From the comments to Using a Pediatric BVM on Adults:
- Vince said…
Hmmm…
This post comes as a shock!
Captain Renault: I’m shocked, shocked to find that gambling is going on in here!
[a croupier hands Renault a pile of money]
Croupier: Your winnings, sir.
Captain Renault: [sotto voce] Oh, thank you very much.
[aloud]
Captain Renault: Everybody out at once!
That kind of a shock?
You are usually quick to make the case against tossing out the baby with the bathwater (a la OLMC ass-clownery).
I think that OLMC (On Line Medical Command) requirements are like bathwaterboarding the baby in order to manage the airway, and using too much Mr. Bubble, but not everyone agrees.
Please go easy on the clown comments. Some clown-phobic people may visit the blog.
Doth mine eyes deceive, or are you suggesting that my toys come with warning labels, my scissors be replaced with the round-tip variety, governors be installed on all my transmissions, and my big scary adult ambu-bags be restricted to the diminutive flavors- just so the baby gorilla doesn’t make boo boos with the airway?
I thought all of your toys did come with warning labels, such as “keep out of the reach of medical students.”
If I feel the need to make such a statement, I will state it clearly. Obviously, I made no such statement.
“Mongo make hard skweezy on bag, hey, look!… hot dogs!”
Remember, “Mongo only pawn… in game of life.”
I would prefer to get rid of all of the Mongos out there, but everyone keeps telling me that there are no airway problems. While on the other hand, they are telling me that it is not the fault of the medical director that the medical director allows them to carry out their assassinations without criticism or correction. That it would be asking too much of the medical director to actually oversee patient care. That the medical director has no say in patient care issues, because the bosses can fire the medical director. That if the medical director is replaced by someone else, things will only get worse. Human sacrifice, dogs and cats living together… mass hysteria! That EMS services often do not have the money to provide competent care. That it is unreasonable to deprive patients of this incompetent care.
I suppose your crowbar is poised menacingly betwixt my none-too-dead-nor-cold fingers and my happiness too!(that’s a warm gun, for you non Beatles fans!)
Say it ain’t so!
No. That really is a Beatles reference.
Instead of idiot-proofing the equipment, we should just equipment-proof the idiots!
Actually, I have continually criticized those who put equipment in the hands of incompetents. In response, I have repeatedly been told that the medical director just can’t help it. That it is all the fault of the medic and a lot more up sucking from a bunch of sycophants and those incapable of independent thought. That medical directors feel they can get away with absentee oversight through OLMC (On Line Medical Command) requirements and chart review, should disqualify them from any position of responsibility in the medical field. Homeopathy is calling.
If I were not gifted with a healthy dose of skepticism, I might trust some of these otherwise respectable doctors, nurses, and medics.
If you can’t learn to do it right, then perhaps a career in foreign policy advising is more your speed.
I agree. How do we get those, who are supposed to be responsible, to act the part?
How do we get medical directors to stop promoting the Typhoid Marys of the EMS world?
Problem solved, and my stock in Laerdal stays safe đ
It is not a problem that can be solved with just improved competence, sometimes better tools mean better care. BVM ventilation is one of the most difficult skills to do well. If you don’t believe me, let Mongo bag you for a few minutes. He will convince you. If Mongo is not available, find any medic and request the same performance.
I am still not claiming that this solves much, since I have no experience with it on a real patient, but it does deserve some investigation.
Maybe, by quoting the only sentence I wrote, that included lettering highlighted in red and amplified with bold type, you might notice that I was not suggesting that this is a substitute for quality care. Sometimes I am just too subtle.
I do not pretend that we can make things fool proof, but that does not mean that we should not consider other possible ways to address airway management problems.
.
Sorry I am so late getting a reponse to this…busy busy and all that.I would have to make the argument that any tool that would give the false sense of security (i.e. I can’t do any real harm with this wee little bag) would actually discourage careful attention to the skill employed and the need for constant re-assessment.
