Thursday, August 5, 2010

So many questions...

Why had the life guard passed her location a moment to early?

Why was your mom out of sight at that very moment?

Why weren't you wearing your water wings that day? Did you forget them at home?

Why did no one notice you floating in the non-swimmer basin? For minutes. Face down.

Why did take almost seven minutes to get you out of the pool?

Why wasn't the off-duty pediatrician's CPR on scene good enough?

Will you ever leave the PICU alive?

Will you ever go on a first date?

Wednesday, August 4, 2010

Personal Protection and you!

Today I was working with a Paramedic student, who has just started his field rotation last month. He had been an EMT before he went to P-school and gained a good years experience during that time. We took over the ambulance from the early shift and as per usual I would step outside with them and have a cup of coffee and a cigarette and we would chat a little. My student went straight to the ambulance and started inspecting and checking the gear and medical supplies.

A few minutes later, after having finished my coffee, I joined him at the ambulance. And, like I do every day, I hung my jacket on the little hook next to my seat and started my daily paperwork. I looked over to his seat and didn't see his was nowhere to be seen.
He had just finished checking the back of the rig and came to me, so I asked him where his jacket was. He told me it was upstairs in his locker, "why do you ask, it's summer and I won't be needing it" he continued. I was a little taken aback by that and told him that if I were to catch him at an MVA without his jacket, we would need to have a serious talk.

A few days back I was chatting with a paramedic from Texas and she asked my why we were all wearing our jackets at an MCI call in 100° F (39°C) weather. My immediate response was to ask her why I wouldn't be wearing one and if they don't wear jackets during MCI or MVA situations, to which she replied no. I was shocked and here is why.

Our jackets are a vital part of our Personal Protective Equipment for a number of reasons, all of which are standardized by the European Commitee for Standardization (CEN) in so called Euro Norms (EN). Firstly and most obviously it has to protect us from weather influences, mainly the rain and the cold
(EN 343). Then they need to fulfill certain
high visibility requirements (EN 471) in regards to background color (usuallay a bright red, yellow or green) and reflective striping, giving us the necessary proctection to work in flowing traffic without the need to wear additional (traffic) vests. Something I have yet to see in the US, where EMS uniforms are typically composed of dark colored materials - usually navy. Uniforms that I would not feel comfortable working with on any street, road, or highway.

Sample image of a typical German EMS jacket, like the one my service uses.

Another, to me, important fact is that it protects me from mechanical influences to a certain degree. Especially on an MVA scene there will be glass and metal parts scattered around and all sorts of sharp edges that I don't want to cut myself on. Our jackets are made from sturdy materials in order to prevent that from happening. I remember all to well an incident in my first days on the job. It was summer and we were called to an MVA with a person pinned in their car. I don't remember the exact particular, but what I do remember is that Fire had to take down the roof of the car in order for us to extricate the patient. After they had done so the b-pillars, half cut off, stuck up in the air and while I was leaning into the passanger cabin I cut my forearm pretty badly on the sharp edges of said pillar, leaving me bleeding like a stuck pig. That thought me to always wear my jacket on sites like that.

The same is true for helmets. Rarely do I ever see my colleagues wear helmets. Granted the situations were the use of helmets is actually waranted are few and far between, but even then the changes of seeing EMS personnel wear helmets are next to none, in my experience.

An MCI drill. One of the rare occasions, where everyone turns up in full PPE.

I have always been wondering why things are how they are, in that respect. Maybe it's lazyness. Maybe it's because it doesn't look cool - yes our helmets do look ridiculous. Maybe it's something a lot of people don't give it a lot of thought, because in the vast majority of medical calls, those kinds of precautions don't have to be taken. Maybe, sadly, something has to happen first, in order for them to rethink.

Maybe we should take a look at the Fire services. Whenever they turn up on a scene they will generally wear they full bunker gear and helmets. Be it waranted or not, no questions asked. Even in 100 degree weather. And they will keep in on until their commanding officer allows them to take it off. I realize, that this is not the case everywhere on the globe and yet I have the feeling that firemen, in general, show up dressed for the worst.

Firemen - full PPE even while just standing around.

