did.  It helped some come to terms with what happened, and others were still confused and angry but at the end of the day, it was his wish.  It was what he wanted for his life.

By now, the story about the Pennsylvania couple who chose to pray for their child to be healed rather than have them transported to the hospital has gone viral within the EMS community.  This was not the first time this had happened either.  Four years prior, they had lost another child the same way.  The parents were serving probation in relation to the death of their first child four years prior.  They have since been told by a Philadelphia judge that they “are a danger” to their children.  Not only is this a high speed, head on collision between church and state, but it is also a huge ethical and moral dilemma for the medical community.

As emergency medical professionals we are trained, willing, and expected to do everything that we can for a patient.  We work codes to the point of exhaustion, and will without a second thought put our lives on the line to try and save a complete stranger’s.  It is hard for some responders to accept the fact that this may not be what that person wants.  Sure, it might be an easier thing to swallow when someone puts a DNR in front of us and say that their loved one wants to go peacefully, but when it is a child, and the parents say “no thank you” and rely on their faith rather than modern medicine, well, that’s a tough one for almost any person to accept.

We are taught to be respectful.  We are taught to be open, and listen to the complaints and concerns of our patient, and are taught that patients have the right to refuse care, but what are we supposed to do when that refusal of care by a parent could cause a child to lose their life?  When it is a conscious, alert, and oriented adult the decision seems much easier but when it comes to a kid these decisions seem to get exponentially more difficult.

Personally, I don’t really know what the right answer is.  While a person is entitled to their own set of beliefs that I am taught to respect, the logic that these two parents utilized to make the decision that they did goes against every bit of training I have received in all of my years in EMS.  If I was put in this situation as a responder it would be extremely difficult not to act in the best interest of the child, but overcoming the protests of the family could prove to be quite the challenge.  I am sure that we have not heard the last of this case, and I’ll be watching closely as more developments surface.

Twitter post from Boston EMS from this past weekend.

In the wake of yesterday’s tragedy one thing I think everyone needs to realize is how lucky Boston is to have the men and women of Boston EMS caring for the people of their city.  In the days leading up to the Marathon, the Boston EMS Twitter was extremely active talking about the immense amount of preparation leading up to Monday morning.  From the looks of it they were ready for almost anything.  And kudos to Boston EMS for sharing that fact with the world.

If nothing else, those of us in the EMS community need to walk away from this with recognition of how important preplanning is.  None of us should ever take for granted our own personal safety or the safety of any event that we cover.  No one should ever utter the words, “that will never happen here.”  Instead, take the extra time to draw up a detailed plan.  Know your staging areas, know your egress routes, and make sure that every single provider involved is aware of them as well.

Another thing that needs to be pointed out that I think many people not involved in public safety lose sight of rather quickly is while this large response was going on in Copley Square the rest of Boston was still calling 9-1-1.  Boston EMS, Fire, and Police were just as busy as they were on Sunday, and just as busy as they will be today.  In my eyes, that is one of the most remarkable things about incidents like this.  Not only does the public safety community step up to deal with a major crisis at hand, they also continue to handle those routine emergencies that so frequently flood communities.

“Because of the rapid prehospital response, many lives were able to be saved.” Dr. George Velmahos Chief of Trauma Surgery Mass General Hospital.

While watching the news, I saw a number of different ambulances down at that scene: Cataldo, Lifeline, McCabe, AMR, and Professional just to name a few.  In addition to that, there were a number of EMT’s and paramedics who volunteered their time to staff aid tents on the marathon route.  Some of those people were friends, and former partners of mine.  I cannot say how proud I am of all of you, and more importantly how happy I am that you all made it home safe.

The officials at this morning’s press conference summed it up best when they said that if it was not for the response of the responders at the scene and the staff at Boston’s hospitals, the loss of life would have been much more significant.

Thanks to each and every one of you and all that you have done, and will continue to do.

Baystate’s new ER on one of its first days. Photo Credit – Jim Kalbaugh

I was cleaning out my phone the other day and I found some pictures that I took back in November before I left Massachusetts.  On December third of 2012, Baystate Medical Center opened its new emergency room.  In the weeks prior, they were inviting paramedics and EMTs from the area to come and take tours so they would know a little more about the facility before it opened.  I attended one of these tours, and took a few shots.

“B Pod” almost ready to receive patients.

First of all, I have to say that the facility itself was beautiful, and while I always liked Baystate’s old ER, it was a clearly an upgrade.  While this was close to six months ago, and I am sure some might feel that the pictures would have been more relevant a post then, as I reflect back on them the staggering thing about them to me is the actual status of the emergency room when I took the shots.

