A recent story out of Middletown Ohio has gained national attention due to a unique proposal by a city council member that proposes a “3 strike” policy for opioid overdoses where the third time an individual overdoses, the ambulance would not respond and provide care (The story can be found here: http://www.wlwt.com/article/middletown-considers-3-strike-policy-on-responding-to-overdoses/10215284). This story is one of many regarding whether opioid overdoses should receive Narcan. I have encountered many people, both healthcare providers and the public who have made statements such as “we should just let them die it was their choice” or “why can’t we just say no and stop enabling them” (I find both statements to be appalling).
The reality of overdoses…
Many people are quick to jump to prejudicial opinions about victims who overdose on opioids. The classic stereotypical image of an addict or a “junkie” is plastered all over television and movies. The reality of this is that many of these addicts are normal people who ended up in a bad position. Some of these overdose victims did not “make a choice” but instead became addicted following a legitimate prescription and use for opioids. They were eventually “cut off” after becoming addicted with no support from the healthcare system.
What about the ethics of not responding to an overdose or giving Narcan?
The basis for medical ethics consists of four basic concepts including respect for the autonomy of the patient, beneficence (benefit to the patient), non-maleficence (doing no harm), and justice. The concept of justice suggests that all persons in similar situations are allocated the same resources and given the same care. Not all opioid overdoses are heroin overdoses. Many overdose victims are patients who unintentionally overdose from a legitimate opioid prescription. From an ethical standpoint, all overdose patients should be treated equally. Also, in terms of beneficence, the treatment provides benefit to the patient, and not providing treatment would result in further harm.
Let’s look at some facts on Narcan…
Narcan IS NOT Free
I have recently seen numerous posts on social media stating that we should not be giving Narcan to addicts for free if patients with allergies must pay for epinephrine pens or patients with cancer must pay for chemotherapy. Let’s get something straight here… Narcan IS NOT free. As stated above a 2mg dose of Narcan (a standard dose) costs approximately $54. I can also assure you that the Narcan people are receiving is not free. Someone is paying for this, whether it be a government entity or an insurance company.
Let’s look at an example of how Narcan is paid for. If an addict overdoses on heroin and 911 is called the patient will likely be given Narcan by someone in the EMS system (e.g., EMT or paramedic). The EMS service will then transport the patient to a local emergency department and bill the patient for the care provided. If the patient is on Medicaid, reimbursement for an ambulance bill may be as low as $317.30 for an advanced life support ambulance staffed with a paramedic (using the CT Medicaid fee schedule as of August 2015). The patient will likely contribute nothing to this bill and the ambulance service will be reimbursed by Medicaid, a government, therefore tax funded system. This same billing and reimbursement scenario would occur if the patient was having an allergic reaction, having chest pain, having respiratory distress, or they broke their arm and needed pain control. All of these patients will receive the care they need from EMS and the patients are not just being handed a “free” dose of Narcan while we are leaving patients dying in the street of anaphylaxis because they can’t pay.
The argument that Narcan shouldn’t be free to addicts if epinephrine is not for people who have allergies is just absurd, neither are free as you can see.
Are we giving too much Narcan?
One thing I do believe is that we may be giving too much Narcan. The following is anecdotal but I as well as my colleagues have observed this on numerous occasions. Paramedics tend to give small doses of Narcan to get the patient breathing again and surprising to many, a number of overdose patients do not require Narcan because their respiratory drive is not depressed. Many patients who become euphoric are unconscious but breathe normally after using an opioid are mistaken as “overdoses” when in fact they achieved their desired effect and took a “dose”.
With non-healthcare providers such as police officers, firefighters, and the general public using Narcan we have seen a lot of patients receiving Narcan that frankly don’t need it. So I do agree that we are giving too much and Narcan is arguably overused.
(Note: For the patients who do need it who require large doses due to the strength of the drug they overdosed on, I think the doses given to reverse respiratory depression are typically appropriate and not excessive.)
