February 15, 2023 • 45 mins
Is the EMS physician an elusive creature only occasionally seen by EMS providers? Or is the EMS physician a tireless advocate and constant presence in a provider's life? Dr. Will Krost, an emergency physician and paramedic, helps take some of the mystery out of the physician-provider relationship. When you are done listening to this podcast, you will wish Dr. Krost was your medical director.
Get CE for listening! 1 hour CAPCE-approved F3 CE (basic medical director). Purchase here: https://www.lc-ready.com/store/details/93-7_things_your_medical_director_wants_you_to_know
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Episode Transcript
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(00:00):
Welcome to the Seven Things EMS Podcast, a continuing education offering of limer education.
(00:12):
Seven Things EMS Podcast is designed to give you what you need to succeed in EMS, it's
conversational, informational and without the fluff.
And welcome to another episode of Seven Things EMS, I'm your host Dan Lemmer, we have a great
(00:36):
episode for you today.
Seven Things from the medical director's perspective and I am thrilled to be able to
introduce a physician and good friend Will Cross.
Will is a system medical director for emergency medicine at the University of Louisville Health
System.
I've known Will for many, many years from his EMS days to flight medic days through med
(00:59):
school and now as an emergency physician.
I think generally EMS systems are always better off with involved physicians.
I think physicians that have a past EMS perspective are even better.
So using our format here we have a quick introduction, I'm going to say hello to Will and we're
going to get into our Seven Things which I believe you're going to enjoy.
(01:21):
Welcome Will Cross MD.
Thanks Dan.
This is awesome to actually be a part of this conversation and as you said we've been
with each other a really long time.
A very long time and we certainly could tell some stories but that's not our goal here
today we're going to get right to it and I just love saying MD after your need.
(01:43):
It seems like now that's more of a thrill for me today than you but I just think it's
awesome.
So Seven Things from the medical director.
What I like about the Seven Things you've created and everybody that's a guest here
does their own Seven Things and what I like about them is you've done some clinical things,
you've done some understanding the doc things and then even some more clinical things.
(02:06):
I think it's a great way to put these together.
So let's start with number one.
And it's a great start.
Always strive to take great care of people.
Don't be afraid to defend the decisions you make on the patient's behalf.
Tell me about that one.
So I think sometimes in the specifically ED environment it can be intimidating when you're
(02:32):
the provider bringing a patient in and you're giving a report and sometimes I think you
can fall back on well just did I do the right thing and somebody asks you a question and
it's oh man did I really do this right and there's almost a sense that you have to defend
(02:52):
yourself.
And what I would tell you is that that is so far from what you should be thinking and
from where you should be.
I think all of us whether you're a EMR, a first responder, EMT, paramedic, nurse, physician
we got into this business because we like to take care of people.
(03:15):
It's hokey, it's cliche, but the reality of it is it's a lot of what we do and I think
sometimes we make decisions on the fly.
Actually we always make decisions on the fly and when you're making decisions kind of as
you go a big part of that is being able to say I did what was in the best interest of
the patient period.
(03:35):
And so it may be that you are approaching a family or approaching a family member approaching
the patient in a certain way and if it's a way that you can very easily say I did this
because it was one clinically well or clinically better for the patient and two if it's something
(03:56):
that you can say in good conscience that made a difference for the positive I don't think
you have a whole lot to defend.
But I think the bottom line is we have to maintain that sort of position of excellence
in everything that we do and if we are always working towards providing great care I think
we're going to provide great care.
You know one of the things you've heard me say when we've spoken at conferences together
(04:20):
is that EMS every call is ultimately a series of decisions that may or may not succeed.
Well let's go into the medical director perspective.
I think there's a lot of people that think that they are judged by the medical director.
The medical director is going to be the person that you get in trouble with or have to worry
about what's your take if an EMT or an AEMT or paramedic comes to you and says the protocols
(04:46):
say this I was really concerned.
Maybe I didn't have time to call in or I really thought this was the right thing to do.
What's your perspective on that?
I think that's a great question Dan and I think it's one of the probably everyday questions
that I hear.
It's not even always the big things sometimes it is the big things but I always default
(05:08):
back to let's talk about your mindset or your thought process.
You know what is it that you did what you did.
I think the concept of medical protocols is really important because they are guidelines
they were designed to be guidelines but they should not replace your ability to critically
(05:30):
think.
You know you've said this a million times over in the lectures as we've talked before
Dan that you know we are not in the business of just rote memorization and really doing
things because the book says so.
It's better and more important that we understand why we do the things.
(05:51):
So if an EMT comes to me and says hey or example I'll give you one that happened paramedic
comes in and says look doc we had this patient they were going crazy on us.
I couldn't get to the radio in time to call for an RSI order but this patient was agitated
delirium.
I needed to put him down he was an asthmatic who was having trouble breathing.
(06:14):
I couldn't get there.
I did what I thought was right for the patient.
I look at that and they say hey good for you because the reality is if this provider didn't
do that this patient would probably be dead.
If you wait until they are so hypoxic and you're watching them deteriorate or hypercarbic and
(06:34):
you're watching them deteriorate but do nothing the outcome is going to be bad.
I would much rather you do something than to do nothing especially in a clinical environment
like that.
I mean that's an extreme right.
And we can put in the your mileage may vary statement you know always follow your local
protocols and blah blah blah we're not telling you to go out and do risky things but the
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truth is the nature of EMS is that you're going to get things that are going to go between
the lines and how we respond is really important in absolutely.
So let's go on to number two.
Addicts and frequent flyers get sick and will die one day.
I love that.
My medical director talked to my paramedic students at down here in Galveston and he
(07:18):
said I treat all patients like they're secretly trying to die and not telling me.
I was like well that was I kind of like that you know I mean but the fact is all your frequent
flyers even people that are on the street that are drug users and everything else people
are alcoholics people that are people that are in tough lives have more medical problems
than most.
(07:39):
So let's I don't want to take all your thing there.
I just love these so much.
Tell me tell me.
You're absolutely right Dan.
I think there are a couple of key points to this.
Let's talk frequent flyers first right.
You go to get Mrs. Jones at three o'clock in the morning and she's out there with her
suitcase waiting for you to take her to the hospital.
It's very easily easy to look at Mrs. Jones and say oh this crazy lady wants me to take
(08:03):
her to the hospital again and you know clearly she's not sick because she brought all her
stuff with her.
Well the problem with that mindset is that it gives you tunnel vision and you miss subtle
findings in your physical exam you bring her in and unfortunately the ER has the same tendency.
Oh Mrs. Jones yep she's back again right.
So it may be hours before she gets appropriately evaluated and she could be actively dying
(08:29):
from the moment you pick her up and so I think it's easy for us to blow things off blow people
off that we see on a regular basis saying Mrs. Jones coming back in and oh she's got
her chest pain again.
What happens if this time is the time right.
This is the time that she's having her MI and you have the ability to identify it and
(08:50):
don't catch it right.
Or she's having this chest pain she's developing her MI and by the time you get to the hospital
she goes into cardiac arrest.
If you didn't do an EKG if you didn't do your evaluation you didn't work her up you wouldn't
know that and I wouldn't know it when you drop her off to me I'd say oh it's starting
cardiac death could be an MI it could be many other things right.
So it is really important to recognize that frequent fliers have disease and unfortunately
(09:16):
many of our frequent fliers truly have real pathology they have diseases that will kill
them one day and it's much easier to just blow it off than it is to try and put the
effort in to really do a good comprehensive work up.
Now I'll share with you another little piece here this is a personal piece.
So as far as addicts go I will tell you that it's really easy and I'll give you an example
(09:41):
the other day I took care of a guy that came in three times in one shift.
Now I was working a nine hour shift he used an opiate he got an arcane by EMS he went
back out he did it again three times in a row EMS brought him in within my nine hour
shift after he went left against medical advice and used again.
(10:02):
Now it's very easy to get frustrated at somebody like that and say man what are you doing?
Trying to kill yourself?
You know I debated actually admitting this guy for a 72 hour hold with psychiatric thoughts
that maybe he was trying to kill himself.
Of course he wasn't he just really needed his high and was ticked that we were taking
it away from him.
But here's the personal piece.
So Dan knows this people that know me well know that I have a brother who's been a heroin
(10:25):
and polypharmacy user for his entire adult life.
So he is 46 and from the time he was 17 until 46 now he's been using heroin, cocaine, meth
pretty much anything you stick in front of him.
(10:45):
And I would just ask you if you had a brother that was doing that how would you want them
to be seen how would you want them to be treated?
