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A Viable Solution

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A Viable Solution

This is an interesting article. It’s also incomplete, but I’ll get to that part later.

 

A $500 fee and a 60% drop: How one department tackled its lift assist crisis

In 2014, the Decatur (Illinois) Fire Department responded to 430 calls for lift assist services. By 2023, the number had risen to more than 1,000.

This is not unique to Decatur, IL. In fact, it’s not unique anywhere. Among the clients for which my company provides auditing services “Falls” are the most common (14-23%) call type. They also have a very high patient refusal rate.

This fee applies to what the author calls “skilled nursing facilities or nursing homes” that call an EMS system to help move patients that have fallen or are otherwise immobile. The author doesn’t explain what difference, if any there is between the two and I’ve always seen the two terms used interchangeably.

“We had facilities that were – I hate to use the word abuse, but they were utilizing our resources rather than the people that are paid to do that,” DFD Chief Neil Elder said. “They were taking liability off themselves and putting it on our taxpayers and our resources.”

Ideally nursing homes whatever term you use should have staff that are capable of moving a patient off the floor and back into bed or a chair of some type. I don’t know about the author, but I’d guess that Chief Elder (ironic name) has seen the kind of people that are employed at nursing homes. I know I have and some are very good at this, but some I wouldn’t trust to lift a full trash bag.

Be that as it may, it is still a resource draining problem for EMS agencies. Most fire departments provide some level of EMS service, even if they don’t have an ambulance.

Not mentioned here is that many states don’t acknowledge a thing known as a “Lift Assist.” This is a medical response since the majority of “lift assists” are the result of a patient falling some distance. For people sixty-five and older that fall distance is usually from standing height. As a result, if EMS providers are called to a scene for a “lift assist” they are required by protocol to perform and evaluation. The second that they make contact the “person” becomes a “patient” and if they refuse transport a patient refusal must be completed and documented.

There are exceptions to that in some areas, but it’s the general requirement in the US.

Every time an ambulance or fire truck rolls out the door there is a cost incurred. The cost varies from place to place, but there is a cost. In general that cost can not be recouped because insurance companies only pay if there is a transport. Again, there are exceptions, but generally a patient refusal is not reimbursable.

When I say “insurance companies” I include Medicare which is the largest medical insurer in the country. Medicaid is also a larger insurer. Between the two they dwarf the private insurance providers. Both only pay if there is a transport.

Most nursing home patients have one or both so EMS services can’t bill for lift assists.

The fee was also waived for nursing home residents who required any medical attention during the call, and residential calls for lift assists were also exempt from the fee.

This makes sense and since residents are often voters is politically wise as well.

Over the next 12 months, the DFD generated $13,500 from nursing homes that chose to pay the new $500 fee.

This is an interesting statement. From which I infer that there is no enforcement mechanism as the fee may be of dubious legality. Maybe not. Speaking costs and fees, there is no word if the nursing homes pass that fee along to the patients. Which might also be legally dubious.

In addition to the calls to private residences, which in some instances are multiple times a week, there is no mention of calls to Assisted Living Facilities (ALF) which may not be licensed as medical facilities and thus have legitimate concerns about liability. I’ve had relatives who lived in ALFs and even though they had a nurse on staff neither the nurse or any other workers were allowed to lift patients who had fallen.

Is this the answer to this time and resource consuming issue in EMS? Maybe, maybe not. Harking back to my call review experiences, most “lift assist” calls are to either ALFs or private residences. I have no statistical data as we don’t track that in our database. It might be interesting, I’ll have to see if it’s something my boss would want to add.

While a fee may result in fewer calls to medical facilities, I don’t see that solving the problem in private residence and ALF locations.

Some of those in private residences belong in ALFs and some of those in ALFs belong in nursing homes. People are stubborn and also nursing homes are very expensive.

This article, Ill. city council makes $500 lift assist fee permanent

includes this quote,

Under the ordinance, a lift assist is defined as physically moving a person’s position to a different position who does not require emergency medical treatment or transportation.

Of course the problem here is that you won’t know if the patient does not require treatment or transportation unless someone does an evaluation. The temptation for nursing home staff will be to call 9-1-1 and allege that the person who fell is injured. Not that anyone who works at a nursing home would ever exaggerate the severity of the call.

Anyway, it’s a unique approach and it will be interesting to see how it works out.

 

THE UNANIMOUS DECLARATION OF THE THIRTEEN UNITED STATES OF AMERICA

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DECLARATION OF INDEPENDENCE
In Congress, July 4, 1776,

THE UNANIMOUS DECLARATION OF THE THIRTEEN UNITED STATES OF AMERICA

When in the Course of human events, it becomes necessary for one people to dissolve the political bands which have connected them with another, and to assume among the Powers of the earth, the separate and equal station to which the Laws of Nature and of Nature’s God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness. Prudence, indeed, will dictate that Governments long established should not be changed for light and transient causes; and accordingly all experience hath shown, that mankind are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security.–Such has been the patient sufferance of these Colonies; and such is now the necessity which constrains them to alter their former Systems of Government. The history of the present King of Great Britain is a history of repeated injuries and usurpations, all having in direct object the establishment of an absolute Tyranny over these States. To prove this, let Facts be submitted to a candid world.

He has refused his Assent to Laws, the most wholesome and necessary for the public good.

He has forbidden his Governors to pass Laws of immediate and pressing importance, unless suspended in their operation till his Assent should be obtained; and when so suspended, he has utterly neglected to attend to them.