Much of the ER was ready to go, and probably could have taken patients that day but the place was empty.  Patient rooms were vacant, no one was in any of the nurse’s stations or pods.  Everything in their trauma room was neatly put away, and in two week’s time it would never look like this again.

Baystate can be a pretty chaotic place.  As the only level 1 trauma center west of Worcester, and the region’s premiere STEMI and pediatric center it was constantly full and many times overcrowded.  To see this brand new state of the art ER completely empty was a sight to behold.

In the months since it has opened, the transition has seemed to go relatively well, at least according to some of the folks that I have spoken with about it.  That is not at all surprising to me considering the quality of the nurses, doctors, and staff that work there.  Still though, kudos to them.

A two patient room stocked and ready to go.

One of Baystate’s trauma rooms. Notice the red line on the floor to help designate where people should stand

Response times DO NOT improve ROSC rates.

Directly.

In article after article about response times, there is always that little asterisk that says “in MOST cases response times do not matter.”  Well, I am going to go as far to say that in ALL cases response times do not matter.  There are far more important things than response times in providing a high quality Emergency Medical Service.  I say specifically Emergency Medical Service because Skip Kirkwood made a terrific point in his comment in a recent blog post: “(An) ‘ambulance service’ is not the same thing as ‘EMS.’”

Now, let’s just suppose for a second that we go with the common statement that response times improve outcomes.  An ambulance pulls out of their station or away from their street corner and goes flying across a city, or through suburbia, lights and sirens blaring, and they pull up in front of the address of a patient in cardiac arrest.  Then what?  If that ambulance makes it there in 8 minutes and 59 seconds or less, do the EMS gods simply smile, say “job well done!” and your patient is magically resuscitated?  No.  Far more goes into it than that.

So if response times do not improve ROSC rates, what does make a difference?  Well, let’s start from the beginning:

1.  Public CPR education – Seattle has proven that when trained, people are willing to help.  The rest of the country should follow their example and push public education.  That does not exactly mean putting a CPR card in the back pocket of every citizen, it might just mean educating them on the importance of compressions only CPR.

A First Save AED. $699 or Best Offer on EBAY.

2.  Public access AED’s – Again, here is another piece in the pie that rests mainly on the public.  Since I have been traveling more for conferences I have always kept an eye out in almost every major airport I’ve been to, looking for AED’s to see how accessible they are to the public.  For the most part, I have been pretty impressed.  I recently joined a new gym, and one of the main features that I was looking for that was in plain view of the entire gym was an AED hanging on the wall right under the “emergency phone.”

On the other hand though, I do not feel that I see nearly enough publically accessible AED’s in malls and store fronts that I have shopped in.

3.  A highly trained dispatch center – When tragedy happens and someone picks up their phone and calls 9-1-1, the person at the other end needs to be ready for anything, and they need to be calm, cool, and collected as they give pre-arrival instructions.  Because such a large portion of the population is not trained in CPR, someone needs to talk them through the process.

4.  A highly trained workforce staffing ambulances – It does not matter if they are fire based, private, municipal, volunteer, or any other model that you can possibly think of.  The important thing is the EMTs and paramedics who respond need to be trained and up to date.  They also have to be willing and ready to embrace the nuances of the recent advancements in pre-hospital cardiac arrest and post cardiac arrest care: minimize interruptions in compressions, and stress the importance of compressions.

5.  Don’t transport! – Last but certainly not least, a patient has to be worked where they “drop.”  About a month ago, Tom Bouthillet from EMS12Lead.com created a Meme, an internet cartoon for me, that while it made me laugh was the perfect depiction of cardiac arrest care in my last system: it is a picture of Glinda, the Good Witch of the North from The Wizard of Oz with the caption, “You’ve shocked the patient twice and given one round of drugs but no ROSC?  Quick!  Place the patient on a backboard and drive to the hospital so the resuscitation fairy can save the patient!”

The Resuscitation Fairy! She could save your life. Credit: Tom Bouthilett

The worst thing you can do for a person in cardiac arrest, and especially V-Fib or V-Tach is to throw them on a backboard and rush them to the hospital.  The most important time in cardiac arrest care is those first ten or fifteen minutes.  That is not only the time where we are most likely to save someone, but if we do save them that is when those patients are most likely to have the best outcomes.

It is time for communities to stop high fiving themselves for fast response times.  It is time for state organizations and offices of EMS to recognize what is important, and stop acting as “offices of ambulance response.”  As long as city council members and TV stations raise concerns about “long response times” then our EMS systems will not live up to the expectations that we as an industry place on them.

I am going to quote Skip Kirkwood again, who was quoting Frank Stroud: “ambulance services can be fast, cheap, or efficient.  Choose two out of the three.”