In fact, many times, when not working a fire I would say that they tend to go overboard. Leaving us with another problem alltogether: heat exhaustion. Naturally their bunker gear is not only a whole lot heavier than our clothing, but keeps a whole lot warmer. Yet, they somehow make it work by taking turns, taking rest breaks to hydrate whenever necessary.

I would very much like to hear about your views, protocolls, guideslines, recommendations.

Wednesday, June 30, 2010

Beechcraft down!

Last night I was sitting in front on my blog about to write a post about how I feel like I am the definition of a white cloud. I've now been working for a week after I came back from my vacation and the number of patients I've seen is less than the count of finger on one hand. I kid you not.
Granted right now I'm rotating through one of the slower stations and I enjoy sleeping through the night, but seriously five patients?!

I was going to write how some colleagues go through more than that during a single shift, much less a week. And how they're called black clouds or shit magnets, and whatnot.

But then today at some point it started getting pretty hectic on the radio and we were sent to the Wiesbaden Army Airfield. A US Army installation and one of six major hubs for US forces in Europe. If material or troops are sent to of from the sandbox, chances are it will come through Wiesbaden AAF. Relations between us, the host nation's emergency services, and the US Army are great. Only a few days ago we had our combined annual emergency preparedness drill (click for pics - in German), where we train realistic mass casualty scenarios. I've always wondered when or if there would be a real incident at WAAF. We often do, in fact. Today I was about to find out...

A little after 1530 hrs we got dispatched to WAAF with initial reports of an airplane crash. Situation at first was unclear and MCI protocols were put in place. The call that I have been kind of waiting for was now happening. For real. Boy was I not prepared for this one... but are you really ever prepared for this kind of call? As we sped to the scene my heart was pounding, heart rate through the roof. I went through MCI SOPs in my head, put on my neat orange MCI identification vest (they state the number of your unit and your function) and prayed this wouldn't be The Big One. Big time pucker factor. When reached the area I was on the lookout for a pillar of smoke and other signs that something was out of the ordinary, but I was just a sunny summer day, like any other.

We turned a corner and all of a sudden the fields in front of WAAF where in full view. In the distance I could make out a small-ish propeller plane in on of them. No smoke, no flames, just a plane in the middle of a cornfield. Like a sitting duck. An oddly peaceful picture. The first fire engines pull up simultaneously, one other ambulance was already on scene. I swiftly spoted a staging area for EMS and advised the following units to make their way there. I had my EMT partner and paramedic intern grab our gear, while I ran, yes I ran - can't remember the last time I actually ran to a scene, to the other ambulance which was parked pretty close to the aircraft. After a short conversation with the other in-charge medic it turns out there were only two people involved, pilot and co-pilot, and both were fine. The pilot didn't have a scratch on him and the co-pilot merely cut his thumb on a sharp plastic edge of his broken control stick.

Phew! What a relief! No one seriously hurt. I cancelled all other EMS units, apart from EMS command. By now the scene was getting pretty crowded, our FD, the US Army Airfield FD, Army, German Police, Military Police, even the press where already there and everyone wanted a piece of the action...well... which turned out to be no action at all. The pilots of the Beechcraft RC-12 recon aircraft were in a strangely good mood and most worried about their sunglasses and iPhones (which they later used to document their mishap). The co-pilot mumbled something about how he "couldn't get it up", while the pilot praised the safety of their seatbelts. Apparently they had just started from WAAF for a training flight and, for reasons yet unknown, had to park their Beechcraft in the field a few minutes later. Not quite a hudson landing, but impressive and quite an archievement nonetheless. This could have ended so much worse...

Once everyone on scene there was no casualties, everyone grabbed their cameraphones and started firing away. A colleague of mine made some pretty cool shots for your viewing pleasure. Enjoy.

Medical Commander (Physician in-charge) and I.

Me and the medic from the other crew.

The crews :-)

"Can I keep it?! Pretty please!!!"

More pictures available here. Courtesy of

Blue Balls

I am Jack's blue swollen testicle.

That's what crossed my mind in a fight club-esque narrated voice when I saw the huge blue sphere that once was his testicle, followed by multiple damns and ouches. Let's just roll with it and call him Jack.

Jack had his inguinal hernia operated early this morning and had apparently been running around all day. Jack also didn't quite grasp the concept of rest and, more over, gravity. Resulting in a tennis ball sized swollen and hemorrhaged testicle. Well, at least he was pain free, but he sure isn't going to be doing the dirty anytime soon.