He has refused to pass other Laws for the accommodation of large districts of people, unless those people would relinquish the right of Representation in the Legislature, a right inestimable to them and formidable to tyrants only.

He has called together legislative bodies at places unusual, uncomfortable, and distant from the depository of their Public Records, for the sole purpose of fatiguing them into compliance with his measures.

He has dissolved Representative Houses repeatedly, for opposing with manly firmness his invasions on the rights of the people.

He has refused for a long time, after such dissolutions, to cause others to be elected; whereby the Legislative Powers, incapable of Annihilation, have returned to the People at large for their exercise; the State remaining in the mean time exposed to all the dangers of invasion from without, and convulsions within.

He has endeavoured to prevent the population of these States; for that purpose obstructing the Laws of Naturalization of Foreigners; refusing to pass others to encourage their migration hither, and raising the conditions of new Appropriations of Lands.

He has obstructed the Administration of Justice, by refusing his Assent to Laws for establishing Judiciary Powers.

He has made Judges dependent on his Will alone, for the tenure of their offices, and the amount and payment of their salaries.

He has erected a multitude of New Offices, and sent hither swarms of Officers to harass our People, and eat out their substance.

He has kept among us, in times of peace, Standing Armies without the Consent of our legislature.

He has affected to render the Military independent of and superior to the Civil Power.

He has combined with others to subject us to a jurisdiction foreign to our constitution, and unacknowledged by our laws; giving his Assent to their acts of pretended legislation:

For quartering large bodies of armed troops among us:

For protecting them, by a mock Trial, from Punishment for any Murders which they should commit on the Inhabitants of these States:

For cutting off our Trade with all parts of the world:

For imposing taxes on us without our Consent:

For depriving us in many cases, of the benefits of Trial by Jury:

For transporting us beyond Seas to be tried for pretended offences:

For abolishing the free System of English Laws in a neighbouring Province, establishing therein an Arbitrary government, and enlarging its Boundaries so as to render it at once an example and fit instrument for introducing the same absolute rule into these Colonies:

For taking away our Charters, abolishing our most valuable Laws, and altering fundamentally the Forms of our Governments:

For suspending our own Legislature, and declaring themselves invested with Power to legislate for us in all cases whatsoever.

He has abdicated Government here, by declaring us out of his Protection and waging War against us.

He has plundered our seas, ravaged our Coasts, burnt our towns, and destroyed the lives of our people.

He is at this time transporting large armies of foreign mercenaries to compleat the works of death, desolation and tyranny, already begun with circumstances of Cruelty & perfidy scarcely paralleled in the most barbarous ages, and totally unworthy the Head of a civilized nation.

He has constrained our fellow Citizens taken Captive on the high Seas to bear Arms against their Country, to become the executioners of their friends and Brethren, or to fall themselves by their Hands.

He has excited domestic insurrections amongst us, and has endeavoured to bring on the inhabitants of our frontiers, the merciless Indian Savages, whose known rule of warfare, is an undistinguished destruction of all ages, sexes and conditions.

In every stage of these Oppressions We have Petitioned for Redress in the most humble terms: Our repeated Petitions have been answered only by repeated injury. A Prince, whose character is thus marked by every act which may define a Tyrant, is unfit to be the ruler of a free People.

Nor have We been wanting in attention to our British brethren. We have warned them from time to time of attempts by their legislature to extend an unwarrantable jurisdiction over us. We have reminded them of the circumstances of our emigration and settlement here. We have appealed to their native justice and magnanimity, and we have conjured them by the ties of our common kindred to disavow these usurpations, which, would inevitably interrupt our connections and correspondence. They too have been deaf to the voice of justice and of consanguinity. We must, therefore, acquiesce in the necessity, which denounces our Separation, and hold them, as we hold the rest of mankind, Enemies in War, in Peace Friends.

We, therefore, the Representatives of the united States of America, in General Congress, Assembled, appealing to the Supreme Judge of the world for the rectitude of our intentions, do in the Name, and by Authority of the good People of these Colonies, solemnly publish and declare, That these United Colonies are, and of Right ought to be Free and Independent States; that they are Absolved from all Allegiance to the British Crown, and that all political connection between them and the State of Great Britain, is and ought to be totally dissolved; and that as Free and Independent States, they have full Power to levy War, conclude Peace, contract Alliances, establish Commerce, and to do all other Acts and Things which Independent States may of right do. And for the support of this Declaration, with a firm reliance on the Protection of Divine Providence, we mutually pledge to each other our Lives, our Fortunes and our sacred Honor.

Is EMS Dying?

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Is EMS Dying?

As I’ve probably mentioned a few times, in my post active EMS career I read a lot of Patient Care Reports. I’ve been doing this since shortly before I retired, so it’s close to thirteen years.

As a result of the thousands of PCRs I’ve read I’ve observed some trends. Most medics and EMTs try to do their job well. They don’t take inappropriate shortcuts, perform treatments and procedures competently, and mostly get the diagnosis of their patient correct.

Yes, there are still lazy paramedics out there. The ones I call “line and ride” paramedics who will start an IV and ride in with the patient, but not do anything else. Sometimes they shouldn’t have started the IV and sometimes they should have done a lot more than just start an IV.

I worked with a medic like that. Anything even vaguely, might be, cardiac he’d give them aspirin, IV, NTG and a ride to the hospital. He logic was that while he was on this call, dispatch couldn’t send him on another call.

He also referred to patients as “sausages” for reasons I never understood and never cared to understand. His reward for being such a lazy medic was that he was promoted to management.