No tool should be presented to people in that way.There is no such thing as fool proof. Anyone who says differently is selling something.Anyone who believes that they cannot harm a patient, because they are using a supposedly safer tool, should not be allowed to touch patients. Not that I need to start complaining about the abysmal quality in some places.
So what we should be doing is not let idiots touch patients- my original point. Let’s do that, rather than try to develop “safer” tools. They are only “safer” in the hands of an idiot.By all means, rail on my good brother, rail on! Zeus knows, someone needs to complain!
vince,This is not necessarily “only safer in the hands of an idiot.” It is worth examining.Until you can say “Yes, Master,” cross your arms and blink and eliminate all of the dangerous idiots, there isn’t really much point in pretending that we can just make all of the incompetents go away. Trying to decrease the damage that they do is not without merit. And you don’t even look a little bit like Barbara Eden.Improving patient safety is not a matter of choosing sides – the make the incompetents safer with less dangerous tools side vs. the eliminate the incompetents side. We are not in an all-or-nothing competition, where only one side can win.
So I am wearing this sarong for nothing! Great!There are some that say life itself is a zero-sum game…but I digress.I understand what you are trying to say; it justs hurts me so to see you relinquish even the slightest of yardage when it comes to battle against Medic X and his extra-chromosomed brethren.I think Frank Capra said it best, “When we re-write the rules to help the more knuckle-dragging among us an angel hangs himself with a rosary!”In theory you are probably right, this is the reality we deal with. I just throw up in my mouth a little bit every time we lower the bar …again….and again….I suppose one could make the argument that (at least the handcuffing of medics) that OLMC engages in and its inherent ability to not trust the professionalism/judgment/skillset of paramedics at large is just another way of re-tooling the “tools”(making them “safer”) in EMS to increase patient safety.Someone very wise once said, “Surrounded and out-gunned, I will never surrender”We need to hire more EMS instructors like Gunnery Sergeant Hartman, whose orders will be to “weed out all non hackers who don’t pack the gear to serve in my beloved corps”.
Vince said… “So I am wearing this sarong for nothing! Great!”I refuse to speculate on your sartorial decisions. “There are some that say life itself is a zero-sum game…but I digress.”For those unlucky enough to call 911 in this kind of system. Mongo is there to sum it all up. “I understand what you are trying to say; it justs hurts me so to see you relinquish even the slightest of yardage when it comes to battle against Medic X and his extra-chromosomed brethren.”It is a big field to play with. Then there is that nasty reality factor. “I think Frank Capra said it best, ‘When we re-write the rules to help the more knuckle-dragging among us an angel hangs himself with a rosary!'”I believe it is only an angel second class, but the tinnitus has been known to confuse me. It is good to deal with someone so familiar with the great director’s work. “In theory you are probably right, this is the reality we deal with. I just throw up in my mouth a little bit every time we lower the bar …again….and again….”In theory we have to deal with reality? I think you need to cut back on your Capra.The reflux is not because of me. I can’t write prescriptions for the next little purple pill, that gets its name from being “next.” The follow up will probably be the Nexium II, hoping to copy the marketing of the Pentium line of chips.Meanwhile back at reality – I am not trying to lower the bar, or even keep the bar low. We do need to raise the bar, and a lot. In the mean time, we do need to deal with the witless wonders who already managed to get in under the present largely imaginary bar. “Present” because it is a gift to them, not to the patients. “I suppose one could make the argument that (at least the handcuffing of medics) that OLMC engages in and its inherent ability to not trust the professionalism/judgment/skillset of paramedics at large is just another way of re-tooling the ‘tools'(making them “safer”) in EMS to increase patient safety.”That it is. And it is a counterproductive way of doing this. “Someone very wise once said, ‘Surrounded and out-gunned, I will never surrender'”That has the ring to it of somebody’s last words. “We need to hire more EMS instructors like Gunnery Sergeant Hartman, whose orders will be to ‘weed out all non hackers who don’t pack the gear to serve in my beloved corps'”.Are you my Private Pyle?
