The Unwired Medic

Teaching EMS providers & other public safety pros about using mobile tech to improve their practice, patient care, continuing education, scene safety, general entertainment, & productivity.

September 22, 2018
by The Unwired Medic

Notification Fatigue

Alarm Fatigue…

Some time ago, nurses were studied and found to be suffering from alarm fatigue, which became especially problematic in areas like the ICU, ER, and Cardiac/Telemetry units. Bed alerts were being tuned out. Arrhythmia alarms ignored, and more. Have you spent time admitted to a hospital? How long does it feel like it takes the staff to respond to call lights and IV pump alarms (staffing issues notwithstanding)? Seems like an eternity sometimes. Honestly, it’s not their fault. They cope with their work environment to their ability to tolerate the constant and incessant onslaught of beeps, tones, pages, and dings fairly well, but when is it too much?

Yes, You Too…

How are we in public safety any different? Tones for call outs, pagers, cell notifications, MDTs, radios with squawks and chirps, and then we have our own monitors too, like pulsoxes, ETCO2, glucometers, cardiac monitors, vents, apparatus alarms and chimes, sirens and horns.

Now, lets throw smartphones and fitness bands and smartwatches in to that. Social media, entertainment, fitness, and gaming apps all pining for every moment of our time. “Did you see Joe Nobody’s recent update?” “An event was just posted by this business you visit once a year.” “Traffic congestion on your way to work. Try this route to save 1 minute.” “Special Star Team Event Begins NOW! Login and place on the leaderboard!” “I see you haven’t stepped on your smart scale in a few days. Step on and track your progress towards ignoring your fitness goals now!” How can you be at your best serving the public when you are drowning in alerts and app notifications?

Notification Fatigue…

Today, I decided to sleep in after treating a long-standing migraine, so since I personally have turned off the sound and vibrate notifications on almost everything. I got two text messages out of the blue from a K-12 charter school. My kid goes to one, but not their high school, which implemented their first Varsity team this year. The text program is part of SchoolReach, and the text messages are only used for notices of closures, construction by the schools, Code Reds and Yellows, and other urgent matters. Today they decided we, the parents of all the K-12 students, just had to be told to come support their Varsity team and fill the bleachers.

Simply put, whether a text, an app, or other thing that is deemed worthy of incessant intrusion regardless of relevance, must be dealt with, because none of these platforms gives 2 bowel movements about how you feel today or that you just ended a long, tiring shift, or that you work graveyards.

What can you do?

In my text message notification issue, I promptly responded to school administrators that this expansion qualified as notification fatigue and that the six other ways they keep telling us this information, regardless of campus, are sufficient, and to please stop the madness. App developers, my voice is lost in a sea of apathetic users, so I don’t bother. There are other ways to handle them

For starters, your apps notifications can be configured for silent, vibrate, and audio. They can send push notifications. Good app developers also let you decide how often they can send them. If they don’t offer sufficient options, usually in the phone setting under apps, you can block all their notifications completely. If you can’t see your way to diminishing the amount of notifications you get and are busy responding to most of them, perhaps some self-evaluation is in order. Is it nomophobia? Unsubscribe from text messages and notifications for things that aren’t really important. Do you need an e-mail and text and app and smartwatch notification to tell you what new movie is on Amazon Prime Video or Netflix or Hulu? Do you need to see EVERY social media update that platform’s algorithm deems important enough to ping you on? My kids weren’t that needy as babies. Yours?

Personally, I’ve quit a couple games and more than one social media platform recently. Others I have decided to take a few days or a week away from altogether to force myself to remember there is a sky and sunshine and stars and real people I could be spending my time with. No one will remember me for my social media prowess, but they will remember me for being a part of their lives.

See? Nobody cares!

To rephrase Smokey the Bear, “Only you can prevent unnecessary notification fatigue.”

By the way, don’t forget to subscribe to my blog and social media pages for notifications on my infrequent ramblings and musings. MTFBWY, live long and prosper, and for God’s sake people, let’s be careful out there!

January 22, 2018
by The Unwired Medic

Ehrmagerd! Fentanyl!!!