Another kind of medic is the “Throw the drug box at the patient” medic. I worked with a few and I could never tell if they were super smart or just throwing medication at the patient in the hope that something worked.

Along with the clinically astute paramedic who exams the patient, looks at the medical history, medication and allergy lists and decides what the diagnosis is. He also directs the work of the rest of the crew and monitors the entire call. In some systems that have two medics per ambulance with good BLS providers, he may not actually touch the patient at all during the call. A couple I knew rarely put on gloves when they were the “tech” or “primary.”

Sadly the second two types of medics seem to be disappearing. Mostly that’s because they are retiring or moving on to other career fields. I suspect that volunteer services have similar or maybe worse retention problems. I have no direct experience with any volunteer services, so that’s just a guess.

I started to see what I call a “generational  change” in EMS providers sometime in the 20 teen years. As more people became paramedics the quality of EMS education and training seemed to decline.

There were, and I think still are a few programs run by the training divisions of ambulance services. From talking to medics that went through those programs it seems that academically they were “taught to the test.” Which meant that they could pass the certification exams. but didn’t have the theoretical underpinnings to understand why they were performing the skills and giving the treatments for patients.

An example is that if the patient’s heart rate was fast or slow, they’d start an IV and give a large bolus of fluid. Unless the underlying cause was hypotension, it was unlikely to change the patient condition for the better. They failed to understand that IV fluid is and should be treated as a medication. As with all medications there are indications, contraindications, and the potential for adverse effects.

When I had occasion to sit down and review a case like this I’d try to explain the anatomy and physiology of what had occurred on the call. This is knowledge that they should have been given during paramedic school and maybe had been so taught. Sadly, the looks on their faces told me that they either forgot or never comprehended that information.

All of this was happening in services of all types private or public. Some public services were somewhat better because they had training programs for new paramedics. Some were not better and would take a new paramedic and throw them to the wolves. Most of the private services I dealt with had a one or two day orientation intended to show the new medic where equipment and medications were kept in the ambulance. There was little to no oversight of new medics.

I will note at this point that this was personally good for me because it meant more work hours spent doing re education. It was decidedly not good for their patients because if I was meeting with a medic to review a call there was at least the possibility of some harm to the patient.

Many of the medics were receptive and appreciated the knowledge I passed along to them and based on our evaluation process they started doing better patient care. That’s why I do this work and use my very good EMS education and experience to help medics be better.

Then came COVID. EMS systems were overwhelmed by the call demand plus the isolation requirements that were adopted. This included being confined to their stations between calls and not being able to even watch TV, eat, or even just talk about calls together.

COVID drove a lot of the experienced medics and EMTs out of the field. Those who could retire did so in large numbers. Others just quit and it was almost impossible hire new providers. Providers that test positive, even if they were asymptomatic were sent home for two weeks. A manager I knew told me that if ten percent of his systems providers were out per day it would be impossible to maintain proper staffing levels.

EMS regulatory agencies started to approve “expediencies” that ended up being practices that had been abandoned years before as EMS grew up. Providers in some states were allowed to decide that a patient didn’t need to go to the hospital. This wasn’t so much to help with EMS overload, but was an effort to relieve the same kind of issues that hospitals were having. Staff were overworked for the same reasons as EMS.

Another was a temporary waiver to allow systems to work with one EMT or paramedic on the ambulance and a none certified vehicle operator who had little to no medical training.

Hospitals were tacitly allowed to hold the ambulance and patient outside the building for hours until a bed was available in the ED. More stress on providers and systems for the benefit of hospitals.

COVID is now in the rear view mirror, but the damage still lingers. If spend any time on Facebook you will see that all types of EMS systems are looking for paramedics and EMTs, especially paramedics. An EMT course can be anywhere from a minimum of 120 hours to 190 hours. The 190 hour courses have more information and usually cost more. A 120 hour course can be crammed into about three weeks of full time instruction. Someone can take that course, pass the exam and be hired within a bit more than a month.

An Advanced EMT course is somewhere between 30 to 350 hours of additional training. AEMTs can do some of the things that a paramedic can, but not most of them.

A paramedic program is six months to two years depending on where it is taken. It’s also much more expensive. The two year programs are usually paired with an Associates Degree.

Which is why the demand for paramedics is much higher than for either of the other levels.

That temporary waiver for ambulance staffing? In many areas it’s now become permanent. EMT and Ambulance Driver or worse Paramedic and Ambulance Driver.

How bad is the staffing crisis? I know several other retired paramedics who have been offered jobs by ambulance services. I’m talking about people in their mid 60s or even older.

As if.

At this point there is no way to know when or even if EMS will recover. Based on what I’m seeing, I am not very optimistic. EMS is a hard way to earn a living no matter where one works. There are far easier ways to earn more money and many people are taking those jobs instead.

I hope I’m wrong and that EMS will rebound because patients deserve the best care possible in or out of a hospital.

 

Not Clear On The Concept

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Not Clear On The Concept

Scott Adams said that everyone is an idiot about something. A co worker of mine used to say, “You can be smart or you can be a doctor.”

The same concept, which is that people can be brilliant in many respects while exceedingly dumb in others.

Note that I am not a lawyer and this is neither a legal opinion or legal advice. It’s just a story from reviewing reports.

Which brings me to today’s story.

I reviewed an ambulance report where the crew was dispatched to an unconscious patient. When they arrived they found a conscious patient that may have had a seizure, but maybe didn’t. The patient, a man in his late Thirty’s had no history of seizures, had no history of syncope, and in fact had no medical history at other than one similar episode some time in the past.

