Tuesday, September 27, 2011

Scope of Practice, the Introduction

I've been having a lot of conversations recently regarding scope of practice, more specifically skills that are included in protocol. This has been a hot topic in VA recently, as it has been nation wide as well, due to the future changes that the national registry will supposedly be undergoing in the near future.

However, this discussion or protocol and scope of practice has always been a hot topic. Just check out one of the many blogs in the EMS blog-o-sphere (maybe AmboDriver or StreetWatch?) and you'll come across many posts that discuss the inclusion or exclusion of certain skills, drugs, etc. from protocol, and the merits of each.

But rather than focus on reforming the skills that EMTs around the country should undoubtedly have access to, I'd like to talk about several skills and pieces of equipment that I have found indispensable in my own experience while running at a rural rescue squad; in fact, I believe they are indispensable no matter where you run.

If you run with my service, you're looking at--unfailingly--at least a half hour transport to the nearest hospital, most likely closer to 45 minutes, maybe even an hour if you get sent on a mutual aid request. This exceedingly long transport time, potentially with a critical patient, is something that I don't think a lot of big city (or small city) providers fully understand the reality of. At my station, the majority of volunteer crews mark up at the basic level. Our medic level providers are few and far between, and as a result we rely heavily on a nearby county career-staffed station for medic-level services. QRVs are virtually unheard of, and if you have more than one crew in the building a shift, then you're the exception not the rule. While we do have access to a helicopter service for some of those calls that you know are going to be bad when you hear them go out, if you don't put them in the air immediately, there is a distinct possibility that ground transport may be just as efficient as flying them out. And you would be shocked to realize how long 30 minutes in the back of an ambulance with a patient who is seizing uncontrollably (and you have no medic-level rendezvous in your near future because they're on a call in their own first due) can feel.

So given that context, I want to talk about the merits of having the following three skills approved at the Basic level: 12-Leads, King LT Airways, and CPAP. In the following three posts, I will discuss some of my personal experience with these skills and pieces of equipment, as well as potential advantages and disadvantages. On the whole, I will be straightforward and say that I think these three skills are significantly more beneficial than they are problematic, but if you disagree, I would like to hear your ideas.

Coming soon: 12 Thoughts about 12-Leads.

Til next time,

Monday, September 26, 2011

Some Calls You Never Forget

In EMS, there are just some addresses that you remember. Some of them may be associated with frequent fliers, some are associated with the most bizarre calls of your EMS career, and some are forever associated with those calls that leave ghosts behind.

In EMS, we all have those calls that we'll never forget. Over time, the may fade or blend into the memories of other calls, but they are never truly forgotten. In time, you are often able make peace with those ghosts left behind from tough calls, but in a small town EMS service there's a very good chance that you'll never be able to let them truly rest.

Small town EMS is an entity unlike any other. When you run those "oh sh*t" calls, they are to addresses that you may know; they are for family, friends, people you have grown up around, and maybe even members of your own department. That's not to say that you don't run those same calls in big city EMS, they just happen to be a bit more concentrated out here in the country.

I ran a call with a good friend of mine awhile back--ultimately, a fatality from an MVC (motor vehicle crash). The call was one of a series that we had that night (because where I run, when it rains it pours); this was our second response from the hospital, and as we were en route to the scene, we were advised that we were facing a potential code.

My friend and colleague happens to be small-town-born-and-raised, as many of my fellow providers are. Even as a transplant from the North, one of the first things you understand about this town is that it's a tight community, and when you hear a potential code go out over the radio you start fervently wishing that it's no one you know--that this time you'll get lucky and you won't be working a family friend or acquaintance. There was a look that flashed briefly over my friend's face, a look of desperation like I had never seen from her before.

Needless to say, she was not so lucky that night. Our transport for that call was to the hospital, but more specifically the morgue. The front of the truck was silent on the ride in, with few interruptions limited to the tones for the rest of the county dropping quietly in the background.

No words were needed that night, at least not immediately. The talking will, and does come, and the support of other providers can help you reconcile your actions as an EMS worker and make peace; yet the question remains, how do you grieve? Because it these kinds of situations you are not just a provider, you are a friend, a loved one, an individual who shares more common ties with the patient than just a singular call.

It's a question that I'm not sure a lot of small town providers have yet answered; in fact, I think that there are many answers to this question that are as unique as the relationships between patient and provider themselves. But I do know this: there are just some calls that you never forget. And that's okay.


