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Perils of Paramedics Pursing imProper Patient Refusals

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Inspector General Faults DC Paramedic’s Response to ‘Acid Reflux’ Case

This article comes to us from JEMS.com which has a link to the full article over at The Washington Times. It’s not necessary to read both articles, but since JEMS originally called it to my attention it’s only fair to link the boys over there first. Read the full article, please… I want to see if you feel the same way about it that I do.

Ok, ya back? Good.

In this case that is very reminiscent of the case law I wrote about last year in “EMS Case Law – AMA Refusals, Death, and Documentation” – A DCFD EMS paramedic obtained a signed refusal from a patient who called 911 for chest pain. According to the < sarcasm> stellar, just friggin’ stellar < /sarcasm> journalism employed in the story by the reporter (I mean seriously, can any reporter anywhere ever write a story about EMS that doesn’t sound like a 5 year old’s understanding of Mozart?) the Evil paramedic did bad things that caused someone to die.

And, well… Here are some quotes from the piece, although I still think you should read the whole thing:

“The crew found Givens, 39, on the floor of his home after his mother called 911 — “an indication that he may have experienced something more serious than what was later described as simple acid reflux,” the report says.

Although they asked Givens multiple times whether he wanted to be taken to a hospital and he declined, the report suggests responders should have done more to persuade him to go.”

So they find some guy, a 38yo guy, a young guy who lives with his mother (maybe) laying on the floor probably being all dramatic and stuff… I’m sure he was all like “Ow. My chest hurts” and the medics were all like “Dude, we have a low index of suspicion for your condition being cardiac related due to the fact that you’re young and don’t appear to have many risk factors” n’ stuff.

Or something like that. At any rate, I’m sure they were less concerned about this guy than they would have been with say, a middle-aged male with classic STEMI (heart attack) symptoms. Yes, they signed him off AMA while telling him to take Pepto-Bismol, and yes… the article does indeed say this:

“The inspector general’s report also faults emergency workers for not recording fundamental information, such as Givens’ first name, age and medical history and interactions with his family members on a patient care report. The reports are typically passed on to hospital personnel when a patient is taken to a hospital but are considered necessary even in cases in which a patient is not taken to a hospital to provide medical and legal documentation of responder’s actions.”

But that doesn’t mean that they just plain didn’t care about the guy and were encouraging the refusal, right?

“When Givens asked one of the four emergency workers who responded if he needed to go to the hospital, the responder replied, “That’s up to you; if you want to go we will take you,” according to the report.”

Yea… I’m just going to come out and say that the only time I ever use that line is at 0330hrs when I’ve been called out for a stubbed toe in the winter time and I am actively encouraging the AMA.

But this can’t be a systemic problem with the whole administration of the DC Fire Department EMS division, can it? I mean… that’s one of the nation’s busiest fire-based EMS providers and I’m sure they care a great deal about EMS and give it the full attention it deserves.

“A 2009 investigation by The Washington Times into the training and education of the District’s paramedics found many could not pass basic written exams testing their medical knowledge or that they mishandled basic life-saving procedures during videotaped assessments.

The test results of the paramedic who treated Givens were among those criticized by experts in the report by The Times, and the lawsuit filed by the Givens family accuses the fire department of being aware of the paramedic’s “poor performance” but leaving him in the field.”

Um… but that was in 2009! And I’m sure that the DC Fire Department EMS Division has progressed greatly in improving their EMS care and service delivery, right?

DC BLS Ambulances out of service as Hot Weather Arrives

<sigh>

I will admit, there isn't enough information or proof here to make a decision on due to the *amazing* clarity of the reporting here. I'll admit that I read between the lines when I made my judgement and then pulled back from my original thoughts. Then again, it does seem like my worries about this case are correct… I don't know exactly what the truth is, but I'm guessing it's not favorable for DC Fire EMS.

Excuse me, I mean "FEMS."

<sigh>

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Have you ever read my post on the ultimate, most off-limits “no go” topic in EMS blogging? It might tick you off as well.

 

Posted by on June 17, 2011 • Filed under: Administration & Leadership, Case law, Command & Leadership, Emergency Medical Services, EMS, EMS Management, EMS rant, ems report, EMS Topics, everyday ems ethics, Fire Rescue Topics, Paramedic, training-fire-rescue-topics

Lazy EMS – Encouraging the RMA

17 comments

I had an EMT friend call me the other day with a problem she’s having at work. After listening to her and being less than helpful, I thought that I’d share this with you and see what you’d all have to say about it. I’ll give you my advice to her, but I didn’t honestly have all that good of advice to give her. Let’s see what you think.

My friend who we’ll call her “Ann” even though that may or may not be her real name, is a former partner of mine. She’s a cool girl. She’s as much of the caring, kind, and competent EMT as you’d ever want in a partner and she’s also pretty fun to work with. I liked working with her and was sad to see her move away. I was happy for her when she got this BLS 911/Transfer job on a “big city” ambulance service, but she’s had some troubles there. Now, I’ve worked with her for a year as one of my regular partners and I know she’s good at what she does. I also know that the reputations of all of the ambulance services in this “Big City” aren’t all that stellar. Frankly, I’d take her word over theirs if I was pressed to answer a about it. 

She called me and asked my opinion on what she should do about a situation that’s developing with a new partner of hers up there in the big city. She explained that this guy is a know-it-all type who encourages RMA’s (refusals, Against-Medical-Advice, etc) on almost every patient. She says that he won’t touch anything unless it’s a true emergency and tries to dissuade every patient who he feels is beneath wasting his valuable BLS time on. She says that it’s reckless and that he does it to excess, even when it’s clearly not in the patient’s best interest in her opinion. She says that he rationalizes it by saying that the patients won’t pay their bills anyway, and that some of these patients are simply being a burden on the system in general and that he’s just doing his job.

And I can understand that… to a point. I mean, who among us has ever rolled their eyes as a drama-filled patient tries to overplay their conditions to get sympathy and a transport or simply doesn’t even try and expects a free ride to three hots and a cot… I get that. In fact, I see it all the time. It bothers me to no end… and yet I rarely, if ever, encourage an RMA.

Ahhh, this is SO much better than doing a report

In fact, there are only certain times that I ever will encourage a refusal… and that is when there is a clear benefit to the patient not be transported to an ER via ambulance. I will do this at times when the patient will be better served by something like an urgent care center, or by a quick trip to their primary care doctor. I’ll show up, provide a full and detailed assessment, and actually talk to the patient about their options for medical care. I’ll tell them that maybe the stitches they need would be done faster and cheaper at the Urgent care down the street than at the ER, or that their need for a simple x-ray or throat culture could be handled somewhere else. I’ll even tell them when I think they can save money and still be safe by being transported to the ER via private car rather than by my ambulance. I feel comfortable doing that when it’s clearly in the PATIENT’S best interest – NEVER when it’s in MY best interest. Even then, if the patient still wants to go via ambulance to an ER or is unsure that my option is the best option for them I transport them without complaint. It’s just safer for my career to do that. Ultimately, I’m not a physician and I can’t make the final legal determination on what’s best. Only the patient or a physician can do that and I am usually not the patient.

However, that’s not what Ann says this new partner of hers is doing. She says that he tries to defer every transport on the grounds that he’s lazy and then he writes very sloppy reports about the calls he refuses. She says that he’s been in trouble for this before and that while he was working at another service, he was actually almost terminated for this behavior.

I know the type of EMT he is… He’s the “So, do you want to be transported or what?” kind of EMT. The kind of EMS person who feels that he or she doesn’t ever respond to “Check someone out” and that only the patients that absolutely have to be transported to an ER for an “awesome” enough medical complaint are truly worth their time.

I hate those kinds of EMTs.