The patient attributed whatever happened to his blood glucose level being low. A quick test with a glucometer revealed that it was fine. Vital signs were checked, which in acceptable ranges. A 12 lead EKG was obtained, which was also fine. A Stroke Exam was negative.

The patient agreed to be transported to the hospital for a more complete examination by a physician. Which is the best thing to do under these circumstances.

Along the way to the hospital an IV was started just in case something happened that required medication. Vital signs were repeated and another 12 lead EKG was obtained. Which was identical to the first one.

Then it started to go sideways. As the ambulance arrived at the hospital, the patient had a change of heart. He decided he didn’t need to be examined in the hospital, he just wanted to go home.

This put the EMS crew in a bit of a situation. They had initiated care and had transported to a hospital per their protocols. Now, the patient had thrown a curve ball at them. They contacted the Emergency Department and asked for a doctor to come out to the ambulance.

In a minute the doctor in charge of the Emergency Department came out, talked to the patient, looked at the EKG print out, and then told the paramedics it was okay for the patient to refuse. The patient signed a refusal, the IV was removed, and he left.

Pretty routine except for one problem. YOU CAN’T DO THAT! At least not in the state where this occurred and it appears to be a violation of a federal health care law.

The Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986 after a series of cases across the country where hospitals, mostly for profit hospitals, refused to examine and treat patients who came to their Emergency Rooms seeking treatment. Mostly it was because said patients were indigent and couldn’t pay. After a couple of these patients, one a woman in labor, died Congress took action.

The American College of Emergency Physicians (ACEP) is an organization that is dedicated improving in hospital emergency medical care. They publish a lot of guidelines and information for emergency physicians.

This is one of them,  Understanding EMTALA. It’s pretty thorough and here is one section that explains the obligation of Emergency Departments and medical staff,

Physicians can get penalized for refusing to provide necessary stabilizing care for an individual presenting with an emergency medical condition or facilitating an appropriate transfer of that individual if the hospital does not have the capacity to stabilize the emergency condition.

Hospitals have three main obligations under EMTALA:

    1. Any individual who comes and requests must receive a medical screening examination to determine whether an emergency medical condition exists. Examination and treatment cannot be delayed to inquire about methods of payment or insurance coverage. Emergency departments also must post signs that notify patients and visitors of their rights to a medical screening examination and treatment. Signage that could deter patients from seeking emergency care could be an EMTALA violation.
    2. If an emergency medical condition exists, treatment must be provided until the emergency medical condition is resolved or stabilized. If the hospital does not have the capability to treat the emergency medical condition, an “appropriate” transfer of the patient to another hospital must be done in accordance with the EMTALA provisions.
  • Hospitals with specialized capabilities are obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medical condition.

While the doctor may have thought that this met the requirements, it didn’t.

First, a patient is considered by this law and regulations to have “arrived” at the Emergency Department when the ambulance is on the hospital property whether or not it has stopped at the ED. The hospital “owns” the patient now.

Second, the hospital not the EMS crew is responsible for documenting the conditions of the refusal, the examination, the explanation of the potential risks of not allowing examination and treatment.

There is now NO record that the patient was ever at the hospital other than the ambulance report, which the way it is written contradicts itself by stating in one part that they transported to the hospital, but in another section that the patient refused transport.

Chances are that nothing will happen as the patient decided not to be treated and since the crew documented it as a patient refusal he will be unlikely to receive a bill.

So it’s a violation of the law, but there will be no consequences. Unless, that is, the patient went home and died for some reason. Or even if he went home, became ill and survived.

In which case someone is going to come looking for answers to some uncomfortable questions. One of which is why didn’t the EMS crew wheel the patient into the ED and let him tell the nurse at triage that he didn’t want to be seen? At which point the EMS crew had fulfilled it’s duty to treat and transport.

I could, at least as a worst case scenario, get sticky from there for the doctor.

It’s very surprising, I might even say astonishing that an Emergency Physician would not understand his obligations under EMTALA. I’m not surprised at the EMS crew asking him to come out and look at the patient. EMS providers aren’t usually well versed in EMTALA, but the doctor should have told them to bring the patient in so that he could comply with the law.

Sometimes, efforts to cover one’s derriere result in doing the exact opposite. This seems to be one of those cases although it’s likely nothing will come of it. I sent the call on to the system medical director for his review. I hope he doesn’t hurt his head too much when he bangs it on his desk.

If it does go anywhere, the hospital risk management team are going to get Agita.

“Lift Assist”

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“Lift Assist”

If there is one call that EMS providers dislike responding to it is the so called “Lift Assist.” I’ll be a bit more specific about this. In most states and EMS systems, there is no such thing as a “Lift Assist.” At least not legally even though factually that may be what happens.

What is a “Lift Assist” you say. A “Lift Assist” is a type of EMS call that most often is a response to an elderly person who fell. For dispatch purposes the height of the call rarely matters. What matters is that the person can’t get up on their own.

I know that everyone has seen those “I’ve fallen and I can’t get up” commercials. Some falls result in no injury and the person just needs assistance getting up off the floor. In fact, in some systems that’s about half of the calls. The other half are the trickier part. They might have an injury and they need to be assessed, if injured they also need to be treated and transported to a hospital.

One problem though. Elderly people are often stubborn and will refused to “Go back to the damned hospital again.” Elderly will often minimize their injury and will also, well I can only put this one way, lie about what happened.

