Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

ABQ to Pay $.3 Million More for Bad Oversight of Bad Medic

 

It appears that bad management tolerated, and promoted, bad patient care – right up until it affected one of their own. Now the residents have to pay a lot of money for this failure of oversight.

How typical is this medic?
 

Throughout the litigation, Tate denied any wrongdoing. He maintained his work behavior was part of the “culture” of the Fire Department.[1]

 

AFD_logo
 

The AFD (Albuquerque Fire Department) disagrees and convinced at least one “hearing officer” that it is only because the rest of the paramedics are better than Tate that his patients did not have worse outcomes.

Does that make any sense?

I discussed the complaints at the time of an earlier article about Tate and AFD.[2]

If you work with a dangerous paramedic, and you do not report any problems, does that make you better than the problem paramedic?

How does such a dangerous paramedic get promoted to lieutenant?

Is it likely that competent management remained unaware of these problems for a decade, or that this was a sudden onset of an unprecedented problem, or that in some other way this is not an example of bad management?
 

Other organizations have had to deal with criticism after their management of the corruption was exposed –
 

The Vatican revealed Tuesday that over the past decade, it has defrocked 848 priests who raped or molested children and sanctioned another 2,572 with lesser penalties, providing the first ever breakdown of how it handled the more than 3,400 cases of abuse reported to the Holy See since 2004.[3]

 

For hundreds of years we have been told that priests don’t rape children, because they are more moral than the rest of us. Evidence has demonstrated otherwise, but the corrupt culture still discourages reporting these crimes to the police.

Is there some reason to believe that Tate is just one rotten apple?

No.

This appears to be another example of a corrupt culture, that will end up costing a lot more money and setting bad standards of care.

Are the patients surviving to the emergency department because of the care provided or just because most people will survive what EMS does to them?
 

Cadigan told the Journal in 2014 that he was confident Tate would be “vindicated when he has a neutral judge to review the city’s unfair and arbitrary action. The taxpayers will likely have to pick up the tab for this absurd witch hunt.”[1]

 

Vindicated for treating the family of a fellow AFD lieutenant the same way he would treat other patients?
 

Tate claimed his conduct was consistent with what he learned at the Fire Department and argued that even if he did commit the alleged acts, he should be given corrective training.[1]

 

Maybe Tate did receive corrective training.

Repeated reminders to fit in with the culture is how corruption works.

If the culture is not the problem, why did an investigation only begin after a complaint about Tate treating one of his own the same way he is reported to treat other patients?

Footnotes:

[1] $300K settlement keeps paramedic from getting job back
By Colleen Heild / Journal Investigative Reporter
Saturday, April 2nd, 2016 at 11:45pm
Albuquerque Journal
Article

[2] How Do We Stop Dangerous Paramedics From Harming Patients?
Sat, 02 Nov 2013
Rogue Medic
Article

[3] Vatican says it’s punished over 3,400 priests since ’04 for raping or molesting children
The Associated Press
Published: 06 May 2014 03:56 PM
Updated: 06 May 2014 04:04 PM
The Dallas Morning News
Article

.

Does a Medic Need Two Eyes to be Safe?


 

When this story first was reported, there were plenty of social media comments about the lack of safety of having only one eye.

Is there any difference in outcomes for patients treated by two-eyed medics and one-eyed medics? What about medics who wear glasses? Should a three-eyed medic be given preference over two-eyed medics?

Is there any evidence of a difference in job performance?

Is there any evidence of a difference in driving?

Is there any evidence of a difference in anything that is a part of the job?

Provide some valid evidence.

If we are going to make these decisions without evidence, we should admit that we are basing our decisions on prejudice.
 

A Queens woman with a prosthetic eye is suing the FDNY because it won’t hire her as a paramedic.[1]

 

The article lacks information. There may be other reasons she has not been hired, but NYFD is not likely to discuss those directly in the media, because that might also lead to a law suit. If this does go to court there should be more information available.

This topic has generated a lot of righteous indignation from those who insist that two eyes are necessary for the safety of patients. I have not yet seen any evidence to support their attitude.

If there is valid evidence that I am wrong, I am willing to learn from that.
 

See also –

Improving EMS By Hiring Deaf EMTs

Footnotes:

[1] FDNY won’t hire woman with fake eye as paramedic: suit
By Kathianne Boniello and Georgett Roberts
July 6, 2014 | 4:37am
NY Post
Article

.

IAFF’s Jack Reall faces discipline for delaying a 911 call in order to protest research he does not like


 

One of the advantages of fire department-based EMS is that there is a clear chain of command and that discipline is not a problem. The exceptions to this may be rare enough that they make headlines. Here is one.
 

