First Responder | David Konig

Breaking Twitter Rules Answering @SteveWhiteHead In Greater Than 140 Characters About Breaking Protocol

March 11, 2010 By Dave Konig 1 Comment

I like Twitter.

I stress the word like because I find it useful for some things, but not so useful for many others. This doesn’t mean that I don’t believe in it’s power or it’s influence, just that I recognize the limitations the tool has and my expectations don’t exceed it. It’s important to remember that as you read on.

So in the same vain of answering Greg’s question, I am now going to answer a question most recently asked by Steve Whitehead on Twitter that deserves more than 140 characters will allow:

Can The Real Protocol Please Step Forward?

There is a reason why medicine is still considered an art.

You can have two patients with the same complaint, but because of having vastly different histories the same treatment applied to both may help one but harm the other.

This is one of the reasons why you will find some vastly different protocols across the country. What works well for some areas may not work well for others, and what works well for some patients may also not work well for others.

In My Experience

It’s important to understand that I am New York State Certified, so my experiences are limited to working within NYS Protocols. On the fifth page of those protocols under the Introduction heading appears this paragraph:

God bless the New York State Department Of Health Bureau of EMS.
The Continuing Problem

Unfortunately, even with that paragraph there, it still leads to problems. EMT recruitment is as easy as checking the ABCs. If you’ve got a pulse and can breathe you can become an EMT. The current education is centered around the protocols and complying with them as opposed to independent thinking with good clinical judgement, because by not following them you run the risk of being held liable if anything goes wrong with the patient.

Why is that 90 year old patient with osteoporosis strapped to a backboard after falling out of bed? Protocol.

Why is that hyper-ventilating patient suffering from an anxiety attack wearing a non-rebreather set to 15 liters per minute? Protocol.

Why is that patient sitting on a roadside construction sign (next to the car he was in when rear ended ever so slightly and obviously got out of) being strapped into a soft Spinal Immobilization Vest? Protocol.

Burn The Protocol Book, Care For Them All, Let The Triage Nurse Sort It Out

I once had a paramedic who would always refer back to the protocol book. If you were turning cyanotic and gasping for breathe in the tripod position in front of him, he would take a minute to look it up in the protocol book before giving you some much needed oxygen. This over reliance on protocol is a bad indicator that our education model needs to be revamped, our recruitment methods are not working, and that we are more concerned with the potential lawsuit down the road than we are the patient in front of us.

If that paragraph didn’t exist in the NYS Protocols, I probably wouldn’t be in EMS anymore today. Heck, I probably wouldn’t have made it out of my first year because strapping down 90 year old patients with osteoporosis is just not something I think I could actually do with or without legal “justification”.

Which is another thing I blame protocol for. EMTs and Paramedics use protocols as justification for providing treatment that doesn’t benefit the patient, but benefits them. Such as taking the patient to the nearest hospital as opposed to the hospital the patient has a doctor at. Sure in a perfect world hospitals would be able to share records, test results, and other information… but right now they can’t. It’s a major shortfall of the healthcare system that we won’t be able to solve, but for that specific patient we may be able to alleviate that issue as well as some anxiety by simply taking them the extra mile (or five) to where they already have received treatment.

Finally, I hate protocol because so many people think that providing patient care is a black and white issue when it is far more complicated than that. Sure protocol can provide you guidance on the basic treatment a patient should receive, but it doesn’t provide you with a methodology or the tools to provide exceptional patient care. As I said before, there is a difference between treating and caring for your patients. Which one would you rather do? Which one would you rather be on the receiving end of?

I say burn the protocol book, care for them all, and let the triage nurse sort it out.

Don’t Treat Your Patients, Care For Them

March 1, 2010 By Dave Konig Leave a Comment

There were two blog posts last week that really made me think about where EMS is as an industry and where we need to be.

The first blog post came from Chris Kaiser titled Two Cases, One Letter – From One Paramedic’s Struggle Change Can Come. To summarize the post, it was about a letter from an anonymous Paramedic who had two cases that left him concerned about the priorities of his organization. The first case had to deal with the transfer of a patient with MRSA to a birthing unit, where he did what the facility had called for and did not speak up about the potential contamination of the birthing unit, he was not reprimanded for this failure to identify and prevent a potentially dangerous situation. The second case had to do with a terminal patient being transported for a direct admission and their condition in the paramedic’s assessment warranted them going to the emergency room instead, against the family’s will but in accordance with treatment protocol, which ended in the paramedic being reprimanded for this decision. I left a comment on the original post regarding my thoughts on both cases. This blog post shows us where we are.