You admit this way of thinking is counter-productive. Do you not see the similarities?Premise 1 :There are many unskilled/under trained/ card carrying Delta medics.Solution 1Design tools that make it easier for them to safely treat patients without upgrading their skills.Solution 2:Limit the role of medics at large; never expect them to use any skill they may have at assessment/clinical judgment, and treat them all like children.Both solutions provide for a mechanism to increase patient safety. Both are fatally flawed….and now back to the weather.
Yes. I admit there are similarities.The medics are already there, with their limited “skills.”Limiting only some of the skills that may be used by medics without OLMC permission; interrupting the assessment and treatment to request this permission; being denied or limited to the point of uselessness; claiming this is the job of a medical director; these do not improve safety, only the appearance of safety to the blind observers. That is a big difference between the two.The Mongo medical directors have placed these miniMongo medics in these positions of destruction. I am critical of that. I do not expect things to change over night. In the mean time, looking at this to see if it might make a difference that makes it worthwhile. This is not unreasonable.It can also be used by basic EMTs, who do not have even as much medical oversight as medics.Avoiding a method of inquiry, because you don’t like where you think it will go, is not logical. All I have done is suggested that this be looked at. From the responses, you would think that I was gratuitously flatulent in church.
As opposed to actually charging the Holy See for your flatus? đ
It is a gift.
Touche!
Why not get rid of the manual monitor / defib units, and only allow ALS units to carry AEDs ?? There might be less mistakes.
“Why not get rid of the manual monitor / defib units, and only allow ALS units to carry AEDs ?? There might be less mistakes.”Why not require a literacy test to post on this blog?First, unless you are saying that BLS units should not carry AEDs, but not limiting what ALS units can carry, the wording should be “allow ALS units to only carry AEDs for defibrillation.”Second, “less mistakes” should be “fewer mistakes.”Third, I don’t see any support for your conclusion. If you feel so passionately about limiting medics to AEDs, you should provide evidence that this will improve care or increase safety, or something that supports your claim.Fourth, my post made no comment about banning anything other than idiots and OLMC.Why do you act as if you are threatened? Why do you oppose this?
Your response is true to form — you never miss an opportunity to underwhelm.My comment was designed to demonstrate how ridiculous it is to advocate using pediatric bags on adult patients. Eliminating the manual monitor/ defib units, and replacing them with AEDs is simply a natural extension of your skewed logic. I worked for a company once that had the same attitude about paramedics —- a few medics forgot to perform their daily narc count …. so the clinical coordinator removed the controlled drugs from all the ALS units as a’punishment’ …. I informed the manager that his action was ill advised ….. he declined to change the ‘policy’ ….. we tangled ….. he lost. The answer is to ensure that all ALS providers possess the skills necessary to do their job. Remediate, counsel, and ultimately fire those who do not meet the standards.
ld,So, considering other possible ways of managing an airway is the same as ‘punishing’ medics by removing the narcotics?Asking if anyone has any experience with a device is the same as limiting medics to the use of AEDs.I’m glad you pointed out that it is my logic that is skewed. However, we do agree on the last part of what you wrote. You are repeating what I have written many times:”The answer is to ensure that all ALS providers possess the skills necessary to do their job. Remediate, counsel, and ultimately fire those who do not meet the standards.”Until this is common, I will write about other methods of trying to improve care. Not just the lack of quality in EMS.I’m not holding my breath for a sudden onslaught of competence in EMS. Are you?
I appreciate your concerns, BUT …..employing this tactic: (below)’Until this is common, I will write about other methods of trying to improve care. Not just the lack of quality in EMS.’will forever keep our goal (below) out of reach. ‘”The answer is to ensure that all ALS providers possess the skills necessary to do their job. Remediate, counsel, and ultimately fire those who do not meet the standards.”‘The welfare state has created a permanent under-class —– its the same principle.
ld, Bad medics come from medical directors allowing them to treat patients without requiring that they demonstrate competence. Maintaining competence is ignored, too.Medical directors may rationalize what they do with all sorts of nonsense, but it is the medical director’s signature that allows a bad medic to treat patients.More than anything else, we need to remediate, or eliminate, the medical directors who do this.