A Columbus Fire battalion chief could face discipline for insubordination after an internal investigation found that he disrupted a pilot program intended to more efficiently respond to emergencies.[1]

 

The first oddity is that the Battalion Chief (Jack Reall) is also the president of Local 67 of the International Association of Fire Fighters. A management position and a union position – and not just any union position, but president. Jack Reall apparently cannot keep his priorities in order.

The fire department is studying whether 911 calls should receive an initial response from one paramedic with a basic EMT or from a pair of paramedics. There is no evidence that sending one paramedic and one EMT causes any kind of harm, or that two paramedics provide better care, so there is no basis to claim that anyone is being in any way endangered by this pilot program.

If there were a legitimate concern, then the time to address that was when the pilot program was being considered. It appears that Jack Reall is not happy with that and his union boss persona delayed a 911 response in violation of fire department rules.
 

The Fire Division launched a pilot program that morning to reduce the number of paramedics who respond to routine calls, allowing the division to disperse medics elsewhere. Instead of two paramedics on a truck, there would be one medic and a basic emergency-medical technician, or EMT.[1]

 

Is it possible that this was a complete surprise to Battalion Chief/Union President Jack Reall?

I don’t know what kind of preparations were made by the fire department, but I suspect that they began well in advance of BC/Pres. Jack Reall’s attempt at sabotage.

It is appropriate to study things when there is a state of equipoise about which is best.

Equipoise is just a fancy word for We do not know which is best.

When we do not know what is best, we should find out, rather than arrogantly assume that we know all that we need to know to force an uninformed opinion on others. That is the alternative – I don’t know, but I am going to force my opinion on everyone else because I am certain my opinion is more important than learning the truth.

Research means we learn more, even if we never learn the whole truth. Opposing research is opposing learning more – especially if the truth disagrees with opinion.

Equipoise means that we cannot be certain, because we do not know enough to be certain.
 

Reall was against the plan from the start and said fewer paramedics meant lower-quality service.[1]

 

The fire department and the union probably have worked out procedures for resolving these differences of opinion. They probably do not include delaying 911 responses to make a point.

If Jack Reall were behaving responsibly, he would have raised these concerns at an appropriate time and place.
 

Reall said the plan was not presented well to firefighters and paramedics and was “not well thought out.”[1]

 

He did raise them at the appropriate time, but he did not get what he wanted.

When I don’t get what I want, as a responsible adult, I should throw a tantrum.

True or False?

A Battalion Chief is supposed to be a person to turn to to resolve confusion, not to create confusion. One part of the job is to make a clear decision (such as to protect the interests of a patient) and to take responsibility for that decision.

It appears that Reall was doing the opposite.

Footnotes:

[1] Firefighters-union chief faces discipline from Fire Division
By Lucas Sullivan
The Columbus Dispatch
Wednesday July 9, 2014 5:51 AM
Article

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Ambulance Crash ‘Caused by’ Overtime?


 

Was this crash caused by paramedics working an extra shift, or two, or three, or . . . ?

Does management’s math work (as reported)? Does management’s math (as reported) suggest that management does not understand math (or that a mistake was made reporting the story)?
 

HONOLULU (HawaiiNewsNow) – An ambulance crash at Ala Moana Center involved overworked paramedics on overtime.[1]

 

A paramedic on overtime? Oh, no! In many places, it seems that paramedics (who get paid more than basic EMTs) have to work more than one job to just be able to live paycheck to paycheck. Part of the problem is that we humans spend money unwisely (as a species, we are horrible at money management). Part of the problem is that EMS often does not pay well. If pay is low, people will work other jobs – or they will not be able to continue to pay their bills and complications ensue.

Here is the math problem.
 

The city wants to reduce chronic vacancies which lead to back-to-back shifts by changing the length of the shift from eight to 12 hours. The move would mean the city’s 22 ambulances could be run with one-third less staff each day, allowing other medics to have much-needed time off, but sources said the United Public Workers union is holding up the negotiations.[1]

 

If shifts are changed from 8 hours to 12 hours, there will be one third fewer shift changes, but that should not affect the number of calls the ambulances run. If the ambulances are not currently busy, changing the schedules might reduce the amount of time crews are not on calls, but so would cutting shifts. That does not seem to be an option, so this appears to be a bit of bad math that nobody in management has corrected.

If I work six 8 hour shifts a week, I am working 48 hours a week.

If I work four 12 hour shifts a week, I am still working 48 hours. I am only cutting the number of shifts in a week, not cutting the hours worked in a week.