She is concerned for her job, her license, and her career while she works with this guy. She doesn’t want his bad behavior to get her roped into a complaint, lawsuit, or worse… she wanted to know if there was a way she could protect herself legally from his actions while she was working with him.

I went with my stock answer on this. Being an EMS supervisor myself, I asked her if she’d talked to her superiors about this. She said she had done just that, and it hadn’t gotten anywhere.

I wasn’t surprised.

Unfortunately for my friend, there’s just no reasoning with this kind of EMT. I’ve worked with their kind before and I know how painful one’s working relationship with these people can get when you force them to *gasp* do their jobs and take people places while treating them for whatever they say their medical complaint is. They tend to get growly at you when you tell them you’re having trouble hearing them over the sound of you not caring what they think. It makes lunch time a tenuous situation and totally ruins the Christmas party.

My next pearl of advice to her was to tell her to actually send a written letter to her supervisors, detailing her complaints and stating her concerns in writing. My thoughts would be that then, there would be a paper trail that shows she at least tried to do something about it. Unfortunately, I also had to warn her that it may end up branding her as a trouble-maker when the bosses realize that they now have a paper trail too, only they actually have to do something about it. They may retaliate against her instead.

Then I told her to CC a copy of the letter to the medical director, just for emphasis. It’s because I’m a devious trouble-maker myself.

Situations like this are all too common out there and they are the things that hold our profession back. Yes, I know that there are system abusers out there in patientville. We’re not going to fix that with our current system and really need to get more options out there for appropriate treatment pathways. However, putting people at risk by encouraging RMAs because you’re a lazy provider hurts our efforts by setting a bad precedent. Please don’t do this people. Take it from me. I’d never let you get away with it on my shift.

Does anyone else have any better advice for my friend Ann?

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Also, it may be helpful to read this post: a primer on the people I call “Grumblemedics”

Posted by on January 30, 2011 • Filed under: Administration & Leadership, Command & Leadership, Emergency Medical Services, EMS, EMS ethics, EMS Management, EMS Topics, EMT, everyday ems ethics, grumblemedics, medical ethics

A Late-Night Rant about Petty Politics in EMS

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I had to think about a Facebook comment that I just posted on my personal Facebook page. Admittedly, I’m pretty angry right now and I probably shouldn’t be writing. It’s been a long night, you see… and I’ve had it up to my eyeballs with what I’m angry at.

However, this blog is my therapy and I can use it to get some stuff off of my chest whenever I see fit, right? Good, then here goes.

Tonight I’m going to forget that my computer has been acting up on me and has lost two 1000word-plus articles that I was lining up for the end of the week. I’m not even going to mention that I’m behind on a lot of projects because I’ve been overwhelmed with work. I’m not even going to talk about how the workload that I’ve let pile up has been making the blog suffer… Nope. I’m going to jump to the front of the line and bring that Facebook comment right here, to the front of this blog page where a few thousand EMTs and Medics might read it this month.

“Revenue Preservation, Area Preservation, Ego Preservation, and Political Capital Preservation” – These things are the top priorities of some EMS agencies I’ve dealt with over the years. Patient care is on the list, but its way down on the bottom of these agencies’ priorities. Some agencies have their priorities straight, but more it’s more common than I’d like to admit that EMS agencies have those four things at the beginning of this paragraph firmly implanted into their unwritten mission statements.  

I’ve written at length about EMS politics and how I hate them. For example:

-          Is What You Do “The Best You Can Do”

-          Volunteer Fire/EMS – Taking the High Road and Letting Go

-          Two Cases, One Letter: From One Paramedic’s Struggles, Change Can Come

-          Cat Puke Chicken

-          EMS 2.0, Bernoulli, Fluid Dynamics, and Changing the World

-          And Much, Much more…

And tonight, again, I’ve seen yet another example of the worst kind of EMS politics. I’ve seen these situations countless times before and I’ll see them countless times again, I’m afraid. People who don’t put the patient first have missed the whole point to this EMS thing. We’re here for the patient. We’re here for the citizens. There is a selfless aspect to EMS that must be respected in the preservation of the greater good. To miss that for almost any reason is to disrespect not only the foundation that EMS was built upon, but also the foundation of the entire healthcare system.

“First, Do No Harm”

Yea, that’s the first pledge of the Hippocratic Oath, the same one that Physicians take when they become doctors. EMS people are an off-shoot of physicians and we should follow those four words up there as much as they have to. Using the citizens of your jurisdiction as pawns in a political game is to violate those most sacred of oaths. EMS people tend to feud for the flimsiest of forgettable reasons. These feuds escalate unchecked for years until every action taking by the opposing party seems only to reinforce the perceived validity of the petty feud, even when the original actions or inactions that caused the feud were lost to history or died with the people who started the feud to begin with. Often, neighboring squads hate each other for no reason that they can remember. Factions within a single EMS agency may feud internally for no good reason whatsoever. These things escalate and escalate until patients are harmed by them… for no reason at all.

And if there ever has been a reason to harm a patient for a petty feud between services, between cliques, or between individuals, I’ve yet to hear it. In my opinion, using a patient as a pawn in a political game is the worst kind of offense.

These petty EMS politics, these laughable feuds, and the little kingdoms must have the light shown upon them. As I said in my probably politically incorrect Facebook post:

“I don’t like it when Petty People play petty politics with peoples’ lives. Really, people die from the kind of stuff I’m angry at without ever knowing that they were pawns in a political game. EMS politics must be exposed to the light so that the people that play them can be scattered like the cockroaches they are.”

Do you see anything that I’m going to be in trouble for tomorrow when people read that post? Remember, that’s on my personal account… not the blog account. Yes, I do take personal responsibility for everything I say on this blog page or in any of my public speaking or writing for that matter, but there’s a chance that people I know and may or may not have been talking about will read that tomorrow. My guess is that I will be the bad guy for saying it.

And frankly, I don’t care.

As I said in the post that I linked to above, Volunteer Fire/EMS – Taking the High Road and Letting Go – I am willing to bury each and every hatchet I do now hold or have ever held and solemnly pledge to conduct myself in friendship, mutual understanding, and for the good of the ideals in which we all should share. My guess is that there are people out there tonight who should do exactly the same. Don’t let petty politics harm those whom we’re pledged to serve. It’s not about us. It’s about them. It’s about our ideals.
It’s bigger than us. We are more than the sum of our parts. Don’t forget that.

I know that this hasn’t been the most polished piece I’ve ever posted up here, but everything I’ve said I believe. That’s why I’m a blogger. It’s why I’m a paramedic as well. Thanks for letting me rant.

The EMT Oath as adopted by the NAMET

EMTs have an Oath as well...

Posted by on October 27, 2010 • Filed under: Administration & Leadership, change, ckemtp rants, Command & Leadership, edemse, Emergency Medical Services, emotions, EMS, EMS ethics, EMS Management, EMS rant, EMS Topics, Ethics, everyday ems ethics, Fire Rescue Topics, medical ethics, Paramedic, politics, professionalism, rant, Uncategorized

What Difference Does EMS Make? Choose Your Own Ending

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John didn’t need his alarm clock this morning. In fact, he was wide awake just a few minutes before it went off. He turned it off so as to not wake up his wife and got up quietly to start the day. Today was going to be great. It was huge. Months of work at the office were finally going to be recognized today in the biggest project meeting he’d had in a year. Today’s meeting would launch his career faster than almost anything he’d done before. He was excited. He was ready.

John showered, shaved, and got dressed up in his new suit that he’d bought the day before. He wanted to look his best for this meeting. Everything was counting on it. His wife Joanne had coffee and a quick breakfast ready for him when he came down the stairs. He sipped on his coffee for a bit as he ate his breakfast. It was really sweet of her to do that, He thought and he told her so with an extra hug and kiss as he left for his commute. He wanted to be to work early today to make sure that he was there to answer any pre-meeting questions. This was the day.