Before I post my next musing, I feel like I should give a quick rundown of the rules that I will be following for discussing actual EMS calls on my blog. I'm borrowing liberally from Peter Canning of StreetWatch, one of EMS' most prolific authors and bloggers (and also, a personal role model of mine), so I will direct you to the following page:
I will try my best to convey the heart, or the essence of each story, but to protect my patients, fellow providers, the service I run for, and myself, there will be several alterations of superficial details.

I hope you enjoy the posts to come,

Band Wagon

I have now joined the masses. Follow me @CountrySpark_CW on twitter.

You can blame my Teaching with Technology class for this one :)

Thursday, September 22, 2011

Role Models

I've come to the conclusion that when the going gets tough, the tough find role models that can provide that extra bit of incentive and support to achieve one's goals--and then they get going. Recently, I've been feeling kind of overwhelmed by life, particularly by the demands that my academic pursuits have been making on my time.

For those of you who have been around since the beginning, the fact that I am simultaneously pursuing both an undergraduate and graduate degree comes as no surprise. For those of you that know me personally, the fact that I am on an accelerated track for both degrees is also not new information. For anyone with a bit of common sense, the fact that I am struggling and under some pretty intense stress should not blow you out of the water.

As a result of this academic (and many-other-factors induced overload), I've been floundering a bit. For most of my life, I have been largely intrinsically motivated. I choose to do and pursue things that I am passionate about because accomplishing those acts makes ME happy. There was a substantial period in my life where I struggled with the lose-lose reality of pursuing not-quite-passions because I believed that they would make other people happy, and thereby make me happy; it turns out my theory was horribly wrong in that regard.

And I'll be honest: history and teaching do make me happy. In fact, they are two of the things in my life that I am most passionate about (if there is confusion on this point, I refer you to why I started the blog in the first place...); however, lately I've realized that my personal fulfillment in the pursuit of an undergraduate and graduate degree is hardly cutting it anymore. I feel as if sometimes my workload is isolating me from the relationships that will make my eventual achievement of these goals enjoyable. Sometimes I feel like Hermione Granger.

No...I'm not kidding. If you want a better understanding of why I identify with a fictional character, read this; maybe then you'll understand. To me, Hermione Granger is an inspiration of sorts; the girl who didn't let anything get in the way of her voracious academic pursuits; the girl who wasn't afraid to fight for her dreams and what she believed in; the girl who valued her friendships above all else; the girl that I grew up idolizing. Yes, Hermione Granger has been and always will be a role model to me as a still-trying-to-find-my-way, at times graceless, yet well intention-ed young adult. With some of the stuff that I have been dealing with in the past few months, having a role model like Hermione has provided me with a model of how to keep on in the face of adversity and challenge.

That's not to say that all of my role models exist in the fictional realm. I am so unbelievably blessed to have an extraordinarily high number of impressive and commendable individuals in my life after whom I can model my own actions and choices, as well as rely on for support. And since my life has kicked into high gear recently, that support has been indispensable. So I would like to say a thank you to a few people whom have remained steadfast in their support, compassion, love and inspiration in recent months. Your companionship and dignity with which you live your lives continues to amaze me, and makes everything that I am working towards that much richer.

To my mom: I love you and you are truly one of the strongest women and supporters that I know. I don't know where I would be without you in my life.

To my adopted grandfather and mentor: your kindness helped a very lost little girl find her voice and her way, and I look up to you in more ways than you will ever know. Thank you for taking this fellow Yank under your wing, and teaching by example that a little bit of compassion, humility, laughter and common sense can take you far in this world.

To my beautiful cousins and sister: each of you have inspired me in unique and varied ways to try and be the best person that I can be. Each of you are veritable fonts of strength, grace, compassion and fun, and I am constantly amazed and humbled by the women you have turned out to be.

To the three musketeers: it always comes back to you. You are the rocks at the center of everything I do, and I know that we can face anything together and come out stronger for it.

To the family that I have chosen: friendship does not even begin to cover what I have with each and every one of you. Celebrating life's little moments and pleasures with you, whether it is a rich cup of coffee, or one another's triumphs and achievements, has left an indelible print on my heart.

It is with and because of each of you that the stress becomes manageable and the rewards become richer and the memories become stronger. You are the true role models that are helping me get through the overwhelming stress that enable me to keep my head in the game, channel my inner Hermione Granger, and face each challenge head on with no fear and the sweet taste of satisfaction. Thank you, and I love all of you.

Wednesday, September 21, 2011

What Exactly Is Social Studies?

So I realized that in my last post, I may have jumped ahead of myself. If you were to create a taxonomy of social studies (the field in which I am earning my Masters), history would fall under the heading of social studies. That is to say that before one can discuss history education, one must consider the greater category that it falls in. In order to correct such a massive oversight, I offer the following. Enjoy!

