Episode 050 - Mistakes Writers Make about First Responders and How to Avoid Them with Ken Fritz
October 27, 2020
Ken Fritz talks about the difference between EMTs and paramedics; the problematic portrayal of CPR and defibrillation in books, movies, and TV; and how much of emergency medical service’s work is really emergencies.
Ken Fritz has been in emergency services for over 20 years. Starting as a volunteer firefighter, he has worked his way up through the ranks of EMT, Fire Department Captain, and Paramedic. Ken currently serves as a volunteer firefighter / paramedic in his local community and has worked as a career firefighter / paramedic for numerous departments over his career. He's married with two kids and two dogs, and lives in rural southeastern Pennsylvania.
"All paramedics are EMTs but not all EMTs are paramedics. So if you consider that relationship, it makes it a little bit easier to understand. And it's not improper necessarily to call a paramedic an EMT, but it is somewhat improper to call an EMT a paramedic." Ken Fritz
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Matty: Hello and welcome to The Indy Author Podcast, today my guest is Ken Fritz. Hey, Ken, how are you doing?
[00:00:06] Ken: Good, how are you?
[00:00:07] Matty: I am doing great, thank you. So to give a little background on Ken -- Ken Fritz has been in emergency services for over 20 years. Starting as a volunteer firefighter, he's worked his way up through the ranks of EMT, fire department captain, and paramedic. Ken currently serves as a volunteer firefighter paramedic in his local community and has worked as a career firefighter paramedic for numerous departments over his career. He's married with two kids and two dogs, and he lives in rural Southeastern Pennsylvania, not far from where I am.
[00:00:39] So the conversation we're going to be having today is part of a mini theme I have going on the podcast about Mistakes Writers Make and How to Fix Them. Just recently on Episode 46, we had Jennifer Graeser Dornbush talking about Mistakes Writers Make about Coroners and How to Avoid Them. On Episode 35, Bruce Robert Coffin talked about Mistakes Writers Make about Police Procedure and How to Avoid Them. And way back in Episode 12, Chris Grall talked about Top Firearms Mistakes Writers Make and How to Avoid Them.
[00:01:10] And so today, not surprisingly based on that bio I read, we're going to be talking about Mistakes Writers Make about First Responders and How to Fix Them. And I'm going to start out with the classic question that I always need a clarification from Ken on -- Ken has served as a consultant for me on all my books -- and that is the difference between an EMT and a paramedic.
[00:01:32] Ken: So that's both an easy and complicated question to answer. The big thing is there's a difference in training. Before I get into the explicit differences, what I should say is that all paramedics are EMTs but not all EMTs are paramedics. So if you consider that relationship, it makes it a little bit easier to understand. And it's not improper necessarily to call a paramedic an EMT, but it is somewhat improper to call an EMT a paramedic.
[00:01:55] The reason I say that is that there's a big disparity in training, so right now, EMT training is somewhere around 180 hours, give or take. So you figure three, four months, depending on the program. Paramedic school starts at about a thousand classroom hours and usually entails about another 800 to a thousand clinical hours, which is time that you spend on ambulances, in the hospital, really practicing procedures and assessments and things like that.
[00:02:25] And where we're trending in the industry now is that a lot of paramedic programs are becoming at least two-year associate degrees, with some places offering bachelor's degrees. So it's just a much higher level of training, which of course results in a much different scope of practice and set of capabilities.
[00:02:42] So your EMTs will generally do what we call basic life support, which is things like splinting, wound care, oxygen, CPR, they use an AED, and some very basic medications now, depending on where you are and what state. Some will give aspirin, nitroglycerin, albuterol, EpiPens. Generally things that are prescribed to a patient that they can use at home on their own.
[00:03:10] Whereas a paramedic, depending again on the jurisdiction, we have a much larger scope of practice, especially in the area of drugs. I think in Pennsylvania, we're up to somewhere in the mid-forties in terms of how many drugs we give. We can also do quite a bit more in terms of invasive procedures. So IVs, endotracheal intubation, emergency airways, surgical airways, cardiac monitoring, manual defibrillation, pacemakers. All that kind of stuff that's more critical, high acuity care is handled by a paramedic.
[00:03:45] So that's really the gist of it is levels of training and scope of practice. And the paramedic is always quite expanded beyond what an EMT can do. ...
[00:00:06] Ken: Good, how are you?
[00:00:07] Matty: I am doing great, thank you. So to give a little background on Ken -- Ken Fritz has been in emergency services for over 20 years. Starting as a volunteer firefighter, he's worked his way up through the ranks of EMT, fire department captain, and paramedic. Ken currently serves as a volunteer firefighter paramedic in his local community and has worked as a career firefighter paramedic for numerous departments over his career. He's married with two kids and two dogs, and he lives in rural Southeastern Pennsylvania, not far from where I am.
[00:00:39] So the conversation we're going to be having today is part of a mini theme I have going on the podcast about Mistakes Writers Make and How to Fix Them. Just recently on Episode 46, we had Jennifer Graeser Dornbush talking about Mistakes Writers Make about Coroners and How to Avoid Them. On Episode 35, Bruce Robert Coffin talked about Mistakes Writers Make about Police Procedure and How to Avoid Them. And way back in Episode 12, Chris Grall talked about Top Firearms Mistakes Writers Make and How to Avoid Them.
[00:01:10] And so today, not surprisingly based on that bio I read, we're going to be talking about Mistakes Writers Make about First Responders and How to Fix Them. And I'm going to start out with the classic question that I always need a clarification from Ken on -- Ken has served as a consultant for me on all my books -- and that is the difference between an EMT and a paramedic.
[00:01:32] Ken: So that's both an easy and complicated question to answer. The big thing is there's a difference in training. Before I get into the explicit differences, what I should say is that all paramedics are EMTs but not all EMTs are paramedics. So if you consider that relationship, it makes it a little bit easier to understand. And it's not improper necessarily to call a paramedic an EMT, but it is somewhat improper to call an EMT a paramedic.
[00:01:55] The reason I say that is that there's a big disparity in training, so right now, EMT training is somewhere around 180 hours, give or take. So you figure three, four months, depending on the program. Paramedic school starts at about a thousand classroom hours and usually entails about another 800 to a thousand clinical hours, which is time that you spend on ambulances, in the hospital, really practicing procedures and assessments and things like that.
[00:02:25] And where we're trending in the industry now is that a lot of paramedic programs are becoming at least two-year associate degrees, with some places offering bachelor's degrees. So it's just a much higher level of training, which of course results in a much different scope of practice and set of capabilities.
[00:02:42] So your EMTs will generally do what we call basic life support, which is things like splinting, wound care, oxygen, CPR, they use an AED, and some very basic medications now, depending on where you are and what state. Some will give aspirin, nitroglycerin, albuterol, EpiPens. Generally things that are prescribed to a patient that they can use at home on their own.