Traffic was light on the interstate that morning and John was moving at a good clip. It was strange, he thought, for traffic to be this kind to him on a Monday morning but he figured it was a good omen. His phone buzzed with an e-mail and he glanced at it. It wasn’t anything that couldn’t wait until he was in the office, he thought. Then a great song came on the radio. John reached down to turn up the volume so he could get pumped up for the drive…

He never saw the cars stopped just in front of him.

Mary took care of herself pretty well for a type one diabetic. Her doctor had told her that. She stuck to her diet, maintained her sugar levels meticulously, and took her insulin on a sliding scale that seemed to be working perfectly. Her blood sugar readings were always right where her doctor said they should be. Mary was proud of that. She worked out and tried to get out walking or jogging the trail at the park at least 3 or 4 times a week. She felt good, looked good, and thought that she was doing all she could to take charge of her health.

It was a beautiful Saturday morning and Mary thought that she should take her dog Patches out for a walk around the pond. Patches was a 1 year old Golden Retriever and loved jumping in the lake to fetch sticks. Mary had taken her morning dose of insulin, popped a multivitamin tablet from her new bottle that she’d bought the day before, and ate a quick bit of breakfast before she put Patches on his leash and started walking to the park. It was about five blocks away and patches knew the route well. Everything was great, until the nausea hit… Mary tried to fight it but knew that she was going to throw up when she started salivating and breathing heavily. She ended up throwing up in some bushes next to the sidewalk. She thought that she was lucky. Nobody saw her hurl up her breakfast and she immediately felt better. It must have just been the new vitamins that made her stomach upset, she thought as she continued walking to the park. She figured that she just wouldn’t take them again.

Mary never felt sick. She just thought that she should take a nap. The rock over there looked like a good place. Why was she so sleepy? Never mind… Just lay down and nap. Nap good.

Luckily, another jogger happened by to find Mary unresponsive.

Work had been scarce lately and Steve was happy to get his truck back on the road. He drove a live-bottom trailer hauling asphalt for a big local paving company and they hadn’t had many big projects come their way lately. Driveway work was steady, but rarely did the company need Steve to drive a big truck out to a site for a driveway job. Steve made his best money and hours when the company had highway work and today was the first day of a big job they’d just gotten. He’d been in line with the other trucks waiting his turn to dump his load into the paver for hours and even though he was happy to be working, he had to pee. Minutes turned into hours and finally it was his turn to drop his blacktop and head back for a new load. He couldn’t wait to be done. He really had to pee by this time and he knew exactly where his next opportunity would be. He backed his trailer up to the paver and raised the bed. Then through his rear-view mirror he saw the people scramble and jump off of the paver. He felt his truck lurch forward as the paver machine was pushed into it from the impact of a car travelling too fast in the construction zone. When he jumped out of his truck after looking to make sure there was nobody coming at him, he saw his friend Luke laying on the ground. Luke was bleeding, bad. The car and the paver were a tangled mess of metal and there was someone screaming at an unmoving figure in the passenger seat of the car.

Steve no longer had to pee…

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Note to blog readers:     I can’t quite decide on what I should do from this point on. I can take two paths, one is a rallying call to community members asking them to put themselves in the place of the people in the above cases and get out there and support their local EMS. The other, is a rallying call to us EMS people… I’ve written it both ways. You can see what you like best.

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Option #1

Every day, Paramedics and EMTs put on their uniforms, fire up their ambulances, and get ready to face the onslaught of whatever mayhem the streets produce for them during their shift. They do a job that is unpredictable, complicated, and vital to the community. These three stories could happen to you or someone you love tomorrow and each of them will require the response of a highly trained, expert Emergency Medical Services (EMS) provider. There are times when your local ambulance service makes the difference between life and death but there are far more times when they make a big difference in a person’s continuing quality of life. By interceding in the first few moments of a medical emergency with highly trained experts, EMS makes a difference for us all. Communities that support their local Emergency Medical Services have better services and community members that are more educated about what makes quality EMS are better suited to support their local services.

You may not think about the people who respond to your call when you dial 911, but all we do is think about you. Get informed, get involved, and support your local Emergency Medical Services.

We’re there for you. We need you to return the favor.

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Option #2

As you come in to work today, lace up your boots, or turn on your pager, think about the patients in the above cases. They’re people just like anyone you see in your day to day life. They and others like them didn’t intend to be placed in the situations they’re facing and to them; theirs is one of the most intense situations of their life. Their very life and the continuing quality of their lives could rest in your hands today. They are depending on you. Their families are depending on you. Your knowledge, skill, and preparation to perform your best are paramount to these people. Their care rests on you. You owe them your best and there is no excuse they’ll accept for poor performance.

EMS providers transcend their self when they lace up their boots and sign on for duty. Society needs us. Our patients need us. We need us. We will never know the impact we’ll have on the lives of our patients, their families, and their communities… but it’s huge. We as EMS providers play a pivotal role in our communities. They’ll never acknowledge it en masse… but that doesn’t diminish its importance. Recognition for our skills isn’t necessary for our skills to be vital. EMS people do their jobs because they’re important. We do our jobs because our guts tell us that what we’re doing is right… and even when we stumble and find ways to improve ourselves and our care, it doesn’t diminish the importance of what we’ve done. We have acted, and we continue to act in the best interest of humanity.

Today you can make a choice. You can make the choice to seek out and become the best EMS provider you can be or you can choose not to. I suggest that you make the right choice but no one will ever be able to force you. Your care is an art and a science. Your performance is based upon hard science and soft intuition. There can never be a book that will tell you exactly what is right for every situation… you simply have to learn it and learn how to make the right decisions to fit the situations you find yourself in.

My advice to all EMS providers is to take the high road. Err on the side of what you truly feel is best for your patient. Do your best. Study hard and learn from those you consider the best among us. As an EMS provider, you bear the burden of an overloaded system that pays poorly and garners little respect. I feel it too. I say that it doesn’t diminish the importance of what we do and it isn’t the individual patient’s fault. They deserve our best no matter what the system is doing to us. It’s our responsibility and our calling. It has been said that the definition of a “Professional” is one who can perform their duty adequately in conditions that would cause the amateur to turn back. I’d say that we’re living in those conditions today, but we still have to perform. Do your best and know your stuff. Lives depend on your commitment.

It is our job to promote ourselves. It is our job to elevate EMS. It is our job to speak out and optimize the system. The fault for its failings lies within our profession and it is our job to change it. All of us, individually and collectively have the responsibility.

Will you answer?

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So I got a little philosophical in this one. Which ending do you like better?

Posted by on September 7, 2010 • Filed under: 911, edemse, Emergency Medical Services, EMS, ems 2.0, ems education, EMS Motivation, EMS pep talk, ems scenario, ems scenario based education, EMS Topics, EMS training, Ethics, everyday ems ethics, Fire Rescue Topics, In the Line of Duty, inside the mind of a paramedic, letter to the editor, Line of Duty, Paramedic, paramedic education, Patient Management, pride, profession, professionalism, Public relations, scenario, scenario based training, stories, Training & Development, training-fire-rescue-topics

Four Words: EMS, Apathy, Disgrace, Massachusetts.

12 comments

By now you’ve all heard of the flap that is happening in Mass. regarding the 200 or so EMTs and Paramedics that had their licenses suspended or revoked for running a non-existent training program or for falsely representing that they attended non-existent training classes. If you haven’t heard about it by now, you’re probably not following EMS news as much as you should.

Here is one of the articles on the subject from JEMS.com

The issue has been discussed quite a bit around the EMS blogosphere. Some big name bloggers have written on it, and I even discussed it a little bit on the EMS Educast the other day.