While it’s not uncommon for elderly people to trip, or catch their foot on a rug, or even just slide off of a bed or chair, it’s also not uncommon for them to pass out and have an unprotected fall to the ground. Even a fall from standing height can cause serious injury. Denial of injury or illness is common.

I won’t go into detail on patient refusals as the subject is rather complicated and varies a bit from state to state and even agency to agency. What I will say is that smart EMS managers discourage crews from taking the easy way out by accepting a refusal from someone that the crew is not completely confident can make an informed decision.

One other thing. Among my company’s client agencies “Falls” are the most common call type. Depending on the agency and population demographics that can be between 17 and 24 percent of all EMS calls. That’s a lot of calls.

A lot of these calls originate because some facilities require staff to call 9-1-1 whenever a resident or patient falls for any reason. Even if it’s a slip out of chair or bed with a “soft” landing. Assisted Living Facilities almost always call for an ambulance (or someone) when a resident falls. Nursing Homes sometimes do, but sometimes don’t. Falls in Nursing Homes may trigger state reporting requirements, so sometimes they may not call even though they should.

Which brings me to this article at EMS1. Geriatric slips, trips, and falls. There are some good points in the article, but there are some things that based on my field career and post retirement Continuous Quality Improvement career are not entirely correct. I do recommend that you read the article.

Obtaining your party’s blood pressure – and I say “party” because they may not be a patient quite yet – may be a courtesy measure that you offer to any individual that you interact with.

This may be true in some areas, but if so I haven’t run into it. Exactly when a person becomes a patient is not completely clear, however as soon as you make contact it is appropriate to work on the basis that the person in front of you is a patient. They are called “Patient Refusals” for a reason. The patient doesn’t have to be the person that called, doesn’t have to say “Take me to the hospital.” In the state where I spent my active career the state EMS agency regulations stated that it was the expectation that when an ambulance was called, someone would be going to the hospital. Other states don’t go quite that far, but there is always some level of expectation that someone thought that the patient needed to be assessed, treated, and transported.

Here are some considerations that may sway your decision toward patient transport of an elderly fall victim:

    • Are there any injuries noted or observed (old; indicating a pattern of multiple falls, or new; indicating recent trauma)?
    • Are there any complicating factors that might have led to the fall (i.e., medications, additional symptoms, etc.)?
    • Is the patient prescribed any blood thinners (anticoagulants or antiplatelets)? Do you have an available list to reference these medications?
  • Is there something more to this fall? Could the patient be suffering from a stroke or TIA, or could this have been the result of a syncopal episode?

I mostly agree with this. I advise all of my client agency medics to do a thorough examination of fall patients to the extent that the patient will allow them to do so.

The bolded part is where I think that there is a problem. It is never in the patient or for that matter the providers best interests to suggest anything other than transport. Provider initiated refusals run a high risk of a career ending mistake.

If the patient had Loss of Consciousness then an ALS assessment including Stroke Exam and 12 lead EKG is indicated. Vital signs should be assessed before the patient is moved. Never allow or “assist” a patient to stand without taking vital signs including a Blood Pressure. If they passed out because of a loss of blood pressure, that is very, very likely to happen if you stand them up.

Don’t be a dumbass.

Most patients with Atrial Fibrillation are on blood thinners these days. Eliquis is the most common, then Xarelto. There are still a few on Coumadin (Warfarin). A stronger dose of Warfarin is used as rat poison because it causes internal bleeding at high doses.

That that means is that any of those three drugs can cause cerebral hemorrhage, especially if the patient strikes his or her head when they fall. Even without loss of consciousness that is a risk.

Some of these calls are classified as “High Risk” refusals. That risk is primarily to the patient, but mishandling a patient refusal call is also high risk to the providers.

As far as “trip” risks, those little area rugs that elderly people seem to have an affinity for are very dangerous, especially on hardwood or other polished floors. I refer to them as “landmines for the elderly” and can result in serious or even devastating injuries.

Lift assists aren’t as simple as they may seem on the surface, especially among elderly populations.

 

The Great Crusade Begins

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Soldiers, Sailors and Airmen of the Allied Expeditionary Forces:

You are about to embark upon the Great Crusade, toward which we have striven these many months. The eyes of the world are upon you. The hopes and prayers of liberty-loving people everywhere march with you. In company with our brave Allies and brothers-in-arms on other Fronts you will bring about the destruction of the German war machine, the elimination of Nazi tyranny over oppressed peoples of Europe, and security for ourselves in a free world.

Your task will not be an easy one. Your enemy is well trained, well equipped and battle-hardened. He will fight savagely.

But this is the year 1944. Much has happened since the Nazi triumphs of 1940-41. The United Nations have inflicted upon the Germans great defeats, in open battle, man-to-man. Our air offensive has seriously reduced their strength in the air and their capacity to wage war on the ground. Our Home Fronts have given us an overwhelming superiority in weapons and munitions of war, and placed at our disposal great reserves of trained fighting men. The tide has turned. The free men of the world are marching together to victory.

I have full confidence in your courage, devotion to duty, and skill in battle. We will accept nothing less than full victory.

Good Luck! And let us all beseech the blessing of Almighty God upon this great and noble undertaking.

Salary Emergency

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Salary Emergency

A short history to set up the main part of the article, On March 17, 1996, NYC*EMS was assimilated merged with the Fired Department of New York City (FDNY) by order of then Mayor Rudolph Giuliani. As Mayor Giuliani did some very good things for the residents and visitors to New York City. This wasn’t one of them. It the joining together of two different agencies with two different missions, two different cultures, two different shift schedules, different uniforms, and two different salary structures. Oh, and two different unions, but that’s a whole other story.