[00:03:10] Whereas a paramedic, depending again on the jurisdiction, we have a much larger scope of practice, especially in the area of drugs. I think in Pennsylvania, we're up to somewhere in the mid-forties in terms of how many drugs we give. We can also do quite a bit more in terms of invasive procedures. So IVs, endotracheal intubation, emergency airways, surgical airways, cardiac monitoring, manual defibrillation, pacemakers. All that kind of stuff that's more critical, high acuity care is handled by a paramedic.
[00:03:45] So that's really the gist of it is levels of training and scope of practice. And the paramedic is always quite expanded beyond what an EMT can do. ...
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[00:03:55] Matty: That explanation actually addresses a challenge that I run into every time I write a scene -- it seems like especially Lizzy Ballard always has to have an ambulance called and you've been very helpful there -- and I've always struggled with how to refer to the people who show up in the ambulance, because as a fiction author, you can't write more than the point of view character knows. So if two people get out of the ambulance, then the point of view character is not going to know whether they're EMTs or paramedics.
[00:04:26] And we've had this conversation about how to refer to them in that scenario? And technician was an idea, but that sounds a little weird, but it sounds like an author could say EMT and they'd always be correct, although they might be underrepresenting the skill of some of those people who are getting out of the ambulance.
[00:04:47] Ken: Yeah. And nobody's going to get upset about underrepresentation. And frankly, in most cases, they're not going to get upset about overrepresentation too much either. But there's a lot of generic terms you can use to refer to the people that get out of the ambulance. You call them an ambulance crew or ambulance attendants, EMTs, medics. Really any generic term is fine.
[00:05:08] The only one that people generally don't appreciate, and really shouldn't be used, is ambulance drivers. We really don't like that. A lot of people get really offended about that. I really don't care. You can call me whatever you want. But a lot of people really do get pretty upset about that one, just because it's really an old connotation of what it was back when EMS started. It actually started with people from funeral homes picking up people and taking them one of two places, either a hospital or elsewhere. And back then they were truly ambulance drivers because they really didn't have training. They didn't have equipment. The field has evolved far beyond that at this point. So generally that's the only term that I would really seriously avoid.
[00:05:50] Matty: Is there any cutoff in the history of first responders, if someone was doing something set not in current day, but they were looking at current day guidelines. Obviously if they're writing it and it's set in the 1800s, then you might really have an ambulance driver, as you're discussing. Is there a point at which you would recommend an author who's writing at some time in the past start doing specifically historical research on first responders, as opposed to just looking at current resources.
[00:06:20] Ken: EMS in its current form really started to evolve in the late sixties, early seventies, where you had things like, paramedics leading teams. Now the field is always changing. We've changed greatly even since I've been in EMS and that's been in the past 20 years, but I don't know that there's a strict cut off.
[00:06:39] I would say you'd be fairly safe talking about, EMTs and paramedics in general if you're pretty much anywhere after about the mid-eighties, early nineties. Prior to that, availability of those services with spotty. Paramedicine as a trade started out in Los Angeles County. A lot of your folks might remember the show EMERGENCY. That's actually obviously a fictional show, but it does give a lot of context into how it started. And that's where it started.
[00:07:08] So yeah, if you're looking, in terms of the timeline, like I said, eighties, nineties, you're probably okay using some of the same generic terms and things as you would today. Although the specific technologies and treatment modalities have changed quite a bit.
[00:07:25] Matty: What kind of things do you see in the portrayal of EMTs and paramedics on TV or in books that are especially irksome to you?
[00:07:32] Ken:
[00:07:33] So there's really a lot of little pet peeves. But really it's portraying EMS as not much more than taxi drivers. There's a lot more to it and we can talk about some of those specifics. But really looking at EMS as that just vacuous truck that takes people places.
[00:07:53] There's a lot more to it than that. And I think a lot of authors, and especially TV and movies, do a big disservice to what EMS actually does and the prevalence of EMS services. So that's kind of annoying. The other stuff is really around specific treatments. Some of the ones that I know you and I have talked about is things like CPR and defibrillation and stuff that it really doesn't work the way that people think it does. And especially if you watch TV, they really get it wrong.
[00:08:22] Matty: Talk a little bit specifically about CPR.
[00:08:25] Ken: Look at the prototypical TV show where somebody gets hurt in any given way, they got shot or they drown, whatever. And the hero of the day will come in and do CPR for 30 seconds and the person wakes up and says, Oh, thank you for saving me. That doesn't happen. CPR when it's needed is because the person is clinically dead, right? Their heart has stopped. You're doing CPR to circulate blood and oxygen around the body.
[00:08:55] Matty:
[00:08:55] Ken: 99% of the time CPR does not restart the heart. It is a measure to help maintain organ and brain tissue viability until you can restart the heart, either through medication or defibrillation or through surgical intervention. So that's what the people usually get wrong, is that, Oh, I do CPR and everything will be okay. No. The success rate for CPR is somewhere, depending again on where you are and the circumstances, somewhere around five to 7%. So if your heart stops outside of the hospital, I wouldn't count on a really great outcome. Whereas obviously TV shows and things like that portray it as something that works almost all the time.
[00:09:40] We may get a heartbeat started again using CPR and medications and defibrillation but survival hovers generally around five to 7%. Higher in some locations that have different systems. I think King County, Washington, was one of the really big success stories and they're up to somewhere like 10 to 15%, but still not great.
[00:10:03] The bottom line is that it's hard to bring people back from the dead and there's a limited time window in which to do it. So, yeah, CPR is a big one.
[00:10:12] Matty: What is happening in King County that increases their rate?
[00:10:17] Ken: King County has had a program for a number of years that they really focused on quality improvement, systematic changes, and really looking at ways that the overall system can improve their practices. Some of the other things are how they actually do resuscitation, what protocols they use, what drugs they use. The big thing that drives all that is their quality improvement process. At least from how I understand it, they review everything that they've done, look at what works, and change it. So it's very similar to what we do in other industries in terms of continuous improvement. And then some of that is certainly system related.
[00:10:57] Some of it is probably due to their service areas, primarily the city of Seattle and King County, so they may have a shorter response time. They may locate their units more appropriately. Time in terms of cardiac resuscitation is the key metric. If you're not there within the first couple of minutes, your chances of success drop drastically. If you're not there in the first 10 minutes, there's pretty much almost no chance at all. So that's probably a lot of why that works.
[00:11:27] Matty: There's some factors there that the individual first responder wouldn't have much control over, like how long it takes them to get there. But there are some things that if someone were studying up what was happening in King County, and that was different than what was happening, let's say, in Southeastern Pennsylvania, how much latitude does an individual first responder have in terms of the practices they're applying? Or is it so structured that an individual wouldn't be able to adopt those practices that are being successful in Washington state for their own personal use.