Here’s TOTWTYTR’s take on this: I’m Not Very Sympathetic

And here’s Rogue Medic’s take on it: (this is a part-2 that reiterates the first)

Here’s the episode of the EMS Educast where we discussed the issue briefly

Other than for speaking about the issue briefly, I’ve been avoiding writing on it. My job is usually to report positive things that are happening in the EMS world and this is definitely not a positive thing. In fact, it’s a disgrace to us all. Rogue Medic has it right when he asks the question “Why do we Encourage such apathy in EMS?”

And that’s what this is. It’s not just that it’s apathy for the boring destruction of brain cells that we call “Continuing Education” in most areas of EMS, it’s the apathy for the whole process. The apathy where we as a profession have let the standards get to this point.

I mean, really. How many of you feel that the continuing education you receive is anything more than something you have to do in order to keep your license up? How many of you feel that your regularly scheduled, mandatory, continuing education classes are of any quality? How many of you feel like they’re actually doing anything good for you?

And that’s the system in which we function. TOTWTYTR made the statement that he sits through boring traning classes all the time because those are the hoops he has to jump through in order to maintain his licensure. I do too, of course. I sit through probably as many or even more classes than anyone reading this article because I am a practicing paramedic with National Registry and licensure in three states. Sometimes the training from one state carries over into the next, and sometimes it doesn’t. At any rate, I get to listen to unmotivated speakers read flat material whilst sitting in an uncomfortable chair on a very regular basis. We all do.

However, I feel that I keep up my continuing education quite well on my own through other means such as extensive self study and non-credit medical education. Keeping my professional skills sharp is very important for me because not only am I proud of my professional skills, but I am well aware of the fact that the quality of my skills translates into the quality of life for my patients. If I keep myself sharp, I’m a better paramedic. If I let them get dull, well then I’m an apathetic paramedic who isn’t doing my duty. Duty is important to me. So are things like Pride, Professionalism, and Honor. In fact, those three words are more than just the slogan for my blog, they are how I think that I and other EMS professionals should live their lives and careers.

Others have been quick to demonize the 200 suspended EMTs. Others have been quick to defend them. The ones defending them have said that these people are apt to lose their incomes, their livelihoods, and that the punishment is unfair. Well, for that part I disagree. The punishment is indeed fair. You could have killed someone by being untrained oafs with lackluster skills. You never proved you were otherwise. However, if you were to ask me if I thought that a state EMS agency – ANY state EMS agency – was competent to manage such a program, I would laugh at you.  Every state has made an attempt to regulate continuing education and I agree that there is a good reason for them to do so. I would also agree that the prospect of regulating a group of EMS people in their continuing education efforts is a daunting task. I would say that the perfect system has yet to be developed and that a good number of the 200 were simply “playing the game” and thought that since their states EMS continuing educational system was a joke that they could make a joke out of it as well.

Here’s the most biting apathy of all to me. If you believe that a system that you work under is a joke. If you believe that there is a better way to do something. If you believe that what you’re made to do is pointless and obsolete… then why the heck haven’t you done anything about it?

I’d like you to look at this issue from this perspective, folks. Sure, not everyone in that group of 200 were caring, competent professionals. I’m sure some of them were jackasses. (And yes, I said “Jackasses). However, I’m also sure that there is a percentage of them in that group that sincerely care about being the best they can be in EMS and they simply got caught up in the mob mentality. I’m sure that some of them had just given up. I’m sure some of them were good people who just became apathetic.

I hate apathy.

If what, say 50% of that group were of the caring kind, that leaves 100 people who thought that the system was broken. Did it not occur to any of those 100 people to try and change it? Did they not try and band together to improve the system? Could one person do it? Could 100 people do it?

If we are to be regulated and controlled by obsolete and ineffective bureaucratic systems, then it is our duty to rise up and change things. Sure, that sounds melodramatic… but how many times have you thought that your state regulations were stupid. One of the defining aspects of a Profession is Self-Regulation. Look at your states “Bar Association” for Lawyers, or the states “Medical Association” for physicians.

Is there any state out there that has a “Paramedic’s Association” that has any teeth to it?

No continuing education system or relicensure processes is even close to perfect. That’s because of a few reasons, not the least of which is because the government is the one running it. The other reason could be because it isn’t being policed by the paramedics who care about it the most.

I’ve said it before, I’ll say it again. It’s time for us to take ownership of our profession. Stand up and make this the profession it deserves to be. Stamp out apathy and band together to let your voices be heard. If you don’t start the process of meaningful change, who do you expect to do so?

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For more positive discussion on EMS, check out the comments section in “Negativity? You Won’t Find That Here” or for a description of two real-world moral and ethical dilemmas in EMS, check out “Two Cases, one letter. From one paramedic’s struggles, change can come”

Posted by on July 9, 2010 • Filed under: Administration & Leadership, ckemtp rants, Command & Leadership, edemse, Emergency Medical Services, EMS, ems education, EMS ethics, EMS rant, EMS Topics, Ethics, everyday ems ethics, Paramedic, paramedic education, politics, Training & Development, Uncategorized

Saved by the Bell? High School Student EMS

61 comments

Ahhh, High School. The classes, the lockers, the bells, the peer pressure, the parties, the immaturity, the congestive heart failure, the overdoses, the emergent response, the…

Wait, what?

I’ve been hearing a lot recently about Emergency Medical Technician training being held in High Schools (9th – 12th grades) with teenage high school students being trained to be EMTs. At first blush, it actually seems like an innovative way for communities to meet the EMS staffing shortage problem head-on. In addition, it would seem to be a great way to get young people interested in EMS. In fact, THIS ARTICLE posted recently by Zoll EMS&Fire on their Facebook page seemed like a good idea to me at first. A county partnered with a technical high school in order to train new EMTs to swell the rosters of their county’s services. It’s gotta be a good idea? Right?

Then how about this service in Darien, CT. that is ENTIRELY STAFFED BY TEENAGERS AND HIGH SCHOOL STUDENTS? (Dept. Web Site)

Or this service, in Hoboken, NJ that has a student emergency response team that “respond(s) with the school nurse to non-emergency calls”? (additional article)

I have been hearing about such things for a while now and even spoke about it with Tiger Schmittendorf on the March edition of the Firefighter Netcast, however I didn’t give it very much thought until I read the “Last Word” section of JEMS Magazine in what I believe was the March 2010 issue (although I can’t find it anywhere on their web site www.jems.com). It talked about our friends in Darien Connecticut that run Post 53 EMS, a service that is staffed and ran almost entirely by high school students. I was a bit peeved after I read that. Then yesterday when I read the article about the service in Sussex County, I got just plain mad. I don’t agree with this at all. In fact, even though I might have been for it without thinking it through, now I am coming out completely against it.

There, I’ve said it. I am against beginning Emergency Medical Technician training in high school and I am most certainly against persons under the age of 18 staffing ambulances. I also must strongly condemn persons under the age of eighteen responding to emergencies, operating emergency vehicles, or taking responsibility for professional level patient care.

Look at the words there and understand just how much I condemn the actions of the politicians and officials that permit this. You are endangering the public, harming the profession of EMS, and creating a systemic negative impact on patient care throughout the system. You run the chance of increasing patient morbidity and mortality, run the risk of getting teenagers injured and/or killed on an emergency scene, and are exposing youth to situations that they cannot possibly be experienced enough to understand.

I am fully aware that the above paragraph is inflammatory and I am aware that the proponents of these situations are not going to like what I have said, but that doesn’t make it less true. Look for a minute beyond the arguments that you are going to make about the kids themselves, who I am sure are all upstanding young citizens who are surely beyond reproach. Look for a minute even beyond the fact that evaluation of the kids themselves must be taken on “a case by case basis” as I’ve heard before when this issue is argued. T o be certain, there are kids that are capable of functioning to the EMT-Basic level with proper, adult, professional supervision… However, I want to know why there is a perceived need?