And I look at it kind of differently because of personal experience but what I typically
tell people to do is kind of look at that person's mom and then ask yourself if you
can just see them as the quote unquote trash off the streets because that's how people
(11:06):
frequently see drug addicts.
You know my brother would be what you would consider to be trash off the streets but
he's still my mom's little boy and he always will be at 46.
And so it's difficult for us to deal with difficult people but sometimes those are the
exact people we need to spend extra time dealing with because it may just be that you're the
(11:29):
one person that they connect with that saves their life at that time and may change something
around for them.
You never know.
But I think you've got to remember that we see people.
We take care of people.
It's hard when you see a lot of it.
It doesn't matter really now if you're urban or suburban or rural it's everywhere and
you see a lot of it and I think we can both admit practically that it's sometimes an
(11:53):
uphill slog to see this several of these a day and you do it but you can never let your
guard down as a clinician or a human.
And I think that's really what separates some of our amazing providers from others is that
they're able to do that.
And there certainly is talk with everything going on now about compassion fatigue and
(12:15):
general fatigue in medicine and nursing and EMS that certainly doesn't help.
But I think that I very much appreciate your personal perspective and I hope people really
take that to heart.
Number three talks about destination.
Yeah.
Number three talks about destination and that matters.
So patients better serve from an additional 10 minute trip than they are being brought
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to the closest hospital.
And now you have gone from paramedic, flight medic, now physician.
And I think that there's a lot of EMS people that don't necessarily think of themselves
as as big a part of the health care system as they are and see what a decision they make
(12:59):
when they go to a place that can comprehensively treat a stroke or have a cat scanner or have
some type of cardiology available.
What a difference that decision can make.
I think that we feel like we're on the outside of the hospital but I think there's times
that all of the things you do on the scene go into the right place might be the biggest
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thing we do.
You're 100% right.
One of the things and I have the luxury of working at seven different emergency departments.
Luxury discomfort, whatever you want to call it.
I was going to say that.
I know you were.
I can tell.
I just know you.
At any rate, I get to work at seven different places and they're all very unique.
(13:44):
Trauma center, community hospitals, freestanding emergency departments.
I get to see those patients who, for example, get appropriately taken to a trauma center
and I see how they're managed from a trauma perspective.
I also see when those patients are brought into our community hospital or freestanding
ER, if they're a trauma patient and they're brought into one of these facilities, all
(14:07):
we are simply doing is delaying care in many cases.
I would argue that a majority of these patients that get brought into us are probably okay
and don't need definitive surgical intervention.
For those few cases where they are really sick, I know the American College of Surgeons
has gone away from a lot of the mechanism stuff.
Dan, you and I have been doing this long enough to know that mechanism matters.
(14:30):
It does make a difference.
They're putting less stock in trauma center destinations for mechanism.
I would tell you that, again, you're the ones that are seeing things in the streets and
what you see makes a difference.
That's trauma.
Let's talk cardiology.
You have a great story for.
(14:53):
I'll give you a good example that happened to me today.
I worked in the ER today.
I had an old lady, 87 years old, came in crushing, substernal chest pain, radiated to her left
arm, diaphragmatic, nauseous.
You know where I'm headed with this, right?
But EKG looks okay.
I don't see any EKG changes.
I still feel clinically like this woman's having an MI.
(15:15):
What do I do?
I call the cardiologist.
He goes, yeah, well, maybe, maybe not.
I'm not waiting for the blood levels to come back, her troponin to come back.
I'm like, listen, I just want you to come down and take a look at this lady.
He comes down, he looks at her and goes, oh, I'm taking her to the lab right now.
I said, huh, what do you know?
The beautiful part about that is we had a cath lab where I was.
(15:37):
What if you were at the middle point between me and one of the other institutions and maybe
you were a couple minutes closer to a freestanding ER who had no other facility and no other
resource?
You take this woman there.
She's going to end up there.
You're going to, I'm going to do my work up, but I'm going to be kind of thinking, why
did they bring this woman here?
(15:57):
Because she's clearly having an MI even though her EKG doesn't show it.
Now, by the way, I'll tell you that lady had a 99% LED, proximal LED occlusion, which means
her widow maker about made, well, she's not a widow.
She'd be a widower, right?
Something.
Anyways, I'm going to pull that to the view bill for sure.
Yes, absolutely.
(16:18):
Great answer, Dan.
So anyways, knowing what resources are available to you and how you can get somebody from point
A to point B is important and knowing what they're capable of doing.
How about that 30 year old teacher who now has left-sided deficits?
They can't move their left arm, they can't move their left leg.
You know, it's a full-blown stroke and I have the decision now that I can take them somewhere
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where they can actually go in and physically pull that clot out or I take them to another
facility where they may not have those resources.
Do I want to take that 30 year old who relies heavily on her arms and hands and everything
else to maybe get better with TPA versus I can definitively say, I take her to get a
(17:02):
thrombectomy and they pull that clot out, I can watch her improve immediately.
It's all about destination and the only person that dictates that really is going to be
you.
I mean, your protocols will tell you certain things, but at the end, it's up to you as
to where patients go.
I think another word that really comes to mind from what you're saying, you've done
(17:22):
it as a physician, but I think there's ways that the EMS people on the trucks can also
do it is the word is advocacy.
You're really an advocate for this.
You're making decisions and the best interest on somebody again.
If you say this is your mother or grandmother or brother, what would you want?
The concept of the advocate, especially in a healthcare system that can kind of just
(17:44):
charge along on its own sometimes, having an advocate is really important.
Great.
Great word.
I agree.
Well, going into number four, I think this could probably play in.
Not all ER docs are created equally, so don't take negative feedback personally.
Some docs are going to get it and they will educate you and not scold you.
(18:07):
I think everybody has a story.
You probably have them as a paramedic where you've come into the hospital and the doc
has been somewhere between unkind and irate.
I think we've all have been there at some point and quite frankly, we take that relationship
very seriously.
We look for approval.
We look for our good job comes from how our handoff goes and there sometimes are off,
(18:34):
but I do think you have a perspective from a doc that you're going to add to this.
Absolutely.
I think it's one of my biggest frustrations when I watch an EMS provider get belittled.
This is back when I was a EMS provider full-time and now as a doc.
I think what I recognize is that the doctors who belittle and do not really get it have
(19:02):
never gotten it, have never understood EMS, have never understood the environment that
we work in in EMS.
They think that what they do in an emergency department is exactly what the environment
in the back of an ambulance is like because they just don't know any better.
They will have a tendency, I think, to hold you accountable.
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Now, remember, so much of what we do in EMS is at a high level.
We are saving lives on a daily basis.
So much of what we do looks like what we do in the ER.
There's this level of accountability.
Well, if I can do it here and they have the capabilities of doing it out in the field,
why are they not doing it?
I think it goes back to, again, not really understanding what it takes to get a patient
(19:48):
from the seventh story behind the toilet and then have to take them down in a stair chair
to finally get them there, get them into the hospital and have been the only provider in
the back of the truck taking care of this person and you show up in the ER where you've
got five nurses and a doctor and respiratory therapy and everybody else.
(20:14):
So I would tell you that when they come at you like that, take a step back and recognize
it's not you, it's their ignorance that's causing them to react the way that they do,
but any encounter should be a learning experience for all parties involved.
I would hope that, and I will tell you that if any of my docs ever did that, we would
(20:36):
be having words because I don't find that to be acceptable at all.
I'd be naive in thinking that this is not going to continue to happen, but what I would
say is if one of the docs comes at you and says, why didn't you do this?
Why didn't you do that?
If you don't understand, ask them.
So you know doc, I didn't do it because I honestly didn't think about it.
Tell me why you're thinking that way.
(20:58):
They may still not like your response, but take that negative and make it into a positive.
Use it to help yourself grow.
That's a tough thing to do, and as a doctor who works with lots of doctors, I can tell
you there's no bigger egos in the world than doctors.
(21:19):
So recognize that they are going to eat that up if it's one of those things where they
feel like they're right and you're wrong and that's a horrible scenario, but that's
sometimes how it is.
So the bottom line in it is I would hope that they spend their time educating you, but recognize
that they will and continue to, I hope at some point we can educate them enough to stop,
(21:45):
but they will continue to have, as Dan said, maybe that irate comment, less than nice comment.
Just don't take it personal because you didn't do anything to them personally.
You didn't do anything maliciously.
You did nothing that warrants the kind of feedback you may sometimes get.
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And there's times that one or both parties in a conversation are having just a bad day,
whether it be the doctor, the medic, or both.
When he or she in both situations, I don't care if it's a husband and wife or coworkers,
bad days or make things prone to arguments.
And there's always another day, and you'll come back in there again and that other day
(22:30):
is good.
And that rolls into number five.