Yes, addiction is a disease.
I have also seen this argument recently on social media; addiction is a choice not a disease. The individual may have made a choice to take a pill or inject a drug for the first time, but the subsequent addiction to the drug is a disease. That choice to take the drug may have been the result of a legitimate need for an opioid and a legitimate prescription from a well meaning healthcare professional.
The term disease can be loosely defined as a disorder of human function that results in specific signs or symptoms. In the case of addiction a physical dependency to the substance is developed, in this case opioids (the same applies to alcohol, sugar, caffeine, etc.). That physical dependence results in an alteration of the brain’s reward system and the neurotransmitters involved. Patients with addictions can have physical modifications of the nucleus accumbens core, an area of the brain with dopamine receptors that is associated with reward. This physical dependence produces signs and symptoms, consistent with the definition of disease.
As with many other diseases comes other comorbidities. In the case of opioid addiction patients are often at higher risk of HIV, hepatitis C, endocarditis, and many other health complications.
Narcan is only the tip of the iceberg.
In the grand scheme of the opioid epidemic, the debate about Narcan is only the tip of the iceberg. All over social media and in news outlets people who are misinformed will continue to argue about whether we should provide a lifesaving medication to an opioid overdose.
In terms of the cost to the system, the $53.99 spent on a dose of Narcan is nothing compared to the medical bills associated with an HIV diagnosis that requires expensive medications for life and leads to other comorbid medical problems that are expensive to manage. Instead of talking about safe injection sites and clean needle programs, we continue to debate the cost of Narcan.
As we continue to argue about the availability of Narcan and who should have access to it, we forget that there are many addicts who seek treatment who are denied because of their insurance or the lack of available resources. Instead of finding solutions to expand access to addiction treatment, we continue to debate who should get Narcan.
We continue to worry about whether Narcan is enabling addicts and whether addiction is a disease. Instead, we could be evaluating the healthcare system and developing safer non-opioid treatments for pain and plans for patients on long term opioids that prevent addiction.
It’s time to stop talking about Narcan and it’s time we start looking at solving the opioid epidemic.
You respond to “that road” where all the bad accidents seem to happen. You arrive on scene and find a car wrapped around a tree with two 17 year old patients entrapped inside the vehicle. The windshield is starred, the dash is deformed, and it’s going to require extensive extrication to get the patients out of the vehicle. The extrication is complete, the patients are transported, and while you remain on scene you grab your cell phone and take a few pictures of the car.
Is that ok? The answer: It depends on what you do with them…
Both individuals and departments often post pictures of accidents, fires, and technical rescues on social media to “show off” the interesting call that they did and they will undoubtedly receive comments from both professional colleagues interested in the call as well as a thankful community. But, those aren’t the only people who see your pictures.
That 17 year olds friends from high school follow your Facebook page. One of the two patients in that car dies the next morning. The friends and family of your patient are just starting to grieve when they innocently log into Facebook to see something they should never see, the accident scene. A high quality image of the scene where their son, daughter, brother, cousin, or friend died. An image that will add to their trauma, add to their grief, and stay engrained in their memory whenever you bring up the accident.
What if the patient didn’t die, but they login to Facebook only to find pictures of an incident that has already caused them trauma? What if a member of your department had a hard time with this call? One of the common symptoms of PTSD is re-experiencing symptoms, the “flashbacks” we often associate with PTSD. Their memory of that night may not have been able to piece together the accident scene, but now they have a high definition image to start putting the pieces of that traumatic evening back together.
This extends to other calls as well, another common example is the pictures of structure fires. The common answer is that there are no patients involved in these situations. Someone losing their home can still cause a significant amount of trauma and grief. Fire photographers are often running around the scene trying to “showcase” the event.
If you’re in this business to see your picture on Facebook and get thanked for your service, do us all a favor… get out.