The communities that support and offer these plans where students are trained to the EMT level and especially those communities where persons under the age of 18 are active emergency responders generally purport to be offering these plans in order to combat a “shortage” of trained emergency responders. This is where my biggest grievance lies. This “shortage” of which they speak is manufactured. It’s false, and it’s created by the very attitude that causes the local political powers to think that a program that provides a consistent stream of young, inexperienced, naive EMTs who are willing to work just for the “excitement”, “honor”, and “cool factor” that these programs seem to offer is a good idea. Here’s the thing, these communities don’t have a shortage of adult, professional EMTs who are willing to do the job. They have a shortage of adult, professional EMTs who are willing to work for peanuts in a system that has no respect for what they do.

Get it? If you have such little respect for EMS and the EMTs that provide it that you are comfortable letting teenage kids work your trucks, you obviously have such little respect for EMS that you provide horrible pay and working conditions to the point where no self-respecting adult can make a living on the wages and conditions you offer them. There’s no shortage of EMTs willing to provide excellent EMS. There’s a shortage of pay and professional respect that causes them not to be able to survive working the available jobs. Trust me, if these communities paid better and provided better jobs there would be no shortage of EMTs. It’s manufactured by their willingness to just have someone with a pulse and an EMT card on their trucks. It’s manufactured by their thought process that EMS is simply childs’ play and that since “any idiot can do it” they might as well put kids on the trucks. The EMT shortage has always been created by lack of pay, poor working conditions, and an unwillingness of local politicians to provide adequate amounts of these things. Creating high-school EMT programs reinforce this by always providing a stream of fresh meat willing to work for nothing. Young people don’t worry about such things as pay high enough to support a family, nor do they care so much about things like insurance, benefits, or retirement plans. They just want to get out there and go to work. 

I make the argument that putting inexperienced high-schoolers on ambulances increases morbidity and mortality using my experience as an experienced long time paramedic. I offer the full body of research that proves that experienced healthcare providers provide better healthcare than do inexperienced ones. The fact that there’s such little research out there does not diminish the fact that you have no such research that shows safety in what you do. I say that your communities would be better served by adult, professional, well compensated providers. I say that they would save more lives and reduce more suffering than do your high-school kids. It is well known that patients have better outcomes when they trust their healthcare provider and you ask your patients to put their trust in high school students. There are many possible scenarios out there where the patient’s very life and/or death rest upon the skilled interventions provided by an EMT. In these situations, even experienced providers make mistakes. You’re telling me that the incidence of these mistakes will not be unacceptably higher using teenagers?

When your Wife, Son, Husband, Daughter, or friend is lying there, dying on the floor, the roadway, or on the cot, will you feel comfortable with your decision to put a high school student at their side to be in charge of their continued comfortable survival? I make the charge that you will not. Your community members do not need a child coming to them in their hour of highest need. They need a professional, adult provider and your system denies them this.

I support EMS education in high schools. I support explorer programs that give firsthand experience and education to teenagers and younger students. I support CPR and First Aid Training at any age. I will support students coming to the EMS station, cleaning the trucks, taking classes with the crews, learning about EMS, and even staffing first-aid stations and special events under the watchful eye of an experienced adult provider. I do not support students responding in ambulances for the reasons I’ve stated above… but in closing I also offer this:

In one of the articles above, someone stated that these programs prepare students for a career in the emergency medical services. They might. However, by their very existence they prepare students for a career in a low-wage, low respect industry that might as well be provided by teenagers. These programs are a slap in the face to our profession. We will never advance when mindsets like these are allowed to propagate and flourish

Your thoughts?

Posted by on March 29, 2010 • Filed under: 911 fail, Administration & Leadership, ckemtp, ckemtp rants, Command & Leadership, edemse, Emergency Medical Services, EMS, ems education, EMS ethics, EMS Health & Safety, EMS Management, EMS rant, EMS Topics, EMS training, EMT, Ethics, everyday ems ethics, Fire Rescue Topics, Firefighter Safety & Health, medical ethics, politics, rant, Training & Development, volunteer fire department, volunteer firefighter

Huddled Masses. Healthcare. Honor. EMS.

19 comments

A conversation that I had with another healthcare provider has me pondering a lot of things. Until now, I’d been pondering these things in a solitary way but I think that I’m going to put these ponderable thoughts up on the blog.

This post gets a little more political than my usual stuff. I don’t post politics up here unless the politics specifically relate to EMS (unless they’d get me in a lot of trouble, for example the best EMS delivery model).

But today, I’m making an exception. I think that some of the things that I’m pondering have to be put out there and I think that if I don’t throw this out to the blogosphere I’m gonna go nuts.

I work in a community that has a large Hispanic population. A good portion of them are probably undocumented immigrants from Mexico. Yes, I said “undocumented” and that can mean Illegal immigrants if you so choose to say that. It’s a fact that small towns in the Midwest have been growing by leaps and bounds with undocumented immigrants looking to find work wherever they can. Some of them have legal members of their family that they live with, some don’t.

There’s a huge debate going on in this country over illegal immigration. It’s bigger than me, it’s bigger than this blog, and it’s bigger than EMS. I’m not going to get into my personal opinion on the topic as much as I would if we were discussing this in a bar over a couple of beers, or a country cafe over coffee if you’re a morning person. I can say this: I’m all for border security. I’m all for people following the law and I believe that illegal immigration is a drain on our resources. Those points are barely arguable. Another thing I believe in are the words to a song that I used to sing when I was with a rather patriotic small-town childrens’ choir. The song went something like this: “Give me your tired, your poor, your huddled masses yearning to breathe fee. The wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me. I lift my lamp beside the golden door!” There’s a lady that stands in the harbor that has these words inscribed upon her, and they mean something.

I look upon this debate and I see both sides fervently trying to destroy any point-of-view other than their own. The lefties want them here because their hearts bleed for them. The righties think that the lefties want them because they can mold them into a new communist workers’ party. Both of them may be right. I am more of the opinion that America is an experiment. We’re a melting pot of people that have come together over the last two-hundred and some odd years to be stronger in our diversity. I believe that any cultural group entering our melting pot should come here and embrace the American ideals. “Melt” into the pot if you will. This has made us strong over the centuries and has built the country that I love, the one I will stand up for. Europe didn’t do that, they isolated their ethnicities into countries and fought amonst each other for a thousand years. We melted and homogenized into a strong nation full of rugged individuals championing their best ideals. I say that the most successful immigrant groups in the storied history of this nation celebrated their old cultures while melting in to our diverse one.

As far as today’s debate goes, I wonder if that would be the whole rub. Are the new illegal immigrants celebrating their own culture while melting into ours? Or our they placing their old culture on top of the American culture and creating discord within a proud nation? I think that we have always accepted the “Tired and poor huddled massess yearning to breathe free” because of our American Dream. People here have equal opportunity, a guarantee of the equal chance for humans to strive to reach their potential. Everyone has the chance to try and succeed to their own definition of success. “Life, Liberty, and the Pursuit of Happiness” is a guarantee of the chance to pursue. It is not, however, a guarantee of results. Our experiment is that everyone who has the chance will strive to give it their best shot, and that the people who succeed will pull others up alongside them.

I can’t say what’s right here. I don’t know. I don’t want to offend, but here I am, a paramedic. My job is to help everyone and anyone who needs me. I will do so. I have always done so. I took an oath and I honor my convictions. The hypocratic oath means something to me. Healthcare providers are honor-bound to help everyone as much as they can. I always will.