CoEMS first hand - InsomniacMedic

Earlier this month I had two weeks of vacation. Initially I wanted to travel to Spain, but that didn't work out in the end. So decided travel around in Germany the first week and visit friends who I hadn't seen in quite some time. One of which I became to know over the Internet about 4 years ago and has since become one of my best mates. He lives rather far away, but we still try to make it a habit to visit each other a couple of times a year.

Over the years I've met a lot of people from the web in person and I have yet to regret meeting "strangers" from the creepy Internet. I'm sure there are creeps and weirdos out there somewhere, but I have never run across one in the "real world". The Internet in general isn't as bad a place as many people, such as my mom, make it out to be. She was scared to death some ten years ago when I set sail for my first endeavour to meet people, who I got to know through online gaming back in the day. She was horrified of all the things that could happen to me. I didn't share her fears, fortunately, otherwise I would have never met a long of awesome people over the years.

One of these great experiences occurred on the second week of my vacation when I visited my cousin in London. I'm pretty new to the whole Chronicles of EMS movement and have only been aware of a bunch of great EMS blogs out there for a couple of months. I never considered blogging or even following blogs until that day, but CoEMS and those blogs changed my mind. There really are great people out there who put a lot of effort in their blogs, some funny, some tragic, some educational, but all great reading material.

InsomniacMedic is one of these bloggers I have stumbled across. I have been following his blog for quite some time, but only before I left for my Trip to London, did I remember that he is not only from Britain, but works for London Ambulance Service. Naturally I thought this was a great opportunity to meet.
I had sent him an email and while I was sitting at Frankfurt Airport his response came and we was interested as well. A few emails later we had setup a meet for the very next day at his LAS station.

So I hopped on the tube and made my way north to his station. Once there I was greeted by a warm smile and a hot mug of coffee, and I got to know a not only a great blogger, but a great paramedic and hilariously funny person, known to his colleagues as the Shit Magnet, for some reason... The next two hours we chatted away about our EMS systems, about calls, about protocols and life in general. We also did drugs, but that expression seems to have a completely different meaning in British English...

This was my first real life CoEMS experience and it was a great afternoon. I sure hope there will be more event like this in the near future.

I want to thank InsomniacMedic for making the time on such short notice and also the guys and girls at his station, who are a great bunch.

Tuesday, June 29, 2010


Apparently there is this meme going around, where bloggers let their audiences know what they read, when they get "down to buisness". It all started with a certain Lissa, of which until today I have never heard of. She started sharing the reading material she has lying around in her bathroom and then tagged other people to follow suit. Kinda weird, but I'll bite. It would seem the trend caught on and now even I got tagged by InsomniacMedic.
So here it goes.

I've never been a big fan of reading on the toilet. There was a time when I prolonged the stay on the porcelain throne to enjoy a good read, but in the flat I've now been living in for the past five years the bathroom is just to narrow an uncomfortable to actually relax and stay for a while. Nowadays I tend to do my number two and get out of there as soon as I can. Also my legs tend to fall asleep and that is something I'd rather not have.

I've always found it fascinating how people, men in particular, take their time and enjoy the peace of their own WC and read while doing their thing. Some friends of mine will spend up to an hour in there. Yes, some even take their laptops in there and thanks to WiFi surf the web or catch up on emails. Talk about efficiency... I never quite got the hang of that concept and I'm quite happy with getting out of there rather quickly.

On occasion, when I do decide to read little, I will thumb through a copy of "RETTUNGSDIENST" (lit. "EMS" in German), a German EMS publication. There are a handfull lying around within arms reach. The only thing I do on a regular basis is play with my mobile phone. Check twitter and facebook, look for apps on the Android Market Place, write the occasional text message or email. That's about it. I do not, however, blog from the bathroom, just in case you are wondering...

Something I will always do when I'm at home, however, is smoking. I know, I know.... ewwwww. Maybe it's because it masks the smell, maybe... well, to be honest, I don't know exactly why. I just enjoy to light up a fag when I'm on the dumpster. Don't judge me!

