Monday, July 6, 2009

Old School

This is mainly for my EMS type readers. Some of you "regular" folks might find it interesting...or not. Gals and guys, I'd really like some feed back.

Our department (combo fire/ems) has switched over to electronic clipboards for all EMS runs. What they have is a laptop computer with touch screen. It is able to download and integrate dispatch info, generate a 'run' form, and then the medics just fill it in. At the completion of the run, when the form is filled out, the computer report is done. They don't have to go back to the station and then input the info from a paper report into the computer any longer.

Now, so far what I have described to you is a good thing as far as I am concerned. I'm all for making it 'easier' on the guys on the box. They make more runs, so anything that helps them get the 'paper work' done faster is good.

But I've noticed some things that concern me. Not directly due to the use of the computers, but possibly a symptom of use. And maybe it’s just that I've turned into that old guy that used to ride the box. Help me out here folks;

back when I was on the ambulance.....
The old story about how things used to be. When I started as an EMT, and then 3 years later as a Paramedic, we used LP 5's, carried MAST pants, hung both D5W and Ringers....We had standing orders only for IV's if the patient was "alive", and the first round of drugs in CPR. We called and had to have a Dr on the radio for any further treatment. On that front, things have improved a lot! My system now has standing orders for about 80% of possible treatment options we have. We run a CPR and then call in for a report after. We've added IO's, CPAP, 12 leads.....we really are a progressive system.

We didn't have automatic BP cuffs, O2 sats, and end tidal equipment. WE had to figure out what was going on, not wait for a machine to tell us.

I don't know if it is the fact that there are so many machines that do things for us on the ambulance now, or maybe the way medics are trained. But I see lots of 'hands off' with the paramedics now. I have walked into several houses and heard the wheezing as we made the door, and then stood there while the medic waited to see an O2 sat before giving oxygen to a patient with SOB.

I've seen medics start IV's and push drugs, before they ever got the patients name or introduced themselves. I've seen them wait until they got a patient in the box, and when they were doing a 12-lead finally ask a name, only because they needed to put it into the 12-lead. I've watched a group of 4-5 medics talk all around the patient, asking each other what the sat was, the EKG showed, what the machine read the vitals were, and never explained to the patient what was happening.

It seems a lot of (not all) medics are only there to work the machines and follow a protocol, not to treat the patient.

Now I have to take a minute here and tell you how I work things on an EMS scene. When I arrive on the engine at an EMS call, my policy is to first make sure the scene is safe for my guys. I know they are focused on getting to a patient, so I survey and try to take it all in. After that, I am there to support the medics, either with my manpower (myself and my firefighters who are usually medics too), or with logistics (calling for more help, helicopters, setting up LZ'z and such). The medics are in charge of the patient and the situation.

I offer suggestions, just like the other medics, but I try very hard not to make them sound like I am trying to tell them what to do. It's kind of a strange duel role I play. On one hand I am the officer, but on the other hand I am a 'veteran' paramedic. I try to be careful not to give the impression I am taking over or giving orders. But on the other hand I've seen some things a few of the kids on the ambulance have only heard about.

Now with all the new gadgets and gizmos, especially the computer clip board (CCB), it seems to me that the guys on the ambulance are taking longer and longer to get things done, or to figure out what needs to be done. When they are taking a history, the CCB forces them to do things in a certain order. No more can you ask a question, get an answer, and then go off on a tangent because of what you suspect. You have to follow the order on the form, or it takes even longer to navigate back and forth to get all the information in.

The big thing is this; although I'm still a paramedic, I'm not riding the ambulance, and haven't' in a few years. I have no direct experience with the CCB, although all the other equipment was in use in some form when I was assigned to the box. I have a big question as to whether this is a good as it can be, or have things somehow changed.

I'd like to hear from you EMS folks. Spread this far and wide. Do you use an electronic clip board? How has it affected your patient interactions? Am I wrong to be questioning my medic’s behavior? Should I just accept that I'm no longer on the 'bolance and am now an "old guy"? I'd really like to hear your views on patient care/interaction now versus say 5 years ago. I'd also like to hear your opinion of having an 'old' paramedic on scene as a scene officer.