Welcome everyone. Get ready, because critical thinking time begins now. Today's lesson will examine the following question: what exactly is social studies? There are a few things that I would like you to think about as we make our inquiries today. They are:
  • What disciplines make up social studies?
  • What is the "point" of social studies?
  • Why do we teach social studies?
  • How can we make learning social studies fun?
  • Why is social studies relevant to your life?

To get you thinking, I present the following situation:
Your name is Harry Potter. You have been chosen and marked by the Dark Lord as his equal. Your mother died to protect you, and you have powers beyond your own that protect you as a result; these powers derive from love. You have twice faced Voldemort and and you know that a third meeting is imminent thanks to Sybill Trelawney's prophecy. You also know that there is a single remaining horcrux (remnant of his soul that binds Voldemort to the realm of the living) beside the one that exists within you. You have a choice to make. Sacrifice your life for the destruction of Voldemort, or let Voldemort reign once more?
How could an understanding of disciplines found within social studies allow you to turn the advantage in this situation? We will return to this question a little bit later.

If nothing else, I hope that at the end of today you take away this understanding: social studies is a series of interconnected disciplines that focus on human interactions with a variety of institutions, individuals, and places, and the study of these disciplines can provide individuals with the necessary skill sets to be informed and contributing citizens.

Now if you would, I ask that each of you take a moment to briefly consider what disciplines you believe would fall under the heading of "Social Studies". Some that come to mind for me, include but are not limited to: history, geography, human (cultural) geography, sociology, anthropology, archaeology, philosophy, political science, civics, religion, economics and psychology.

Have you ever previously considered just how diverse a field social studies actually is? If you were anything like me, you probably had a class that was called "Social Studies" in middle school but you never actually knew what they meant by that term. Did it mean history? Did it mean memorizing maps? Did it mean learning about other cultures? Was it ultimately a mixture of all of the above? Again, if you are anything like me, you would probably identify most with the latter of all those questions. But the question begs to be asked...why does this mixture of random subjects matter?

I posit this in response: social studies matters because it helps students  learn essential life skills that force them to think beyond the scope of their individual existences. We teach social studies because we aim to prepare our students for a global, interconnected and complex world that requires them to understand the dynamics of cause and effect, the value of grounding logically based arguments in evidence, thinking critically about sources of information, and understand how past actions and decisions can influence present and future circumstances and events. Earlier, I argued that a social studies education "can provide individuals with the necessary skill sets to be informed and contributing citizens," and I stand by that claim. An effective implementation of social studies curriculum can produce an informed and engaged citizenry that is prepared to meet and overcome the challenges that your students will face and be saddled with in their lifetime.

But while this all sounds well and good in theory, I am sure that many of you would be quick to point out that with many, if not all, of the disciplines that I have listed, your experiences have been overwhelmingly less than stimulating; and this is the part that returns to my previous post on teaching a "dead" subject.

Unfortunately, it is exceedingly easy to fall back on the standard method of teaching social studies. For those of you that have enjoyed J.K. Rowling's masterpiece that is Harry Potter, I invoke the image of Professor Binns' History of Magic class: dry descriptions of facts, individuals and events, in a monotone voice, in the face of death or other such trivial happenstances. Thus, the alternative becomes the critical question: how do we not become the Professor Binns of social studies? This is a question that pre-service and in-service teachers alike grapple with on a daily basis. How can we "hook" our students into caring about social studies?

To this end, I would like to return to my initial question and situation (re: Harry Potter). For a child of the 1990s, that situation alone would have made devoting my attention to the subsequent lesson worthwhile. For a child of today, Suzanne Collins' The Hunger Games trilogy offers ample material in which to base a social studies lesson that will have many students hanging off their seats and eager to draw connections. There are many possible answers to the question I posed though; having a understanding of the past can better inform Harry about his present choices and the possible consequences; understanding the psychological condition of  Voldemort can help him better plan his strategy to victory; understanding the political machinations of the Death Eaters allows him to better understand how to dismantle their reign. I could go on and on, and regardless of how far fetched this may seem, there is a legitimate connection that can draw in students. It is the art of finding those connections that social studies teachers must focus on and make a priority.

As I continue down my teaching career path, this question will arise again and again. And when it does, I hope to be able to provide additional answers and suggestions along the way. Additionally, if you have ideas or comments regarding this topic, I would love to hear them. Dialogue on this topic is welcomed and encouraged.

If nothing else, I hope that I made even the tiniest bit of headway in convincing you that there is much more to social studies than you ever believed, and that it is indeed "a series of interconnected disciplines that focus on human interactions with a variety of institutions, individuals, and places, and the study of these disciplines can provide individuals with the necessary skill sets to be informed and contributing citizens."