He says, show me you want to learn.
This is not coincidence.
Show me you want to learn.
I will go out of my way to teach you.
I'd love to hear if you have an example of that.
I do.
The motive.
All right, let's do it then.
So here's the thing.
I love when EMS people came in excited.
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I love when they come in after a chaotic scene and things just didn't go super well.
They couldn't get an airway.
I love those experiences.
And I love them because I don't let them walk out of that ER bay until they've gotten that
airway.
Right?
So the EMS folks around us know that when I'm working, if they bring something into
(23:13):
me and it needs something done, they're not leaving the ER without doing that procedure.
I have our EMS folks work the arrest.
So when they bring an arrest in, for example, I have them run a code in our ER bay.
It is the coolest thing.
They absolutely love it.
The nursing staff loves it.
And what it does is it shows the nursing staff, especially now with all these new nurses.
(23:37):
Man, post COVID, we have so many new grad nurses that we're using our EMS providers so
much more to be able to help educate them.
But at any rate, let's say it's a bad tube.
I pull them in, I get the glide scope out, which has the big camera.
I say, hey, let's go, let's walk through this.
Right?
Real time education.
It is the single best thing to do.
(23:59):
And they eat it up.
The staff loves it.
And everybody gets to learn from that experience.
And so if I see that these EMS providers really want to get engaged, man, I will pull them
in and I will have them do anything and everything they can.
It's the coolest experience.
What an opportunity to give someone to be able to rise to an occasion, especially in
(24:21):
a setting like that.
You can add a little bit saying that you have a lot of new nurses and that's just a little
spot that you cut out.
But I don't think it's really any better way to make somebody part of the team and to continue
with training and relationship.
I'd also probably say, plug for the universal Louva Health Systems, that after hearing this,
(24:42):
it's going to be a lot of people going to want to be paramedics there.
If they know that you're going to be out there.
So that's an awesome thing.
Well, the other thing, let me just throw this in, Dan.
What I love about the missed airway or the code that didn't go so well, the things that
are what we would consider to be the imperfections and the things that intuitively we would say
(25:07):
we failed at is that they get to recover right then and get to say, okay, now I see maybe
how this could have gone better.
And it's not punitive.
It's completely educational.
And they literally walk out of that room successful.
They don't walk out thinking I missed the tube or I failed this resuscitation or I didn't
(25:28):
do X correctly.
They walk out, I think, with a completely different appreciation for what they've done
that day.
And that's what I love about it.
No, and it's, they will, I'm sure, have similar feelings that they can have some resolution,
have some understanding, have the ability to learn and to really feel part of the system.
(25:51):
And I just think that's, I think that's outstanding.
Like I said, that's University of Louisville Health Systems, Dr. Will Cross.
We hire our electronics in the ER too.
And they get to a full scope of practice in our ER.
Call Collette, call Direct, operators are standing by.
And at the end, I would grade Dan Limmer's cell phone number so you can call that direct.
(26:17):
Number six, vital signs are vital, abnormal vital signs mean something.
And I'm gonna, I'm gonna serve this up to you again.
I'm gonna throw my quick thought in here is that I think that not only is abnormal, abnormal,
but we're so stuck on the concept of normal.
You know, if we say respirations are 12 to 20, there's times 18 in a resting person is
(26:38):
bad, right?
There's times that that 60 to 100 or whatever we do for the pulse, right?
That there's times that even normal can be abnormal in the context that you see them.
So great statement.
Tell me some of that doc stuff.
Well, Dan, I mean, most people don't know this or those that have known us a long time
(27:00):
know that you were one of my earliest mentors.
And so a lot of what I learned in this business comes from you.
So you're telling me to teach you doc stuff.
Well, the stuff you taught me for all these years is stuff that I apply to medicine.
So.
I'm not gonna say it for these kind words or is this just on the house?
I'll show you.
Or should I send it to my insurance?
(27:22):
So anyways, honestly, here's the deal.
You teed up something perfect for me and that is so much we see people day in and day out.
We see them as we're walking down the street.
We see them in our jobs.
Seeing normal is never really typical.
We see it all the time.
(27:43):
It's those subtle differences that you look at and say something just isn't right.
You use the analogy of somebody who's breathing 18 times a minute.
And while, again, you've you defaulted to that could be normal and that is normal.
In many cases, if that person doesn't look good breathing at 18 times a minute, they
look like they're working to breathe 18 times a minute.
(28:04):
That's relevant and that's important.
Now, the big piece of this and the reason that this really was kind of point number
six for me is because I see all the time where EMS will document, for example, that
somebody had a hypotensive blood pressure in the field, but never mention it because
(28:25):
their pressure is fine when they arrive at the hospital.
If I have an episode of hypotension, the true episode of hypotension, that from somebody
who's got risk for bleeding, doesn't have to be trauma, it could be GI bleed, it could
be vaginal bleeding, it could be anything.
But you come in and tell me that they've had a single episode of hypotension, you gave
(28:46):
them some fluids and they got better.
That tells me a lot more than somebody coming in and their blood pressure is 110 over 70
and their heart rate is 100.
That initial finding says to me, increase your index of suspicion, if you're considering
doing, for example, a CT scan, don't wait, do it because you want to know if there's
(29:09):
some bleeding somewhere.
Those subtleties are important.
The identifying the abnormal thing is super important as well.
I remember as a paramedic when I was working in the ER, the docs would be crazy about if
the person's heart rate was over 100, you never discharge them.
They'd think, man, that's really stupid.
(29:31):
I see people with heart rates of 110, 120 all the time as a paramedic.
What's the deal?
Well, the deal is that a heart rate over 100 is never normal.
Just for context, not that you care about this, but just to give you some perspective
around this, one of the single biggest ways doctors are sued are discharging people with
abnormal vital signs.
If you get a heart rate of 110 and I discharge you and you go home and you die from eating
(29:57):
too many chicken wings, I probably meant fault because I let you go with a heart rate of
110.
It sounds crazy, and it kind of is, but it's also critically important.
That patient who has tachycardia, who's hypotensive, that may be aseptic, or maybe they're tachycardic
(30:18):
and their temperature's up, that's really important because you give them a little bit
of IV fluid, they took a Tylenol before they left, and by the time they show up, it's brought
their heart rate down enough, it's brought their temperature down.
Now they look like they're totally normal to me, but at the time that you saw them,
they were hyperthermic.
They had a temperature, they were tachycardic, and plus or minus hypotension.
(30:42):
All really important things, and I think COVID has probably taught us now that we take temperatures
on people.
I can tell you, and I'm sure Dan you'd say, maybe, well, you're super medic, so forget
it, but the rest of us, back in the day, we didn't take temperatures on people.
It was just like, temperature, who cares about what their temp is?
(31:02):
We didn't even carry thermometers on the trucks.
Now, I'll go one more.
We thought the nurses were crazy for taking the temperature first instead of doing other
things when we came into the hospital until we realized the value of it.
We didn't realize what the big picture was.
We only wanted the cool stuff.
That's right.
(31:23):
Now, you look at, pulse ox has taken on a whole new meaning after COVID too.
The happy hypoxic, the person who looks great talking to you, they don't look like they're
in respiratory distress, but their sats are 80%.
A lot of that stuff has changed over the years.
So I think recognizing abnormalities is really critical, and it's super important for me
(31:46):
to hear in the ER.
When you drop a patient off, you tell me anything that doesn't sit right with you.
I promise you it will be relevant.
If you still work in one of those places where they don't listen to you, shame on them.
That's really unfortunate, but I can promise you that if you go to a place where you have
somebody who gets it, we're going to listen to what you have to say, and we're going to
(32:06):
try and apply any information you give us to help us make our decisions.
I think you've mentioned some physician, hospital-based things.
I think EMS tends to poo poo things, but against that, well, that's a hospital.
But I was looking at one of the, I think it was a syncope score.
It was a Canadian or one of the syncope scores.
(32:30):
And then there's some of those things that are hospital-based, but I always say to myself,
if this is valid enough for a doc to look at and come up with, that we should look at
those things.
And then we talk about discharging patients.
For you, discharging patients is the liability, whether it's minimum or not, sometimes is
your biggest decision.
But yet we feel that we can just refuse patients all the time without looking at all these
(32:54):
things.
I don't know.
I just really think that we can learn a lot from some of the physician tools and measures
and the different scoring systems, the pulmonary embolism scores, the syncope scores, these
different things, not that we're even going to complete the whole scoring thing, but if
we look at something important enough to be in those scores, they're things that we should
(33:15):
be looking at in the field and that we should be able to learn from that.
Hey, Dan, I think we just came up with our next seven things.
Oh, seven scores.
All right.
