October 2004 Letters

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Mail: EMS, 7626 Densmore Ave., Van Nuys, CA 91406-2042
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We received an overwhelming response to Mike Smith’s Beyond the Books column, What’s Up At the Airport?, in the July 2004 issue of EMS. We appreciate your input on the issues Mike raised, as well as the effort he has taken to respond to everyone’s comments (see Mike’s comments in italics). Watch for more letters on this hot topic in the November issue. —Ed

Raising Voices—Raising the Bar

I am writing in response to Mike Smith’s Beyond the Books column, What’s Up At the Airport?, in the July issue of EMS. In addition to working as a staff RN in the office of Employee Health for Menlo Worldwide Forwarding, a heavy freight-forwarding company situated on Dayton (OH) airport property, I have served as a paid on-call (formerly volunteer) paramedic for the Butler Township Fire Department for over 20 years—we provide the ambulance service for the Dayton Airport.

Over the years I have found the EMS staff (EMT-B, I and Ps) at the airport to be very professional and willing to respond to sound medical suggestions when offered by bystanders or other medical professionals on the scene. Because the airport EMS staff responds on all medical emergencies on airport property, I have observed them as an RN while at work and as an EMT-P on an ambulance. I have also been able to work with airport crews at the Fire Department when they join us for our monthly EMS and mandatory yearly Montgomery County standing orders testing. While all of us are subject to having a “bad day,” I have great respect for the Dayton Airport EMS Staff.

Bruce L. Hill, RN, EMT-P
Employee Health Services/HDY

Thanks for taking the time to write in response to my question regarding other EMSers experience relative to “What’s up at the airport?” It would certainly appear that you have not had the same experiences I encountered. However, when a paramedic hears their patient retching and gagging as the laryngoscope blade is inserted, and ignores it completely, along with the feedback from three healthcare professionals (one nurse, one paramedic, one cardiologist), I don’t believe that can simply be written off as “having a bad day.” I believe it goes well beyond that.

It seems to me that you used the broadest brush at hand in your near-indictment of airport medics. I would wager that there are good, average and bad medics at airports, just like in every other EMS system in the country.

I was trudging through Dallas-Ft. Worth two weeks ago and heard a gate agent ask if there was a doctor in the lounge. I looked over and saw an elderly female on the floor who had apparently lost consciousness and slipped out of her seat. A gentleman responded and identified himself as a physician, I identified myself as a paramedic, and a woman was there a minute or so later who identified herself as an RN. The patient was in serious distress: bradycardic with a respiratory rate of eight and dropping. The gate agents were great—they had EMS responding, gave us their ETA (six minutes) and asked if we wanted the medical equipment from the aircraft parked at the gate. About a minute before DFW EMS arrived I lost the patient’s radial pulse, but she still had a carotid pulse.

I identified myself to the paramedic and gave him a 45-second report that included current patient status, events as we knew them, and possible medical history deduced from the medications she had in her purse. He listened while getting his gear arranged. His partner successfully intubated the patient while he started an IV. At this point, the patient became pulseless, so another firefighter began compressions. Three minutes later—after drug therapy and ventilation—the patient’s pulse was restored and she was transported. I don’t know the patient outcome.

At no time did the responding firefighters/paramedics (I think there were five total) dismiss us as “mere bystanders.” I offered assistance and it was accepted. The lead paramedic found time to (briefly) answer a question about a difference in protocols between their system and mine.

Was this a response by the best medic at DFW? I don’t know. Average? Bad? I don’t know. As your friend rightly pointed out: “Once is an event.” What I do know is that this patient received prompt and efficient treatment by skilled paramedics.

Douglass Sisk
MS, NREMT-P
Sierra Ambulance Service

I find it interesting that you think I used such a broad brush. I simply related my experience with three consecutive airport emergencies (two being codes and one being a serious/critical) where I personally witnessed negligence and/or malpractice in all three cases. That sounds like a pretty small brush to me.

Nonetheless, consider the mathematical probability of that level of care being rendered in three different airports spread across the country, three times in a row. That’s what got me worrying. I would hope the situation is as you described, a mix of good, average and bad, with bad being the minority of the group. Kind of a bell curve of prehospital care, eh?

In any case, that level of worry on my part is what prompted me to ask the question, so I could get a feel as to whether what I witnessed was consistent with other EMSers airport experiences. Obviously, the experience you described sounds to me like above-average care, with a real possibility of a very positive outcome.