If I work nine 8 hour shifts a week, I am working 72 hours a week. If I work six 12 hour shifts a week, I am still working 72 hours.

Should I expect to be any less tired if my shifts are divisible by 12, rather than by 8?

Will the proposed schedule result in fewer ambulances on the street at peak times. Someone will still have to pick up the patients. If ambulances are not currently busy, this could result in treating and transporting the same number of patients with fewer paramedics, but that can also be achieved with 8 hour shifts. Ambulance contracts often mandate that a certain percentage of response times be under X minutes. If management is able to get that to change, that could result in fewer crews on the street, but working much harder, and might be seen as a success by shortsighted management.
 

[youtube]8NPzLBSBzPI[/youtube]
 

We can speed up what we do, but at some point we will increase the rate of errors. This is to be expected and should not be blamed on the employees. Management deserves the blame. The role of management is to help the income producing employees to do their jobs, not to blame the employees for bad management.

I have worked for people who manage this way – and not just in EMS, but we do seem eager to make excuses for bad management.

If management is not capable of competence with simple math (as was reported here), what are their other weaknesses?

If management isn’t able to manage with 8 hour shifts, will Goldilocks come to the rescue when the shifts are 12 hours long?

Footnotes:

[1] First responders hurt in ambulance accident at Ala Moana
Posted: Jul 12, 2014 11:40 PM EDT
Updated: Jul 13, 2014 4:45 AM EDT
Hawaii News Now
Article

.

Dispatch – Activate Our Honeybee Swarm Removal Plan


 

Delaware does have a honeybee swarm removal plan. Up until this week, the plan was probably used more as a punchline for jokes than anything else. The plan was created in 1995, but Yesterday was its first use.

Why have a honeybee swarm removal plan?

If you are dealing with a swarm of bees, your ability to solve problems may not be that good.

Who ya gonna call?

Dispatch.

Whom will dispatch call?

Probably someone who does not know what to do. Unfortunately, that person – the one who does not know what to do – probably will suggest something. Well, I’m not 100% certain, but . . . . This is when you should just disconnect the line, because not 100% certain means I haven’t the slightest idea, but my ego won’t let me admit the truth out loud. This is the equivalent of the guy with a beer in one hand, doing something reckless, and saying, Watch this!

More dangerous than the guy who is not 100% certain is the person who takes advice from him. Maybe pouring gasoline all over the highway and setting it on fire will control the bees, but I would rather get that information from someone who is familiar with bees and can tell me of a specific instance when it has worked, how this scene is the same/different, and how I can get further information about it. Anecdotes can be very dangerous. Experts citing anecdotes may not be any better than the guy who is not 100% certain.

As it turns out, Kill it with fire was not a part of the honeybee swarm removal plan.

What is needed for a plan like this?

A list of several emergency contacts and numbers where they can be reached at night, on the weekends, and during holidays.

Descriptions of how to deal with the variations of the emergency that can be anticipated.

Contact numbers for people outside of the area, who would be needed in the event of a very large disaster of this kind.

Recommendations for first responders who are probably already in the middle of things when the plan is initiated.

Tuesday, a truck carrying bees overturned on I-95. Bees can be a problem. Drivers may not respond to emergencies the way we would like. A swarm of bees may lead people to panic.

How many bees?

16 to 20 million bees.

Am I going to be able to give an accurate estimate of 20,000 bees, 200,000 bees, 2,000,000 bees, or 20,000,000 bees?
 


 

First responder – Dispatch, we appear to have a bit of a bee problem. Do we have some sort of disaster plan?

Dispatch – Today is your lucky day. We do have a bee swarm plan.
 

The plan, which was updated in March, involves a response network of beekeepers statewide. Three beekeepers from New Castle County responded to the scene after Tuesday’s accident. The initial response including using fire hoses to tamp down the swarms.[1]

 

This worked well, but having a plan does not guarantee any kind of success. Reality does not come with guarantees, so having people who understand how to adapt to change is important.

No plan survives the first contact intact, but well prepared people produce their own luck.

What number do people call when things go wrong? 911. We deal with what happens when it is worse than expected. We should have some sort of plan, even if only cursory, for the things that cause us to call for help. Rare things happen rarely, but they do happen.

Footnotes:

[1] Delaware motorists warned to watch out for bees
By Associated Press
Published: May 20
Updated: Wednesday, May 21, 1:46 PM
Washington Post
Article

.

Drunk? or Auto vs. Pedestrian With Major Injuries?

 

Sometimes we miss things that we are expected to miss, such as an atypical presentation of an uncommon condition.

Other times we miss something that even a rookie should not miss.
 