When I'm at work however I will regularly (and by regularly I mean every now and then, not 4 times a shift...) disappear with a news paper or some sort of catalogue in my hand. Whatever I can grab will do. That way my 15 minutes get me up to speed on current events, news and/or product offers. I always found this rather odd, because I know a lot of my colleagues can't relax when they're at work, for fear of the impending doom of the next alarm. Some even choose not to go number two at all while they're at work. Doesn't bother me though... strangely enough.

So yeah, I got a little carried away and now you more than you ever wanted to know about me. But you had to ask didn't you?

I shall tag the only one that apparently reads my blog and hasn't been tagged so far:

The MICT Student

Your move!

Wednesday, June 2, 2010


A day after the United States honored their soldiers and veterans commemorating Memorial Day, an American WWII aerial bomb exploded in the city of Göttingen, Niedersachsen (Lower Saxony), killing three and critically injuring two EOD experts. How's that for irony?

Isn't it strange how a war three-quarters of a century in the past, can so suddenly recall itself into our present times? Something that now seems so distant, so far away, that we, the following generations, can not even relate to.

Granted we Germans aren't big on military. While Americans celebrate Memorial Day and honor their troops whenever they can, our mindset is different, almost inexplicable to foreigners. We generally don't care much for uniforms, military parades and such. We don't like war, we don't want war and we sure as hell don't reminisce about "our" wars. But then we were the bad guys back then... We? No, them! And even though it wasn't actually us, it was an entire different generation and we - the German people of this generation - had nothing to do with what happened back then, still feel guilty and ashamed of the crimes commited in those years. Why? I honestly don't know. Maybe because of the unbearable cruelty, maybe because it was our ancestors, our family, our blood.

Yesterday three people died, because of what our grandparents and great-grandparents did. It makes me sad. It makes me think. But it also makes me proud of what my country has become in the decades since. Our country was rebuilt, by a hard working after-war-generation suffering from poverty, inflation and food deprivation, and the generosity of winning parties that helped us shape a modern and democratic Germany. A free country ruled by law, based on unalienable civil liberties. For that I am eternally grateful.

The discovery of WWII UXOs (unexploded ordnance) is actually quite common here. Experts say that up to 20% of all aerial bombs never exploded and an estimated 250,000 bombs are still out there. They usually turn up during construction work and are safely defused and disposed of, rarely do they ever explode. I remember only one other occasion when a drilling machine hit a bomb, which was burried under the tarmac of the German Autobahn (freeway) A3, killing the machine operator in 2006.

Wednesday, May 26, 2010

Bad Luck comes in...

....threes, usually. This time it got one-upped.

Some strange stroke of fate lead to four unrelated ALS patients within a 100 yard radius. It all started when patient A called EMS for shortness of breath from a park bench across the road from a grocery store.

An ambulance and emergency physician unit responded, when at the same time a clerk at said grocery store called EMS for a co-worker who was having grand-mal seizures in the managers office - patient B.

Another ambulance and EPU responded and before they arrived one of the neighbors from around the corner called EMS for chest pain - patient C. And yet another ambulance and EPU responded to that block.

The crew for patient B arrived on scene to find a man down having seizures in front of the grocery store. Thinking they had found their patient, they radioed it in and started treating.

Hold on a second, I thought staring at the screen of my dispatch system. Did they say in front of the store? I asked them to make sure there was no other patient inside the store, just to be on the safe side. And I'll be damned, not ten seconds later they called for another unit for patient B, who had, until then, been seizing away merrily.

So another ambulance sped to, what by now must have looked like, the grounds of an mass casualty incident.

Karma? Fate? Destiny? Who am I to tell?
Strange and unusual? You bet!

Sunday, May 9, 2010

EMS in Germany, Part II

I wrote an article about EMS in Germany the other day and ran out of time to give you a little more in-dept look into our system. I've been pretty swamped lately, but I've found some time to write up part two.

The who is who of German EMS:

Unlike in the United States where EMS is provided by a multitude of agencies, many of which private, we can narrow it down to six agencies in Germany. The main four are non-profit NGOs, which provide a multitude of services above and beyond EMS. These services include blood donation services (and blood banks), public first aid education, disaster relief and emergency management, humanitarian aid overseas, outpatient nursing/care services, nursing facilities, meals on wheels, hospitals and even kindergartens. In essence they are huge networks that cater to public health, public education... well the public in general. Most of which is financed by donations or at cost-covering fees.
While many of the services are rendered by volunteers, EMS has in recent years moved away from employing volunteers. Nowadays it's safe to say that, apart from a handful exceptions, EMS in general is staffed by professional personnel.