Sunday, September 18, 2011

Stuck In My Head All Day


Because this music video makes a girl's heart scream of adoration and cuteness, and it's a great song :)

Love, CW

How to Make History Come Alive, or the Dilemma of Teaching a "Dead" Subject

I once had a history teacher play a word association game with the class at the start of a new school year. The stem word: "history". There were many responses that dealt with famous events, famous people and famous places, but the word that stuck out most in my mind was the word "dusty".

When the student who tossed out "dusty" was asked to explain their reasoning, they presented the following train of thought:
"Well, whenever I think of history I think of an old man sitting in a dusty old library, poring over dusty old books, wearing a tweed coat, and glasses that sit half way down his nose...smudged with dirt and dust."--Anonymous

The picture this student painted was that of an antiquated, stale, decrepit..and dare I say it, "dead" subject.

Let me be the first to present a rebuttal: history is not dead.

In fact, I cannot thing of a subject that is more relevant to the on going interactions and decisions of our daily lives. Every thing we do, every decision we make is informed by past events. Whether we are talking in the context of a person, nation, or international community, the past is inseparable from our daily lives. I could provide numerous examples grounded in psychology, historiography, sociology, etc. to further my point, but I fear that we would be here much longer than I planned if I were to do that.

However, it is not this oversight that irks me the most about this student's assessment of history; rather, it is the fact that in some ways the student is right in his characterization of history. For centuries, the study of the social sciences was "an old man sitting in a dusty old library, poring over dusty old books, wearing a tweed coat, and glasses that sit half way down his nose...smudged with dirt and dust." Only is this starting to change now as the twenty-first century unfurls before us. We now have resources that can take those dusty old tomes of time and make them come alive for students. There have been major advancements made in digitizing history in the past two decades, and this trend has opened up a world of possibility for teachers and students alike. It is now just a matter of finding ways to use those resources in new and exciting ways.

This semester, I am taking a lab class called Teaching with Technology as part of my teacher education program. Each week, we play with a new set of teaching tools that help us create new ways of incorporating technology into our humanities classrooms. For this class, we each have websites chronicling the projects and thoughts that we have about incorporating technology into the classroom. If you're even slightly interested, you can follow my progress here.

My greatest challenge in the coming year will be to figure out how to make history come alive for my students, and I hope that you will join me here and revel in that journey. I'm excited to play and challenge myself and my own creativity. As always, if you have ideas of your own on this subject, feel free to chip in at any time. In doing so, you just might find your ideas memorialized in my lab's final project!

Explore, Dream, Discover--CW

The Involuntary Commitment Dilemma, cont.

So...have you been pondering? Come up with anything exciting? If you did, I hope you'll consent to sharing...

But until I hear back from you, I shall now commence a monologue on my own thoughts.

The first thing that I would do is finish assessing my patient and going through my own checklist for getting a refusal. The patient, comes first, and Officer Congeniality may need a subtle reminder of that. Secondly, don't engage with crazy; coming back with a snarky, "You do realize that what you're suggesting amounts to kidnapping, Oh Officer of the Most Sacred Law?" won't get you anywhere productive. If there's one thing that I've learned in my two years in EMS (sparkie though I may be), it would be that you want to be friends with as many people possible that show up to a scene. (Especially if you run in a rural area like I do, and there's only one or two golden guns in town that regularly show up to bail you out when you get the call for "domestic violence, scene not secure"). So this is where I would remind you to play nice.

And now that you've consciously reminded yourself to choke back that witty, sarcastic rejoinder that would have felt so fricken' good, I would suggest that you invoke the inherent usefulness of your partner in distracting the patient while you request a word with Officer Congeniality out of the ear shot of said patient. (If the reasoning behind this is unclear, refer to above point: play nice and make friends). There is nothing you want less than to embarrass an officer of the law who is wrong about...well, the law...in front of a patient. Calm and cool is the way to play this one, and hopefully you will get lucky and Officer Congeniality will see the error of his ways.

Should this not come to pass, you do have options. In our jurisdiction, medical command is always a viable option. Explain the situation, and most doctors will come back with a "Really?! Yes, you have permission to release the medically stable drunk man." On the off chance that your fail to get such a doctor with common sense, you may be told to transport regardless. In this case, put on your salesman hat and try for the transport one more time. If you fail yet again, go back to Medical Command and state your case. However, under no circumstances should you transport the patient without their consent. Even if the officer says that they will follow you to the hospital, that is going beyond your scope of practice and beyond his scope of the law. The officer, in order to properly invoke and ECO (emergency commitment order), MUST have legitimate proof that the individual is either a danger to himself or others without medical intervention.