The conversation that we had was short, but he got his point across. I had brought up that while we have a large hispanic population in our coverage area, we rarely have calls involving those hispanic members of our population. I think that this is a bad thing because obviously these people fall ill and get injured at a rate comparable or even moreso than the other demographic groups in our area. I don’t know why they’re not calling but I can figure that it might be alleviated for the good of our community as a whole if we reach out to this population and let them know how, and when, to access the emergency healthcare system. I don’t believe in race and to me “hispanic” is a cultural label and is not even close to whatever “racial” means, but this is a cultural group that should be calling us and doesn’t. It’s deliniated over cultural lines and therefore is handy to address that way.

The other guy thought that it was stupid, pointless, and maybe even wrong to do this. It was because of the “illegal” thing. As strongly as I feel on that issue, and I do have strong feelings, as a healthcare provider my job is to help everyone. Every human deserves the best care that we can give them, every time. I don’t judge people. He shouldn’t either.

Neither should you.

Thoughts?

Posted by on March 25, 2010 • Filed under: Administration & Leadership, Command & Leadership, Economics, edemse, Emergency Medical Services, EMS, EMS ethics, EMS Health & Safety, EMS Topics, Ethics, everyday ems ethics, Fire Rescue Topics, In the Line of Duty, inside the mind of a paramedic, medical ethics, politics, professionalism, socialized medicine, Uncategorized

Trust… It’s everything

4 comments

Dooooo Doooooo! Beep Beep Beep Beep Beep Beep Beep  - Attention AMBULANCE ONE, Ambulance One. Respond Code 3. 1234 Anystreet lane, 1234 Anystreet lane for the (Insert Age and Gender Here) patient found unresponsive, unknown if breathing.

Imagine you heard that dispatch go out just now. Imagine you’re at home, off duty, and just happen to be listening to your dispatch channel. Perhaps you’re a volunteer, perhaps you have a scanner, but picture yourself hearing that and realizing… “Oh My God… That’s So-and-So’s house! A (blank) aged Male/Female? That’s gotta be So-And-So!!”

As an EMS person who lives in your district you know the people who work on the service. Now you’re sure you know the patient too. It’s someone you care deeply about and it sounds like they may be in mortal danger. As someone “in the know” you know what you’re going to do next, right? You’re going to listen intently to whatever traffic happens to come out next on the radio, aren’t you?

“Come on, Come on, Come on!” you think to yourself as you wait the agonizing seconds for the crew to acknowledge the page and go enroute to the scene. “What’s taking them so long!?” you ask yourself. “Ambulance 1 is enroute to 1234 Anystreet Lane” says the crew of Ambulance One over the radio. You don’t think that they sound excited enough. They must not know that this is So-and-So! To them, this is just a routine response for an unresponsive patient. They’re going to do a routine, every day job and perform their routine, every day care. They don’t have any idea that this patient is special to you and they’re going to give this patient the same care they’d give anyone else.

Now, since you’re sitting at home and unable to respond, you’re going to be glued to that radio, right? You’re going to know from the voice on the radio exactly who it is that will be taking care of “So-and-So”. You’re going to either be relieved or horrified by your knowledge of who’s on that responding ambulance. If you have trust in the medic on the truck, you’ll feel slightly better about So-and-So’s chances of survival. If you don’t have trust in the medics, you’ll probably feel a lot worse… right?

It’s always been a sticky ethical situation for a healthcare provider at any level to work on someone they know well and care deeply about. Try it just once, or more realistically for an EMS provider, have the situation thrust upon you, and you’ll see that “Stuff gets real” really quick. We have a vested interest in the care that our loved ones receive and while some of us may know that it isn’t always best that we personally be the one caring for them, we all understandably want them to receive the best care possible.

Trusting a provider to care for your special “So-and-So” is a big deal. I’m sure we all have secret mental lists of our colleagues whom we’d want caring for our loved ones and also our lists of who we wouldn’t. It is a supreme responsibility to be a healthcare provider in charge of the care of any patient and I believe that EMTs and Paramedics hold that responsibility every bit as much as or more so than any other healthcare provider. It is a responsibility that I don’t take lightly and one that I hope my colleagues do not either. We are the first people that our patients and their families want to see walk through their door when the unthinkable happens. When the situation is critical, and skilled, complex, time-sensitive care makes the difference between life and death, we are the ones out there doing just that. A good paramedic must be knowledgeable, highly skilled, and experienced to provide that level of care. Not just that, they must do it every time they get in their truck; because every patient is somebody’s “So-and-So”.

Speaking of “stuff getting real” I have to ask you: What kind of provider are you?

Are you out there every day earning the trust of your peers?

Do you work hard enough, study hard enough, and train hard enough?

Do you do your absolute best for every patient, every time?

When it does happen (and it will) that you are sent to care for a colleague’s “So-and-So”, are you the kind of provider they will trust?

If you think about these questions, you know the answers already. If you can honestly say that you’re good enough, I salute you. If not, well then we have some work to do, don’t we?

Earn it. Study hard. Know your stuff. Do your best. Every patient. Every time.

Posted by on March 15, 2010 • Filed under: Administration & Leadership, edemse, Emergency Medical Services, EMS, ems education, EMS ethics, EMS Motivation, EMS Topics, EMS training, Ethics, everyday ems ethics, Fire Rescue Topics, medical ethics, Paramedic, paramedic education, patient care, Patient Management, pride, profession, professionalism, scenario, Training & Development

Any Random Person

560 comments

I love Dave Barry, he has been called the most influential humor writer since Mark Twain. If you haven’t read any of his stuff, you really should. In fact, I’ll even provide a link to his web site here: www.davebarry.com. Yes, I’m providing that before what I’m sure will be my well-written, extremely interesting content below. He’s that good.

I put that up there because I am going to use a quote of his that he put into one of his columns; he asks his readers if they are saying to themselves “Hey, I can do this! *Any* random person can do this!” And he counters that they are wrong, because “It takes a very special kind of random person to do this”.

And that’s how I’m tying this into EMS.

I work with a few EMT-Intermediates (I-99 curriculum) and some EMT-IV Techs (WI has a version of a basic that can start IVs with NS and give a few IV meds) that are very sour on the fact that they aren’t paramedics yet. They’re not sour on the fact that they do not yet wish to sit through the required education to become paramedics, but they’re sour that there are skills that they can’t do that they see their ALS counterparts doing. They see us “paragods” performing ALS skills and say, “Hey, I can do that”.

And it may indeed be true. I see these days that they keep pushing skills that were once only the domain of paramedics down to the BLS providers. Heck, that’s what EMS is entirely built upon. In the far beginnings of our profession (and we’re still really in the beginning phases) the skills that Paramedics and EMTs perform were once only the domain of physicians. If you would have asked a physician in the 70′s whether a non-physician could interpret an EKG and give relevant medications and treatment as well as he could, you probably would have gotten a very incredulous answer. EMS is all about proving to the medical profession that treatments once firmly entrenched as only for use in the hospital have a demonstrated benefit to the patient when used quickly at the patient’s side close to the onset of symptoms. EMS personnel were trained for that most probably because it just isn’t cost effective to have doctors sitting around manning ambulances.

However, the question that has come up in my mind is where the bottom of that lowering of educational requirements for advanced skill performance ends. I have seen in my career a paradoxical movement in educational standards for paramedics and EMTs. There are a smattering of disparate and yet somehow complimentary certifications in some states, but while some educational standards have improved, most of them have decreased. While a good argument can be made for EMS levels between the Paramedic and the EMT-Basic, such as the I-99 and the IV tech in WI or the Iowa Intermediate in Iowa in the sense that they allow rural communities to be able to perform some advanced skills without having to shoulder the full breadth of costs and responsibilities associated with full paramedics, they also don’t take into account that a lot of those skills require a whole heck of education to be safely performed in the outlying patient that can be harmed by inexperienced providers.