From the Northern New England Poison Control: “The risk of significant opioid exposure is minimal for first responders who encounter fentanyl, carfentanil or other fentanyl analogs in the field. The evidence suggests that limited precautions, such as nitrile gloves, provide sufficient protection from harm. Use of excessive protective equipment could delay patient care and prevent first responders from performing their duties well.”

Fentanyl Everywhere

Sensationalistic articles are popping up like wildfire about Fentanyl exposure. So how on earth have Paramedics and Nurses been able to give Fentanyl and Duragesic Patches to patients for decades without dying of overdoses? It’s astounding any of us have survived!

Look, the hype and hysteria is just that. Touching a drawer handle isn’t going to make you weak-kneed and give you headaches and make you feel like you will pass out. You’re awake and fully lucid one second and lying on the floor the next. That’s just not reality. What we seem to be missing from all these reports are toxicology labs proving Fentanyl is the culprit. I have no doubt some of these cases are psychosomatic due to the stigma over Fentanyl and its cousins, like Carfentanil.

Are the drugs dangerous? Sure, with extensive exposure and even injection of high doses.

Should we be concerned with exposure? Yes, but no more so than with contracting Hep C, influenza, or any other communicable pathogen.

Now, the Northern New England Poison Control has released some solid, common sense guidance on dealing with Fentanyl (and related drugs) exposure, and NOTE the guidance on administration of Narcan (naloxone). Only for RESPIRATORY DEPRESSION! Not for any other symptom! This is what proper use of Narcan is for. Not for pinpoint pupils, not for fatigue, not for weakness, and NOT AS A PREVENTATIVE MEDICATION “just in case” you come across Fentanyl.

Download the .pdf flyer on Fentanyl and please pass it arpund as a memo to your department, and train on this too!

Here are some photos of the document:

EDIT: The following information is the position of the nation’s boards of toxicology experts:

ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to
Emergency Responders

The position of the American College of Medical Toxicology (ACMT) and American Academy of Clinical Toxicology
(AACT), is as follows:

Fentanyl and its analogs are potent opioid receptor agonists, but the risk of clinically significant exposure to
emergency responders is extremely low. To date, we have not seen reports of emergency responders developing
signs or symptoms consistent with opioid toxicity from incidental contact with opioids. Incidental dermal absorption is unlikely to cause opioid toxicity. For routine handling of drug, nitrile gloves provide sufficient dermal protection. In exceptional circumstances where there are drug particles or droplets suspended in the air, an N95 respirator provides
sufficient protection. Workers who may encounter fentanyl or fentanyl analogs should be trained to recognize the
signs and symptoms of opioid intoxication, have naloxone readily available, and be trained to administer naloxone and provide active medical assistance. In the unlikely event of poisoning, naloxone should be administered to those with objective signs of hypoventilation or a depressed level of consciousness, and not for vague concerns such as dizziness or anxiety. In the absence of prolonged hypoxia, no persistent effects are expected following fentanyl or fentanyl analog exposures. Those with small subclinical exposures and those who awaken normally following naloxone administration will not experience long-term effects. While individual practitioners may differ, these are the
positions of American College of Medical Toxicology and American Academy of Clinical Toxicology at the time written, after a review of the issue and scientific literature.

December 21, 2017
by The Unwired Medic

Apple Cheats iPhone Owners Ahead Of Upgrade Time

It basically amounts to theft. Apple has admitted to pushing updates to older phones that slow your iPhone down, but then they try to pawn it off in true Apple style as a “feature”. Rather than telling you your battery is no good and you need a new one, they slow your phone down.

Apple iPhone X

Apple iPhone X – Photo from GSM Arena

It isn’t a feature! It’s theft! If you get a pie  from the market and then pay for it at the register, you expect to find the whole pie there when you get home. You don’t expect the cashier to have squirreled your pie away while you weren’t looking and removed a piece to put back at the bakery so you would be compelled to come back and buy another pie!

You bought and paid for that hardware, so they have no right to do this. They tried to hide it for a long time, denying claims of devices running slower as anecdote and despite proof that legacy hardware was still quite capable of handling upgraded features. Now they were caught Reddit handed and had no choice but to fess up! 