So I've managed to muck things up for you and answer fewer questions than you thought I would, right? Well welcome to the world of refusals. Rarely is there an easy answer, and some of the most interesting ethical questions in EMS (I think) arise out of situations involving AMA and the art of the refusal, as well as the role of ECOs. So to pose a new question to you: has there been any questions or debates that have sprung up among you and your colleagues after a refusal or ECO?

Til next time, CW

Wednesday, September 7, 2011

It's Here!

Football is back.


Refusals and the Involuntary Commitment Dilemma

Refusal [ri-fyoo-zuhl]: one of the more complex decisions an EMS provider is faced with on a daily basis; a refusal of medical evaluation, treatment or transportation; a rejection of emergency medical services often made against medical advice.

Today, many EMS workers practice in a world where there is little flexibility in regards to a patient's ability to refuse medical care. We practice in a world where practically any call that does not result in patient transport is considered "against medical advice", regardless of the actual circumstances; we work in an environment where judgment calls about your patient's true needs could easily mean the revocation of your livelihood if your assessment of the situation is wrong. We also happen to work in a world where the resources that we have at our disposal are often abused by those who do not in fact need them, and used sparingly by individuals who could actually benefit from our services in the manner which they were intended to be used.

Given these circumstances, it's a hardly a surprise that refusals are the grounds for some of the most profound decisions an EMS worker makes. How do you navigate the presses of the patient's needs, your organization's protocol and the availability of resources when dealing with a patient who is attempting to refuse medical care--all without jeopardizing the patient's well-being and your scope of practice?

In my first due, the most common refusal situation that we come upon--that oft puts the provider between the patient, concerned family, neighbor, etc. and a hard place--are individuals who are intoxicated either in their own homes or in public, but aside from being intoxicated appear to have no medical complaint. I don't know about your local protocol, but in my protocol if an intoxicated patient is attempting to refuse care, they technically are in violation of one of the conditions for an AMA refusal. However, I am not allowed to people-nap just because they are drunk and the law enforcement personnel on scene is trying to get out of taking responsibility for the individual, or a family member insists that they go to the hospital. If the patient can prove competency, meet my alertness and orientation guidelines, has stable vitals, no mechanism of injury, no chief complaint, and are refusing my care or transportation, then I am bound to release them after informing them of the potential consequences of refusing care.

Situations like the one I just described are the ones that generally come back to bite you in the butt; however, we do have a few measures in place to help you CYA. In our jurisdiction, if there is a possibility for concern, yet a refusal of care, the crew that responded to the call can ask the duty officer to make a welfare check a few hours later. Also, it should go without saying that in this situation medical command can be your best friend. Provided you supply medical command with accurate and detailed information, the decision is really then out of your hands. Finally, documentation, documentation, documentation is a priority. As with any refusal, documentation that is thorough and accurate is essential. Laziness and refusals are never a good combination, and a refusal should never be seen as the easy way out.

But now comes the twist...you've been dispatched for an "unknown problem, man lying on bench" and you arrive on scene to a patient who has copious amounts of ETOH on board, and a policeman with a low tolerance level. It's 11:30 on a Friday night, and this officer's headache is only just beginning. You approach your patient, do some assessment and then offer to transport the patient if he would like to go, to the hospital. You make the offer because it's the patient's choice of whether or not it's an emergency, not yours, but ultimately he doesn't want to sober up. There doesn't appear to be anything medically wrong except for the fact that he's drunk--and he freely admits to it, bordering along the line of hubris. But drunk, at least to this officer, qualifies as a medical problem--the EMTs jurisdiction, not his (at least for tonight). So as you start going through your AMA checklist, Officer Congeniality butts in with the bomb: the threat of an involuntary commitment. So, I pose this: what's your next move?

I hope the first thing that you said was know your laws; if there is a law that impacts your scope of practice, know it. If there's a law about transporting a patient while restrained, know it. If there's a law about committing patients involuntarily to medical care, know it. One of the first things that they teach you in EMT class is that you play many different roles in dealing with your patient--one of them being the role of advocate. If you don't know your states', county's, city's, etc. laws, then you cannot appropriately advocate for your patient. For example: in the state of Virginia, a patient cannot be committed to the care of medical providers unless the two following conditions are met in conjunction with a demonstration of mental illness or compromised mental health: 1) the patient is a risk to themselves, or 2) the patient is a risk to others.

So assuming you know your laws, how do you proceed next? I'll pose my thoughts in an upcoming post. Ponder as you will until next time :)