I'm going to take this because we're doing good on time, which is unusual for us because
we can talk pretty well.
Tell me about how you look at things.
I know in medicine it's big, but in EMS, Cushing's triad and Beck's triad and all these things.
(33:44):
There was a paper out somewhere I saw that the number of people at Tampana that actually
exhibit all of Beck's triad isn't all we thought it was.
Any thoughts you want to throw out about how much we hang our hat on what things?
I know I'm putting on the spot a little, but I'm just thinking this really goes to the
vital science thing.
It really does.
Beck's triad is absolutely one of those things that part of my struggle is that I feel like
(34:11):
at one point when these things were discovered, it was like, oh, this is really a neat coincidence.
But much of what we discover by way of these triads and dyads and the different presentations
doesn't always fit everybody, number one.
Number two, you think of Cushing's and the Cushing's triad and you're talking about hypertension
(34:37):
and bradycardia and you're talking about increased intracranial pressures.
With that dynamic, physiologically they make sense.
If I can look at something and I can say, well, because the pressure goes up inside
the cranial vault, the body's trying to regulate and so it slows the heart rate down to decrease
cardiac output to be able to do that and so bradycardia makes sense because our cardiac
(35:02):
output decreases, will increase our respiration.
Those things all, they make sense because you can rationalize them from a physiologic
perspective.
When you talk about mechanisms and you think of Beck's triad, they also can exist, but
you hit it right on the head by saying, it's not all, you can't always put your money on
(35:29):
meeting all three equations.
The one I think of off top of my head is Tension Pneumothorax.
How many people have actually seen a deviated trachea?
It's something that we're taught.
It's something that I think intuitively makes sense until you realize that up in the neck,
there's a lot of muscle and a lot of structures there that won't allow that trachea to really
(35:52):
deviate.
So where we see tracheal deviation is in the cadaver because they're dead or it's in somebody
who is a cadaver and we can open their chest and see that they've deviated intratherastically,
not outside.
So I think there are a lot of things that we learn, I won't say that are hocus pocus
because they're not, they're legit, but they're not truly applicable to what we do.
(36:17):
But take that flip side and we just talked about Cushing's, right in the Cushing's
Triad, you look at that and go, oh, wow, I got this person who's got this horrible head
injury and all of a sudden they're tachycardic and getting bradycardic, or I'm sorry, they're
hypertensive and getting bradycardic.
Ooh, that tells me something.
That means that says, yeah.
So I think you have to take each of those a little bit and say, do I understand why they
(36:41):
present the way they do?
If you can understand why those things exist, then you can actually use them as applicable
tools.
If you don't really understand it, then you're just looking for these elements like you're
checking a box and then it becomes ineffective in my mind.
I think that's a great way to say it.
We have a mutual friend who talks a lot about pathophysiology, Joe Misdovich, a prince among
(37:06):
men and Misdovich stories here could be no whole other seven things, but that's always
been his thing and that if you understand it, it's a lot different than seeing signs
and symptoms.
So we're winding down number seven and this, we talked before we started today about how
things change so much.
Here number seven is protect yourself.
(37:28):
An N95 can be sexy, being real and vulnerable is not weak, making it home sane and whole
is not overrated.
Whether we're talking about the current COVID situation, which we're divided on pretty
politically and opinion wise and so many things, yet we are clinicians and we do have a responsibility
(37:52):
to be there to ourselves and our families and quite frankly, COVID isn't the last thing
that's going to happen in our times in the US and medicine.
So how do we learn from this?
What would you say to people to say, all right, listen, we may or may not be in a home
stretch, but if we are, something else is going to come along.
Think, well, of the things that have come along in our lifetimes from avian flues to
(38:17):
everybody worrying about Ebola and all these different things.
There's always going to be stuff going on.
Protection should be smart.
People should be smart in the application, even when it's not easy or it's getting old.
Absolutely.
Yeah, you know, this one, you could say was prompted by COVID and I think it is in a lot
(38:42):
of ways, but it's not because COVID was the end all be all like you just said.
I think what COVID did is it gave us an awareness of so many things.
One, I think in the way that we approached infectious disease and the way we approached
sort of that unknown patient population, we were exposing ourselves every day and never
(39:03):
knew it, right, when COVID came along and we all of a sudden had this lethal disease
that we were watching our coworkers die from and our family members die from.
All of a sudden it was like, okay, I can now, I now have to be protecting myself.
But I think the other thing that came from it that's really pretty powerful is that,
(39:28):
you know, some of us have been around long enough to see the ebbs and flows of taking
care of yourself.
Dan, I always fall back on your talks about suicide and what that does to people or what
leads them to that place.
And a big part of that is not having the support system, not being willing to allow yourself
(39:54):
to be vulnerable and say, hey, I'm hurting, I need help.
I'm in a bad place.
I'm burned out.
You know, and in the end, if you don't take care of yourself from a, we just talked about
an N95, right, meaning you got to use personal protective stuff.
But even bigger and something that COVID I think really showed us, there are so many
(40:17):
people that went and did these travel contracts and we're working in New York City and working
on the, you know, in the throes of the most heavily hit areas day in and day out, not
taking care of themselves emotionally, not taking care of themselves physically.
And I think, number one, we saw a lot of burnout.
(40:38):
But two, we saw physicians, we saw EMS providers, we saw nurses, we saw healthcare workers
killing themselves at an alarming rate during this pandemic.
You know, we see little bits and pieces of information on it as the stories make it to
mainstream media.
I haven't seen anything that kind of aggregates this, but you know, I have some friends over
(41:02):
in Italy and if you recall, they were getting crushed.
Nurses over there and three nurses in one hospital killed themselves because they did
not want to go back into the hospital.
They were so overwhelmed.
Three nurses in one hospital killed themselves because this overwhelmed them so much.
And you can't help but ask yourself, what if somebody asked them how they were doing
(41:26):
and somebody pulled them off the line and said, we're going to help you, right?
I'm not blaming this on anyone at all.
I think as we've already said, this is unprecedented, nothing we could have foreseen.
You've hit it right on the head by saying again, this isn't the last we're going to see of
chaos and craziness.
(41:46):
Nonetheless, it's been a great learning experience for all of us.
Protect ourselves physically, but man, we got to protect ourselves and each other emotionally.
You know, I think that there's a certain group of people coming to EMS and believe that emotional
damage is inevitable.
(42:08):
And I think that there are certain things in any person, different things from person
to person that can push us over the edge.
But I do think it's important to say that we hopefully have learned from this.
And there are times, there are desperate times and we're pushed beyond what we believe that
we can do.
(42:30):
But I also don't want people to come into EMS and think that emotional damage is inevitable.
There are people who've been in this a long time and still love what they do and have
it happen.
And I think that taking care of oneself, I think that taking care of each other, and
I think that systems working together to do this, as you say, can certainly help prevent
(42:53):
a lot of this.
I don't want people to go away and say, oh, why would I go into this because of all the
people, you know, killings, whatever.
Those are warnings to us to take care of ourselves, take care of our friends and to take care
of our system, to do what we need to do.
I would actually advocate leaning into EMS a little bit, being a part of it, being part
of a solution, and being okay, but also know that there's times it's okay to not be okay.
(43:19):
Just like it is, people see a horrible call or a scene and when you're new, you feel
badly because you don't feel bad.
And this stuff is not predictable.
If you had a horrible call and you say, cool, when's your first one?
You stop and say, is that bad?
(43:39):
But then there's something that's relatively small.
Somebody's got the same name as your brother or sister, something that looks like your
uncle and it hits you harder and it seems like a mild call.
We have to be aware of these things.
We have to stick together.
We have to do them.
Emotional damage is not inevitable.
It's certainly possible and it's been a lot in this, but there's ways to take care of
(44:01):
yourself and do things.
I want to keep people in the game and do this despite that.
Absolutely.
Totally agree with you, Dan.
We have generally about a 45 minute conversation and we're hitting that point, but I do end
(44:22):
all of these with one thing.
From any of the seven things or even anything new that you'd say as a physician, medical
director, what's your last word?
Your parting shot to the people listening today.
What would you want them to hear in their earbuds last before we end this session?
Pretty simple.
(44:42):
You guys are awesome.
Take pride in what you do.
We are a profession, medical profession because of you guys and the fact that you're putting
in the sacrifice and the effort to take care of people day in and day out.
Take care of yourselves and just simply thank you for continuing to do what you do.
(45:03):
I think we couldn't end that better.
Will from your experience in EMS, taking that through to emergency medicine.
We're very fortunate to have you here as they are for you there in Louisville.
He'll have some great experiences there.
People will be very lucky to have you.
You're a good man.