Bad medics come from medical directors allowing them to treat patients without requiring that they demonstrate competence. Maintaining competence is ignored, too.Bad medic are only bad medics when they fail to have the integrity to realize “these are other people’s lives I am playing with and I better make sure I get my shit together.”A bad OLMC physician may allow medics to continue to deliver substandard care, an issue that needs redress to be sure, but he certainly did not force anyone to be a bad medic.Personal Responsibility.This is why it is outrageous to me, in principle, to focus on ways to make bad medics ‘less dangerous’ by any means other than those discussed above (remediation, counseling et al)I realize your motivation is patient care and, after all, that is what this is all about. I also concede that these are not mutually exclusive ideas.But as I alluded to earlier, any tool/device etc. that makes it ‘appear’ easier and ‘more foolproof ‘ will likely have the unintended consequence of allowing an already sub-standard paramedic, to rely on them at the exclusion of his underdeveloped assessment skills and judgment. I am just advocating eliminating the middleman ;)Obviously, anything that would improve patient care and eliminate potentially fatal errors are something I think we are all on board with. I am not that arrogant. I just would put more of my ova into the standard raising basket. If you remember for many many years I have been of the opinion that the paramedic profession take similar steps that nursing did insofar as making itself a profession, i.e. with minimum education requirements. Not only would this serve as a first-line filter to keep out some of the knuckle-draggers with the “Your life is my hobby” attitude, it may make inroads in garnering much deserved respect from other professionals, in particular OLMC physicians, not to say anything about an increase in salary.Perhaps you can post on this idea….
People will rise to the level of expectation, as long as there are consequences for failing to meet standards.It seems a little childish to me to blame ‘bad paramedics’ on medical directors. Dr. Spock’s children are masters at displacing responsibility. Why not hold ER nurses accountable for wayward medics ….. maybe the human resource directors are at fault too … let’s nail anybody but the paramedics themselves …. its like a script for an Oprah show !!! Why the f*ck can’t paramedics police themselves ?? Do you ‘write up’ every transgression that you observe ?? Good paramedics should not tolerate ‘bad paramedics’ within their ranks. Doctors QA doctors, and nurses QA nurses. What your system needs is a clinical specialist program — clinical experts (paramedics) who work directly with / evaluate all staff medics on a rotating basis.
Well, we used to have a similar system where medics evaluated other medics, …but on 2nd thought it wasn’t exactly for QA/QI purposes đ
Vince, You must be referring to the F.T. certification program — as I recall you were able to mentor quite a few folks in the greater Philadelphia area. I certainly hope that …. in your absence ….. they haven’t let their skills go to pot …. đ You should contact the ‘cream of the crop’ and let them know that you may return — unannounced —- for spot inspections đ
ld,Why are you trying to keep the medical directors from facing their responsibility?No medic can treat patients without permission from a medical director.We need to insist that medical directors do their jobs and get rid of the medics who cannot be remediated. More important is that the medical directors prevent the bad medics from being authorized to treat patients to begin with.Or, we should stop telling lies about medical directors providing physician oversight, because it doesn’t seem that many provide anything that would come close to meeting that description.
Well, the President is ultimately responsible for everything that happens on his watch —– so why don’t you just blame it all on Bush?? Do doctors QA ER nurses? …. not in my experience …… do doctors QA x-ray techs, respiratory therapists, or physical therapists ? …. NO NO NO. Doctors, nurses, and paramedics all have very different training. Most physicians / nurses have very little prehospital experience. As the adage goes, “to catch a thief you must think like a thief.” Paramedicine will not be a profession until such time as its members begin to act like professionals. The ‘good’ paramedics should flush out the ‘bad apples’ …… take a deep breath and do a nut sack check …. you don’t need big daddy MD to clean your house !!!!Professional firemen take care of their own problems, doctors police their own too —- all you need to do is cowboy the f*ck up and get it done.