Despite what your departments social media policy says or your department posts the pictures themselves, consider your own morals and whether or not you would want these pictures to be posted if you were the victim.
Another thing to remember… the internet is forever and unforgiving.
Whether it was your intention or not, that picture could be the next dark humor meme or it gets shared somewhere where it attracts nothing but tasteless comments. It could also backfire on you and your department and be the source of bashing against your department and their tactics.
Well, is there an acceptable reason to take pictures?
Absolutely. Using incident pictures in training and after action reviews is an invaluable tool. I often use de-identified accident pictures in a kinematics case studies presentation I use with initial and renewal EMT classes. Keeping an album to document the history and activities of your department is also an appropriate way to use incident pictures.
Just be careful that however you use them they don’t end up causing someone unnecessary harm and negative emotions.
What you or your department posts on social media should showcase your department. It should demonstrate the pride you have in what you do and the professionalism that your department has.
So… if you shouldn’t post incident pictures, what should you post?
Find things that make your department look good. Post pictures of a training event where you practiced extrication on a donated car, pictures of a community outreach event teaching CPR. This gives you the opportunity to keep the community engaged with your department without contributing to someone’s grief or traumatic experience.
What does it mean to be good at what we do and can we truly measure what it takes to be a good EMS provider? If you're an EMT does being good mean you do excellent CPR? If you're a paramedic are you a good paramedic if you can conquer the difficult airway, get the difficult IV, or pick up on that subtle ST elevation on an EKG full of artifact? Those are things we can measure but I don't think those things alone make a good EMS provider.
Although some may disagree with me, I don't think being a good EMS provider is something that can be measured. I think there are a few things that make for an excellent provider, but first let's talk about what motivates us to be good at what we do.
At a very simplistic level motivation can be looked at as having a need to fulfill, performing a behavior that fulfills that need, being rewarded for that, and feeling satisfaction. There are a number of theories that attempt to explain motivation such as the cognitive evaluation theory.
The cognitive evaluation theory is based on the principle that we have two distinct types of motivators, both intrinsic and extrinsic. Examples of intrinsic motivators include responsibility, achievement, and competence. Extrinsic motivators include factors such as pay, feedback, and the conditions in which we work.
For the EMS provider I think the cognitive evaluation theory provides an excellent framework for what makes EMS providers "tick". Many of us are intrinsically motivated by a sense of responsibility in what it means to care for others, being competent and seen that way by our colleagues and patients, and the various achievements we make as EMS providers whether that be a good outcome or performing well in a complex situation. The extrinsic motivators also seem to be important to most EMS providers. Although this may only be anecdotal, providers who are treated well, provided feedback on their performance, and are adequately compensated for their work (and as a volunteer this may be a sense of fulfillment, not necessarily pay) tend to perform well. When these motivators are absent, we risk a decrease in our performance, and the people who suffer are the very people we got into this business to take care of, our patients.
How then, can we also make sure we are good at what we do and take the best care of our patients? What are the qualities that make a "good" provider?
A Constant Desire to Improve Performance
A good friend of mine always says, there is a difference between 20 years of experience and one year of experience repeated twenty times. Medicine is always evolving and pre-hospital medicine is constantly changing. Staying current and providing the best care possible is part of being an excellent provider. Pick up a book, take a continuing education course, go to a conference, listen to a podcast, and explore some of the free open access medical education available online.
The Soft Skills: Caring and Compassion
This is the reason a lot of us cite for why we got into this field... to take care of other people. As the saying goes, people may not always remember the care you rendered, but they will always remember the way you made them feel. Think about the healthcare providers you have encountered as a patient. What made the good providers good? Their medicine probably wasn't the first thing that came to mind, it was probably their bedside manner, their demeanor, the time they took with you, and how they made you feel.
Being a good healthcare provider is about being good at taking care of others, which isn't always easy. If you haven't read it, Thom Dick's "People Care" is an excellent book that should be mandatory reading for anyone in this field. If you are looking for some renewed motivation for taking care of people, give it a read.