The push was for planned obsolescence, which I can agree with to some degree. So you didn’t get all the new bells and whistles turned on a year later in a software upgrade. Okay. Fine. You bought what is in your hand and some support for new patches and software upgrades. You may get lucky in the new feature littery too. All phones are like that. But to have them reach back and take away from what was already yours? WRONG!

Apple is playing the PR role here and politely saying they aren’t incentivizing you to upgrade, but how would you know if you thought your old phone were just getting automagically slower with age? That must be it, right? They just wear out like putting a couple hundred thousand miles on the car. Apple didn’t volunteer to share that they were throttling your device due to a weaker battery, so you may think a new device would be the fix when in reality, your phone works just fine. Of course a new phone will also fix the problem, for several hundred dollars more. Apple wins, the phone retailer wins, the phone carrier wins, phone insurance wins (if you pay for it). A new battery could have been $150 or less and extended the life of your phone by even two years. 

Don’t get me wrong. I like iOS and Apple devices just fine, really. I don’t own any presently because I don’t want to spend my money there, but they’re good devices with a sound and user-friendly interface, and a great app store. But no user and customer deserves to be treated like this. They should have been up front about it. They should have said your battery performance is too weak to sustain processing at peak speed and you either need a new battery or you need to accept a decreased performance mode. They didn’t offer you that choice through. They made it for you. I prefer to have the ability to make these kinds of choices for myself and Apple apparently doesn’t think I’m to be trusted with that.

Android Performance Mode Settings Screenshot

Android Performance Mode Settings Screenshot

That is what makes Android superior in many (but not all) ways. I can customize my performance as shown in this screenshot on my Android 7 phone (Samsung Galaxy Note 8). Don’t like the way your system is being handled? Flash a new custom or barebones ROM or add a different app to make it do what you want. Yes, risk comes with independence (I’ve heard that said of other things besides smartphone ecosystems too). 

Source: Business Insider – Apple Throttling Gives Customers Reason To Distrust

December 20, 2017
by The Unwired Medic

You’ve Been Left Behind

EMS is being left behind, whether you like it or not. We’re too busy bitching about how hard it is to complete a 120 hour basic first aid course and a meager amount of CE every two years, but we want to be paid $15+/hour as a simple, entry-level EMT. That amount of training equates to only THREE WEEKS OF FULL TIME WORK. You can be replaced easily.

A nurse takes years to create. At least a Paramedic takes 1 to 2 years to create. This right here is why RN’s and BSN’s are paid $30 to $60+/hour. It’s high time for us to put up, or shut up. 

“If you stop and think about it, the RN is usually the least educated discipline on a multidisciplinary team. PTs, OTs, ST, Pharm Ds and social workers all are required to have bachelor’s, master’s or doctoral degrees.” – NY Governor Signs BSN in 10 Into Law for Nurses

April 30, 2017
by The Unwired Medic
1 Comment

Modern Day Barbarism

I find it just a bit ironic that as I type this article, I have recently been in the ER for my customary Status Asthmaticus that accompanies the high pressure, windy stormfronts, was sent home on PRN and NOC home oxygen, and I am taking a DuoNeb.  The ER doc that took my case “got it”.  I think I may have even scared him a bit as I am not really a typical asthmatic.  Ultimately, because of the Pulmonologist, not the ER doc, I wasn’t admitted on what was nearly the two year anniversary of my anaphylaxis episode and the beginning of a regular occurrence of severe asthma episodes that really don’t respond well to customary treatment.  Each time I go in, I wonder, “Will I be in time for them to stop it or will I buy the tube?”

No two ways about it – It’s barbaric:

Today, yet another Facebook discussion is going on with unnamed EMS transport team arriving to an unnamed small ER to take a vent patient to unnamed big ER.  This is nothing new.  We have this discussion several times a week lately.  Frankly, in this day and age, where we are pretty damned enlightened about the effects of the medications we give our patients, what is inappropriate to give, and especially what is inappropriate to not give certain patients, it scares the $h!T out of me to think I will be the next guy getting a laryngoscope shoved down my throat after getting Succs, Etomidate, and…, and…, and nothing else.

How many times does it need to be said?

Paralytics and Pharmacologic Facilitation are NOT Analgesics and Amnestics!