These organizations are:

  • The German Red Cross: Undoubtedly the biggest aid network worldwide and also the biggest EMS provider in Germany (with an estimated market share of 50-60%).
  • The Order of Malta (Malteser): A branch of the catholic church in Germany.
  • St. John's Ambulance (Johanniter): A brach of the German protestant church.
  • Samaritan Union (literally "Worker-Samaritan-Union"): A union that historically formed in the time of the industrial revolution, to aid workers and craftsmen. Which, by the way, is how the St. John's Ambulance Association came to be in the UK. Part of SAINT (Samaritans International).
The other two are:
  • Fire Departments: Mostly in the northern German states, aswell as in major cities.
  • Private EMS agecies: Privates are few and far between. Although present, they play a rather small role in German EMS.
The Role of Fire in EMS:

I'm often asked "Is there Fire based EMS in Germany?" Well, yes and no. Yes, there is, but not how you would imagine it to be (coming from the US).

While in many US systems Fire - and by Fire I mean actual Fire engines - play a huge role in EMS, you will generally not see engines responding to medicals in Germany. The concept of an ALS staffed engine providing first response until an ambulance takes over the patient for transport is a very strange idea to us, and not practised over here.

German fire departments differ to much from American FDs in order for this to work. One of the main differences here is what I call centralization. We tend to centralize our fire resources in a small amount of stations, whereas in American cities you can find a (single engine) fire station every couple of blocks.

Take my hometown Wiesbaden, for example. With a population of around 300,000 we are considered a major city by our standards - tiny by US standards, but thats not the point.
While we have 9 MICUs (at night; 15 during the day), we only have 4 fire engines stationed at three fire stations. And, while a typical Amercian station usually houses less than a handfull of apparatus (engine, ladder, sometimes a batt. chief, and maybe one other vehicle) our stations 1 and 2 house up to two dozen fire apparatus. And they don't even provide EMS.
If you were, for sake of argument, to transplant my city to America, I'm sure it would have at least 8, maybe 10, fire stations and just as much engines, but only maybe 4 or 5 ambulances.

So if fire provides EMS over here, and many departments do, they will not employ fire apparatus to medical call. They will staff EMS vehicles shown in part I of my blogpost and respond to calls.

What to do with a patient?

As an American you might think this is a stupid question. Begin treatment and haul him to a hospital or get him to sign a refusal and be done with it.

It's not that simple over here. Fortunately so, because first of all we get to say No. Yep, you heard me. You want to go to the ER for a stubbed toe or a toothache at zero-dark-thirty at night? Not happening! A freedom that many American EMS providers envy us for.

But we don't just say No, because we are mean and don't care for our patients. We can say No, because we have system in place for sub-acute or non-emergent patient care.
Unlike the UK our health care system is not what you would consider "socialized medicine" or goverment operated, but everyone is health insured and health care is basically free. Or should I say almost free, as this is not entirely true, but it would take books to explain it otherwise, so let's just roll with it for now.

As a result of this, public health as I perceive it is better. People see their GPs more frequently and prevention is better. But people get sick, like anywhere else in the world. It's what happens then, that makes the difference.

Assume you call 112 (the German counterpart to 911) for a runny nose, run-of-the-mill cold, or strained ankle from a soccer match past sunday. While in the US and ambulance would be dispatched to you right away (if you insist long enough), a German dispatcher will advise you to call your GP or give you the location of the location of an urgent care clinic and have them treat you for your non-emergent medical condition. During non-office hours we have a service especially for this kind of clientel, basically an on-call doctor service. They make housecalls and see patients for non-emergent conditions at night and on week-ends and treat a multitude of patients that don't necessarily have to be seen at an ER. So why go to the ER, when you can have your inner ear infection examined and treated in the comfort of your own house? Thus keeping our ER clear for "real emergencies".