(45:24):
You're a good friend.
A great doc and I thank you for coming by.
Thanks Dan.
Thank you for listening to another Limmer Education Continuing Education podcast.
For more podcasts that are relevant to your practice of EMS, limeregucation.com slash
Seven Thinks.
Welcome to the Seven Things EMS Podcast, a continuing education offering of limer education.
(00:12):
Seven Things EMS Podcast is designed to give you what you need to succeed in EMS, it's
conversational, informational and without the fluff.
And welcome to another episode of Seven Things EMS, I'm your host Dan Lemmer, we have a great
(00:36):
episode for you today.
Seven Things from the medical director's perspective and I am thrilled to be able to
introduce a physician and good friend Will Cross.
Will is a system medical director for emergency medicine at the University of Louisville Health
System.
I've known Will for many, many years from his EMS days to flight medic days through med
(00:59):
school and now as an emergency physician.
I think generally EMS systems are always better off with involved physicians.
I think physicians that have a past EMS perspective are even better.
So using our format here we have a quick introduction, I'm going to say hello to Will and we're
going to get into our Seven Things which I believe you're going to enjoy.
(01:21):
Welcome Will Cross MD.
Thanks Dan.
This is awesome to actually be a part of this conversation and as you said we've been
with each other a really long time.
A very long time and we certainly could tell some stories but that's not our goal here
today we're going to get right to it and I just love saying MD after your need.
(01:43):
It seems like now that's more of a thrill for me today than you but I just think it's
awesome.
So Seven Things from the medical director.
What I like about the Seven Things you've created and everybody that's a guest here
does their own Seven Things and what I like about them is you've done some clinical things,
you've done some understanding the doc things and then even some more clinical things.
(02:06):
I think it's a great way to put these together.
So let's start with number one.
And it's a great start.
Always strive to take great care of people.
Don't be afraid to defend the decisions you make on the patient's behalf.
Tell me about that one.
So I think sometimes in the specifically ED environment it can be intimidating when you're
(02:32):
the provider bringing a patient in and you're giving a report and sometimes I think you
can fall back on well just did I do the right thing and somebody asks you a question and
it's oh man did I really do this right and there's almost a sense that you have to defend
(02:52):
yourself.
And what I would tell you is that that is so far from what you should be thinking and
from where you should be.
I think all of us whether you're a EMR, a first responder, EMT, paramedic, nurse, physician
we got into this business because we like to take care of people.
(03:15):
It's hokey, it's cliche, but the reality of it is it's a lot of what we do and I think
sometimes we make decisions on the fly.
Actually we always make decisions on the fly and when you're making decisions kind of as
you go a big part of that is being able to say I did what was in the best interest of
the patient period.
(03:35):
And so it may be that you are approaching a family or approaching a family member approaching
the patient in a certain way and if it's a way that you can very easily say I did this
because it was one clinically well or clinically better for the patient and two if it's something
(03:56):
that you can say in good conscience that made a difference for the positive I don't think
you have a whole lot to defend.
But I think the bottom line is we have to maintain that sort of position of excellence
in everything that we do and if we are always working towards providing great care I think
we're going to provide great care.
You know one of the things you've heard me say when we've spoken at conferences together
(04:20):
is that EMS every call is ultimately a series of decisions that may or may not succeed.
Well let's go into the medical director perspective.
I think there's a lot of people that think that they are judged by the medical director.
The medical director is going to be the person that you get in trouble with or have to worry
about what's your take if an EMT or an AEMT or paramedic comes to you and says the protocols
(04:46):
say this I was really concerned.
Maybe I didn't have time to call in or I really thought this was the right thing to do.
What's your perspective on that?
I think that's a great question Dan and I think it's one of the probably everyday questions
that I hear.
It's not even always the big things sometimes it is the big things but I always default
(05:08):
back to let's talk about your mindset or your thought process.
You know what is it that you did what you did.
I think the concept of medical protocols is really important because they are guidelines
they were designed to be guidelines but they should not replace your ability to critically
(05:30):
think.
You know you've said this a million times over in the lectures as we've talked before
Dan that you know we are not in the business of just rote memorization and really doing
things because the book says so.
It's better and more important that we understand why we do the things.
(05:51):
So if an EMT comes to me and says hey or example I'll give you one that happened paramedic
comes in and says look doc we had this patient they were going crazy on us.
I couldn't get to the radio in time to call for an RSI order but this patient was agitated
delirium.
I needed to put him down he was an asthmatic who was having trouble breathing.
(06:14):
I couldn't get there.
I did what I thought was right for the patient.
I look at that and they say hey good for you because the reality is if this provider didn't
do that this patient would probably be dead.
If you wait until they are so hypoxic and you're watching them deteriorate or hypercarbic and
(06:34):
you're watching them deteriorate but do nothing the outcome is going to be bad.
I would much rather you do something than to do nothing especially in a clinical environment
like that.
I mean that's an extreme right.
And we can put in the your mileage may vary statement you know always follow your local
protocols and blah blah blah we're not telling you to go out and do risky things but the
(06:56):
truth is the nature of EMS is that you're going to get things that are going to go between
the lines and how we respond is really important in absolutely.
So let's go on to number two.
Addicts and frequent flyers get sick and will die one day.
I love that.
My medical director talked to my paramedic students at down here in Galveston and he
(07:18):
said I treat all patients like they're secretly trying to die and not telling me.
I was like well that was I kind of like that you know I mean but the fact is all your frequent
flyers even people that are on the street that are drug users and everything else people
are alcoholics people that are people that are in tough lives have more medical problems
than most.
(07:39):
So let's I don't want to take all your thing there.
I just love these so much.
Tell me tell me.
You're absolutely right Dan.
I think there are a couple of key points to this.
Let's talk frequent flyers first right.
You go to get Mrs. Jones at three o'clock in the morning and she's out there with her
suitcase waiting for you to take her to the hospital.
It's very easily easy to look at Mrs. Jones and say oh this crazy lady wants me to take
(08:03):
her to the hospital again and you know clearly she's not sick because she brought all her
stuff with her.
Well the problem with that mindset is that it gives you tunnel vision and you miss subtle
findings in your physical exam you bring her in and unfortunately the ER has the same tendency.
Oh Mrs. Jones yep she's back again right.
So it may be hours before she gets appropriately evaluated and she could be actively dying
(08:29):
from the moment you pick her up and so I think it's easy for us to blow things off blow people
off that we see on a regular basis saying Mrs. Jones coming back in and oh she's got
her chest pain again.
What happens if this time is the time right.
This is the time that she's having her MI and you have the ability to identify it and
(08:50):
don't catch it right.
Or she's having this chest pain she's developing her MI and by the time you get to the hospital
she goes into cardiac arrest.
If you didn't do an EKG if you didn't do your evaluation you didn't work her up you wouldn't
know that and I wouldn't know it when you drop her off to me I'd say oh it's starting
cardiac death could be an MI it could be many other things right.
So it is really important to recognize that frequent fliers have disease and unfortunately
(09:16):
many of our frequent fliers truly have real pathology they have diseases that will kill
them one day and it's much easier to just blow it off than it is to try and put the
effort in to really do a good comprehensive work up.
Now I'll share with you another little piece here this is a personal piece.
So as far as addicts go I will tell you that it's really easy and I'll give you an example
(09:41):
the other day I took care of a guy that came in three times in one shift.
Now I was working a nine hour shift he used an opiate he got an arcane by EMS he went
back out he did it again three times in a row EMS brought him in within my nine hour
shift after he went left against medical advice and used again.
(10:02):
Now it's very easy to get frustrated at somebody like that and say man what are you doing?
Trying to kill yourself?
You know I debated actually admitting this guy for a 72 hour hold with psychiatric thoughts
that maybe he was trying to kill himself.
Of course he wasn't he just really needed his high and was ticked that we were taking
it away from him.
But here's the personal piece.
So Dan knows this people that know me well know that I have a brother who's been a heroin
(10:25):
and polypharmacy user for his entire adult life.
So he is 46 and from the time he was 17 until 46 now he's been using heroin, cocaine, meth
pretty much anything you stick in front of him.
(10:45):
And I would just ask you if you had a brother that was doing that how would you want them
to be seen how would you want them to be treated?
And I look at it kind of differently because of personal experience but what I typically
tell people to do is kind of look at that person's mom and then ask yourself if you
can just see them as the quote unquote trash off the streets because that's how people
(11:06):
frequently see drug addicts.
You know my brother would be what you would consider to be trash off the streets but
he's still my mom's little boy and he always will be at 46.
And so it's difficult for us to deal with difficult people but sometimes those are the
exact people we need to spend extra time dealing with because it may just be that you're the
(11:29):
one person that they connect with that saves their life at that time and may change something
around for them.