[00:12:00] Ken: So a lot of the rest of the country, including Pennsylvania, has started to use a lot of the learnings that have come out of King County. One of the things that we've seen adopted over the past couple of years here in Pennsylvania is the use of what's been referred to as either team or pit crew CPR, having a certain number of providers on scene to do different tasks, that division of labor, and really the procedures that they've pioneered in King County and a few other places. So those have spread through official channels.
[00:12:32] Now in terms of latitude given to an individual first responder, there's not a whole lot. We are bound by protocols since we're not licensed medical professionals. Here in Pennsylvania, we're certified. But there is a important kind of medical legal distinction there. We don't practice on our own. We practice under the authority of physician's license, because it's what we call medical demand. So we do have to follow the guidelines that they set and, to an equal degree, the guidelines the state sets.
[00:13:04] Now within that, there are some things that you can consider judgment calls as to how we manage the airway, how we get intravenous access, whether we do it through a standard IV catheter that everybody's used to, or we can use a tool called an IO drill. So it's actually a bone drill that you can inject medications directly into the bone, which is both faster and generally more reliable, but not everybody likes to use that.
[00:13:32] So there are different levels of flex in those protocols, but really when it comes down to sweeping systemic change, that has to come from the state and from the medical direction, physicians.
[00:13:45] Matty: You had spoken a little bit when you were talking generally about CPR, about defibrillators, which is a word I always have to struggle with it, but any other concerns about the portrayal of defibrillators in fiction?
[00:13:58] Ken: Absolutely. Go back to that product prototypical scene on TV, because it's the most egregious kind of offense in terms of defibrillation. And you see the patient's on the heart monitor and they do generally something dramatically and take a last breath that they say something prophetic, and then you see their heart rate or the heart monitor go flat line. And everybody's like, Oh, get the defibrillator! No, that's not what we do.
[00:14:21] And it goes back to the mechanics of defibrillation. So if you break down the word a little bit -- de-fibrillate -- and let's talk about what fibrillate means for a second. Fibrillate means to quiver. When the heart muscle is either injured, starved for oxygen, or a number of different things can cause it, it'll actually shake. And what I can associate that with is, if you do a lot of exercise where you run, sometimes you'll feel your muscles shake a bit after that. It's like that on a much grander scale within your heart, where your heart is just shaking and firing spasmodically.
[00:14:58] The issue with the heart is, to get effective circulation, the heart needs to contract in a coordinated way, where it actually squeezes the blood out of the heart into the rest of the body. If the heart is misshaping and fibrillating, it doesn't do that. So the whole idea of a defibrillator is to stop fibrillation. Now, if you don't have fibrillation in the first place, it doesn't work.
[00:15:22] So the heart has to be in that fibrillatory pattern, which you would actually see on the heart monitor as chaotic lines, very spiky, up and down, and you would not see a flat line. The whole idea of a defibrillator is it passes current through the thoracic cavity to actually stop that fibrillation, stop all electrical activity in the heart to let the heart's natural pacemaker cells pick back up again. Doing that while the patient is "flatlined" is useless and it actually can cause even more damage because now you're putting electrical current that is completely non-therapeutic into a heart muscle that's already been injured.
[00:16:00] So the procedure we would follow if somebody is actually flat flatlined is start CPR. There are some drugs we would give, notably epinephrin, to get the heart either started again, which may happen if you get some circulation going through the heart and you get some oxygenation, it may spontaneously restart. Or sometimes what you'll also see is that you'll get enough circulation to get the heart to fibrillate again, and then you defibrillate and hopefully then it goes back. But again, it's one of those big things that we don't shock flat line.
[00:16:36] The other big one that you see is similar to the CPR paradigm, where you've got people that get defibrillated and immediately wake up and say, Oh, thank you for saving my life. No, that doesn't happen either. Defibrillation is a traumatic event. They were just dead. There's a pretty big insult of the body systems. So they're not going to just wake back up and think everything's okay again. It just doesn't work that way. Generally, they're going to be unconscious, and unconscious for a number of hours or even days after defibrillation. Now, again, there are exceptions to every rule. Sometimes it's a very short duration cardiac arrest, you shock somebody, they immediately come back and they may wake up. Not common.
[00:17:18] Matty: In a scenario where a non-trained person, a "civilian," I'll say, is using one of those defibrillator machines that are sometimes found in office buildings and things like that, my understanding is that those are all programmed so you can't really shock someone who doesn't need it, right? That the system is perceiving if it's a flat line, perhaps the machine wouldn't even let you activate a shock. Is that true?
[00:17:46] Ken: That's completely true. Yeah, you'll get "no shock advised" generally on the machine and it won't even charge the defibrillator. The algorithms in those machines actually sense the heart rhythm and really will only shock in the case of two different specific rhythms. One is ventricular fibrillation, like we talked about, the other one has ventricular tachycardia. Very specific, easily machine-interpreted patterns that the machine is basically built to recognize. Outside of that, it won't do anything for you.
[00:18:17] Matty: In terms of the types of calls that you're responding to, how many of them are truly emergencies?
[00:18:23] Ken: Not that many. It depends on how you define emergencies. It's really a wide-reaching term. But if you're talking about things that are critical, where the people will die without us being there, this is a guess, I'd say we're somewhere, maybe, 5% of the calls are actually critical that they get EMS care immediately. That number may be on the rise now due to the opioid epidemic. We're starting to see more and more overdoses. Those are the kinds of things that if somebody doesn't have either the skills to ventilate the person or to give them Narcan, they're probably going to die.
[00:18:57] So that number of 5% outside of the opioid stuff is probably fairly accurate. If you include that, it's probably higher. But the vast majority of the rest of the calls, we can absolutely make a positive difference, where we make them feel better, we can give them a safe ride to the hospital. and there are problems that we can remediate in the field to the point that they don't have to go to the hospital. But the large majority of them would probably at least survive if not do just as well going via another method of transportation.
[00:19:33] Now that's not to say you shouldn't call 911. I want to make sure that's clear to people. If you're ever in doubt, please call, because that's a determination that really only we can make. And frankly, there's a lot of times where we may not necessarily know exactly what's going on, other than you need to go to the hospital. Don't try to decide that on your own. If you feel that the situation is bad enough that you need to go to the hospital, don't hesitate to call.
[00:19:59] Now that's to say, if you stub your toe and break your toenail, don't call me. That's only happened six or seven times.
[00:20:10] Matty: Have you ever encountered a situation where let's say a wife calls 911 and you go out and the husband's having some medical emergency and the husband refuses to be transported to the hospital or even refuses to be treated? I'm assuming that the individual, if they seem relatively with it, has the right to refuse treatment, is that true?
[00:20:34] Ken: Absolutely. There are very specific criteria as to when people can refuse treatment, when they should refuse treatment, and what we need to do. So the big thing is looking at what we call a person's mental status. Really the standard there is making sure that they're conscious, obviously alert and oriented. C, A, and O. And there are a number of different dimensions to determining that. So oriented to person, place, time, and situation. All of those need to be true for somebody to legitimately refuse treatment safely.