A paramedic has been suspended for a year after he mistook as drunk a man who had in fact been victim of a hit-and-run, suffering a broken back and 12 broken ribs.[1]

 

Suspended for a year is a serious punishment, right?

Maybe not if the medic is retiring anyway – after 30 years on the job.

How does someone with 30 years of experience miss those injuries?
 

A passerby found Mr Wonnacott at 4am on November 20, 2011, and the paramedic failed to establish any of his injuries and made him walk into the ambulance.

While en route to hospital, Mr Gaiger called Mr Wonnacott’s parents and said he was “absolutely plastered” and it was only on arrival to the hospital that his injuries were discovered.[1]

 


Image credit.
 

4 AM on a Sunday morning is a time when we expect to see a higher percentage of drunks.

I have missed things on scene, only to identify them during transport, and I have continued to miss things during transport, but, . . .

Maybe if there were only 11 rib fractures, it would be understandable.

Maybe if it were only 2 vertebrae.

Maybe if both the liver and the spleen hadn’t been lacerated.

Maybe if there hadn’t been a pneumothorax.

Maybe these injuries were actually quite subtle.
 

David Rosenbaum was just another drunk in Washington, DC.[2]

Except that he wasn’t drunk. He had a head injury and died before anyone realized that he was not drunk.
 

“This is not a witch hunt. I just don’t want another family or patient to go through what we have been made to go through as a result of Mr Gaiger’s actions.”[1]

 

The Rosenbaum family said the same thing.

We don’t want money. We want to fix the system so that this does not happen again.

Did anything really change at DC Fire and EMS?

Will anything really change at South East Coast Ambulance Service?

This is a medic they have employed for 30 years. Was this the first time something like this happened? Was this the first time that the news media became aware of the problem? Was he burned out after 30 years? Was he having a horrible day – although a day infinitely better than his patient was having? Out of sight, due to retirement, out of mind? The articles have not been very helpful.

Maybe Mr Wonnacott was gently run over, by someone who really was drunk, and suffered a brain injury that made him appear to be drunk, and only the hospital people could identify the multiple fractures and brain injury.

Maybe, but maybe we should discourage people from concluding a patient is just a drunk, or that the epigastic pressure is just indigestion, or that the hyperventilation of the young female is just hysteria, or . . . .

Hmmmm. Those are things I learned in my original paramedic class that have not changed.

Footnotes:

[1] Chessington paramedic suspended for a year after treating seriously Esher injured man as though he were drunk
By Laura Proto
6:10am Thursday 20th March 2014
Elmbridge Guardian
Article

[2] The Death of David Rosenbaum
By Colbert I. King
Saturday, February 25, 2006
Washington Post
Article

.

Issues and Challenges Discussed by Medical Directors at Eagles Conference – Part 2

 

Continuing from Part 1, where A.J. Heightman writes that there are several issues that are important to the medical directors attending the Gathering of Eagles. The conference is over. Here are the rest of the issues –
 

Need for exchange of data between hospital and EMS systems;[1]

 

I can find out what happened to my patients much more easily than most people, because I know the unofficial ways to get the information.

That should not be necessary and HIPAA does allow sharing of this information.
 

Active Shooter management, policies and integration issues, particularly in their Police & EMS integration;[1]

 

It isn’t about who is in charge.

It is about having everyone recognize the same person as being in charge and having that person know how to handle the scene. The person should probably be a specialist, rather than cross-trained to do everything with just the appearance of minimum competence.
 


Images credit from Life in the Fast Lane.
 

STEMI transfers – Hospital are demanding valuable ALS resouces to transfer STEMI and stroke patients when, in some cases, BLS units could handle the task;[1]

 

Why were these patients taken to hospitals that need to transfer the STEMI and stroke patients?

If they were transported by paramedics initially, what good is that kind of paramedic during any transport.

I can’t recognize a stroke or a STEMI, but I am here because you think I am someone who understands strokes and STEMIs.

If the problem is that the protocols require transport to the wrong hospitals, change the protocol.
 


 

Intranasal Narcan delivery by police and firefighters (There is a national push for this by responders who arrive on scene before EMS);[1]

 

It is popular?

So was blood-letting.

Being popular does not mean that it is safe, effective, or a good idea.

What about the well documented opioid overdose mimics that paramedics have trouble with – stroke, hypoglycemia, seizures, et cetera?

What are the outcomes for these patients in systems that make naloxone a BLS treatment, or even just an advanced first aid treatment?
 

Consistency in approach to patient refusals;[1]

 

The patient has the capacity to make informed decisions.

EMS is able to provide adequate information for a person to make an informed decision.

EMS is not coercing refusals.