You never know.
But I think you've got to remember that we see people.
We take care of people.
It's hard when you see a lot of it.
It doesn't matter really now if you're urban or suburban or rural it's everywhere and
you see a lot of it and I think we can both admit practically that it's sometimes an
(11:53):
uphill slog to see this several of these a day and you do it but you can never let your
guard down as a clinician or a human.
And I think that's really what separates some of our amazing providers from others is that
they're able to do that.
And there certainly is talk with everything going on now about compassion fatigue and
(12:15):
general fatigue in medicine and nursing and EMS that certainly doesn't help.
But I think that I very much appreciate your personal perspective and I hope people really
take that to heart.
Number three talks about destination.
Yeah.
Number three talks about destination and that matters.
So patients better serve from an additional 10 minute trip than they are being brought
(12:39):
to the closest hospital.
And now you have gone from paramedic, flight medic, now physician.
And I think that there's a lot of EMS people that don't necessarily think of themselves
as as big a part of the health care system as they are and see what a decision they make
(12:59):
when they go to a place that can comprehensively treat a stroke or have a cat scanner or have
some type of cardiology available.
What a difference that decision can make.
I think that we feel like we're on the outside of the hospital but I think there's times
that all of the things you do on the scene go into the right place might be the biggest
(13:21):
thing we do.
You're 100% right.
One of the things and I have the luxury of working at seven different emergency departments.
Luxury discomfort, whatever you want to call it.
I was going to say that.
I know you were.
I can tell.
I just know you.
At any rate, I get to work at seven different places and they're all very unique.
(13:44):
Trauma center, community hospitals, freestanding emergency departments.
I get to see those patients who, for example, get appropriately taken to a trauma center
and I see how they're managed from a trauma perspective.
I also see when those patients are brought into our community hospital or freestanding
ER, if they're a trauma patient and they're brought into one of these facilities, all
(14:07):
we are simply doing is delaying care in many cases.
I would argue that a majority of these patients that get brought into us are probably okay
and don't need definitive surgical intervention.
For those few cases where they are really sick, I know the American College of Surgeons
has gone away from a lot of the mechanism stuff.
Dan, you and I have been doing this long enough to know that mechanism matters.
(14:30):
It does make a difference.
They're putting less stock in trauma center destinations for mechanism.
I would tell you that, again, you're the ones that are seeing things in the streets and
what you see makes a difference.
That's trauma.
Let's talk cardiology.
You have a great story for.
(14:53):
I'll give you a good example that happened to me today.
I worked in the ER today.
I had an old lady, 87 years old, came in crushing, substernal chest pain, radiated to her left
arm, diaphragmatic, nauseous.
You know where I'm headed with this, right?
But EKG looks okay.
I don't see any EKG changes.
I still feel clinically like this woman's having an MI.
(15:15):
What do I do?
I call the cardiologist.
He goes, yeah, well, maybe, maybe not.
I'm not waiting for the blood levels to come back, her troponin to come back.
I'm like, listen, I just want you to come down and take a look at this lady.
He comes down, he looks at her and goes, oh, I'm taking her to the lab right now.
I said, huh, what do you know?
The beautiful part about that is we had a cath lab where I was.
(15:37):
What if you were at the middle point between me and one of the other institutions and maybe
you were a couple minutes closer to a freestanding ER who had no other facility and no other
resource?
You take this woman there.
She's going to end up there.
You're going to, I'm going to do my work up, but I'm going to be kind of thinking, why
did they bring this woman here?
(15:57):
Because she's clearly having an MI even though her EKG doesn't show it.
Now, by the way, I'll tell you that lady had a 99% LED, proximal LED occlusion, which means
her widow maker about made, well, she's not a widow.
She'd be a widower, right?
Something.
Anyways, I'm going to pull that to the view bill for sure.
Yes, absolutely.
(16:18):
Great answer, Dan.
So anyways, knowing what resources are available to you and how you can get somebody from point
A to point B is important and knowing what they're capable of doing.
How about that 30 year old teacher who now has left-sided deficits?
They can't move their left arm, they can't move their left leg.
You know, it's a full-blown stroke and I have the decision now that I can take them somewhere
(16:41):
where they can actually go in and physically pull that clot out or I take them to another
facility where they may not have those resources.
Do I want to take that 30 year old who relies heavily on her arms and hands and everything
else to maybe get better with TPA versus I can definitively say, I take her to get a
(17:02):
thrombectomy and they pull that clot out, I can watch her improve immediately.
It's all about destination and the only person that dictates that really is going to be
you.
I mean, your protocols will tell you certain things, but at the end, it's up to you as
to where patients go.
I think another word that really comes to mind from what you're saying, you've done
(17:22):
it as a physician, but I think there's ways that the EMS people on the trucks can also
do it is the word is advocacy.
You're really an advocate for this.
You're making decisions and the best interest on somebody again.
If you say this is your mother or grandmother or brother, what would you want?
The concept of the advocate, especially in a healthcare system that can kind of just
(17:44):
charge along on its own sometimes, having an advocate is really important.
Great.
Great word.
I agree.
Well, going into number four, I think this could probably play in.
Not all ER docs are created equally, so don't take negative feedback personally.
Some docs are going to get it and they will educate you and not scold you.
(18:07):
I think everybody has a story.
You probably have them as a paramedic where you've come into the hospital and the doc
has been somewhere between unkind and irate.
I think we've all have been there at some point and quite frankly, we take that relationship
very seriously.
We look for approval.
We look for our good job comes from how our handoff goes and there sometimes are off,
(18:34):
but I do think you have a perspective from a doc that you're going to add to this.
Absolutely.
I think it's one of my biggest frustrations when I watch an EMS provider get belittled.
This is back when I was a EMS provider full-time and now as a doc.
I think what I recognize is that the doctors who belittle and do not really get it have
(19:02):
never gotten it, have never understood EMS, have never understood the environment that
we work in in EMS.
They think that what they do in an emergency department is exactly what the environment
in the back of an ambulance is like because they just don't know any better.
They will have a tendency, I think, to hold you accountable.
(19:23):
Now, remember, so much of what we do in EMS is at a high level.
We are saving lives on a daily basis.
So much of what we do looks like what we do in the ER.
There's this level of accountability.
Well, if I can do it here and they have the capabilities of doing it out in the field,
why are they not doing it?
I think it goes back to, again, not really understanding what it takes to get a patient
(19:48):
from the seventh story behind the toilet and then have to take them down in a stair chair
to finally get them there, get them into the hospital and have been the only provider in
the back of the truck taking care of this person and you show up in the ER where you've
got five nurses and a doctor and respiratory therapy and everybody else.
(20:14):
So I would tell you that when they come at you like that, take a step back and recognize
it's not you, it's their ignorance that's causing them to react the way that they do,
but any encounter should be a learning experience for all parties involved.
I would hope that, and I will tell you that if any of my docs ever did that, we would
(20:36):
be having words because I don't find that to be acceptable at all.
I'd be naive in thinking that this is not going to continue to happen, but what I would
say is if one of the docs comes at you and says, why didn't you do this?
Why didn't you do that?
If you don't understand, ask them.
So you know doc, I didn't do it because I honestly didn't think about it.
Tell me why you're thinking that way.
(20:58):
They may still not like your response, but take that negative and make it into a positive.
Use it to help yourself grow.
That's a tough thing to do, and as a doctor who works with lots of doctors, I can tell
you there's no bigger egos in the world than doctors.
(21:19):
So recognize that they are going to eat that up if it's one of those things where they
feel like they're right and you're wrong and that's a horrible scenario, but that's
sometimes how it is.
So the bottom line in it is I would hope that they spend their time educating you, but recognize
that they will and continue to, I hope at some point we can educate them enough to stop,
(21:45):
but they will continue to have, as Dan said, maybe that irate comment, less than nice comment.
Just don't take it personal because you didn't do anything to them personally.
You didn't do anything maliciously.
You did nothing that warrants the kind of feedback you may sometimes get.
(22:08):
And there's times that one or both parties in a conversation are having just a bad day,
whether it be the doctor, the medic, or both.
When he or she in both situations, I don't care if it's a husband and wife or coworkers,
bad days or make things prone to arguments.
And there's always another day, and you'll come back in there again and that other day
(22:30):
is good.
And that rolls into number five.
He says, show me you want to learn.
This is not coincidence.
Show me you want to learn.
I will go out of my way to teach you.
I'd love to hear if you have an example of that.
I do.
The motive.
All right, let's do it then.
So here's the thing.
I love when EMS people came in excited.