[00:21:08] Now it's not to say that if they're somewhat disoriented, there aren't other cases where they can refuse treatment. And in fact, other people can refuse treatment on their behalf depending on the law and the circumstances. But especially in the case of what we call third-party calls, where it's somebody that is not the patient or may not even be on scene with the patient, calls on their behalf. And they can say, I didn't call you. I don't want you here, some of those criteria don't even apply. They could be completely unaware of what's going on, but if they say, I didn't call you, I don't want you, we don't really have the right to barge in your house and force you to have your blood pressure taken or whatever people might say.
[00:21:48] Outside of that, there's specific things if we're called for what is legitimately a medical problem, the person's conscious, alert, and oriented, then we have a whole flowchart of criteria that we have to follow to say if that's okay or not. In most cases where there could be a more serious problem, we actually have to call a physician at the hospital to get them to give their consent for us to discontinue treatment or otherwise it can be considered legal abandonment on our part.
[00:22:14] Matty: In a scenario where the person does accept treatment, does accept transportation to the hospital, what's the process for turning the patient over to the emergency room doctor or whoever picks up responsibility for them after you've transported them?
[00:22:29] Ken: One of our important concepts is continuity of care. And that is that from the point that person makes contact with the medical system in any sort of meaningful way, we make sure that they have a continuous flow of not only information but proper treatment. So what we're doing when we get to the hospital is obviously doing the rote physical stuff, like moving the patient into a bed or a chair, wherever we are going to end up.
[00:22:58] But the other big part is giving a comprehensive report to the receiving physician or nurse -- generally, it's a nurse that you're going to talk to -- so that they know what the problem is, first of all, and what we did about it and what response there really was to those treatments, plus the patient's medical history, so things like medications, allergies, and other pertinent information.
[00:23:19] A lot of that is also documented on what we call a transfer of care form here in Pennsylvania, a lot of states have a similar thing, where we actually have to get that signed by the receiving person, whether it's a nurse or a doctor, that says, Hey, I gave you a copy of this. You're aware of it and you're accepting care of the patient. So it just gives that kind of medical legal transfer to make sure that they can't say, You didn't tell us that. Well, it's right there on the form. Yes, I did. And frankly, medicine nowadays is not only about patient care, it's also about caring for your own legal rights as a provider. So that's a lot of, as we might call it, CYA. You can figure out what that stands for.
[00:23:57] Matty: And I'm assuming that within the team of people who are staffing an ambulance, there is some kind of hierarchy so that it would be clear who would be responsible for that kind of procedural turnover versus maybe someone else is simultaneously helping the patient into a bed. Is that true?
[00:24:18] Ken: Yeah, that is true. It depends on the makeup of the ambulance crew. Ambulance crews can be either an EMT and a driver, two EMTs, an EMT and a paramedic, two paramedics. It just really depends. There's two levels of hierarchy within that. Well, actually there's three. The major two when it comes to patient care is, one, the person who's primarily responsible for that transfer and continuity of care is whoever's providing care to patient. Just because there's an EMT and a paramedic on the truck, doesn't mean that the paramedic's always providing patient care and the EMT is always driving. It depends on the level of acuity. We may switch back and forth depending on what the patient's condition is. That's the first hierarchy. So whoever's taking care of the patient is responsible for that transfer.
[00:25:02] Secondarily the highest-ranking provider on the vehicle, if you've got a paramedic, generally that's going to be your highest-level provider, is overall responsible for the operation of everything on the truck. If you've got two EMTs, you're both responsible. But in terms of that really patient care aspect, paramedic's responsible.
[00:25:23] And then of course, more situationally, if somebody's driving the ambulance, that they're responsible for safe vehicle operation and communications. So that's kind of the entire plan, where we get into that.
[00:25:36] Matty: And is there a distinction between volunteer and non-volunteer EMTs or paramedics the way there is for firefighters?
[00:25:45] Ken: A one gets a paycheck and the other one doesn't.
[00:25:48] Matty: They both exist, I guess. There are volunteer and paid.
[00:25:53] Ken: Yep. And I've been both. And you can be both simultaneously, although at different agencies. But in terms of licensing and training, there's really no difference, whether you get a paycheck or not. Now some people see them differently, but they are trained the same way.
[00:26:10] Matty: Is that always driven by geographic location?
[00:26:13] Ken: Geographic location to a degree. Politics. Funding. Obviously, it costs money to have paid EMS and fire services. The other thing is really the demographics of the area. More rural areas, you'll see more volunteerism just because people tend to work in their local communities. They're available during the day to go out on ambulance and fire calls. Whereas somewhere that's a little bit more suburban, like this area, is starting to see a hybrid. And then in areas that are more urbanized, you see almost entirely career because people just don't have the time or really the willingness to volunteer anymore.
[00:26:51] Matty: You had talked earlier about the fact that one of the things that we as writers should not do is portray an ambulance as just a glorified taxicab. What are some recent technical developments in the actual equipment that an ambulance has available to it that writers might want to consider for their stories?
[00:27:11] Ken: What we generally can say nowadays is that a modern ambulance will have most of the base capabilities of at least an entry level or lower level ER, so we've got cardiac monitoring capabilities, we have ventilators, we have automated CPR devices. And really what's driven that is technology and miniaturization to a degree. So in one easily carried device, I've got a heart monitor. I've got a defibrillator, an automated blood pressure cuff, and a number of other analytical tools that I can use to treat a patient.
[00:27:50] It's the same as a bedside monitor would be in a hospital, and in some cases, ours are actually more capable. So what I'd want to stress to most authors and other folks that are listening to this is that the capability of an ambulance nowadays is far and beyond what you might believe. We can treat most things in the field. There are very few things that we can't do anything about. We may not be able to fix the problem, but we can do a lot of that, if that makes sense.
[00:28:19] Matty: If you were in a scenario where you had to hike away from the ambulance to treat someone, what is a normal set of equipment that you would be bringing with you and how much would it weigh?
[00:28:31] Ken: That completely depends on what the problem is and, to an even greater degree, what the terrain is. One of those things where you might say you need to really hike away from an ambulance is somebody that is out on a trail somewhere and has a fracture, for instance. In a case like that, we may carry some splints and bandaging supplies. It depends on what we know. I may carry some pain-relieving medication so it's a little easier to get the person out. So that way may not weigh a whole lot, maybe 10, 15 pounds. Now, if somebody is having a heart attack out on the trail, I'm going to need to bring my cardiac monitor, my drugs, things like that. That can weigh another, 20, 30 pounds. It really depends.
[00:29:14] Now most places that have the potential to go out on trails or parks and things like that, they'll have access to things like ATVs or four-wheel drive vehicles that can drive them out there. So we don't hike much. It happens, but it's pretty rare.
[00:29:34] Matty: I have to ask how COVID has changed the procedures that EMTs and paramedics follow, both if they think they're responding to someone because of COVID symptoms or just as precautionary measures when there's nothing ostensibly about COVID, but you never know.
