Texas EMS Conference - Day 3

The first session of the morning was entitled "The Emergency Reponse to Africanized Honey Bees" by Dr. Bryan Bledsoe. Here are some points he brought up:

• Because someone is stung so many times in an Africanized attack there is not only an allergic reaction risk but also a risk of invenomnation. Even though the venom is no more potent than European bees' but because they sting more during an attack more venom is introduced to the stingee.
• It's hard to tell the difference between africanized and European bees.
• Bee venom contains histamine, pheromones, enzymes, peptides, acids and amino acids.
• Brazilian researchers were experimenting with interbreeding africanized and European honey bees to try to get more honey. Several swarms escaped and the bees began to spread north.
• The bees migrate north at about 200 miles per year. They are now around San Francisco across the country and are even found in Florida.
• Africanized bees prefer to nest in the ground.
• It's important to make a plan to respond to bee attacks.
• Persons who are allergic should not respond to bee attacks even if they are on duty to avoid EMS personnel becoming patients.
• It's a good idea to have a list of experts in dealing with africanized bees to assist.
• A good thing to also have a bee response cache with beekeeping clothing, duct tape, and allergic reaction meds.
• Fire personnel can use water to knock the bees down enough to affect a rescue, but this is only temporary. In order to kill the bees foam or soapy water must be used.
• There is a device called BeeAlert™ which can be deployed to kill the bees. It uses a proprietary surfactant in a fog which will drown bees. The product can also be sprayed on victims to kill the attacking bees.
• Victims need to be carefully evaluated for systemic versus localized reactions. Remove the stingers to relieve pain and stop continuing envenomnation. Consider prophylactic diphenhydramine. Victims with systemic reactions should be transported.

Dr. Bledsoe was the speaker for the next session entitled "Neurological Trauma." He reviewed the physiology of brain injury, signs and symptoms, and treatment options. It was a very good review with some new things - at least new to me.

The Hilton had hot water problems again this morning. My roomie told me he waited about an hour for the hot water to come for his shower in the evening. I don't think we'll stay in this hotel again.

** Follow up on the hot water problem **

Overall, it was a good event. I learned a bit from the sessions I attended - lots of new information.

Now, it comes time to head home. I hope the traffic isn't too bad. Considering this is the busiest travel day of the year, I'm not too optimistic.

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.

Texas EMS Conference - Day 1

The EMS Conference kicked off this morning with the keynote address by Dr. John Griswell who spoke on medical ethics. That's a tough sell first thing in the morning, and it's tough to make it interesting, but he did a pretty good job and he brought up some good points:

• Doctors and EMS are in the medical practice together and neither can function alone.
• Ethics is not legality. Legal standards are minimum standards. Ethical standards should go above legality.
• One common denominator in unethical behavior us a sense of entitlement or superiority. "We're better than they are so we can use them," or "They were going to die anyway" statements can be used to rationalize ethical lapses such as in Nazi Germany or in many ethical lapses in the US.

The second session I attended was entitled "America's School Shootings" by Ken Bouvier. His was a very informative and entertaining presentation. Don't get me wrong, the subject was totally serious and Ken was serious. But, he did throw in a joke or two at tasteful and appropriate times. Some of the main points of his presentation were:

• School shootings have been going on for a long time and will happen again. It's up to the police, fire and EMS communities to have a plan in place in case it happens in their area.
• The scenes are usually chaotic and inherently unsafe. Sometimes EMS crews will have to jump in before the "all clear" is given. It could take up to an hour for things to settle down enough to where things are truly "safe."
• The kids who perpetrate school shootings fit a certain profile:
  
• • History of clinical depression or signs of clinical depression which were not noted until after the fact
  • History of suicidal thoughts or actions
  • Had low self-esteem
  • Tended towards satanic and/or Nazi ideals
  • Were taking Ritalin and sometimes another anti-depressant
  • Many were late bed-wetters
  • Most were members of broken homes
  • Almost all were victims of some kind of abuse

It is mostly incumbent on the parents to lock up their guns securely and to only allow kids to use them under proper supervision - especially if they have some of the profile signs listed above.

The last session of the morning was entitled "The ABCs of Cardiac Arrest: Is the 'B' Necessary?" given by Ken Navarro. Ken made some very interesting observations about assisting cardiac arrest victims with compression-only CPR (or CCR - Cardio-Cerebral Resuscitation):

• Despite changes in ALS techniques, there has been no statistical increase in survivals of cardiac arrest victims.
• Studies have show there is no real statistical increase in out of hospital cardiac arrest patients, and good-quality CPR is most effective.
• CPR techniques need to be taught properly and graded objectively. Most people cannot tell if they are compressing deep enough, fast enough and allowing the proper time between compressions.
• Starting in the 16th century and continuing until the 19th, a fireplace bellows was commonly used to resuscitate those in respiratory arrest. (Trivial fact which was interesting to me)
• Compressing the heart alone isn't responsible for moving blood around the body during compressions. It's also the effect of pressure change in the chest which helps move things along. Compressions must be deep enough to change the pressure in the chest to sufficiently help the heart move blood.
• Often times, while using a BVM, too much pressure is built up in the chest so blood movement is either slowed or stopped because the blood can't get into the heart to get pumped.
• Studies show that bystander no-compression CPR is no less effective than more traditional methods.
• A Wisconsin study showed (again) that good quality compressions make the most difference when determining what will lead to greater survivability.