Believe me, I would love to find out that what I experienced was an anomaly. However, the simple fact is, I wouldn’t know if I didn’t ask, and if it turned out that other reports were consistent with mine, my hopes would be that action would be taken to improve the care provided. If it turns out that I’ve simply encountered some twist of fate, that would be great news. Unfortunately not for the three patients in my encounters, whose survival was either compromised or tanked, depending on which case we’re talking about.

I haven’t been in a situation like the one you describe at the Denver Airport, in an airport, anyway. Nonetheless, I have seen variations of this situation in the prehospital setting. So my comments are: 1) I don’t think what you’re describing is limited to paramedics in airports; and 2) I have to ask, “Where’s the CQI & medical direction here?” If there is a CQI program in place and the medical director has an appropriate level of involvement, why isn’t this being picked up on? (I’m sure this paramedic wasn’t inappropriate in just this isolated incident.) Finally, if this is being picked up on, why isn’t anything being done about it?

I think this highlights the dangers of educational programs that strive only for “competence.” If our goal is what is minimally acceptable, any skill or knowledge decay at all puts the practitioner below acceptable. Obviously, this is a multifaceted problem involving primary education, credentialing, CQI, medical direction, continuing education and operations.

Thanks for soliciting input on this issue.

Melissa Alexander
Oakhurst, CA

I do agree with your observation that no particular venue owns the rights for “bad medicine.” As I shared with other readers who have written in about my piece on airport EMS, my take is that there is a blend of excellent, average, and bad in every branch of medicine. One can only hope that the “bad” section is only a tiny part of the bell curve.

In regard to your question about the medical director and CQI, you can read his letter and my reply in next month’s Letters section.

On the topic of “competence,” you raise an interesting issue. In the world of medicine, competence to me is another way of saying “safe to work on people rather than training manikins.” If the new graduate who is just at the competent level, does not go to work in a relatively busy environment and/or get partnered with a seasoned veteran to mentor them, it may take them a year or more to come up to speed. If either or neither occurs, that competence thing goes away.

I think you are also right on the money with your point that it is all tied together. From the day you walk into class until the day you hang up your stethoscope, it is truly a commitment to a lifetime of learning. Sadly, some providers think that the day they get their certificate, the learning is over.

Thanks for taking the time to respond to my request for feedback. ’Tis most appreciated.

As the assistant fire chief, and the person in charge of EMS Operations at the Cleveland Hopkins International and Burke Lakefront Airports’ Fire-Rescue Depart­ments, in Cleveland, OH, I found your generalization and categorizing of all airport paramedics quite disturbing. As a critical care paramedic, former flight paramedic, state EMS and fire instructor, BTLS affiliate and ACLS instructor, I can attest to witnessing my share of inadequate prehospital care being delivered also. However, for me to say that ALL suburban, third-party EMS or fire department paramedics are inferiorly skilled and trained would certainly not be fair to any of those organizations or agencies. I could even go further to say that, other than myself, most of the MICN and critical care paramedics that I know are very egotistical, but again that would not be a true or fair statement. One should never judge any one organization, agency or group of individuals by separate incidents. But, I guess when you’re the editor of a magazine, you can exercise your individual opinion in print.

I’m sure that your article was meant to generate responses and conflict. I fell into your ploy. I am very proud of my department’s paramedics, their skill levels and quality patient care. Maybe one should spend his energies in editorials on something more positive, like highlighting the quality EMS caregivers around the country.

Joe Zemek
Assistant Fire Chief
Cleveland Hopkins International Airport Fire Rescue Department

I read with interest your reply to my recent column. It would appear that you may have somehow misread the column or misinterpreted my intentions.

At no point do I recall writing anything about “all airport paramedics,” and I certainly did not say that anyone was “inferiorly skilled and trained.” I simply related my personal experiences with three successive critical/serious patients who received negligent care—and in two of the cases what I would term malpractice—from airport EMS. My concern is that even with great education and training, both can evaporate if not used with some degree of frequency.

Also, I am not judging anyone. I simply raised a question in a professional journal, in hopes of getting a handle on whether I was seeing a fluke or possibly the tip of an iceberg. As I have shared with others who wrote in, most of the medicine (prehospital and otherwise) I have seen over the last 30 years is pretty much a bell curve: excellence to the right, competent care in the middle, incompetent or sub-standard care on the left. I’m sure you’ve seen the recent flurry in writing about errors in hospital medicine. No one is immune. Bad medicine is unfortunately a side effect of the practice of medicine in any venue. One can only hope that it is the exception rather than the rule.