[00:29:52] Ken: It really starts from the point of dispatch. When you call for an ambulance now, you'll be asked a series of screening questions and they ask them of everybody. It doesn't matter what the situation is, in terms of, have you been exposed to someone, do you have any symptoms, have you traveled outside the United States? All the typical stuff that you'd expect to be asked in terms of screening for COVID. That will be translated into an algorithm that the dispatcher will follow to tell us is there's a potential COVID exposure.
[00:30:21] Now, if there's a potential or known exposure, the crews will generally use a higher level of personal protective equipment, so better respirators, face shielding, sometimes gowns, depending on where they are. That was more common at the beginning of the pandemic when nobody really knew exactly how it spread. Now if the patient either doesn't have an exposure or it doesn't have symptoms of anything like that, you'll see the crews wearing generally just cloth masks, like everybody else. It just depends on the situation. So that's how it's changed our interaction.
[00:30:56] Now, some of the other things that have changed are some of the procedures we do a little bit differently. So you might be familiar with what's called a nebulizer for asthma. It produces kind of like a mist. Those are generally to be avoided at this point, unless the patient absolutely needs them. And in general, there are other ways to treat that. The reason is that mist goes into your lungs and then it comes back out and it's a very effective infectious vector for COVID. Other things are things like intubation where you're putting a breathing tube down somebody's throat to help them breathe. That's also a direct vector for exposure. So we're doing that a little bit more cautiously. We're using different filters on those kinds of tubes. So practice has changed in that way.
[00:31:41] And then the other thing is really the handling with family members. People like that in a lot of cases, they would be allowed to ride in the ambulance with the patient, go to the hospital, pretty much stay with the person through most of that treatment routine. That's generally not allowed anymore, because they will not be allowed into the hospital. Most hospitals are not allowing visitors at all into the emergency room, except under very limited circumstances. So generally we're discouraging people from riding with the ambulance because you're essentially going to get there and you're going to get left outside. So you're a lot better off if you follow the ambulance and drive.
[00:32:14] There are exceptions to that case where if it's, say, a child, a parent would ride with them in most cases. But again, it depends on the state. It depends on the health system. It depends on the individual department's preference.
[00:32:28] Matty: Does it also depend on how much of a danger you think the person might be if they were left to their own devices? So a panicky spouse whose husband or wife has been taken off in the ambulance and it appears that maybe they're going to follow in their own car, but shouldn't, how would you handle that?
[00:32:46] Ken: That's generally something we leave to the police. It's not really our realm to deal with people that should and shouldn't drive. We may recommend they shouldn't, if we feel that, they really shouldn't drive, whether they're just completely out of control or maybe they've been drinking, generally we'll make sure police deal with that.
[00:33:04] In terms of them coming to the hospital, though, we really don't have a lot of latitude. If the hospital says no visitors, it's no visitors, period. For example, a friend of mine went to the hospital recently and his wife wasn't allowed to see him for almost the entire time he was there, which was almost two months. And even my own wife who works for that same health system as an employee couldn't go see him. So it's a pretty iron clad set of rules at this point.
[00:33:33] Matty: Well, Ken, thank you so much for taking the time to talk with us. I think you've done your bit for improving the accuracy of first responder representations in fiction, and if people are intrigued by the information you shared, what would you recommend if they are looking for more information, what are some resources they could use to do that?
[00:33:52] Ken: There's a lot online. JEMS is a good resource. So JEMS is the Journal of Emergency Services and has a lot of good information about what we do. But really, if you want to learn more about EMS paramedicine, stop by your local ambulance service or firehouse, they can point you in the right direction, and just talk with some of us. We're happy to talk and tell you everything you want to know. That's really the best thing to do, is go make friends.
[00:34:17] Matty: Great. Well, Ken, thank you so much. This has been great.
[00:34:20] Ken: Absolutely happy to be here. Thanks.
[00:04:26] And we've had this conversation about how to refer to them in that scenario? And technician was an idea, but that sounds a little weird, but it sounds like an author could say EMT and they'd always be correct, although they might be underrepresenting the skill of some of those people who are getting out of the ambulance.
[00:04:47] Ken: Yeah. And nobody's going to get upset about underrepresentation. And frankly, in most cases, they're not going to get upset about overrepresentation too much either. But there's a lot of generic terms you can use to refer to the people that get out of the ambulance. You call them an ambulance crew or ambulance attendants, EMTs, medics. Really any generic term is fine.
[00:05:08] The only one that people generally don't appreciate, and really shouldn't be used, is ambulance drivers. We really don't like that. A lot of people get really offended about that. I really don't care. You can call me whatever you want. But a lot of people really do get pretty upset about that one, just because it's really an old connotation of what it was back when EMS started. It actually started with people from funeral homes picking up people and taking them one of two places, either a hospital or elsewhere. And back then they were truly ambulance drivers because they really didn't have training. They didn't have equipment. The field has evolved far beyond that at this point. So generally that's the only term that I would really seriously avoid.
[00:05:50] Matty: Is there any cutoff in the history of first responders, if someone was doing something set not in current day, but they were looking at current day guidelines. Obviously if they're writing it and it's set in the 1800s, then you might really have an ambulance driver, as you're discussing. Is there a point at which you would recommend an author who's writing at some time in the past start doing specifically historical research on first responders, as opposed to just looking at current resources.
[00:06:20] Ken: EMS in its current form really started to evolve in the late sixties, early seventies, where you had things like, paramedics leading teams. Now the field is always changing. We've changed greatly even since I've been in EMS and that's been in the past 20 years, but I don't know that there's a strict cut off.
[00:06:39] I would say you'd be fairly safe talking about, EMTs and paramedics in general if you're pretty much anywhere after about the mid-eighties, early nineties. Prior to that, availability of those services with spotty. Paramedicine as a trade started out in Los Angeles County. A lot of your folks might remember the show EMERGENCY. That's actually obviously a fictional show, but it does give a lot of context into how it started. And that's where it started.
[00:07:08] So yeah, if you're looking, in terms of the timeline, like I said, eighties, nineties, you're probably okay using some of the same generic terms and things as you would today. Although the specific technologies and treatment modalities have changed quite a bit.
[00:07:25] Matty: What kind of things do you see in the portrayal of EMTs and paramedics on TV or in books that are especially irksome to you?
[00:07:32] Ken:
[00:07:33] So there's really a lot of little pet peeves. But really it's portraying EMS as not much more than taxi drivers. There's a lot more to it and we can talk about some of those specifics. But really looking at EMS as that just vacuous truck that takes people places.
[00:07:53] There's a lot more to it than that. And I think a lot of authors, and especially TV and movies, do a big disservice to what EMS actually does and the prevalence of EMS services. So that's kind of annoying. The other stuff is really around specific treatments. Some of the ones that I know you and I have talked about is things like CPR and defibrillation and stuff that it really doesn't work the way that people think it does. And especially if you watch TV, they really get it wrong.