To say that there was a period of adjustment would be perhaps the understatement of the 21st Century. It merger was fractious for several years, but as time passed and the “old guard” on both sides of the merger retired or moved on to other jobs, the new normal began.

Some things improved, some stayed the same, arguably some got worse. EMS and fire suppression still seem to operate as two different agencies, which makes sense.

Perhaps the biggest disparity then and now was salary. I don’t know if it’s still true, but for a long time while I followed these festivities and EMT getting hired by the fire suppression part of the operation was considered a “promotion” not a hiring.

To be sure, this is not unusual in EMS at all. After San Francisco merged it’s EMS system with the fire department, there were three different salary scales for paramedics. The lowest pay scale was for single role paramedics who were not cross trained as fire fighters. Next up on the scale was for cross trained paramedics who still were only allowed to work on ambulances. The highest paid paramedics were fire fighters who didn’t work on ambulances or provide more than BLS care at scenes.

Hmmm. I could go on and on, but will only mention that there are still fire based systems that are looking at hiring single role paramedics to work on their ambulances. For less pay, fewer benefits, more work. That’s an incentive, right? Right?

All of this has been compounded by a nationwide shortage of people who want to become paramedics or EMTs and work on ambulances. That was starting to happen before COVID, but since then has become a crisis in most parts of the country. Private, third service, fire based, it doesn’t matter. EVERYONE is having problems finding people to work. I am presuming that the problem is as bad for volunteer services, but can’t swear to it.

I won’t go into the various plans being implemented to change that other than to say that some will help the problem, some won’t, some will lower standards for medical care, some will not. At least I hope they won’t.

One to our main story. After Twenty Nine years of pretending that there is no pay disparity at FDNY EMS, the New York City Council has decided that there is a “Salary Emergency.”

This article is from “The Chief” which bills itself as “A Voice For Workers.” Note that most of the content is behind a paywall, but they put this in front of it. The article is short, so I’m only going to post what I think is the key point.

Salary Emergency

The historically out-of-kilter EMS wages mean it’s increasingly harder for the city to recruit and retain medically trained and experienced first responders. In 2024, city EMS personnel responded to more than 600,000 calls for life-threatening medical emergencies, the kind that can kill.  But on a recent day, just 70 percent of the city’s target for EMS ambulances were in service, while the number of fire trucks in service was over 90 percent. Soon, hundreds will be moving from the EMS to the firefighting side.

Imagine that, people want to leave a lower paying job with better benefits and a lighter work load for one that is, in a word, better.

Keep in mind that FDNY ambulances are supplemented by a combination of hospital based (voluntary), private, and even volunteer ambulance services. The article doesn’t tell us if the 70% is just city ambulances are all 9-1-1 ambulances.

The Fire Commissioner has sounded the alarm over the situation, Harry Siegel: Fire commish sounds alarm: EMS about to collapse.

Note that I typed my preamble before I read this article,

The job comes with a limited number of use-them-or-lose-them sick days, a big pay disparity with other uniformed service workers, a culture that’s nearly as isolated as a firehouse is intimate and a rapidly churning workforce mostly there because it’s a four-year backdoor to becoming a firefighter.

By the way, the term “backdoor” is usually used as an insult, but Harry Siegel is probably too dumb to know that.

In a phone conversation on Thursday, he elaborated about “what’s been sort of the tale of two cities” inside the FDNY between fire operations and EMS operations: “They’ve never adequately been merged. They wear the same patch, but they hardly operate under anywhere near the same conditions,” Tucker said, adding that EMS members “still do a phenomenal job despite the setup.”

Commissioner Tucker understands the problem, but has about no capacity to fix any of it unless the Mayor and City Council are willing to spend a lot of money. I won’t be surprised if someone, probably on the City Council proposes that New York City just contract the whole mess out to some private ambulance company. Which, of course, will make things a lot worse, but it will be cheaper. Or something.

Here is one last link for your reading pleasure. It’s also from “The Chief” and is also in front of their paywall. It’s from 2024 where the Mayor says he wants to fix the inequities at EMS. Oddly, he’s done nothing about it since then.

Adams, Kavanagh express support for EMS pay parity

Note that the Commissioner last year is not the Commissioner this year. Apparently the tenure at that job is measured with a stop watch, not a calendar.

I’ll close by saying that the problems in New York City may be extreme, but it’s not the only such case. I’ll even say that it’s not uncommon. Can think of several large city EMS systems, not fire based, that have similar problems. In those agencies it’s common for EMTs or paramedics to work for a couple of years and then try to get hired by fire departments. Back to better pay, better benefits, better schedules, better retirement, and so on.

Private services are even worse.

I don’t know if or when the situation will get better.

 

The Older Shooter

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The Older Shooter

As we age things change. Some for the better, some for the worse. For the better, we get discounts on some things we buy, easier access to other things, and sometimes people even valued our experience and opinions. On the other hand, it gets harder to keep off weight, muscles and joints are not as flexible as they used to be, eyesight can get worse, and coordination can become an issue.

As a I sometimes say when people call it the “Golden Years,” that’s not gold, its rust.

Getting older means that there are going to be more challenges to being able to shoot. That will affect all varieties of shooting, hunting, target/competition, and of course self defense.

Until fairly recently there was little to no information or advice available to aging shooters. It was mostly “get better glasses,” “find an easier gun to shoot,” or even “if you don’t feel safe stay home.”