It was a very interesting session.

The afternoon kicked off with a presentation by Kirk Mittleman entitled "Critical Calls Take Critical Thinking." 

He started off the session by showing two video clips showing the importance of seat belt usage and how wearing them can increase the survivability of people in motor vehicle collisions. The first was by the Montana Department of Transportation called "Room To Live" which stressed the fact that there is room to live inside a vehicle during a collision and that being ejected raises the chances of being killed. It is quite a moving story. The second was of a related topic showing how one person not wearing a seat belt can cause injury or death to the other passengers even if they are belted. Here's where you can catch it on YouTube. 

The rest of the presentation was quite good, but I really think these two videos should be the highlights of it. I plan to show these to my kids (one drives, another is about to, and the youngest needs to make sure to wear his belts).

Dr. Ed Racht and Dr. Paul Pepe gave a great talk entitled "In-Hospital Care Driven by EMS" which pointed out examples of equipment and techniques which started in EMS and made their was into hospitals instead of the other way around. Those in EMS have always had to be more "creative" and find ways to get things done for their patients outside the "nice" confines of a hospital. EMS is also aided by hospitals which now specialize in types of care (i.e. trauma, stroke, sepsis, pediatrics, etc.). 

Dr. Racht talked about a web site which rates hospitals by certain criteria based on surveys taken by patients of those hospitals: www.hospitalcompare.nhs.gov. I just checked out some of the hospitals in my area and it was a bit of an eye-opener. I recommend you check it out.

The last session of the day I attended was called "Port-Partum Pre-Eclampsia" given by John Rinard. Not knowing much about pre-eclampsia I found it quite informative. It's especially telling that pre-eclampsia and eclampsia can occur up to 4 weeks post-partum. I had no idea that was the case.

We're staying at the Hilton. It's a nice place with a bit of history. This is the former "Hotel Texas" which is where John F. Kennedy stayed the night before he was shot in Dallas. There are pictures hung all around the building showing President Kennedy at various times around the hotel that fateful morning.

I have a complaint about the accomodations. In the bathroom are the "obligatory" signs inviting guests to help save the Earth by reusing their towels. It's a nice idea, which I often do. But, I think it's rather hypocritical to ask us to save the Earth by reusing our towels when I have to run the water for 10 minutes before it gets hot enough to shave with. That's very wasteful. I know it might be petty, but I've shaved with cold water enough times that I know I don't like it. Although there is not sticker on the back of the door indicating how much the room is worth per night, I'm sure we're paying enough for there to be hot water without waiting that long.
** Follow up on the hot water situation **

There is also a low-flow shower head in the tub. Hotel owners and managers: please hear this - "low-flow" and "water-saving" does not have to mean low water pressure. You can have both water savings and high pressure.

Now, that's not to say I'm totally dissatisfied with the hotel. It's good, but I expect a bit more from the Hilton name.

Dinner this evening was at The Reata. Very good chicken-fried steak and excellet desserts. If you're in Downtown Fort Worth it's definitely worth stopping by.

Texas EMS Conference - The Day Before

We drove up to Fort Worth this afternoon to get ready for the Texas EMS Conference which begins tomorrow at 8:30am. The trip itself was uneventful, other than the unusually high traffic volume compared to other Sundays I've made the trip north. We made our obligatory stop at the Czech Stop in West to get some poppy seed kolache (yes, that the way it's spelled in Tex-Czech and I know it's not a "real" kolac if it has stuff other than fruit on it - but they are so good).

After we checked into the hotel, we headed over to the convention center to check out the exhibition hall. There were a lot of EMS services actively recruiting - I guess showing that medical care is a real recession

-proof field. No matter what the economy is like, people get sick and hurt and need assistance.

I took some pictures of a few interesting vehicles. Harris County EMS had some new vehicles on

 display. I like the new Dodge Charger, though I think it would have been excellent in red or yellow (the Charger being one of the only cars I think looks good in yellow). The

 ambulance looks good in the same color scheme.

There was another, smaller, vehicle on display which I can only describe as a Segway on steroids. there were two models, one which looked pretty basic and the same basic setup, but with plastic motorcycle saddle bags.

We had dinner at Razzoo's, which is a chain restaurant featuring Cajun style food. I hadn't eaten at one before, but we went on the recommendation of one of our group. He did not disappoint, either. The food was excellent and I ate way too much. There is a Ruth's Chris Steakhouse connected to the hotel. I've never eaten at Ruth's Chris and have wanted to try one. Although we are limited in what we can claim on an expense report, we might eat there tomorrow and "eat" the cost over the limit ourselves.

I heard someone call on 146.52 a while ago, but didn't respond when I called back. I'm beginning to think the antenna which came with my Yaesu VX-3 is very limited. The higher gain antenna I purchased separately is rather long and somewhat inconvenient to carry, but it seems to make a huge difference in my transmission strength. I might just switch to it permanently. I'm also thinking a telescoping whip might work well, too. With that I can collapse it for monitoring and extend it when necessary.

I'll write up some thoughts about the sessions I attend tomorrow. I'm looking forward to some good instruction.