In addition, and for the sake of clarification, I am not an editor. I am a 30-year EMSer with an unswerving commitment to patient care who happens to write a monthly column for EMS Magazine.

Also, did I suspect that this column would generate some controversy? Of course. However, make no mistake, I simply asked what I considered a fair question in a non-public, professional forum.

In regard to your closing comments, I guess I’m a bit confused. If you go back and read the columns I have written for EMS Magazine, you will see many involve me bringing to light innovations and excellence in patient care. I’ve gone out of my way to highlight excellence. To the best of my recollection, I believe this is only the second time I felt a need to go down a road such as this one.

That being said, Joe, what are you suggesting in your closing comments? That I should have turned my back, walked away and pretended that I didn’t see what I did? If that is the case, I’m sorry, Joe, I just couldn’t do that. If we as a profession aren’t willing to look at both the good AND the bad, and do what it takes to continuously improve the care we provide, then how professional are we?

I have just finished reading your article about your April 22 Denver Airport experience, and I don’t know whether to be horrified or offended.

It sounds as though the paramedic in the article was showing bad judgment, but how are we to know what his motivation was for the intubation attempts?

Given that the patient was showing signs of recovery, you indicated that there still was no respiratory effort, and you do not give an oxygen saturation reading.

Quite possibly, using an oral or a nasal airway with bag-valve mask would have been sufficient; it is difficult to tell.

Hopefully, the patient is fully recovered.

It does sound like you travel quite extensively for you to have been exposed to so many different incidents involving so many different airport paramedics.

The reason I would take offense is because I too am an airport paramedic, and have been for going on six years.

As to our system, you hit the nail right on the head when you mentioned the senior moment. Our organization bases station assignment on a seniority bid system. Because of that, the six senior paramedics based at the airport station tend to stay put. However, we can and do work “street shifts” to keep our skills in check, and each one of us can claim at least 20 years of paramedic experience.

Like most, if not all, airports, ours utilizes AEDs, and our first responders are the police officers who provide airport security. I personally have had three recent “saves” at the airport where prompt defibrillation was provided. In two of these cases, my partner and I had the patient intubated, had an IV started and meds on board, and had the patient packaged and ready for transport before the off-airport engine even arrived at scene. I do not believe that my skills have deteriorated in the least.

An airport is like a small transient city. Just last month alone, 1.7 million passengers came through our doors, and there are literally thousands of employees who work at the airport, many of whom work around heavy machinery and in high places.

Granted, the majority of our calls at the airport are falls involving elderly patients. We do, however, see our share of major trauma, cardiac and respiratory events, and many other medical emergencies requiring prompt treatment. We do get everything from Explorer Scouts to veterinarians trying to give us unsolicited advice, but that is all part of working the airport unit, and we take most of it with a grain of salt.

We also teach three monthly CPR/AED/first aid classes per month to airport personnel, and help the Airport Rescue firefighters with EMT review so they can retain their certifications.

We are held to the same high standards as any one of our street medics. Possibly higher standards, due to our need to understand and respond to the airport disaster protocols, knowing the etiology and recognizing the symptoms of in-flight emergencies, and being able to treat these emergencies appropriately.

Because I am stationed at an airport does not mean I should automatically be placed in your category of a medic with deteriorating skills and judgment, so, yes, I am offended, and I’m sure I’m not the only airport paramedic who will feel this way. If I were you, I’d get ready for some heat.

That’s just my two cents worth.

Tom Venditti, EMT-P
San Diego International Airport

Thanks for sharing an “inside view” from your experience. Had I not wanted the opinions of our readers, I certainly wouldn’t have asked.

While I certainly do not believe that my views of these three events is the bottom line, after over 30 years in the profession, 20 of which involved teaching paramedics, I also believe I can recognize bad medicine.

To address your thoughts about the intubation in question, let me tighten up the scenario for you. This was a witnessed arrest with almost-immediate CPR and the delivery of a single shock in less than two minutes after she went down that converted the patient, with the production of carotid pulses in about 15 seconds. Her skin color immediately improved and her pupils constricted, all prior to the arrival of airport EMS and without the benefit of the administration of oxygen. I don’t need a saturation reading to tell me that this was an extremely viable patient.

Upon insertion of the laryngoscope blade, the retching and gagging was unbelievable, and even worse with the second attempt. If that isn’t enough, the intubation technique was terrible—the tube was shaped like a large “C,” much like you’d configure it for a nasal attempt, only it had a stylette in it.