In 2016 the much maligned National Rifle Association came out with it’s first class for “The Aging Defender” as they called it. This was presented in a class at the 2016 NRA Annual Meeting. The session was presented by Dr. Joseph Logar PT, DPT. He is an experienced Physical Therapist and Certified Functional Strength Coach.

I took this course and still use many of the techniques that Dr. Logar demonstrated. I also work out and stretch on a regular basis, which help with both strength and balance.

Unfortunately, this is only available to those who attend the NRA Annual Meeting. It would be great if the NRA could video a session and make it available to members. In the meantime, here is a link The Aging Defender from 2020  in “American Rifleman” . It’s course, but it does provide some helpful hints. It seems to be available to those without NRA membership, at least I didn’t have to log in to anything to access it.

This is another NRA article  Self-Defense for the Aging Shooter, again with free access.

The NRA has an Adaptive Shooting Program which seems to be more oriented to shooters with physical disabilities. Which I understand, however there are a lot of long time, and some not so long time shooters who are getting older and can use some help. I’ve belonged to a couple of gun clubs in a couple of different states and one constant is that many of the members, maybe most, or older men. Many are retired and have plenty of time to shoot, but some find it challenging. To say the least.

I think it’s a mistake by the NRA to lump older shooters in with disabled shooters. As an older shooter I don’t need to be reminded that I can’t do everything that I could even ten years ago. Believe me, we all know that even if we don’t admit it.

One last link to free NRA material for older shooters, Tips For Senior Shooters. This article is written by an older, very experienced shooter and has some practical ideas for making it easier to shoot as we age. I particularly like his comments about hearing protection as I too recently upgraded my hearing protection to a similar product.

The February/March issue of Concealed Carry Magazine, which is published by the US Concealed Carry Association has an article on Adaptive Self Defense. The on line version of the magazine is available only to members and membership is an adjunct to buying their insurance plan.

The article is mostly about mental preparation and equipment choices for older shooters and is geared to self defense options. At times Concealed Carry Magazine goes a bit overboard on the “Tacticool” stuff, but this story has solid advice regarding being aware of ones physical limitations, situational awareness, equipment choices, and training.

Situational Awareness simply explained is being aware of your surroundings. Even older people are apt to get thoroughly immersed in their smart phone can become distracted. I see it often among all age groups at gas stations. A place like Sam’s Club or Costco is relatively low risk, but gas stations with attached convenience stores seem like asshole magnets. In that vagrants and other unsavory characters seem to hang around them looking for victims to mug.

Many years ago I stopped at gas station near a large airport to top off the gas on my rental car. It was after dark and airports are often not in desirable areas. After I paid and started pumping gas I spent the time looking around with my hand in a pocket holding on to my carry revolver. While I wasn’t sure that I’d be accosted it was a distinct possibility. It would be more likely to happen if I was like some of the other customers who were looking at the pump handle with my back turned to the street or parking lot. Predators like the unaware.

Training can be going to the range and practicing or it can be taking a formal defensive shooting course. Some of which are rather expensive, but some are very reasonably priced.

I’ll quote the closing paragraphs from the article for consideration.

 If you are disabled or ill, your ability to defend yourself doesn’t disappear. You are not helpless; you can still protect yourself, your family and your friends.

 It starts by being smarter than the wolves. Build an effective strategy and practice it. Work on strengthening yourself. Seek out as much training as possible and spend as much time as you can at the range. If you are honest with yourself and prepare accordingly, you can stay safe. Repeat after me: Prepare, perceive and protect. Commit these three Ps to memory and practice them daily.

There is now equipment that is well suited to the older shooter and anyone who has issues with grip strength. Smith & Wesson has several new guns with easier to cycle slides, less recoil, options for better sights, and other enhancements.

The Enforcer is a good choice for self defense for older people and comes with a variety of options to make it more effective. It has a built in mount for Red Dot sights and there is a Crimson Trace Laser version as well. I quibble a bit with their term of “Micro-Comact” for this gun, but it is concealable and lightweight. There are other models that have similar features and other manufacturers may have similar models, but S&W seems to be leading the market right now.

Maglula makes the Uplula semi auto pistol magazine loader. They are great for loading magazines at the range or loading the magazines you use with your self defense pistol. I’ve started using one for all of my range trips as tiring out my hands loading magazines has an adverse effect on my shooting.

Human predators are like predators in the wild. They seek out the weak and infirm because they are easier to overcome and kill. Muggers and other violent criminals may not kill their intended victims, but they can still overpower them because they are usually younger, more fit, and more agile than their targets. Firearms and less lethal weapons are the equalizers here as they allow the older defender to improve their odds of surviving an encounter.

Getting older doesn’t mean becoming defenseless. You just have to be smarter about it and prepare ahead of time.

Victory In Europe

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Victory In Europe

May 8 is the anniversary of Victory in Europe Day. It celebrates the formal end of the war in Europe and complete surrender of the German military.

Adolph Hitler committed suicide on April 30, 1945, but the actual surrender took over a week as elements of the German Army continued a futile defense against the rapidly advancing Soviet Armies.

The Soviet Armies crushed all defeat in and around Berlin over the next several days. They also raped about 80,000 German women along the way. Additionally, the Soviet troops looted buildings and murdered an unknown number of Germans.

The German Instrument of Surrender was signed at 22:43 German time on May 8.

It reads,

The German High Command will at once issue orders to all German military, naval and air authorities and to all forces under German control to cease active operations at 23.01 hours Central European time on 8 May 1945…

The war that Germany had started on September 1, 1939 by invading Poland on a false pretext was finally over in Europe.