Apart from that we have another major advantage. We have emergency physicians on scene. That gives us many treatment options that American paramedics don't have. Many emergent medical conditions, acute asthma attacks for instance, can be treated at home and in many cases can be left at home without the need to be taken to a hospital.

Another thing I've noticed, and that only became apparent to me after watching Justin Schorr of Chronicles of EMS talk about the expiriences he has made in the UK, is that the public trusts our clinical judgement. People don't tend to demand to be taken to a hospital over here. They listen to us when we tell them it's not necessary to go to the ER. They take our advice and go see their GP in the morning for minor things. I'm not talking about neglecting your patient, what I'm talking about is sound clinical judgement and involving the patient in an informed decision. Very rarely have I had a patient ask me to take him to a hospital after explaining his medical condition and talk his treatment options through with him.

To me that's an invaluable freedom and part of my personal EMS 2.0. Our system is far from perfect and many things are in dire need of improvement, but it's a start.

Monday, April 26, 2010

Improvements in pain scoring

In modern medicine there are breakthroughs happening left and right on a daily basis. A new and improved pain scoring technique especially developed for emergent care provider, both pre-hospital and in an ED setting, will now help improve accuracy in pain management and will make the old 1 to 10 visual analogue scale superfluous.

Introducing the

CRAP Score - Cynical Real Alternative Pain Score

CRAP Score = (OPS+AF) x (SC)x (EC)

OPS = 10-point pain score (Old Pain Scale)
AF = Adjustment Factor (see below)
SC = Story Credibility
EC = Exam Credibility

For LPT (Low Pain Threshold) patients; calculate CRAP score:

  • If the patient reports their pain as being more than 10 on the conventional 10-point pain scale, subtract 1 point for every point over 10. If a patient claims their pain is 12, subtract 2 points and start with an 8.
  • For every visit the patient has had to your a&E in the past 12 months claiming a "chronic" or "undiagnosed" painful condition subtract 1 point.
  • Every time the patient says "ow" when you push on a non-painful or uninjured area of their body, subtract 1 point.
  • For every claimed allergy to a non-narcotic pain relief medication, subtract 1 point.
  • If they are wearing sunglasses/wrist-splints/neck-brace/insist on wheelchair/lying down, subtract 1 point.
  • If they have tape or ECG lead residue on their body from a prior hospital exam, subtract 2 points. (Waive the wheelchair/neck-brace penalty is the patient is registered with a disability)

For HPT (High Pain Threshold) patients, you add to their reported pain score:
  • If a spouse or family member forced them to come in, add 1.
  • If patient history shows that every A&E visit for a painful condition related to something torn, broken, ischaemic or perforated, add 2.
  • If they have no allergies add 1.
  • If they are tachycardic (racing heart) or hypertensive (high blood pressure) add 1.
  • If they have visible major injuries they may be in shock and won't feel the true pain till the endorphins wear off

Worked example 1
Young guy/gal goes to A&E for the 7th time in the past year for migraine (-6) reporting his headache as 12 on a 10 point scale (-2). He claims to be allergic to 5 over-the-counter pain meds (-5). He has been to A&E 5 times in the past year claiming other painful ailments e.g. back pain, belly pain, but tests found no disease or injury (-5). He is in the examination cubicle eating crisps/choccy and yelling into his mobile phone. He claims his migraine is a killer. When his abdomen is pressed he claims it is tender (-1), but he hadn't noticed due to the migraine being so bad.
CRAP score = (10 -6 -2 -5 -5 -1) x (0.5) x (1) = -4.5.
Even without Story Credibility of 0.5 and Exam Credibility of 1 that's a CRAP score of -9.

Worked example 2
Limping guy/gal is taken to A&E by spouse, but reports "fuss about nothing" and pain score of 4. Blood pressure and heartbeat are increased (+1). They've taken a couple of aspirin. Examination finds torn ankle ligaments, probable fractured tarsals plus fluid retention around ankle plus abrasions to forehead and forearms. Patient states s/he fell on icy pavement. Patient history over several years shows 3 previous visits for fractures/torn ligaments/open wounds requiring stitching.
OPS + AF = (4 +1 +1 +2) = 7
Even without a Story Credibility and Exam Credibility, that's a CRAP score of +8 and they've sustained real damage.

Found on Dragonqueen's Site, all credits go to her.