A Desire to Improve Your Profession
The people who are often the most unmotivated are often the first to get offended when someone tosses the word "ambulance driver" around or doesn't treat them with the respect they believe they deserve. EMS will only ever be seen as a profession when we become professionals. How you dress, how you act, how you treat your patients and colleagues, and how much you know will determine how you are perceived and also sets the tone for how someone who is unfamiliar with EMS will view EMS providers.
If you want EMS to be seen as a profession, you can start by acting like a professional.
Also, take advantage of explaining to those who know less about EMS what we actually do. Instead of getting offended the next time someone refers to you as an "ambulance driver", turn it into a teachable moment. Explain to them what you as an EMS professional really do.
Humility, Reflection, and Self-Care
Sometimes we need to take a step back to reflect on what we do and why we do it. Is the reason you got into EMS the reason you are still here? Most of us did not get into this field with the hope of financial gain, a regular schedule, and low stress. Most of us got into this profession because there was some motivator to help others, to deal with high stress situations, because we were interested in pre-hospital medicine, and because we genuinely just enjoyed doing what we do. If you're not in it for that reason anymore, it may be time to re-evaluate your circumstances or look for some renewed motivation.
If you have been in EMS for more than a year you have hopefully realized the reality of the job is not saving lives very often. The reality of our job is taking care of people, bringing a sense of calm to high stress situations, being empathetic, and in the midst of all this, providing some good pre-hospital medicine. Being good at this requires the ability to be humble.
One of the most important things we can all do to stay good at what we do is take care of ourselves. Managing stress and dealing with difficult calls is an important aspect of this field and career longevity.
Recently, a friend and former co-worker, Tyler, exemplified all of these traits. After realizing that a child might not be able to go trick-or-treating for Halloween he stopped at the store and purchased some Hallowen candy for the children. Tyler wasn't expecting any thanks, any recognition, he was just doing what paramedics do best... caring. Tyler's action was humble, kind, compassionate, and made our profession look good. There are many other examples like Tyler's in EMS, be good at what you do!
One of the most common questions I receive from EMTs who have just registered for paramedic school is “What should I start studying?” Most people are looking for answers such as studying various drugs and cardiac rhythms. Nobody expects you to be a paramedic day one of paramedic school. You will have plenty of time to learn pharmacology and different drug classes when they fit into the context of learning a specific topic, or learning to interpret rhythms when you are learning cardiology. There are a few things that you may want to consider doing before paramedic school starts that will hopefully prepare you to be a good paramedic.
Learn How to Learn
Do you highlight? Do you record all of your lectures? Do you typically re-read your textbooks shortly before an exam? Have you been out of school for a while?
Learning to learn is not as easy as it might sound but it has a great payoff. As a paramedic you will be required to use a lot of the knowledge you gain in paramedic school on a daily basis and be able to recall it quickly and under pressure. Here are a few resources to help you learn to learn.
What Works, What Doesn’t is a short guide to some successful and not so successful learning strategies - http://cpr.molsci.ucla.edu/cpr/data/library/400241/resources/res011/file/What%20Works%20in%20Learning%20Study.pdf
Make It stick – The Science of Successful Learning
This book provides a number of strategies for learning that are supported by evidence. You may be surprised by the strategies the authors suggest and those they identify as weak learning strategies. You can visit their website at http://makeitstick.net/ and their book is widely available.
If you don’t have time to read the entire book, here are a few tips from the authors - https://www.psychologytoday.com/blog/make-it-stick/201406/make-it-stick-six-tips-students.
If you have some time, check out What the Best College Students Do by Ken Bain. I have not had time to read the entire book myself, but it appears to be another excellent resource. (Amazon Link: https://www.amazon.com/What-Best-College-Students-Do/dp/0674066642/ref=sr_1_1?ie=UTF8&qid=1466615369&sr=8-1&keywords=what+the+best+college+students+do).