EMS is competently assessing patients and communicating with patients.
 

Use of video laryngoscopes and capturing the data from them for QA review and documentation;[1]

 

Maybe we should find out if video laryngoscopy is the right tool before we make it the standard of care.

EMS loves standards of care. We don’t care how dangerous they are.
 

Limited funds to bring people in for continuing education;[1]

 

More than continuing – expanding education.

Keeping up with original paramedic education is not enough.

What we need to know changes. We need to keep up, with the changes, not with the past.
 

Airway management and monitoring (particularly failure by crews to use waveform capnography) continues to be an issue;[1]

 

The medic did not include waveform capnography tracings with the chart?

There is less than 100% QA/QI/CYA of intubations?

The medical director does not understand waveform capnography, airway management, and/or oversight?

Not using waveform capnography is due to a critical failure of management that has been adopted by paramedics who have a ceremonial understanding of EMS – enough to pass a test to get a patch, but not enough to provide competent care.

Footnotes:

[1] Issues and Challenges Discussed by Medical Directors at Eagles Conference – Editor-in-Chief A.J. Heightman reports from the 2014 Eagle Creek Retreat in Dallas
A.J. Heightman, MPA, EMT-P
Wednesday, February 26, 2014
JEMS
Article

.

Issues and Challenges Discussed by Medical Directors at Eagles Conference – Part 1


 

A.J. Heightman writes that there are several issues that are important to the medical directors attending the Gathering of Eagles. The conference is over, but here are some of the issues –
 

More attention to crew “time on chest” during resuscitations and avoiding interruptions;[1]

 

Other than defibrillation, chest compressions are the only treatment that has been shown to improve the one outcome that matters – survival with a working brain.

Why is this so hard for people to understand?

Don’t stop until the patient is no longer in need of compressions. OK, pause for a couple of seconds to analyze the rhythm and deliver a shock from the defibrillator that was charged before the pause. More than that is bad patient care.
 

Shortage of paramedics and new EMS leaders – Referenced by several systems;[1]

 

Is this a real shortage?

Or are they trying to have all responders be paramedics?
 

The expense of placing the same monitor/defibrillators on ALS engines is now becoming an issue. Some systems are exploring use of AEDs with screens on first response units because the number of times the “full system” is needed is not high;[1]

 

When the paramedic on the engine is there just to stop a clock, the position is purely ceremonial and there is no reason to give the ceremonial paramedic real paramedic equipment. We really do not want these inexperienced ceremonial paramedics treating patients, because almost everything a paramedic carries can kill the patient.

There is a shortage of EMS leaders who lead in a way that is good for our patients.
 

Budget cuts and shortages are limiting what can be done in EMS systems, particularly in training, equipment replacement/updating and quality assurance;[1]

 

We need to spend more on fewer paramedics, so that they are better able to provide appropriately aggressive care to the few patients who will really benefit from paramedic care.

We do not need a bunch of IV technicians to save the nurse from having to start an IV.

We need medics capable of appropriately assessing patients. We have more than enough protocol monkeys.
 

The ability to do effective QA with limited staff, funding and data resources was pointed out as a key need. The need for the seemless and timely integration of data was referenced by multiple medical directors;[1]

 

Do the metrics matter, or are they just making sure that the protocol monkeys are doing the Macarena the way the medical director wants it done.
 

Need for better education and treatment of pediatric patients;[1]

 

Even pediatric hospitals have trouble with this, so there is no easy solution and it is a real problem.
 

Instilling pride back in EMS providers, particularly in systems that do not fully appreciate EMS;[1]

 

Imagine a system that does just EMS and does EMS very well.

We have too many all hazard systems that try to do everything just well enough to avoid getting in the way with whatever they consider their primary job.

Incompetence is common – just don’t point it out. the patients don’t need to know.
 

Use of technology and negative news to help EMS systems solve system woes. Bad publicity can force politicians to correct (and fund) system issue;[1]

 

Rather than punish those pointing out problems, we should be asking them to help fix the problems before they become embarrassing stories on the news.

Embarrassing generally means somebody died and it was our fault and we have to find a way to make people forget that it was our fault.
 

Need to return to basics and not just rely on devices and technology to “assess” the patient;[1]

 

And not rely on a bunch of impressive patches on inexperienced people doing ceremonial paramedic work.

To be continued in Part 2.

Footnotes:

[1] Issues and Challenges Discussed by Medical Directors at Eagles Conference – Editor-in-Chief A.J. Heightman reports from the 2014 Eagle Creek Retreat in Dallas
A.J. Heightman, MPA, EMT-P
Wednesday, February 26, 2014
JEMS
Article

.