For England and Europe, the war was almost six years long. For the United States World War 2 started with the attack on Pearl Harbor on December 7, 1941. In both the Atlantic and Pacific, the issue was in doubt for several years.

In some ways the war had started earlier with other events. On October 3, 1935, Italian troops invaded Ethopia after a border incident between Ethopia and Italian Somaliland. Mussolini ordered Italian troops to attack Ethopia. Italy won due to it’s superior weaponry and in part because Britain refused to intervene on behalf of Ethiopia.

Japan invaded Manchuria in September of 1931 and China in 1937. On September 12, 1937 Japanese planes attacked and sank the USS Panay on Yangtze River. The Panay was a US gunboat, killing three people on board and injuring 48 people on other US flagged ships. Japan claimed that their pilots had not seen the US flags on the ships, however photographic evidence contradicts that.

In some ways these precursors were the shape of things to come while much of the world wanted nothing but peace.

The Victory in Europe not the end of World War 2. The war would continue through the spring and summer of 1945 until Japan surrendered unconditionally on September 2, 1945 when the Instrument of Surrender was signed on board the battleship USS Missouri in Tokyo Harbor. Japan had ceased fighting on August 15 (August 14 in the US) 1945.

Depending on which date you pick World War 2 could be considered to have lasted almost 15 years.

Shaving Cream In A Can

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The post title is not some sort of Joy Bahar in a spandex suit joke. It’s a story about how great ideas are sometimes rewarded and sometimes not so well rewarded.

My late Father in Law as a bit of curmudgeon sometimes. Given that his family last just about everything during the Great Depression and he never made as much money as he probably should have, I can’t blame him.

He was a Master Electrician and given that he was born in 1915 you might say he got in on the ground floor of the trade.*

He worked at the trade until World War 2 came along. Although the military probably needed electricians, he was draft deferred because being a Master Electrician was classified as exempt. Instead of going into the military, he ended up working at an armory where artillery was made. When he told me this way back when I was first married, I thought it odd that they had him wiring cannons for electricity. He carefully explained, using small words, that his job was to wire the big machines that made the tools to make the machines that made the parts of the big guns.

Forging, casting, machining, all needed electricity to power the equipment.

Oh.

He was also a tinkerer and quasi inventor. He often came up with ideas to make equipment in the armory safer or more efficient. One idea was to put a shroud around the big pully that turned the belt on an air compressor. Since it was wide open there was more than a little risk that someone would get their clothes, hands, or something else caught in the machine.

The Colonel in charge of the armory like they idea and they built the cage as my Father in Law suggested. He got a nice letter from the Colonel thanking him for his suggestion. In fact, he got several nice letters from the Colonel for coming up ideas to improve efficiency and safety.

When the war ended, so did the job. The military didn’t need more artillery, in fact they had way more than they needed since there wasn’t an enemy to blow up any longer.

After working here and there for a few years he ended up at a large company that makes grooming equipment. Mostly for men, but now also for women. Back then they were known for making razors for men, along with things like shaving brushes and shaving soap. They also made shaving cream.

Once again he was hired to wire machines that made things, in this case razors and accessories. I won’t mention the name since the company is still in business and bigger than ever. The interested reader can probably figure it out, but don’t bother asking because even though everyone involved is long dead the company is still around.

At his new employer, he continued his habit of thinking of ways to help make the equipment and the process more efficient and safer. The company had suggestions boxes at various places around the plant and to encourage employees to come up with ideas the company not only offered nice letters, but they would give the employee a bonus if they adopted his idea.

The bonuses were from mostly from $5.00 to $25.00. That might not seem like much now, but back in the 1950s it was a decent sum.

He submitted several ideas, some of which were not accepted, but many of which were. I saw the letters not too long before my Mother in Law died. She was saver of just about everything in and when I heard this story she had all of the letters going back to World War 2. For the record this was in 2019 when she turned 100.

One of his suggestions was that they should put a suggestion box near the lunch counter in the plant where he and many others had their lunches. That way they wouldn’t have to walk any further and it would be easier to drop suggestions in the box.

That was a $5.00 suggestion, along with the nice letter from his boss.

One day he was at a drug store for some reason or another and he watched as the soda jerk pulled on a lever and whipped cream came hissing out into a glass.

BTW, “soda jerk” was the term because they would “jerk” on the handle, not because they were jerks. But, I digress.

Father In Law was struck by inspiration. What if they could put shaving cream into a can with compressed air and a push button on the top? Then men wouldn’t have to use soap and a brush to lather their face. They could just use the foamy stuff that came out of the can.

He wrote up the suggestion and it was an instant hit. It was in fact a $100.00 hit as that’s the amount of the bonus that he got. For an idea that made his employer millions, well now billions, and I expect that the boss got a raise and a promotion.

In addition to the $100.00 bonus, he got a nice letter, and was told that because he was an employee the company owned any ideas that he came up with. If he didn’t like it, he could leave and find a new job.

He didn’t. He stayed on for about another thirty years and continued to wire machines, some of which made the very product that he had invented.

To be fair, the company did treat him pretty well. He got free health care for the rest of his life and when he died my Mother In Law got free health care as well.

You might think that this was just family lore, which is what I thought when I first heard this story. It wasn’t, as I saw the letter from his boss because my Mother In Law never threw anything out.

That’s a story for another day.

*I apologize for that pun and will try not to write any more although I often find them irresistible.

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