[00:08:22] Matty: Talk a little bit specifically about CPR.
[00:08:25] Ken: Look at the prototypical TV show where somebody gets hurt in any given way, they got shot or they drown, whatever. And the hero of the day will come in and do CPR for 30 seconds and the person wakes up and says, Oh, thank you for saving me. That doesn't happen. CPR when it's needed is because the person is clinically dead, right? Their heart has stopped. You're doing CPR to circulate blood and oxygen around the body.
[00:08:55] Matty:
[00:08:55] Ken: 99% of the time CPR does not restart the heart. It is a measure to help maintain organ and brain tissue viability until you can restart the heart, either through medication or defibrillation or through surgical intervention. So that's what the people usually get wrong, is that, Oh, I do CPR and everything will be okay. No. The success rate for CPR is somewhere, depending again on where you are and the circumstances, somewhere around five to 7%. So if your heart stops outside of the hospital, I wouldn't count on a really great outcome. Whereas obviously TV shows and things like that portray it as something that works almost all the time.
[00:09:40] We may get a heartbeat started again using CPR and medications and defibrillation but survival hovers generally around five to 7%. Higher in some locations that have different systems. I think King County, Washington, was one of the really big success stories and they're up to somewhere like 10 to 15%, but still not great.
[00:10:03] The bottom line is that it's hard to bring people back from the dead and there's a limited time window in which to do it. So, yeah, CPR is a big one.
[00:10:12] Matty: What is happening in King County that increases their rate?
[00:10:17] Ken: King County has had a program for a number of years that they really focused on quality improvement, systematic changes, and really looking at ways that the overall system can improve their practices. Some of the other things are how they actually do resuscitation, what protocols they use, what drugs they use. The big thing that drives all that is their quality improvement process. At least from how I understand it, they review everything that they've done, look at what works, and change it. So it's very similar to what we do in other industries in terms of continuous improvement. And then some of that is certainly system related.
[00:10:57] Some of it is probably due to their service areas, primarily the city of Seattle and King County, so they may have a shorter response time. They may locate their units more appropriately. Time in terms of cardiac resuscitation is the key metric. If you're not there within the first couple of minutes, your chances of success drop drastically. If you're not there in the first 10 minutes, there's pretty much almost no chance at all. So that's probably a lot of why that works.
[00:11:27] Matty: There's some factors there that the individual first responder wouldn't have much control over, like how long it takes them to get there. But there are some things that if someone were studying up what was happening in King County, and that was different than what was happening, let's say, in Southeastern Pennsylvania, how much latitude does an individual first responder have in terms of the practices they're applying? Or is it so structured that an individual wouldn't be able to adopt those practices that are being successful in Washington state for their own personal use.
[00:12:00] Ken: So a lot of the rest of the country, including Pennsylvania, has started to use a lot of the learnings that have come out of King County. One of the things that we've seen adopted over the past couple of years here in Pennsylvania is the use of what's been referred to as either team or pit crew CPR, having a certain number of providers on scene to do different tasks, that division of labor, and really the procedures that they've pioneered in King County and a few other places. So those have spread through official channels.
[00:12:32] Now in terms of latitude given to an individual first responder, there's not a whole lot. We are bound by protocols since we're not licensed medical professionals. Here in Pennsylvania, we're certified. But there is a important kind of medical legal distinction there. We don't practice on our own. We practice under the authority of physician's license, because it's what we call medical demand. So we do have to follow the guidelines that they set and, to an equal degree, the guidelines the state sets.
[00:13:04] Now within that, there are some things that you can consider judgment calls as to how we manage the airway, how we get intravenous access, whether we do it through a standard IV catheter that everybody's used to, or we can use a tool called an IO drill. So it's actually a bone drill that you can inject medications directly into the bone, which is both faster and generally more reliable, but not everybody likes to use that.
[00:13:32] So there are different levels of flex in those protocols, but really when it comes down to sweeping systemic change, that has to come from the state and from the medical direction, physicians.
[00:13:45] Matty: You had spoken a little bit when you were talking generally about CPR, about defibrillators, which is a word I always have to struggle with it, but any other concerns about the portrayal of defibrillators in fiction?
[00:13:58] Ken: Absolutely. Go back to that product prototypical scene on TV, because it's the most egregious kind of offense in terms of defibrillation. And you see the patient's on the heart monitor and they do generally something dramatically and take a last breath that they say something prophetic, and then you see their heart rate or the heart monitor go flat line. And everybody's like, Oh, get the defibrillator! No, that's not what we do.
[00:14:21] And it goes back to the mechanics of defibrillation. So if you break down the word a little bit -- de-fibrillate -- and let's talk about what fibrillate means for a second. Fibrillate means to quiver. When the heart muscle is either injured, starved for oxygen, or a number of different things can cause it, it'll actually shake. And what I can associate that with is, if you do a lot of exercise where you run, sometimes you'll feel your muscles shake a bit after that. It's like that on a much grander scale within your heart, where your heart is just shaking and firing spasmodically.
[00:14:58] The issue with the heart is, to get effective circulation, the heart needs to contract in a coordinated way, where it actually squeezes the blood out of the heart into the rest of the body. If the heart is misshaping and fibrillating, it doesn't do that. So the whole idea of a defibrillator is to stop fibrillation. Now, if you don't have fibrillation in the first place, it doesn't work.
[00:15:22] So the heart has to be in that fibrillatory pattern, which you would actually see on the heart monitor as chaotic lines, very spiky, up and down, and you would not see a flat line. The whole idea of a defibrillator is it passes current through the thoracic cavity to actually stop that fibrillation, stop all electrical activity in the heart to let the heart's natural pacemaker cells pick back up again. Doing that while the patient is "flatlined" is useless and it actually can cause even more damage because now you're putting electrical current that is completely non-therapeutic into a heart muscle that's already been injured.
[00:16:00] So the procedure we would follow if somebody is actually flat flatlined is start CPR. There are some drugs we would give, notably epinephrin, to get the heart either started again, which may happen if you get some circulation going through the heart and you get some oxygenation, it may spontaneously restart. Or sometimes what you'll also see is that you'll get enough circulation to get the heart to fibrillate again, and then you defibrillate and hopefully then it goes back. But again, it's one of those big things that we don't shock flat line.
[00:16:36] The other big one that you see is similar to the CPR paradigm, where you've got people that get defibrillated and immediately wake up and say, Oh, thank you for saving my life. No, that doesn't happen either. Defibrillation is a traumatic event. They were just dead. There's a pretty big insult of the body systems. So they're not going to just wake back up and think everything's okay again. It just doesn't work that way. Generally, they're going to be unconscious, and unconscious for a number of hours or even days after defibrillation. Now, again, there are exceptions to every rule. Sometimes it's a very short duration cardiac arrest, you shock somebody, they immediately come back and they may wake up. Not common.