The debate that I got into with an EMT-IV Tech over breakfast the other morning went something like this. He brought up the fact that EMT-IVTs could administer Narcan to reverse heroin OD’s or other narcotic overdoses. His statement to that was that they ought to be then able to give Morphine for pain control “since we already carry the reversing agent” (in case they give the patient too much or the patient has a reaction). My thoughts are that they should not be able to, because the administration of a narcotic for anything requires a requisite knowledge of the pharmacologic, physiological, and social actions of the drug. And while yes, that could be covered in a module I could assume, why should it be? I brought up that it takes physicians years of experience to be able to tell how to identify drug seekers who want to get a high from the legal, medically prescribed narcotic. Contemporary medical journals in family practice and emergency medicine have written volumes on the topic, and still physicians can be fooled. The extrapyramidal reactions possible with morphine, including respiratory and other Central-Nervous-System (CNS) depressing features of the drug have other treatments and symptoms that can be hard to recognize for an inexperienced provider. An EMT-IVT just doesn’t have the breadth of background knowledge needed in order to judiciously use the drug safely in all cases. The fact that most of the time it would work out fine does not withstand the certain percentage of patients that could and would be harmed. I ended the argument with him by bringing up something that I’ve always remembered from paramedic school. Our lead instructor told us that our drug bag was nothing but “A big bag full of poison” if you didn’t know how to use it.

Remember, every single time any medical care provider performs any treatment of any kind on a patient they’re making the statement that “Right now, I know better than your body does. I know better than your brain, your nervous system, and better than all of your body’s self healing systems do what you need to keep living and get better”. Any time you put on a bandage, you’re telling that patient that you know better than their body does that they need to stop bleeding. Every time a paramedic or other provider uses an airway management technique they’re saying that they know how to breathe better for the patient than the patient’s own body does. Every time you give a medication to a patient you’re telling them that you know how best to control their body’s systems. Think about it. Every treatment, every time. It is a HUGE deal to be able to do this stuff, and you dang well better know your stuff.

Physicians are rooted in the quest for knowledge. Their reputation as learned individuals goes back to prehistory in one form or another. They’ve earned their vaulted place in society due to their quest for knowledge and reason and their caring for others above all else. EMS people came from physicians. I can think of no other medical profession that has a downward pressure on their educational standards. I’m saying that, because I think that EMS does. We have elements in our own ranks, and external forces that are continuously working to make us into skills monkeys that can be paid very little and know very little.

This is a big statement: Not everyone can be a good paramedic or EMT. It takes a certain intellect, sound ethical reasoning skills, and a level of professionalism that not everyone can attain.

This is another big statement: There are groups in our society that want to make it so that any random idiot can become a basically qualified one. This keeps us all down and lowers the quality of patient care… a lot.

Yet another: Us good EMS people should be really ticked off that educational standards are so dang low these days. Fight for excellence. Respect ourselves.

If you and or your service want to be able to perform advanced skills, earn the requisite knowledge through your studies and earn the level that it takes to do them. Enough is enough. I don’t believe that we should lower any more educational standards. No other group would do this, not the nurses, not the PA’s, and certainly not the physicians. Why should we? Yes, I understand that with the advent of Urban Fire Based EMS the IAFF and IAFC want to put more paramedics on the streets to increase their influence and their revenues, and that in order to do this they need to match the intellectual skills of medics with the intellectual skills needed to be a good grunt firefighter, but EMS is a MEDICAL profession built from the quest for knowledge. It should not be relegated to the technical performance of skills if X equals Y.

Heck, I think that the current level of Paramedic should be the basic level, and that Paramedics should be as independent as Physician Assistants. In fact, I’d like to see that in the future.

Posted by on March 11, 2010 • Filed under: Ambulance, ckemtp rants, dave barry, edemse, Emergency Medical Services, ems 2.0, ems education, EMS ethics, EMS rant, EMS Topics, EMT, EMT-Intermediate, Ethics, everyday ems ethics, IV, Paramedic, paramedic education, physician

Two Cases, One letter – From one Paramedic’s struggles, change can come

17 comments

A letter I received from a reader recently has gotten me just as mad as he is, even more so maybe. This letter came in from someone who identifies himself as a paramedic but asks that I protect his identity and location completely. I will do so, only identifying that the letter comes from someone who works out west, somewhere between the Mississippi and Montana but not east as Maine or as far south as Amarillo.

So He comes from somewhere in the US, not the east coast, and not Hawaii. He’s a paramedic and he’s male. That’s all I’ll say. I’m going to work the things he wrote me in his letter with my thoughts and feelings on what he wrote and the situation he wrote about. I’ll rewrite the letter keeping the point of it intact. I’m fairly sure that you’ll be just as angered as I. (Note – This is LONG but it’s good. It will probably tick you off too, enjoy)

(more…)

Posted by on February 25, 2010 • Filed under: Administration & Leadership, change, ckemtp rants, DNR, Do Not Resuscitate Order, edemse, Emergency Medical Services, EMS, ems 2.0, ems education, EMS ethics, EMS Health & Safety, EMS Management, EMS paramedics, EMS system, EMS Topics, Ethics, everyday ems ethics, Line of Duty, medical ethics, Paramedic, paramedic education, patient care, Patient Handovers, Patient Management, politics, potential, PR, pride, profession, professionalism, Public relations, rant, stories

The Perfect Emergency? Well, almost

16 comments

So a while ago, I went to an emergency medical call that was about as perfect as an EMS call could be.

Picture this if you will. Our ambulance was in service. The system was at normal operating levels which are well funded and are adequate for our response loads 90% of the time. I had thoroughly checked and cleaned my ambulance and the equipment inside of it at the beginning of my shift and I had even gotten a chance to have a cup of coffee or two before the call came in. When the call did come out over the radio, it was merely a short walk to the ambulance for my paramedic partner and I. We climbed into our dual paramedic staffed, well maintained, state-of-the-art ambulance, and rolled out to the scene of the emergency which was about 8 blocks away through light traffic. We arrived within 4 minutes of the 911 call and were informed by our dispatcher that the residence was equipped with a “Knox Box” entry system so we could quickly gain entry. We retrieved the key from our ambulance, were able to open the Knox Box, and easily entered the residence using the key inside of it. While entering, we noticed that the resident had a “Vial of Life” sticker on the front door, which signified that the patient was most probably participating in our “Vial of Life” program, meaning that the patient had all of their medical information written down properly on one of our stock forms. In fact, we found the “Vial of Life” right in the refrigerator door, where it was supposed to be.  The patient, an elderly person, had used a (Non brand-name specific) home emergency call button to summon assistance, which we also had recommended to him/her during the public outreach that convinced her to have everything else in place for our arrival.

In short, this patient had done almost everything right. He/She had paid taxes throughout his/her long time living in the district and had supported us in order to allow us to have quality, state-of-the-art equipment. He/She had supported us so that we could get good training as well. He/She had listened to us when we suggested that He/She wear an emergency call button as he/she got up there in years, had written down his/her medical information in the “Vial of Life”, had put the Vial of Life in the correct place, and had even installed a Knox Box on the home so we could gain access quickly.

So what wasn’t right with this call? The patient had been experiencing symptoms consistent with a stroke. In fact, it was an easy diagnosis from across the room type of stroke. The patient had noticed that he/she was possibly having stroke-like symptoms and had decided that it would be best to get cleaned up, get dressed, clean up the house a little, and call a neighbor over to see if he would take him/her to the doctor’s office before the neighbor convinced the patient to press the button and call us out to help. By that time… well let’s hope the doctors can work some magic.