(22:53):
I love when they come in after a chaotic scene and things just didn't go super well.
They couldn't get an airway.
I love those experiences.
And I love them because I don't let them walk out of that ER bay until they've gotten that
airway.
Right?
So the EMS folks around us know that when I'm working, if they bring something into
(23:13):
me and it needs something done, they're not leaving the ER without doing that procedure.
I have our EMS folks work the arrest.
So when they bring an arrest in, for example, I have them run a code in our ER bay.
It is the coolest thing.
They absolutely love it.
The nursing staff loves it.
And what it does is it shows the nursing staff, especially now with all these new nurses.
(23:37):
Man, post COVID, we have so many new grad nurses that we're using our EMS providers so
much more to be able to help educate them.
But at any rate, let's say it's a bad tube.
I pull them in, I get the glide scope out, which has the big camera.
I say, hey, let's go, let's walk through this.
Right?
Real time education.
It is the single best thing to do.
(23:59):
And they eat it up.
The staff loves it.
And everybody gets to learn from that experience.
And so if I see that these EMS providers really want to get engaged, man, I will pull them
in and I will have them do anything and everything they can.
It's the coolest experience.
What an opportunity to give someone to be able to rise to an occasion, especially in
(24:21):
a setting like that.
You can add a little bit saying that you have a lot of new nurses and that's just a little
spot that you cut out.
But I don't think it's really any better way to make somebody part of the team and to continue
with training and relationship.
I'd also probably say, plug for the universal Louva Health Systems, that after hearing this,
(24:42):
it's going to be a lot of people going to want to be paramedics there.
If they know that you're going to be out there.
So that's an awesome thing.
Well, the other thing, let me just throw this in, Dan.
What I love about the missed airway or the code that didn't go so well, the things that
are what we would consider to be the imperfections and the things that intuitively we would say
(25:07):
we failed at is that they get to recover right then and get to say, okay, now I see maybe
how this could have gone better.
And it's not punitive.
It's completely educational.
And they literally walk out of that room successful.
They don't walk out thinking I missed the tube or I failed this resuscitation or I didn't
(25:28):
do X correctly.
They walk out, I think, with a completely different appreciation for what they've done
that day.
And that's what I love about it.
No, and it's, they will, I'm sure, have similar feelings that they can have some resolution,
have some understanding, have the ability to learn and to really feel part of the system.
(25:51):
And I just think that's, I think that's outstanding.
Like I said, that's University of Louisville Health Systems, Dr. Will Cross.
We hire our electronics in the ER too.
And they get to a full scope of practice in our ER.
Call Collette, call Direct, operators are standing by.
And at the end, I would grade Dan Limmer's cell phone number so you can call that direct.
(26:17):
Number six, vital signs are vital, abnormal vital signs mean something.
And I'm gonna, I'm gonna serve this up to you again.
I'm gonna throw my quick thought in here is that I think that not only is abnormal, abnormal,
but we're so stuck on the concept of normal.
You know, if we say respirations are 12 to 20, there's times 18 in a resting person is
(26:38):
bad, right?
There's times that that 60 to 100 or whatever we do for the pulse, right?
That there's times that even normal can be abnormal in the context that you see them.
So great statement.
Tell me some of that doc stuff.
Well, Dan, I mean, most people don't know this or those that have known us a long time
(27:00):
know that you were one of my earliest mentors.
And so a lot of what I learned in this business comes from you.
So you're telling me to teach you doc stuff.
Well, the stuff you taught me for all these years is stuff that I apply to medicine.
So.
I'm not gonna say it for these kind words or is this just on the house?
I'll show you.
Or should I send it to my insurance?
(27:22):
So anyways, honestly, here's the deal.
You teed up something perfect for me and that is so much we see people day in and day out.
We see them as we're walking down the street.
We see them in our jobs.
Seeing normal is never really typical.
We see it all the time.
(27:43):
It's those subtle differences that you look at and say something just isn't right.
You use the analogy of somebody who's breathing 18 times a minute.
And while, again, you've you defaulted to that could be normal and that is normal.
In many cases, if that person doesn't look good breathing at 18 times a minute, they
look like they're working to breathe 18 times a minute.
(28:04):
That's relevant and that's important.
Now, the big piece of this and the reason that this really was kind of point number
six for me is because I see all the time where EMS will document, for example, that
somebody had a hypotensive blood pressure in the field, but never mention it because
(28:25):
their pressure is fine when they arrive at the hospital.
If I have an episode of hypotension, the true episode of hypotension, that from somebody
who's got risk for bleeding, doesn't have to be trauma, it could be GI bleed, it could
be vaginal bleeding, it could be anything.
But you come in and tell me that they've had a single episode of hypotension, you gave
(28:46):
them some fluids and they got better.
That tells me a lot more than somebody coming in and their blood pressure is 110 over 70
and their heart rate is 100.
That initial finding says to me, increase your index of suspicion, if you're considering
doing, for example, a CT scan, don't wait, do it because you want to know if there's
(29:09):
some bleeding somewhere.
Those subtleties are important.
The identifying the abnormal thing is super important as well.
I remember as a paramedic when I was working in the ER, the docs would be crazy about if
the person's heart rate was over 100, you never discharge them.
They'd think, man, that's really stupid.
(29:31):
I see people with heart rates of 110, 120 all the time as a paramedic.
What's the deal?
Well, the deal is that a heart rate over 100 is never normal.
Just for context, not that you care about this, but just to give you some perspective
around this, one of the single biggest ways doctors are sued are discharging people with
abnormal vital signs.
If you get a heart rate of 110 and I discharge you and you go home and you die from eating
(29:57):
too many chicken wings, I probably meant fault because I let you go with a heart rate of
110.
It sounds crazy, and it kind of is, but it's also critically important.
That patient who has tachycardia, who's hypotensive, that may be aseptic, or maybe they're tachycardic
(30:18):
and their temperature's up, that's really important because you give them a little bit
of IV fluid, they took a Tylenol before they left, and by the time they show up, it's brought
their heart rate down enough, it's brought their temperature down.
Now they look like they're totally normal to me, but at the time that you saw them,
they were hyperthermic.
They had a temperature, they were tachycardic, and plus or minus hypotension.
(30:42):
All really important things, and I think COVID has probably taught us now that we take temperatures
on people.
I can tell you, and I'm sure Dan you'd say, maybe, well, you're super medic, so forget
it, but the rest of us, back in the day, we didn't take temperatures on people.
It was just like, temperature, who cares about what their temp is?
(31:02):
We didn't even carry thermometers on the trucks.
Now, I'll go one more.
We thought the nurses were crazy for taking the temperature first instead of doing other
things when we came into the hospital until we realized the value of it.
We didn't realize what the big picture was.
We only wanted the cool stuff.
That's right.
(31:23):
Now, you look at, pulse ox has taken on a whole new meaning after COVID too.
The happy hypoxic, the person who looks great talking to you, they don't look like they're
in respiratory distress, but their sats are 80%.
A lot of that stuff has changed over the years.
So I think recognizing abnormalities is really critical, and it's super important for me
(31:46):
to hear in the ER.
When you drop a patient off, you tell me anything that doesn't sit right with you.
I promise you it will be relevant.
If you still work in one of those places where they don't listen to you, shame on them.
That's really unfortunate, but I can promise you that if you go to a place where you have
somebody who gets it, we're going to listen to what you have to say, and we're going to
(32:06):
try and apply any information you give us to help us make our decisions.
I think you've mentioned some physician, hospital-based things.
I think EMS tends to poo poo things, but against that, well, that's a hospital.
But I was looking at one of the, I think it was a syncope score.
It was a Canadian or one of the syncope scores.
(32:30):
And then there's some of those things that are hospital-based, but I always say to myself,
if this is valid enough for a doc to look at and come up with, that we should look at
those things.
And then we talk about discharging patients.
For you, discharging patients is the liability, whether it's minimum or not, sometimes is
your biggest decision.
But yet we feel that we can just refuse patients all the time without looking at all these
(32:54):
things.
I don't know.
I just really think that we can learn a lot from some of the physician tools and measures
and the different scoring systems, the pulmonary embolism scores, the syncope scores, these
different things, not that we're even going to complete the whole scoring thing, but if
we look at something important enough to be in those scores, they're things that we should
(33:15):
be looking at in the field and that we should be able to learn from that.
Hey, Dan, I think we just came up with our next seven things.
Oh, seven scores.
All right.
I'm going to take this because we're doing good on time, which is unusual for us because
we can talk pretty well.
Tell me about how you look at things.
I know in medicine it's big, but in EMS, Cushing's triad and Beck's triad and all these things.