Study Anatomy & Physiology
….and maybe some biology and chemistry as well.
Most paramedic programs may require an A&P program built into the paramedic program, some require a college level anatomy & physiology course. Understanding anatomy & physiology underlies everything you do as a paramedic. Understanding some more general biology and chemistry will also help you with topics such as fluids & electrolytes, acid/base balance, and drug mechanisms.
There are numerous textbooks available on all of these topics, if you are looking to get a textbook try to find something that is both current and comprehensive. This will serve you as a reference throughout your program and for years to come.
You can also learn A&P, biology, and chemistry for free online at KhanAcademy. Plan on spending some time over at https://www.khanacademy.org/ both before and during paramedic school.
Read a Book for Some Perspective
There are a number of books out there on EMS as well as healthcare in general that are worth reading before, during, and after paramedic school. This list is by no means comprehensive but here are a few of my personal favorites (in no particular order).
People Care by Thom Dick
You will spend the rest of your career caring for people. This book is an incredible resource for learning how to take care of people. It appears to no longer be in print but is available relatively cheap as an epub at https://www.emergencystuff.com/people-care-epub-2e-for-ipad-and-nooks/.
A Paramedic’s Story: Life, Death, and Everything In Between by Steven “Kelly” Grayson
You will face a number of challenges as a paramedic, respond to some strange calls, and have many good and bad days throughout your career. Kelly’s book is not only fun to read, but provides a good primer for what lies ahead for you as a paramedic. WARNING: Once you start reading, this one is hard to put down. The book is currently out of print but you can find numerous editions available used online.
Paramedic: On the Front Lines of Medicine by Peter Canning
I had been an EMT for seven years before I became a paramedic. When I first stepped on the truck as a paramedic student, my first day as a precepting paramedic, and my first day cleared it was different than I ever thought it would be. Peter Canning takes you through his journey from becoming an EMT to being a paramedic and shares a number of short stories that will definitely serve to inspire and excite you about being a paramedic (Amazon Link: https://www.amazon.com/Paramedic-Front-Medicine-Peter-Canning/dp/0804116148/ref=sr_1_1?ie=UTF8&qid=1466613478&sr=8-1&keywords=paramedic+on+the+front+lines+of+medicine ).
Being Mortal by Atul Gawande
You will inevitably care for a number of patients at the end of their lives and this book will hopefully give you new perspective in caring for patients with chronic illnesses and those at the end of life. Any of Atual Gawande’s work is worth reading. This book has spent plenty of time on the New York Time’s bestsellers list and is a great read. (Amazon Link: https://www.amazon.com/Being-Mortal-Medicine-What-Matters/dp/0805095152).
Don’t ask me which of these to read because my answer will be to read all of them.
Refresh/Review Weak Areas
There is a reason that being an EMT is a pre-requisite for paramedic school. You are expected to arrive with a knowledge base that you should have gained as an EMT. This will also help you with an important lesson in becoming a paramedic, it is important to know what you don’t know. Here are a few ideas to help you identify your weaknesses and review.
Check out http://www.easyauscultation.com/ and review your lung sounds as well as some medical terminology.
If you are currently practicing as an EMT, start looking up all of your patient’s medications, ALL of them. Also look up conditions listed in their medical history. Websites like http://emedicine.medscape.com/ require a free account but provide a wealth of information about different medications and conditions. This will continue to be a valuable tool throughout paramedic school.
Limmer Creative has a number of flashcard apps that will test your EMT level knowledge and provide you explanations to the question answers. http://limmercreative.com/group/emt/. This will also help you prepare for the type of testing you will encounter in paramedic school.
An EMT textbook may be good to supplement your review but if you are a practicing EMT, re-reading the textbook will probably not be a beneficial use of your time. Identifying your weaknesses and focusing your review will provide greater benefit and better use of your time.
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