“Do doctors QA ER nurses? …. not in my experience …… do doctors QA x-ray techs, respiratory therapists, or physical therapists ? …. NO NO NO.”Because none of them need the permission, in writing, to work.Paramedics require a signature that states that they are safe to treat patients.That puts the responsibility on the physician.I have not said that medics should not police their own. The greater responsibility is on the physicians who allow bad medics to mistreat patients. Medics cannot remove a medic’s medical command. That is the physicians job.”Professional firemen take care of their own problems, doctors police their own too —- all you need to do is cowboy the f*ck up and get it done.”Same as above police and fire do not get their permission to work from doctors. Have you ever tried getting a physician to pull a bad medic’s command? Were you able to do anything without the doctor or the boss cooperating?
Come on — you are not paying attention !!! Most people need ‘a signature’ to work (esp. in healthcare). A few examples: doctors must have the signature of their state’s medical board director, nurses require the approval of their state’s board of nursing, firemen must be ‘signed off’ by their commissioner, and policemen can’t perform their duties without the assent of their chief. All these folks must be judged to be ‘safe’ (by their governing entity) before they can take step one ‘on the job’. I can’t understand why you believe that paramedics are so special (unusual). ‘Have you ever tried getting a physician to pull a bad medic’s command? Were you able to do anything without the doctor or the boss cooperating?’A smart f*cker can do almost anything. 1. Meticulous documentation of any impropriety is your first step. Don’t bitch about screw ups — generate incident reports. Ensure that all witnesses to any ‘event’ also draft IRs. 2. After you have compiled a paper trail —– request a meeting with the appropriate authority — invite any ‘witnesses’ to participate in the discussion.3. Most command docs are reasonable — they do not want to get their tit in a ringer —- Create and implement a remediation program for the offender. If the command doc is an asshole —- well, he has a boss too —— keeping going up the chain until you meet with success —– even if you have to go to the state authorities. (I’ve done it —- it works —)4. Reevaluate the screw up after he has completed remediation —- document progress or lack there of — 5. If the screw up continues to screw up then all your documentation will support termination.It’s a labor intensive process — it takes a great deal of time —- but most of all it requires that you have the courage of your convictions.
ld,I don’t work with any problem medics, so I am not in a position to do this.You list the signatures required for different jobs, but aren’t these signatures saying the same thing, It is the job of the person signing to protect the public from the dangerous people in these jobs?Why do we expect this of police chiefs, fire commissioners, but treat EMS as a special area that claims to have medical oversight, but allows all sorts of problem children to continue to harm patients?
You sound like a dyed in the wool democrat !!!! Its always someone else’s responsibility … ‘the government should take care of that’ … ‘I just need to bitch my way through life — I don’t actually have to do anything (meaningful) to improve my conditions’… Ever wonder why the Katrina situation was so much ‘worse’ than the natural disasters which have occurred in Idaho or Nebraska …. the difference is:Katrina people=the government better get in here and rescue my ass ….. maybe I can do a little looting while I wait.Idaho people=we better pack our shit and get out ….. lets work together as a team …… we (the people) need to ensure that all our neighbors get to safety. I know what you’re thinking …. ‘but Lou …. I’m trying to help by dumbing down the equipment and procedures’ NO NO NO —- all you are doing is contributing to / potentiating the problem !!!If a Delta force member isn’t pulling his weight ….. is it the commanding officer who suggests that he find other work ???? No .. . the other team members show the idiot the door ….. they depend on one another for survival ….. thus they are motivated to do the right thing …… in paramedicine it is the patients’ lives which hang in the balance (not the lives of the medics) so the motivation is not there …. and as such most medics just cry like little girls …. instead of acting like men. The question you need to ask yourself is ….. do I want my ‘profession’ to emulate the delta force or burger king ……..