Ketamine Rocuronium Patch - America Tubes On Ketamine

Ketamine Rocuronium Patch – America Tubes On Ketamine

Did you hear it that time?  It’s barbaric.  It’s cruel and unusual punishment.  Even the most hardened criminal and the most amp’ed up dope addict can be reduced to tears and have lost their ability to have any interaction to what you are doing to them.  Imagine a fragile respiratory failure patient.  Imagine a seizure patient that you paralyzed because you thought you were stopping the seizure (that’s a subject for another article) and now he’s post-ictal and starting to recover his mentation, but unable to move.

If you don’t understand the big colorful letters above, put down your laryngoscope and step away from the patient until you figure out the difference between paralytics and sedatives (any proper combination of benzodiazepines, narcotics, analgesics, and more).  You have no business touching a patient’s airway until you get it through your head how utterly and distinctly different these things are.  Attempting pharmacologically-assisted intubation without the proper combination of these medications can and will cause irreparable damage to the human psyche and maybe even irreparable physical damage too.  Even death row inmates are entitled to humane treatment at their execution.  If you aren’t treating your intubation patients with the proper pharmaceutical cocktail for their present condition, you deserve to have your licenses revoked, or at the very least, suspended pending considerable re-education.

Why is this still happening?

This is 2017, at least at the time of the writing of this article, so why, in this golden age of digital information, available at the fingertips on smorgasbord of digital devices in nearly every room and vehicle we occupy, is it that people still seem unaware that the standard of good care for pharmacologically-assisted intubation and ventilatory maintenance?  To paralyze, facilitate, intubate, restrain, and walk away is surely as cruel as you can possibly be.  Have you not bothered to read the textbooks?  Have you not seen any studies?  Surely, there are multiple studies justifying the use of sedation in RSI and DSI.

The patch I show you in the pic above is on my jacket.  They were pretty popular last year.  They get a good chuckle from medics, nurses, and ER docs.  It goes along with the ROCKETamine pic below.  The thing is, they’re great reminders of what many across the country view as the “hands down” (pun intended) best intubation cocktail out there.  Do you understand what the difference is between the two medications?  Really?  Or do you push them because they’re part of a protocol?  Or because the doc told you to?  Do you understand what could happen when you have one without the other?  And vice versa?  Do you understand what the whole pharmacology-ventilatory management standard is if you don’t have these two specific awesome drugs on your ambulance?  Why Succs and Etomidate alone aren’t a management plan?  If you are being honest, and you don’t understand, you are part of the problem, but you can fix it.  If you are being honest and you don’t care, you are the barbarian.

The Band of Brothers:ROCKETamine

I propose that it is high time we band our collective professional asses together and put an end to this nonsense.  Every professional association and board relevant to airway control, whether EMS, nursing, emergency medicine, critical care, anesthesia, trauma, surgery, pulmonology, psychiatry, and any other relevant group, should co-sign a joint position statement decrying the failure to use proper sedation in the initial and ongoing invasive airway-managed patient.  Sign the death note on the barbaric, cruel treatment of ventilatory patients being withheld or underdosed sedation.  Look upon those who do not comply with scorn and shame, limiting their licenses to practice in this area until they complete a comprehensive re-education program on the subject, and if they fail to see the light, rebuke them and strip them of their lawful ability to inflict harm upon the innocent and those unable to resist and let justice be served!

Come on all you alphabet soup groups (ACEP, NAEMT, NAEMSP, AOBEM, AAOS, BCCTPC, HEMS, SCT, CCT)!  Step up and do something about this.  How many times is too much?  I keep to a couple smaller EMS groups and I hear my colleagues complain about it regularly!  Stop complaining and act!

To my colleagues in the field, don’t just complain anymore.  Report it up.  I hear people saying they don’t necessarily know the whole story, and that may very well be true, but here’s the thing… let the review board decide.  If the caregiver was in the right, then they will and should be exonerated.  Don’t decide for the board.  Let them investigate.  If they find there were problems, then you owe it to the patients to be their advocate and the provider may not even be aware they are not properly caring for their patient.  The provider NEEDS to be re-educated, and once that happens, if they continue to mistreat patients, they MUST be removed from that role so they can never harm another patient.