[00:17:18] Matty: In a scenario where a non-trained person, a "civilian," I'll say, is using one of those defibrillator machines that are sometimes found in office buildings and things like that, my understanding is that those are all programmed so you can't really shock someone who doesn't need it, right? That the system is perceiving if it's a flat line, perhaps the machine wouldn't even let you activate a shock. Is that true?
[00:17:46] Ken: That's completely true. Yeah, you'll get "no shock advised" generally on the machine and it won't even charge the defibrillator. The algorithms in those machines actually sense the heart rhythm and really will only shock in the case of two different specific rhythms. One is ventricular fibrillation, like we talked about, the other one has ventricular tachycardia. Very specific, easily machine-interpreted patterns that the machine is basically built to recognize. Outside of that, it won't do anything for you.
[00:18:17] Matty: In terms of the types of calls that you're responding to, how many of them are truly emergencies?
[00:18:23] Ken: Not that many. It depends on how you define emergencies. It's really a wide-reaching term. But if you're talking about things that are critical, where the people will die without us being there, this is a guess, I'd say we're somewhere, maybe, 5% of the calls are actually critical that they get EMS care immediately. That number may be on the rise now due to the opioid epidemic. We're starting to see more and more overdoses. Those are the kinds of things that if somebody doesn't have either the skills to ventilate the person or to give them Narcan, they're probably going to die.
[00:18:57] So that number of 5% outside of the opioid stuff is probably fairly accurate. If you include that, it's probably higher. But the vast majority of the rest of the calls, we can absolutely make a positive difference, where we make them feel better, we can give them a safe ride to the hospital. and there are problems that we can remediate in the field to the point that they don't have to go to the hospital. But the large majority of them would probably at least survive if not do just as well going via another method of transportation.
[00:19:33] Now that's not to say you shouldn't call 911. I want to make sure that's clear to people. If you're ever in doubt, please call, because that's a determination that really only we can make. And frankly, there's a lot of times where we may not necessarily know exactly what's going on, other than you need to go to the hospital. Don't try to decide that on your own. If you feel that the situation is bad enough that you need to go to the hospital, don't hesitate to call.
[00:19:59] Now that's to say, if you stub your toe and break your toenail, don't call me. That's only happened six or seven times.
[00:20:10] Matty: Have you ever encountered a situation where let's say a wife calls 911 and you go out and the husband's having some medical emergency and the husband refuses to be transported to the hospital or even refuses to be treated? I'm assuming that the individual, if they seem relatively with it, has the right to refuse treatment, is that true?
[00:20:34] Ken: Absolutely. There are very specific criteria as to when people can refuse treatment, when they should refuse treatment, and what we need to do. So the big thing is looking at what we call a person's mental status. Really the standard there is making sure that they're conscious, obviously alert and oriented. C, A, and O. And there are a number of different dimensions to determining that. So oriented to person, place, time, and situation. All of those need to be true for somebody to legitimately refuse treatment safely.
[00:21:08] Now it's not to say that if they're somewhat disoriented, there aren't other cases where they can refuse treatment. And in fact, other people can refuse treatment on their behalf depending on the law and the circumstances. But especially in the case of what we call third-party calls, where it's somebody that is not the patient or may not even be on scene with the patient, calls on their behalf. And they can say, I didn't call you. I don't want you here, some of those criteria don't even apply. They could be completely unaware of what's going on, but if they say, I didn't call you, I don't want you, we don't really have the right to barge in your house and force you to have your blood pressure taken or whatever people might say.
[00:21:48] Outside of that, there's specific things if we're called for what is legitimately a medical problem, the person's conscious, alert, and oriented, then we have a whole flowchart of criteria that we have to follow to say if that's okay or not. In most cases where there could be a more serious problem, we actually have to call a physician at the hospital to get them to give their consent for us to discontinue treatment or otherwise it can be considered legal abandonment on our part.
[00:22:14] Matty: In a scenario where the person does accept treatment, does accept transportation to the hospital, what's the process for turning the patient over to the emergency room doctor or whoever picks up responsibility for them after you've transported them?
[00:22:29] Ken: One of our important concepts is continuity of care. And that is that from the point that person makes contact with the medical system in any sort of meaningful way, we make sure that they have a continuous flow of not only information but proper treatment. So what we're doing when we get to the hospital is obviously doing the rote physical stuff, like moving the patient into a bed or a chair, wherever we are going to end up.
[00:22:58] But the other big part is giving a comprehensive report to the receiving physician or nurse -- generally, it's a nurse that you're going to talk to -- so that they know what the problem is, first of all, and what we did about it and what response there really was to those treatments, plus the patient's medical history, so things like medications, allergies, and other pertinent information.
[00:23:19] A lot of that is also documented on what we call a transfer of care form here in Pennsylvania, a lot of states have a similar thing, where we actually have to get that signed by the receiving person, whether it's a nurse or a doctor, that says, Hey, I gave you a copy of this. You're aware of it and you're accepting care of the patient. So it just gives that kind of medical legal transfer to make sure that they can't say, You didn't tell us that. Well, it's right there on the form. Yes, I did. And frankly, medicine nowadays is not only about patient care, it's also about caring for your own legal rights as a provider. So that's a lot of, as we might call it, CYA. You can figure out what that stands for.
[00:23:57] Matty: And I'm assuming that within the team of people who are staffing an ambulance, there is some kind of hierarchy so that it would be clear who would be responsible for that kind of procedural turnover versus maybe someone else is simultaneously helping the patient into a bed. Is that true?
[00:24:18] Ken: Yeah, that is true. It depends on the makeup of the ambulance crew. Ambulance crews can be either an EMT and a driver, two EMTs, an EMT and a paramedic, two paramedics. It just really depends. There's two levels of hierarchy within that. Well, actually there's three. The major two when it comes to patient care is, one, the person who's primarily responsible for that transfer and continuity of care is whoever's providing care to patient. Just because there's an EMT and a paramedic on the truck, doesn't mean that the paramedic's always providing patient care and the EMT is always driving. It depends on the level of acuity. We may switch back and forth depending on what the patient's condition is. That's the first hierarchy. So whoever's taking care of the patient is responsible for that transfer.
[00:25:02] Secondarily the highest-ranking provider on the vehicle, if you've got a paramedic, generally that's going to be your highest-level provider, is overall responsible for the operation of everything on the truck. If you've got two EMTs, you're both responsible. But in terms of that really patient care aspect, paramedic's responsible.
[00:25:23] And then of course, more situationally, if somebody's driving the ambulance, that they're responsible for safe vehicle operation and communications. So that's kind of the entire plan, where we get into that.
[00:25:36] Matty: And is there a distinction between volunteer and non-volunteer EMTs or paramedics the way there is for firefighters?
[00:25:45] Ken: A one gets a paycheck and the other one doesn't.
