Tuesday, November 25, 2008

Texas EMS Conference - Day 2

First, a note about the hot water: There was hot water this morning and I didn't have to wait very long to get it. I'm glad for that since I was late waking up. My phone locked up sometime in the middle of the night and didn't go off when it was supposed to.

The first session of the morning was entitled: "Precious Cargo: Pediatric Emergencies" and was presented by Bolleter. He had a few points to make regarding pediatric calls and why they shouldn't be difficult:
  • Don't Panic
  • Take a systematic approach to each call (do the same thing every time and be thorough)
  • Look beyond the obvious
  • Follow your protocols
  • Be aggressive - remember: Ventilation, Oxygenation and Perfusion
The main thing to do is to look for something "that just ain't right."

The second morning session was presented by Dr. Racht and was titled "The Twenty Most Important Things." And here they are:
  • Resuscitation
  • Hypothermia - post arrest hypothermia. This is new and important. I don't know much about it, so I attended a session on it in the afternoon.
  • Airway Management
  • Breathing - remember not to over-ventilate
  • Stroke Management
  • Spinal Movement Restriction
  • Infectious Diseases - like MSRA in particular
  • The Medicine of Dispatch - dispatch operators instructing the caller on how to assist until help arrives. They can help quite a bit.
  • Acute Coronary Syndrome
  • End Title Carbon dioxide
  • Interoperability (this is still an issue, though it is getting better)
  • Weirdos - like those who would perpetrate mass casualties
  • Hospital Diversion - Dr. Racht says this practice needs to stop
  • Determination of Death in the Field - we need to get better at this
  • Keeping Up - there is ALWAYS something new to learn
  • EMS Designated Receiving Centers - those emergency departments which specialize in certain areas
  • Errors - we need to be more open about mistakes so we can learn from them
  • Turf and turf wars. This has to go
  • "Customer Service" Pre-hospital, in-hospital, we need to make sure we're doing the right thing, taking care of the patients physical as well as emotional needs. We also need to be sure we treat everyone with respect.
  • Love what you do and do what you love - if you don't love EMS then go do something else.
The final morning session I attended was presented by Dr. Pepe entitled "US Trauma Care: Experience in Iraq." This was a very informative talk dealing mostly with trauma care.

One thing Dr. Pepe stressed was not to ventilate so much that positive pressure builds up in the chest, thus slowing or stopping blood flow back to the heart for recirculation. This is something which goes against was I was taught in school which was to bag fast and bag often. Studies are starting to show that for those patients who have hypoperfusion and hypovolemia will more likely have a bad outcome if they are ventilated too much. Bagging needs to be done much slower, around 12 times per minute. Overzealous positive-pressure ventilation hurts patients more than it helps. Also, bleeding must be stopped before fluid resuscitation begins. Otherwise, you're just wasting your time.

Another thing Dr. Pepe brought up which is something I've heard a little about the use of tourniquets. Because of faster response times, quicker time to definitive care and improvements in treatment, any damage which might be caused by the tourniquet can be repaired. It's better to save that person's life than to worry about losing an extremity.

The first session after lunch was entitled "Liability For Negligence of Paramedics and First Responders" given by Kevin Madison who is an attorney and an EMT with a volunteer service.

Kevin discussed current statues and case law regarding negligence in lawsuits in Texas (of course, I'm not an attorney nor do I profess any legal knowledge other than my opinion based on what Kevin said. If you have any questions, please contact Kevin at his web site: www.code3law.com).

The current wording of the "Good Samaritan" law in Texas indicates that EMTs (basic, intermediate or paramedic) are considered "First Responders" and are not to be help liable for damages unless there is willful and wanton (gross) negligence. Current case law, Dunlap versus Young being one example, also holds that the statue covers EMTs.

But, this exemption is not spelled out as clearly in the statue as it could be. The law reads, in effect, that only those who are licensed in the "healing arts" can be held liable for simple negligence. Those licensed professions are listed in another statute and do not include any level of EMT.

The question comes to mind, and has been argued by plaintiffs seeking damages from EMTs, that since paramedics are licensed under Texas law, they should be included in the simple negligence category. The courts, however, have disagreed.

No cases challenging this interpretation of the law has yet made it to the Texas Supreme Court, so the question is still somewhat up in the air. The way to fix this is to lobby our legislators to change the wording of the "Good Samaritan" statute and specifically include EMTs in the language.

The next session was given by Kelly Grason (www.kellygrason.com) and covered tips for handling those occasions when a patient is violent and needs to be restrained. The bottom line is that all EMS services need to have plans and protocols in place to cover these types of incidents. Most don't. Also, most times it's best to let LEOs handle restraining since they are specifically trained to do so. If a patient is restrained by LEO, make that LEO ride with you in the back of the ambulance.

The last session was a fun and entertaining story session by Kelly Grason and Gary Saffer. They told some funny stories with some good lessons on what not to do as an EMS provider. I'm told Kelly has a book out which can be purchased off his web site (linked above). I'll bet it's a fun read.

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