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

- Rogue Medic

Bad Oversight – Part I

Once upon a time, in an EMS system far, far away, there was a brand spanking new medic. No, I did not spank him, but some others did. This is the story of how they were wrong. A story of how they were the ones, who needed to be spanked.

In this system, the medic is all by his lonesome, in a fly car, in the middle of nowhere. Our hero, Spanky, is brand new as a medic, is not familiar with the area, and has not even had a real orientation to the system. In other words, this situation is just made of WIN!

In this moderately busy system, there are 911 calls. Dispatch sends out the ambulance and medic for the particular location of the call. So far, so good. Spanky is dispatched, not to his own territory, the nowhere that he does not even know his way around. Spanky is dispatched to the next medic’s territory, a whole different nowhere, a nowhere that he did not even know existed prior to being dispatched. This nowhere is between 10 minutes and 20 minutes away. That time is assuming that one proceeds directly to the location.

Spanky is driving like he is at Daytona, because that is the way he sees other medics driving. He is reading the map at the same time, because that is what the other medics do, too. Texting while driving would only improve driving ability, here. Spanky is kind of lost, but after some assistance from dispatch, he does arrive on scene.

The dispatch was for cardiac arrest. This is back before the concentration on not interrupting compressions. The main reason for a medic to drive 10 – 20 minutes to a cardiac arrest is in case the person turns into a vampire. The medic is the only one authorized to drive a stake into the vampire’s heart. It is an invasive procedure, after all. Hospitals become upset if ambulances transport vampires without staking them, first.

Spanky arrives, parks, grabs his gear, and goes to the ambulance. The ambulance is sitting there, lights flashing, maybe the siren is also on, and the driver is sitting in the driver’s seat, ready to go. Spanky opens the doors to the back of the ambulance, where the patient is. As soon as the door closes, before Spanky has a chance to grab a seat, a history, a patient assessment, or even to catch his breath, Ricky Bobby takes off.

Now, to properly understand the benefit provided by Mr. Toad’s Wild Ride, while you are reading, you should bounce up and down and side to side, occasionally throw yourself into the wall. If no wall is handy, throwing yourself off of a balcony might be a reasonable substitute. You should imagine that you are trying to deliver patient care, while this is happening. I even tried to type this post, while using this method, but I crashed the computer.

Anyway, the low-guy-on-the-ambulance-totem-pole is in back with the patient, performing one person CPR. Ricky Bobby has to be up front gunning the engine, waiting for the starting gun. If you remember how goofy one person CPR was back before it was realized that the ventilations make things worse, you can picture the circus atmosphere in the back of this ambulance. But, now our hero is there. Things can only get better, right?

If the CPR had been tolerable, while the ambulance was not moving, it only became worse, when the roller coaster ride began. En route, Spanky intubated the dead patient. They soon arrived at the hospital.

Perhaps, some of the irregularities need to be addressed here.

What did the BLS crew do?

Apparently, they just moved the patient from the residence to the ambulance.

Why move the patient?

Because they don’t know what else to do. If it is embarrassing to be just doing CPR in front of the family, at least they can go hide in the ambulance. And Ricky Bobby can tell the bottom-of-the-2-person-totem-pole guy to do CPR by himself. Ricky Bobby has to drive. Vroom-vroom. Besides it is easy to do one person CPR while moving the patient (no, Ricky Bobby does not participate in the CPR, Ricky Bobby just lifts and drives).

What about an AED[1]?

Yes, the ambulance crew had an AED. I do not know if they brought the AED into the home, but it appears that it was never attached to the patient. The medic will be here soon. We’ll use his defibrillator pads, so we don’t have to restock.

Is there anything the medic or the hospital can do that is more important than defibrillation?

They can bill at a higher rate, but not much else.

It seems as if the ride to the hospital was short. Why didn’t they just transport, in stead of waiting for the medic?

One reason is that in this area, the doctors and nurses will throw a super-duper hissy fit. Screaming, Why didn’t you wait for the medic? This criticism is not at all uncommon, although it is unreasonable and just plain stupid. The closest ALS was the hospital. If the ambulance crew decided to move the patient to the ambulance, they should have continued moving to the hospital without the medic.

In other words, ignoring the AED (as they did), they had 3 choices. Treat the patient on scene. Move the patient to the hospital. Move the patient to the ambulance and treat the patient there. They made the worst choice, as far as patient care is concerned. Best choice – stay on scene delivering the best CPR that they can (and use the AED). Second best choice – if they are foolish enough to move this patient, they should keep going, until they are at the hospital. Worst choice – just move the patient to anyplace where they can hide their ignorance (in this case, the back of the ambulance).

Now, I don’t mean to cast any doubt on the accuracy of the tale recounted by Spanky. That would be wrong. According to Spanky, he properly intubated the patient, but forgot about defibrillation. When they arrived at the ED, the patient was in fine VF (Ventricular Fibrillation, one of the rhythms the AED is designed to shock automatically, preferably before it deteriorates to fine), the patient was shocked into asystole, and eventually the patient was pronounced still dead.

End of story?

Not a chance. Everybody has to have their input on how to punish this medic for being put in a position he never should have been put in.

Management wants to make an example, so that people will not suggest that their irresponsible scheduling and lack of orientation had anything to do with this. Spanky was not there because of any particular trust in his abilities. He had a card and a pulse. He had been signed off by the medical director. He could not refuse to work this shift. Spanky was not there because of any ability to charm people. No way. No how. Not Spanky.

The ambulance crew wants the focus on the inaction of the medic, not on their inability to provide basic CPR and their inability to use an AED appropriately. The crew did have an AED. Of course, they only have to convince their fire chief that they did nothing wrong. They point out that it was a medical problem and the chief immediately loses interest. Don’t bother him with that medical stuff. So they skate. They may even get some street cred for putting up with such a dangerous medic.

The hospital didn’t have much of a problem, but they had not done anything that they needed to cover up.

To atone, Spanky is told he must ride along with an EMS agency, but it may not be his employer, because that would make too much sense. He has a few weeks to complete all of the ride along time. He has to arrange for everything himself. Well, surprisingly Spanky does manage to arrange this with one of the competitors.

The ALS Chairman for that agency is convinced that because Spanky was a respiratory therapist, Spanky thought of airway first and will always think of airway first. The Chairman sees this as a fatal flaw, that can never be repaired. This was one of the big disagreements I had with The Chairman. I wasn’t defending the skills of Spanky. There was not much to defend. I was advocating for him to have a fair shot of demonstrating whether he actually had any skills.

If anything, a problem with EMS is we do not have enough people with respiratory backgrounds. We could learn a lot from respiratory therapists.

Anyway, Spanky did not complete everything to the satisfaction of all involved. After riding with the competition, he would be a pariah, anyway. From what I hear, he moved on to several other companies, and is no longer in EMS. Next time you are at Micky D’s, or Double D’s, ask if the guy there knows the story of Spanky and Ricky Bobby. You just may be getting a Coolata hand made by Spanky.

Rather than try to remediate someone, who might have learned from his mistake – a mistake that probably had nothing to do with the outcome – we reinforce the idiotic way EMS is delivered in this area.

Spanky delivered no Sparky.

But that was the least significant of the problems on that call.


^ 1 AED = Automated External Defibrillator