[00:25:48] Matty: They both exist, I guess. There are volunteer and paid.
[00:25:53] Ken: Yep. And I've been both. And you can be both simultaneously, although at different agencies. But in terms of licensing and training, there's really no difference, whether you get a paycheck or not. Now some people see them differently, but they are trained the same way.
[00:26:10] Matty: Is that always driven by geographic location?
[00:26:13] Ken: Geographic location to a degree. Politics. Funding. Obviously, it costs money to have paid EMS and fire services. The other thing is really the demographics of the area. More rural areas, you'll see more volunteerism just because people tend to work in their local communities. They're available during the day to go out on ambulance and fire calls. Whereas somewhere that's a little bit more suburban, like this area, is starting to see a hybrid. And then in areas that are more urbanized, you see almost entirely career because people just don't have the time or really the willingness to volunteer anymore.
[00:26:51] Matty: You had talked earlier about the fact that one of the things that we as writers should not do is portray an ambulance as just a glorified taxicab. What are some recent technical developments in the actual equipment that an ambulance has available to it that writers might want to consider for their stories?
[00:27:11] Ken: What we generally can say nowadays is that a modern ambulance will have most of the base capabilities of at least an entry level or lower level ER, so we've got cardiac monitoring capabilities, we have ventilators, we have automated CPR devices. And really what's driven that is technology and miniaturization to a degree. So in one easily carried device, I've got a heart monitor. I've got a defibrillator, an automated blood pressure cuff, and a number of other analytical tools that I can use to treat a patient.
[00:27:50] It's the same as a bedside monitor would be in a hospital, and in some cases, ours are actually more capable. So what I'd want to stress to most authors and other folks that are listening to this is that the capability of an ambulance nowadays is far and beyond what you might believe. We can treat most things in the field. There are very few things that we can't do anything about. We may not be able to fix the problem, but we can do a lot of that, if that makes sense.
[00:28:19] Matty: If you were in a scenario where you had to hike away from the ambulance to treat someone, what is a normal set of equipment that you would be bringing with you and how much would it weigh?
[00:28:31] Ken: That completely depends on what the problem is and, to an even greater degree, what the terrain is. One of those things where you might say you need to really hike away from an ambulance is somebody that is out on a trail somewhere and has a fracture, for instance. In a case like that, we may carry some splints and bandaging supplies. It depends on what we know. I may carry some pain-relieving medication so it's a little easier to get the person out. So that way may not weigh a whole lot, maybe 10, 15 pounds. Now, if somebody is having a heart attack out on the trail, I'm going to need to bring my cardiac monitor, my drugs, things like that. That can weigh another, 20, 30 pounds. It really depends.
[00:29:14] Now most places that have the potential to go out on trails or parks and things like that, they'll have access to things like ATVs or four-wheel drive vehicles that can drive them out there. So we don't hike much. It happens, but it's pretty rare.
[00:29:34] Matty: I have to ask how COVID has changed the procedures that EMTs and paramedics follow, both if they think they're responding to someone because of COVID symptoms or just as precautionary measures when there's nothing ostensibly about COVID, but you never know.
[00:29:52] Ken: It really starts from the point of dispatch. When you call for an ambulance now, you'll be asked a series of screening questions and they ask them of everybody. It doesn't matter what the situation is, in terms of, have you been exposed to someone, do you have any symptoms, have you traveled outside the United States? All the typical stuff that you'd expect to be asked in terms of screening for COVID. That will be translated into an algorithm that the dispatcher will follow to tell us is there's a potential COVID exposure.
[00:30:21] Now, if there's a potential or known exposure, the crews will generally use a higher level of personal protective equipment, so better respirators, face shielding, sometimes gowns, depending on where they are. That was more common at the beginning of the pandemic when nobody really knew exactly how it spread. Now if the patient either doesn't have an exposure or it doesn't have symptoms of anything like that, you'll see the crews wearing generally just cloth masks, like everybody else. It just depends on the situation. So that's how it's changed our interaction.
[00:30:56] Now, some of the other things that have changed are some of the procedures we do a little bit differently. So you might be familiar with what's called a nebulizer for asthma. It produces kind of like a mist. Those are generally to be avoided at this point, unless the patient absolutely needs them. And in general, there are other ways to treat that. The reason is that mist goes into your lungs and then it comes back out and it's a very effective infectious vector for COVID. Other things are things like intubation where you're putting a breathing tube down somebody's throat to help them breathe. That's also a direct vector for exposure. So we're doing that a little bit more cautiously. We're using different filters on those kinds of tubes. So practice has changed in that way.
[00:31:41] And then the other thing is really the handling with family members. People like that in a lot of cases, they would be allowed to ride in the ambulance with the patient, go to the hospital, pretty much stay with the person through most of that treatment routine. That's generally not allowed anymore, because they will not be allowed into the hospital. Most hospitals are not allowing visitors at all into the emergency room, except under very limited circumstances. So generally we're discouraging people from riding with the ambulance because you're essentially going to get there and you're going to get left outside. So you're a lot better off if you follow the ambulance and drive.
[00:32:14] There are exceptions to that case where if it's, say, a child, a parent would ride with them in most cases. But again, it depends on the state. It depends on the health system. It depends on the individual department's preference.
[00:32:28] Matty: Does it also depend on how much of a danger you think the person might be if they were left to their own devices? So a panicky spouse whose husband or wife has been taken off in the ambulance and it appears that maybe they're going to follow in their own car, but shouldn't, how would you handle that?
[00:32:46] Ken: That's generally something we leave to the police. It's not really our realm to deal with people that should and shouldn't drive. We may recommend they shouldn't, if we feel that, they really shouldn't drive, whether they're just completely out of control or maybe they've been drinking, generally we'll make sure police deal with that.
[00:33:04] In terms of them coming to the hospital, though, we really don't have a lot of latitude. If the hospital says no visitors, it's no visitors, period. For example, a friend of mine went to the hospital recently and his wife wasn't allowed to see him for almost the entire time he was there, which was almost two months. And even my own wife who works for that same health system as an employee couldn't go see him. So it's a pretty iron clad set of rules at this point.
[00:33:33] Matty: Well, Ken, thank you so much for taking the time to talk with us. I think you've done your bit for improving the accuracy of first responder representations in fiction, and if people are intrigued by the information you shared, what would you recommend if they are looking for more information, what are some resources they could use to do that?
[00:33:52] Ken: There's a lot online. JEMS is a good resource. So JEMS is the Journal of Emergency Services and has a lot of good information about what we do. But really, if you want to learn more about EMS paramedicine, stop by your local ambulance service or firehouse, they can point you in the right direction, and just talk with some of us. We're happy to talk and tell you everything you want to know. That's really the best thing to do, is go make friends.
[00:34:17] Matty: Great. Well, Ken, thank you so much. This has been great.
[00:34:20] Ken: Absolutely happy to be here. Thanks.
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