“You sound like a dyed in the wool democrat !!!! Its always someone else’s responsibility … ‘the government should take care of that’ … ‘I just need to bitch my way through life — I don’t actually have to do anything (meaningful) to improve my conditions’…”Expecting a medical director to do the job of a medical director and not claim that it is somebody else’s responsibility? Why are you whining about the poor misunderstood doctors, who never had a chance, because the medics wouldn’t do the medical director’s job for him. I am amused by your rant about not wanting the government to do things for you, when you are constantly praising the TSA for helping you deal with your fear of people flying with nail clippers.”I know what you’re thinking …. ‘but Lou …. I’m trying to help by dumbing down the equipment and procedures’ NO NO NO —- all you are doing is contributing to / potentiating the problem !!!”No, you don’t know what I’m thinking. You keep making up stuff, claiming that I wrote it, so you can criticize it. I am not trying to dumb down anything. I am trying to get some accountability out of the medical directors. It is their job, after all.”The question you need to ask yourself is ….. do I want my ‘profession’ to emulate the delta force or burger king ……..”EMS isn’t the military and it isn’t fast food, so it should not look like either one. Of course, that would deprive you of a gung ho metaphor. How long were you in delta force, ld?
I guess you (paramedics) are just stuck in a rut …. kept down by the man …. the mean old incompetent medical commanders ……. and your only hope is that visionaries, such as yourself, continue to advocate the use of smaller and smaller BVM devices (to ensure patient safety). This week its pediatric bags for adults — next week it will be neo-natal bags for adults. A knuckle dragger is content to use his finger to plug a hole in the dam — he thinks that he has really accomplished something —- a leader evacuates his people and builds a new f*cking dam.
ld,It’s medical director, not medical commander.Since you didn’t answer my question about how long you were in delta force, should I assume that you weren’t in delta force? You just talk the talk.Actually, you don’t even seem to do that. You are still making commenting on things I did not write.
‘I am amused by your rant about not wanting the government to do things for you, when you are constantly praising the TSA for helping you deal with your fear of people flying with nail clippers.’By the by, 1. The government is involved in way too many aspects of our lives, BUT its number one responsibility is to provide security for its citizens. 2. I never praised the TSA … I lauded the federal government for preventing another 911 attack. The TSA is flawed, but it was not designed to be 99.9999% effective …. it is only one layer in the security system ….. sure it needs improvement ….. my point is that the system is working …. You don’t want to give the TSA any credit for its successes, nor do you want to assume any of the responsibility for fostering ‘bad medics’ within your ranks. I guess you are always above the fray … out of the loop …. not responsible for anything …… You would have made your daddy (Dr. Spock) very proud !!!
‘Since you didn’t answer my question about how long you were in delta force, should I assume that you weren’t in delta force? ‘Oh ….. so your point is that one has to serve in a particular role before one is qualified to opine about it … I seem to recall you offering your perspective about medical directors (MDs), Presidents, TSA workers, etc. Who are you to comment on their performance ?? Did I miss your promotion to MD / President / TSA worker ???
“2. I never praised the TSA … I lauded the federal government for preventing another 911 attack. The TSA is flawed, but it was not designed to be 99.9999% effective …. it is only one layer in the security system ….. sure it needs improvement ….. my point is that the system is working ….”If only they could get to 10% effective, that would be a major improvement for them. Not 100%, but 10%.You make it seem as if they are good at what they do. The old system was much more effective. It was a system that allowed box cutters on planes, but the answer to that is just change what is allowed on the plane.Here is a link to an article that was sent to me by someone who does not understand statistics. The TSA only found 9% of the contraband they were presented with. They practically do a rectal exam and miss over 90% of contraband.If they find anything, it is only by the blind squirrel method.
“Oh ….. so your point is that one has to serve in a particular role before one is qualified to opine about it …I seem to recall you offering your perspective about medical directors (MDs), Presidents, TSA workers, etc. Who are you to comment on their performance ?? Did I miss your promotion to MD / President / TSA worker ???”The way you write about delta force, it gives the impression that you are basing this on your experience. That we should follow your example. That you would have followed your own advice and done things the real delta force way and become a member of delta force. You just want everyone to do things the way you think delta force would do them. Admirable.I do nothing to suggest that I have any experience in the roles you mention. Promotion to TSA worker. You made a funny. đ