The second blog post was Steve Whitehead’s post titled Passion Counts. To summarize the post, Steve points out that to be successful as an EMT or Paramedic you need to have a passion for medicine. I didn’t leave a comment on the post, but instead my opinion will undoubtedly come out in this post. This blog post also shows us where we are, but puts us on the path where we need to be.

Where Do We Need To Be?

Don’t treat your patients, care for them.

I first heard that phrase over a decade ago from a grizzled EMT that most people considered out of touch with what was going on back then. It really resonated with me for quite a few reasons that first time, mainly because I realized that he wasn’t the one out of touch with reality… rather I had been. It reminds me of where we truly need to be as an industry.

One of the things we need to stop doing is complaining about the other healthcare professions and the public lacking respect for our profession. We are providers of a service and as such we can’t expect accolades for providing the service we are supposed to. Really take a moment and think about it. How many of you have taken the time to write a letter or even provide a compliment about a cashier at McDonald’s when they provide you with the correct order? Probably not very many, if any. How likely are you to complain when the order is wrong or not to your liking? Chances are quite a few of you would, if not all. We as a society are not very complimentary to our service providers, which is exactly my point. We need to stop worrying and complaining about these broad perceived injustices and focus on the opinions of those that truly matter… the patient.

When it comes to focusing on the patient, we need to stop thinking of medicine as one solution fits all. There is an absolute need for you to have a strong clinical base of knowledge and understanding. Its true that over time we have slowly moved towards more evidence based medicine influencing our clinical protocols, that does not exclude the unique conditions of patients in both physiology but also emotionally and personally.

We need to be able to listen and understand their wants as opposed to what our protocols dictate their needs are. The true art of medicine is in blending the two together for the best possible outcome. This is the difference between just treating your patient (protocols) and actually caring for them. Yes, you need to be passionate in this job, but you need to be passionate about actually caring for your patient. If we were able to get past being stuck on treating the patient and instead began caring for them, then the respect from the public and other healthcare professionals would come in time.

So make the conscious decision to start passionately caring for your patients as opposed to just treating them.

Because It’s Not All Motions And Theater

January 7, 2010 By Dave Konig 1 Comment

I came across a series of interesting posts from Greg Friese, Steve Whitehead, and Chris Kaiser regarding the common practice of “CPR Theater” or “Going through the motions for the family” when it comes to pediatric arrests. These are blogs that I read often, and I find myself often agreeing with their observations and points of view.

This is not one of those times.

Just for a little background, I spent 2 years working in the Bronx. Out of the five boroughs, the Bronx has the highest infant mortality rate of the city (6.3 deaths per 1,000 births in 2005) that has seen a decline in both birth rates and infant mortality over recent years. Both my first and last calls in the Bronx were infant arrests (speculated to be SIDS victims) and there were more than two handfuls in between, so I have a bit of insight into pediatric cardiac arrests and resuscitation efforts.

On every single one of those resuscitation efforts, I did everything I possibly could, including transporting the pulseless child with their grief-stricken parents up front, even when I obviously knew that there was no hope of regaining a pulse short of a biblical style divine intervention. I made sure the parents understood that not only was I doing everything that I could but that the hospital would do everything they could when we got there. Say what you want about the hospitals in the Bronx, but they never failed me in doing exactly that even when they also knew there was no hope unless the new janitor was also able to turn water into wine amongst other things.

So why do it?

At their very core, every parent ultimately wants the best for their children. Now as Dan Carlin points out in Suffer the Children, this was not always the case in society and while we may revert back to it at some time, right now as a society we place a high value on the very essence of life itself.

In fact, we place such a high value on life that we employee people trained to preserve that life the best way we think we know how whenever we know that the essence of life is threatened. We call those people EMTs and Paramedics. We have also scientifically found ways to extend the essence of life by performing changes on our own bodies (such as open heart surgery) and through machine augmentation (such as ventilators and bypass machines) so much that we have doubled the life expectancy of a person in 100 years.

Every parent wants the best for their child, including healthcare and efforts taken to preserve their essence of life. They want to know that everything that could have been done for them was in fact done for them. So do it. Don’t “go through the motions” or perform “CPR Theater”… actually run the code, perform CPR, and transport as you would a viable patient.

Why?

Because as we hear every so often, there are plenty of patients that are viable when we don’t necessarily think so.