After the first attempt, the medic jammed it down during the second attempt, resulting in vomit blowing out the end of the tube. He attempted to immediately remove it while the patient was flat on her back and while the nurse and I both yelled almost simultaneously “NO!” We both grabbed the patient in an attempt to get her on her side before the medic could pull the tube.

Vomit drained from her mouth as we got her up. I can only hope and pray that little or none went into her lungs.

It is interesting that you described your feelings as either horrified or offended, because what I saw was some of the worst decision-making and poorest intubation skills in over 30 years in our profession. In your words, I was horrified, and that, coupled with the other two events I had witnessed, caused me to raise the question.

Thanks again for sharing your experiences and insights, and for taking the time to write.

I volunteered as an EMT-I for 20 years with Lane Rural Fire/Rescue. Our district is located just north of the city of Eugene, OR, and Eugene’s Malon Sweet Airport is in the middle of our district. The airport is staffed with paid firefighter/medics from the city of Eugene, but Lane Rural Fire/Rescue provides the ambulance transport. Through the years, I have seen some very poor decisions made by the paramedics and some very excellent patient care also. It has always been common knowledge that the airport is staffed by seniority and is the cushy place to work until retirement. I feel you were right on with the comment that their skills may have deteriorated through lack of use.

Von Massey
Staff Captain/Training Officer
Halsey-Shedd RFPD

Thanks for jumping into the fray relative to my quest to figure out what, if anything is going on at the airport relative to the EMS that is provided there. As might be expected, letters are coming in on both sides of the line.

I appreciate your candor in your comments about seniority and the “cushy” road to retirement.

Contrary to what some folks who work at the airport are taking as an attack on my part, I am just an EMSer who believes that we as a profession should pursue excellence in prehospital medicine. If what I saw was a fluke, I will be thrilled to be wrong. Sadly, that isn’t the way this is shaking out, at least at this point in time. Who knows, maybe I’ll get a bunch of letters to convince me otherwise? Unfortunately, it certainly appears that others have experienced similar problems, including yourself.

I could probably write heaps on this subject, but I need to be concise today, quite a task for me.

I work for the San Diego Fire-Rescue Department as a paramedic. In my 22-year career, I have had the opportunity to staff dedicated airport units in both San Diego and New York City. Additionally, not unlike yourself, I have witnessed quite a few episodes of malpractice by EMS staff assigned to airports. I truly related to your article.

I know our management in San Diego has proposed in the past to make it an overtime unit, but the security folks at the port district have concerns about issuing the large number of badges to provide adequate coverage, and also consistency of operations. I agree, the OT way wouldn’t fly.

What other options exist?

• Limiting airport medics to perhaps a three-month rotation.
• Rotation among “special ops” personnel: tactical, hazmat, aviation, etc.
• Share airport responsibilities with another (desirable) unit that actually runs 9-1-1 calls.

For example: Medic-66 is assigned to the airport, dedicated to its use. Medic-67 is assigned to a nice neighborhood, not too busy, not too slow. Maybe those crews could rotate every few months.

• Require they function as “educators,” and consider new medics rotating through for training.

In NYC and San Diego, we have the same dilemma you’ve encountered: high-seniority people who choose to hide from the ever-increasing call volume, and little chance to use their skills between the few calls that happen at airports. I don’t blame them—“up all night” gets old.

Furthermore, they should be considered on the front line of WMD response.

And I suspect that you, like me, have encountered a number of in-flight emergencies. Apart from one decent anaphylaxis, they’ve been mostly syncope and intoxication, but it’s nice to see the increasing availability of emergency medical gear on planes.

Again, thank you for writing the piece.

Tom Anglim
San Diego, CA

I must say that this column has certainly generated a flurry of writing, and that is exactly what I hoped would happen when I raised the question for our readers.

It was my early-on suspicion that there would be tales from both sides of the issue—those who think that airport medicine is fine and without problems, and those who think and have observed something quite to the contrary. All in all, I think every branch of medicine I’ve ever encountered looks like a bell curve: some really extraordinary medicine on the right; decent competent care in the middle; and some crappy care on the left. I could only hope that what I observed was not the norm, and that the left side of the curve wasn’t too large. However, after my third unfortunate experience, my worry level was definitely moving up.

I appreciate you taking the time to write, both to share your insights on the issue of overtime, and for sharing some possible solutions to the possible problem of rust out (or retirement out), as well as to acknowledge that you, too, have observed some bad airport medicine.