(33:44):
There was a paper out somewhere I saw that the number of people at Tampana that actually
exhibit all of Beck's triad isn't all we thought it was.
Any thoughts you want to throw out about how much we hang our hat on what things?
I know I'm putting on the spot a little, but I'm just thinking this really goes to the
vital science thing.
It really does.
Beck's triad is absolutely one of those things that part of my struggle is that I feel like
(34:11):
at one point when these things were discovered, it was like, oh, this is really a neat coincidence.
But much of what we discover by way of these triads and dyads and the different presentations
doesn't always fit everybody, number one.
Number two, you think of Cushing's and the Cushing's triad and you're talking about hypertension
(34:37):
and bradycardia and you're talking about increased intracranial pressures.
With that dynamic, physiologically they make sense.
If I can look at something and I can say, well, because the pressure goes up inside
the cranial vault, the body's trying to regulate and so it slows the heart rate down to decrease
cardiac output to be able to do that and so bradycardia makes sense because our cardiac
(35:02):
output decreases, will increase our respiration.
Those things all, they make sense because you can rationalize them from a physiologic
perspective.
When you talk about mechanisms and you think of Beck's triad, they also can exist, but
you hit it right on the head by saying, it's not all, you can't always put your money on
(35:29):
meeting all three equations.
The one I think of off top of my head is Tension Pneumothorax.
How many people have actually seen a deviated trachea?
It's something that we're taught.
It's something that I think intuitively makes sense until you realize that up in the neck,
there's a lot of muscle and a lot of structures there that won't allow that trachea to really
(35:52):
deviate.
So where we see tracheal deviation is in the cadaver because they're dead or it's in somebody
who is a cadaver and we can open their chest and see that they've deviated intratherastically,
not outside.
So I think there are a lot of things that we learn, I won't say that are hocus pocus
because they're not, they're legit, but they're not truly applicable to what we do.
(36:17):
But take that flip side and we just talked about Cushing's, right in the Cushing's
Triad, you look at that and go, oh, wow, I got this person who's got this horrible head
injury and all of a sudden they're tachycardic and getting bradycardic, or I'm sorry, they're
hypertensive and getting bradycardic.
Ooh, that tells me something.
That means that says, yeah.
So I think you have to take each of those a little bit and say, do I understand why they
(36:41):
present the way they do?
If you can understand why those things exist, then you can actually use them as applicable
tools.
If you don't really understand it, then you're just looking for these elements like you're
checking a box and then it becomes ineffective in my mind.
I think that's a great way to say it.
We have a mutual friend who talks a lot about pathophysiology, Joe Misdovich, a prince among
(37:06):
men and Misdovich stories here could be no whole other seven things, but that's always
been his thing and that if you understand it, it's a lot different than seeing signs
and symptoms.
So we're winding down number seven and this, we talked before we started today about how
things change so much.
Here number seven is protect yourself.
(37:28):
An N95 can be sexy, being real and vulnerable is not weak, making it home sane and whole
is not overrated.
Whether we're talking about the current COVID situation, which we're divided on pretty
politically and opinion wise and so many things, yet we are clinicians and we do have a responsibility
(37:52):
to be there to ourselves and our families and quite frankly, COVID isn't the last thing
that's going to happen in our times in the US and medicine.
So how do we learn from this?
What would you say to people to say, all right, listen, we may or may not be in a home
stretch, but if we are, something else is going to come along.
Think, well, of the things that have come along in our lifetimes from avian flues to
(38:17):
everybody worrying about Ebola and all these different things.
There's always going to be stuff going on.
Protection should be smart.
People should be smart in the application, even when it's not easy or it's getting old.
Absolutely.
Yeah, you know, this one, you could say was prompted by COVID and I think it is in a lot
(38:42):
of ways, but it's not because COVID was the end all be all like you just said.
I think what COVID did is it gave us an awareness of so many things.
One, I think in the way that we approached infectious disease and the way we approached
sort of that unknown patient population, we were exposing ourselves every day and never
(39:03):
knew it, right, when COVID came along and we all of a sudden had this lethal disease
that we were watching our coworkers die from and our family members die from.
All of a sudden it was like, okay, I can now, I now have to be protecting myself.
But I think the other thing that came from it that's really pretty powerful is that,
(39:28):
you know, some of us have been around long enough to see the ebbs and flows of taking
care of yourself.
Dan, I always fall back on your talks about suicide and what that does to people or what
leads them to that place.
And a big part of that is not having the support system, not being willing to allow yourself
(39:54):
to be vulnerable and say, hey, I'm hurting, I need help.
I'm in a bad place.
I'm burned out.
You know, and in the end, if you don't take care of yourself from a, we just talked about
an N95, right, meaning you got to use personal protective stuff.
But even bigger and something that COVID I think really showed us, there are so many
(40:17):
people that went and did these travel contracts and we're working in New York City and working
on the, you know, in the throes of the most heavily hit areas day in and day out, not
taking care of themselves emotionally, not taking care of themselves physically.
And I think, number one, we saw a lot of burnout.
(40:38):
But two, we saw physicians, we saw EMS providers, we saw nurses, we saw healthcare workers
killing themselves at an alarming rate during this pandemic.
You know, we see little bits and pieces of information on it as the stories make it to
mainstream media.
I haven't seen anything that kind of aggregates this, but you know, I have some friends over
(41:02):
in Italy and if you recall, they were getting crushed.
Nurses over there and three nurses in one hospital killed themselves because they did
not want to go back into the hospital.
They were so overwhelmed.
Three nurses in one hospital killed themselves because this overwhelmed them so much.
And you can't help but ask yourself, what if somebody asked them how they were doing
(41:26):
and somebody pulled them off the line and said, we're going to help you, right?
I'm not blaming this on anyone at all.
I think as we've already said, this is unprecedented, nothing we could have foreseen.
You've hit it right on the head by saying again, this isn't the last we're going to see of
chaos and craziness.
(41:46):
Nonetheless, it's been a great learning experience for all of us.
Protect ourselves physically, but man, we got to protect ourselves and each other emotionally.
You know, I think that there's a certain group of people coming to EMS and believe that emotional
damage is inevitable.
(42:08):
And I think that there are certain things in any person, different things from person
to person that can push us over the edge.
But I do think it's important to say that we hopefully have learned from this.
And there are times, there are desperate times and we're pushed beyond what we believe that
we can do.
(42:30):
But I also don't want people to come into EMS and think that emotional damage is inevitable.
There are people who've been in this a long time and still love what they do and have
it happen.
And I think that taking care of oneself, I think that taking care of each other, and
I think that systems working together to do this, as you say, can certainly help prevent
(42:53):
a lot of this.
I don't want people to go away and say, oh, why would I go into this because of all the
people, you know, killings, whatever.
Those are warnings to us to take care of ourselves, take care of our friends and to take care
of our system, to do what we need to do.
I would actually advocate leaning into EMS a little bit, being a part of it, being part
of a solution, and being okay, but also know that there's times it's okay to not be okay.
(43:19):
Just like it is, people see a horrible call or a scene and when you're new, you feel
badly because you don't feel bad.
And this stuff is not predictable.
If you had a horrible call and you say, cool, when's your first one?
You stop and say, is that bad?
(43:39):
But then there's something that's relatively small.
Somebody's got the same name as your brother or sister, something that looks like your
uncle and it hits you harder and it seems like a mild call.
We have to be aware of these things.
We have to stick together.
We have to do them.
Emotional damage is not inevitable.
It's certainly possible and it's been a lot in this, but there's ways to take care of
(44:01):
yourself and do things.
I want to keep people in the game and do this despite that.
Absolutely.
Totally agree with you, Dan.
We have generally about a 45 minute conversation and we're hitting that point, but I do end
(44:22):
all of these with one thing.
From any of the seven things or even anything new that you'd say as a physician, medical
director, what's your last word?
Your parting shot to the people listening today.
What would you want them to hear in their earbuds last before we end this session?
Pretty simple.
(44:42):
You guys are awesome.
Take pride in what you do.
We are a profession, medical profession because of you guys and the fact that you're putting
in the sacrifice and the effort to take care of people day in and day out.
Take care of yourselves and just simply thank you for continuing to do what you do.
(45:03):
I think we couldn't end that better.
Will from your experience in EMS, taking that through to emergency medicine.
We're very fortunate to have you here as they are for you there in Louisville.
He'll have some great experiences there.
People will be very lucky to have you.
You're a good man.
(45:24):
You're a good friend.
A great doc and I thank you for coming by.
Thanks Dan.
Thank you for listening to another Limmer Education Continuing Education podcast.
For more podcasts that are relevant to your practice of EMS, limeregucation.com slash
Seven Thinks.
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