EMS personnel are also not trained or equipped to assist grieving parents either at home or on the scene. Not transporting is denying the parents the knowledge that everything was done for their child, you deny them access to a neutral place they may associate their grief, and professional help on “what happens next”. No parent plans for this event unless there is an underlying condition with an inevitable conclusion. Even if they consider the “what if” scenarios, rarely are they in a state of mind to follow through on what they should do next. This sort of training is beyond just knowing what to say (because in the death of a child there truly are no words, but we should allow our actions to speak for us instead), but more importantly about how to guide them as they step into their new reality.

But aren’t there undue risks involved to both EMTs and the public in transporting a pulseless patient that science says we should leave at the scene?

This is an argument where I sit on both sides of the fence.

On one side, I agree that transporting a patient that qualifies for field termination lights and sirens does create an undue risk and hazard to both personnel and the public.

At the same time, society demands that we respond to these threats to the essence of life expediently even though the perception of that threat may be increased upon by the caller and scientifically the patient’s essence of life is not threatened in the least.

This also creates an undue risk and hazard to both personnel and the public.

Therefore I would submit the argument that as long as society views protecting the essence of life, therefore employing EMTs and Paramedics to protect that essence of life, then the undue risk is an acceptable one. Once society no longer values the essence of life, then we can have real health care reform by not extending lifetimes past their expiration with radical treatments such as chemotherapy and radiation, we will be fine with patients who choose euthanasia, and we will no longer place personnel or the public at undue risk because there will be no more ambulances.

The fact is that perception plays as big a role in all of this as protocols. A field termination of a pediatric will leave the grieving family going through the shock of the 5 Stages of Grief without support from trained personnel.

One of the thoughts among them may very well be, “Those Paramedics did nothing! Nothing!” We already have cases of that, and adding that perception from a grieving parent will be damning to not just the agency, but the industry as a whole. This is not the perception we need to maintain. We need to show that our industry is not only able but willing to go that extra mile in the quest to preserve the essence of life.

In most instances, patients, and their families do not know good patient care from bad patient care. They do know an effort from no effort and nice from not nice. Every now and then though we’ll come across people who know all three… and heaven helps you if that child you chose to field terminate because you didn’t think they were viable happens to be the son of a Chief or Director of a large EMS Agency.

In Conclusion

There are a number of systems with field termination guidelines. While I am a proponent of field termination, specifically for the hospice enrolled patient, I am in opposition to any guideline allowing field termination of a patient under the age of 18 barring significant obvious trauma. Make “No Child Left Behind” more than a failed education initiative, make it your Pediatric Arrest Protocol.

On HIPAA And Photography

October 14, 2009 By Dave Konig 4 Comments

Earlier this week I mentioned a video on STATter 911 that showed an EMT swipe a camera from a local activist in the name of the all powerful 1996 Health Insurance Portability and Acountability Act (HIPAA).

Now I’ll be honest, while the video is slightly disturbing I can understand why it happened. The activist was being obnoxious, rude, beligerant, and basically baiting the EMTs and Police Officers. Unfortunately this particular EMT, identified as Captain Ronald Leslie, took the bait and swallowed it whole like a wide mouthed bass. What I find to be more outrageous, and a blaring indicator to the actual problem, were the comments left on the original post.

So it begs to question how could a Captain be so blatantly wrong in his assertion that HIPAA prevents photographers/videographers from taking images on a public street and how can so many providers think that he was actually in the right?

The answer is that we provide an extremely poor education in not only HIPAA but also laws regarding photography. I’ve had my fair share of people tell me the same thing, including supervisors, chiefs and directors. I thought that we had done better in this area of education, but it appears we haven’t.

Who HIPAA Actually Applies To

To violate HIPAA it must actually apply to you. Some covered entities are:

Doctors
Nurses
Clinics
Hospitals
Dentists
Chiropractors

…and since we bill health insurance for reimbursement…

EMS Agencies
EMTs
Paramedics

Anyone notice something missing? Yes, Firefighters don’t necessarily make the list. However if you are certified as a healthcare provider or belong to a fire based EMS system then you are included as well. For firefighters who are members of a fire department who does not respond to medical emergencies, are not healthcare providers and therefore do not bill for compensation, HIPAA does not apply.

As for everyone else, such as the media and John Q. Public with a Flip UltraHD Camcorder or a cellphone camera, since HIPAA does not cover them then the rules governing patient privacy do not apply to them. Therefore they cannot “violate” them.