So who tells everyone?  Who leads the charge and dares to educate the public about what really happens in the back of an ambulance?  That is a question that I do not know the answer to.  What we need to do though is get over our fear of HIPAA laws, and with that, get over our fear of the media.  We need to dare to point out where we as an individual system and industry can improve.  And we need to stop hanging our hats on what we feel that everyone else thinks is important: the ability to throw on those lights and sirens, and give that call a good old fashioned diesel bolus.

Those days are over.  We need to realize it and admit it and then help everyone else do the same.  Let’s get rid of the smoke and mirrors.

You know what?  On second thought maybe that response time asterisk should stay.  But it should say “Response times matter when the unit responding is delivering responders trained in high quality CPR.”  That is a statement I could get behind.

4/1/2013. This is my last day!

Twelve years as a Massachusetts paramedic.  As tough as it was to let it go, I had to do it.  That National card is in my pocket now though, which is quite the feeling of accomplishment.  If I had one piece of advise to give anyone getting into this field, or anyone who is already in this field, get your National Registry certification if you don’t already have it.  It’s worth it.

But I digress. . . Thanks for a great twelve years, Massachusetts!  Best of luck!

I learned many lessons from many, many different people: patients, doctors, professors, EMTs that I worked with, supervisors who both supervised me and supervised with me, paramedics who reported to me. . . the list goes on and on.  I had a long way to go to be good at my job when I started in Springfield and without those experiences, without those calls that I did both with good and bad outcomes I would not be the person or the paramedic that I am today.

I left for a number of reasons, the culmination of it all contributing to the fact that I was not happy.  Part of it was issues with the local direction of my company, part of it was the major changes happening way above my head that I had absolutely no control over.  I wanted and needed a change, and that is exactly what I got.  None of that took away from the fact that I had some amazing supervisors that I got to work with, and two hundred plus EMT’s and paramedics who I was proud to work in the street with.

Now that I am almost four months out from my departure, I just wanted to once again share that with everyone.  I have written a lot in the last month about the team at AMR Springfield because I believe in them and I believe that no one could do a better job for the people in Springfield.  I believe in the EMTs, the paramedics, the dispatchers, and the team that leads them.

Today is a big day for the group in Springfield.  At 3:30 this afternoon there is a City Council meeting where one of the main topics is their ability to provide an effective and efficient service to the City.  I wish you all the best of luck.  Through all my whining, and complaining, and bitching, and sarcasm, I believe in all of you.

City Councilors of Springfield,

Despite the favorable findings of WGGB in their investigation on emergency response, you have decided to hold a forum to discuss potential short comings of the current EMS provider to the City of Springfield.  Yes, that is right, I said it was favorable.  Although the ebb and flow of the story might not have showed it, all of the information provided shows that AMR exceeds the expectations set for it.  But maybe you should dig a little deeper.  Prior to walking in the door to Tuesday’s meeting, I would like to urge you to do a little research and maybe expand your vocabulary a bit.

For instance, for just a second, let’s forget about response times.  They don’t nearly matter as much as you might think.  Try researching what a ROSC rate is, or how CPAP has reduced the mortality of shortness of breath patients, particularly in Springfield.  Ask Baystate Medical Center about the success of their ST-Elevation Myocardial Infarction program (STEMI for short) and ask them how many of those patients are delivered by AMR.

Still not convinced?  Why not take a good hard look at other communities around the country and see for yourself how good you have it in Springfield.  An ambulance is on scene in a preset amount of time or less 97% of the time.  How do you think that compares to communities like Detroit, Washington DC, or Philadelphia just to name a few?

Or how about closer to home?  Ask around to some of the neighboring more rural communities and see what their response times are like.  I guarantee that some will be longer than the average time publicized by AMR in WGGB’s article, but the patient outcomes will still be favorable.

Just like with in-hospital medicine, perfection will never be obtained in prehospital medicine.  Errors are going to happen because not only are the paramedics, EMTs and dispatchers human but so are the citizens that call 9-1-1.  Mistakes get made.  Addresses get entered wrong, and the severity of an emergency is not always reported properly.

It is not the vehicle and the response that make for a successful EMS system; it is that person behind the wheel and the tech in back.  It is the people.  If you look at response times alone, you will find that AMR exceeds the expectations of the contract and have for a number of years.  As a former paramedic and supervisor in the system, I encourage you to dig deeper.  The successes that the paramedics and EMTs in Springfield have had after the arrival of the ambulance is what really indicates the level and quality of service that Springfield is getting.  That is not always measured in numbers but if you dig deep enough you will find it.

Hopefully all of this information will be provided for you on Tuesday, but if it is not just ask.  The data is there, and the people who can provide it to you will be there as well.  Don’t do a huge disservice to your constituents.  There is no better company in the area to care for Springfield, and more importantly no one has the experience and the skill that the EMTs and paramedics in Springfield possess.