Mr Fixit


Ambulance Driver said...

They actually bring it in on a scene, and gather their history following the report template on the laptop?

If so, that's effed up. That's not the way the critter is supposed to be utilized.

At Acadian, our trucks have laptops, and we can use them for our reports, although it's a pian in the ass because of the Toughbook keyboard, and most of us wait until we reach the station and use the PC there.

We have paper forms we can jot down the particulars to hand to the ER staff before we leave, but all our internal stuff is electronic, or we can send an electronic report to the ER from the computer.

But we don't fill the form out as we go through the call. If your higher-ups actually expect you to do such things, they need their craniorectal inversion fixed, as close to yesterday as possible.

Mr. Fixit said...

You have it right. There is no longer a paper copy of the run form. They walk in with a laptop/tablet, I think a Toughbook 19, and use it instead of a clipboard. It's a touch screen,basically, they fill out the run form on the computer, which is able to accept signatures from the patient and ER.

We have a dispatch computer in the cab with maps, and CAD info. The laptop/clipboard is docked in the back. They take it out on every run.

RevMedic said...

No way. I can't believe they take it in to the patient with them! I've been using electronic charting for 8+ years now, but it gets done at the hospital, after the pt hand-off has been completed. Occasionally I'll enter the pt's name on the way to the hospital, but only if there is nothing else to be done. That way it's faster to get a signature.
In the system I work now, there is a fire engine crew there with us 99% of the time, and it's the captains job to scribe.
In my other system, and when the fire dept is not there, I use a note pad to document the important info, because I have... what's that term?... oh, yeah! Short term memory loss.
But dragging the damned computer inside while you're allegedly assessing and treating your patient is bogus.

Student EMT Cracker said...

I'm only a student but so far we are being taught only paper charts, oxygen for everyone, and talking to the patient and explaning what we are doing is emphasised in clinicals. We also are being taught manual blood pressures only because our instructor feels it's the only correct way of taking BP, and we are told pulse ox meters are only an accessory. Of course this is in NW Arkansas, so it may just be because or school is poor.

TheNanny said...

I live in Los Angeles. I've been both a patient of, and gone on ride-alongs with, LAFD Paramedics. They use paper, and write up all the reports at the end of the day, in a large paper journal and online.

As a patient, I was lucky enough to get medics who explained everything they were doing. Sometimes I had to ask (like when they started an IV in my hand, which I had never seen before), but they were happy to clarify.

As a ride-along, however, I've noticed the beginnings of the same things you've noticed. We walk in, get the name and age, and then the pt gets hooked up to the machines and inevitably transported to the hospital, thanks to MediCal (my tax dollars) and department policy forbidding the medics to refuse transport after a gruesome lawsuit.

This isn't to say that they're not courteous, of course, just that they don't seem particularly interested in the patient. Whether this distant attitude should be attributed to the advances in technology, or to jaded medics who are sick of having to transport BS cases to public hospitals on the taxpayer's dime, I can't say. In five 12-hr ride-alongs, I saw only one call for someone with a legitimate medical complaint. If I had to deal with liars, moochers, and malingerers all day, maybe I wouldn't want to get involved with the patient either.

TOTWTYTR said...

In a previous life, actually during the time that we met at EMStock, I was managing the project for one of these. What you describe is specifically what we didn't want people to do. Since generally only have two people per crew, it's not an issue. Also, even when we were on paper, most crews didn't write the report until they got to the hospital.

Most of us still jot down notes on index cards and then transcribe the information into the electronic PCR. Only on the most routine calls do we do a lot of the documentation on scene or in route. We don't even have hang around at the hospital to do the report since it's automatically delivered to the hospital.

You have my email address, if you want to send me an email I can tell you a lot more than I can in a comment.

Once I get back from vacation, I'm on the way to Miami to do some training for an FD ePCR implementation down there.

Also, if you know anyone in Plano, you might ask them. They've using ePCRs for several years now.