3 Of The 10 Legal Commandments of Photography

Laws will vary from state to state and city to city, but there are some very basic guidelines that are universal thanks to the US Constitution and its Amendments. An excellent guideline to these rights are The Ten Legal Commandments Of Photography. In the case above there are three specific Commandments that apply:

I. Anyone in a public place can take pictures of anything they want. Public places include parks, sidewalks, malls, etc. Malls? Yeah. Even though it’s technically private property, being open to the public makes it public space.

So is a courthouse open to the public? I would hope so. Therefore it is indeed legitimate to photograph/videograph inside of that building. Government buildings deal with highly sensitive materials in regards to national security may indeed prohibit photography as per Commandment IV, but I don’t think the Keene Courthouse is harboring anything of that nature.

V. People can be photographed if they are in public (without their consent) unless they have secluded themselves and can expect a reasonable degree of privacy. Kids swimming in a fountain? Okay. Somebody entering their PIN at the ATM? Not okay.

So this dispels the whole argument about the photographer not having consent forms for the people they photographed. If indeed it is in a public place, it can be photographed. Now what those photographs can be used for is a different issue. If for arguments sake someone wanted to use one of those photographs as an advertisement for a product inferring an endorsement, because it is now for commercial use they will probably need consent forms. The chances of that however are highly unlikely.

VI. The following can almost always be photographed from public places, despite popular opinion:

* accident & fire scenes, criminal activities
* bridges & other infrastructure, transportation facilities (i.e. airports)
* industrial facilities, Superfund sites
* public utilities, residential & commercial buildings
* children, celebrities, law enforcement officers
* UFOs, the Loch Ness Monster, Chuck Norris

Once again, these are things within public view and therefore are legally within the realm of the photographer without the need for any special dispensation.

A few months back I posted the NYPD OPS Order On Photography. If you read the OPS Order it is very specific that the laws and practices the NYPD abides by follows the Ten Commandments very closely.

It is important to realize that these permissions are truly in our best interest as a society. While it may seem not in the best interest of the patient, if the freedom to do so didn’t exist then the video of Paramedic Maurice White getting choked by Trooper Daniel Martin would be illegal as well. Ultimately it is important that Responders understand and respect both their responsibilities to and the rights of their patients and those around them, especially photographers and the media.

This is also a great reason why your agency should be involved in Social Media. If the Keene Fire Department would have had a Social Media presence instead of this webpage, they would have been able to defend themselves in a more direct fashion. If you’re from the Keene Fire Department and reading this, it’s not too late to get started in Social Media.

Oklahoma Trooper Assaults Paramedic

May 28, 2009 By Dave Konig 2 Comments

On Sunday May 24 an Oklahoma State Trooper pulled over an ambulance transporting a patient to an emergency room and reportedly assaulted the Critical Care Paramedic who was charged with the patient’s care.

EMT Paul Franks and Critical Care Paramedic Maurice White from Creek Nation EMS were transporting a patient from Boley along highway 62 to the Prague Hospital Emergency Department. Near Paden the ambulance was pulled over by Oklahoma Highway Patrol Trooper Martin (Badge #606) because of the ambulance’s supposed failure to yield to him further back on the highway.

The incident was caught on video by the patient’s family and posted to YouTube. In the video you can hear EMT Franks request the Trooper to allow them to continue the transport to the Prague Emergency Department and to handle this matter there so as to no longer delay patient care.

Additionally you can clearly see that Paramedic White was in the back of the ambulance caring for the patient when he was pulled out and told that he was “under arrest”. While Paramedic White does in fact appear to resist the arrest, it should be noted that the Trooper Martin attempted to subdue him using a one handed choke hold meant to deny oxygen to his brain while the patient was being left unattended to in the rear of the ambulance. Since Paramedic White was the highest medical authority and charged with the patient’s well being it is understandable why he would in fact resist such an arrest action by the Troopers since there was no equal or higher medical authority for him to transfer care therefore leaving him as the responsible party.

You may think that common sense would dictate that if indeed Paramedic White allowed himself to be taken into custody that he would no longer be held liable for the well being of the patient, but common sense would also dictate that a law enforcement officer should not delay an ambulance crew from delivering a potentially critical patient to the emergency room. Apparently common sense is in very short supply from the Oklahoma Highway Patrol, and therefore it is safe to assume that it would also be in short supply in their other law enforcement and judicial agencies. Oklahoma is afterall the state that legalized upskirt photography to the delight of perverts and sexual deviants everywhere.

There is also reportedly a dashcam recording of this incident from the Trooper’s car that will reportedly show the ambulance crew assaulting the Trooper first, but surprisingly (or not) that has yet to be released.