With all of the bloggers, paramedics, EMTs, and everyone else out there harping about “BS” 911 ambulance calls, one would find it easy to overlook cases like the one above. I for one will come right out and say that I will gladly run 100 nonsense EMS calls rather than miss just one of the above… I don’t want someone to die or suffer further morbidity simply because they were too scared, or polite, or timid to call an ambulance.

I don’t know how to fix the problem, I’d just like to remind you all out there that our job is indeed to take care of people when they’re scared, when they’re sick, and when they’re just plain-ol’ stupid. We’re healthcare providers and it’s our duty. No exceptions.

Remember that.

Posted by on February 22, 2010 • Filed under: 911 fail, Emergency Medical Services, EMS, EMS ethics, EMS Management, EMS system, EMS Topics, Ethics, everyday ems ethics, Fire Prevention & Education, Fire Rescue Topics, Paramedic, patient care, Patient Management, scenario, scenario based training

Equipment Review: Scary Post Ahead

9 comments

This was one of my first posts. Since I’m attending an EMS conference, I figured it deserved a bump-up too. Good Luck!

Some of you have been telling me: “Chris, you’re a good paramedic. You should be providing tips and tricks for EMS people so that they can use your hard-won wisdom to improve their patient care. Don’t spend your time ranting about things that bother you in the back of the truck and keep making feeble attempts to make people laugh. Write a serious article, darn it!!”

Actually, I’m really the only one that’s been telling me that, since this blog is only read by like, six people including my mother, fiancé, and my cat… but nonetheless I am going to attempt a serious piece regarding actual patient care issues. As such, I have identified piece of equipment that is carried on my ambulance and is most probably carried on every ambulance in the country. This particular piece of patient care equipment is rarely used, yet critical for patient care when needed. When this piece of equipment is called for, the patient needs it and needs it NOW. Yet, I’m sure that even the most experienced EMTs and Paramedics are struck with horror at the mere thought of its use.

I’m talking here about: The bedpan.

Yes, in my storied career I have been called upon to use a bedpan more often than I would have liked to. The situation is almost always the same, the patient is otherwise stable but the pressures of the bumpy ride on the human bowels are just too much for him or her during the prolonged transport time. Usually in complicated cases like these I prefer to bring along a nurse, since they are eminently more qualified to perform in these critical patient care scenarios. However, as is often the case in EMS, we are called upon to take care of any patient presentation in any patient population and must perform professionally in all situations. I have researched the use of this piece of patient equipment in numerous trade publications and critical care guides and have been struck with the lack of educational materials available for this critical patient care skill.

So, as any EMS writer would do when setting out to write a patient care article, I hit the streets to query other paramedics and EMTs on their secrets for the proper use of the bedpan. I began with the coworkers I have at my two ambulance jobs, one a private, not-for-profit city 911/Specialty Care Transport service and the other a Fire Department based service. Both of them work around 3000 calls per year and run at the ALS level. Here is a sampling of the responses I received:

Question: By a show of hands, how many of you have used a bedpan in the back of an ambulance??

Answer: I raised my hand.

Some of the people there wanted me to clarify the question, they wanted to know if I meant had THEY themselves personally used a bedpan in the back of an ambulance? One guy admitted to using a urinal in the back while transporting a patient. When badgered by the other providers, he clarified by saying that it “was a pretty long trip”. I offered that there have been some situations in my career where I have put the bedpan under a patient who absolutely HAD to go poopie during a trip to the hospital. However, and I just realized that this is the most blessed thing to ever happen to me ever, not one of them has ever been able to “go” with me hovering over them.

Of course, in EMS, I have been covered with every imaginable bodily fluid, including the unholy trinity of urine, vomit, and feces ALL AT THE SAME TIME. And I have plans to erect a statue to the person who came up with the idea of prehospital people administering Zofran (an anti-throw up medication). The other day I spent a few minutes starting a saline lock IV on a lady in her bed inside her apartment just so that I could give her that blessed medication. My fairly new EMT partner wanted to know why I did that, when I usually wait until we’re back in the truck. I let him know that I had been on the foot end of the stair chair going down the stairs before the golden-age of zofran had arrived.

Yes, us “experienced” EMS providers (read: old people who never got real jobs) will tell you that when you can’t let go of the end of the stair chair without letting your patient plummet down a full flight of stairs and the patient chooses THAT EXACT MOMENT to decide that they just *have* to throw up. You well, you just have to close your eyes, close your mouth, lower your face to cover your nostrils, and take it like a true professional. Been there, done that, cleaned the chicken and rice out of my ears with a q-tip. It’s moments like that when you reevaluate your commitment to the profession, and realize that it must be something other than the *interesting* amount of money that they pay you that keeps you coming to work every day. For me, it’s the amount of time that I get to spend typing up articles about bedpans and vomit in my ears… at least it is right now. Has anyone else ever thought that they had been ruined by EMS? I mean, I don’t think that I could ever do an office job. Years of EMS work has left me with the remarkable ability to begin to focus on something like a laser beam for 90minutes tops, then… Hey look!! A Bunny!!

Oh yea, bedpans. So you slide them under the patient and um… Pray that they’re positioned correctly. Wear correct BSI including a pair of gloves, a mask, goggles, and Vick’s Vapo-Rub under your nostrils. Of course, for us old timers, this is required even when you’re making your partner use the bedpan in the back while you drive (heh) Ever So Carefully to your destination. Tell your partner that they need the experience, tell them how professional they are being and tell them that they’re showing true compassion to the patient. Then go out and buy them an ice cream cone filled with Rocky Road. With any luck, you’ll get to eat that too when they suddenly become less than hungry.

In all seriousness, everyone poops. Never let your patient suffer when you can alleviate their suffering with a simple slide of the bedpan under their derriere. Of course, make sure that they REALLY have to go to lessen your risk of contaminating yourself with some really funky pathogens, and also to avoid ticking off the nurses’ lobby by taking their jobs.

Until next time…

 

Posted by on January 23, 2010 • Filed under: Ambulance, Bed pan, Bed pans, bedpan, EMS, EMS ethics, EMS Health & Safety, EMS Humor, EMS Topics, EMT, Ethics, everyday ems ethics, Fire department, Fire Rescue Topics, Firefighter, odansetron, Paramedic, puke, zofran

Cat Puke Chicken

9 comments

Note: This is a repost. I’ve been a busy blogger and this post deserved a bump-up. Also, the “Fiance” in this post is now my lovely wife. Enjoy.

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The other day I got off shift at 8am and had to be to work at my other full-time job at 10am. Since both of the jobs that I work at are about a half hour from my house in opposite directions it worked out that I had about a half hour to go home, perform the personal hygiene ritual, change uniforms, and get on my way to work again. So I did that, got home, fed the cat, and got all prettied up as quickly as I could. Then, without warning, on my way out of the house I noticed it: A pile of cat puke on my rug.

Yes, I like cats. I have one. She’s a keeper, regardless of her regurgitation issues. I think that I’m more of a man because I love my fluffy-wuffy lil’ Kitty-Witty. So cat puke on my rug isn’t the horror of horrors to me that it might be to some people. In EMS, we tend to get puked on by humans more often than does the regular population and that fact may have further desensitized me to the violent act of emesis perpetrated on my rug by my mostly cute little kitty. However, I do like a clean house and the cat puke on my rug is an issue that normally warrants immediate action.

But of course, that’s not what happened. And for those of you in a spousal relationship with another human being you know exactly what I did. You guessed it, I left the cat puke on my carpet and went to work. For those of you who are not in a spousal relationship with another human you may not understand the thought process here. Yes, as I looked down at the cat puke on my otherwise (mostly) spotless rug the thought that it must be immediately cleaned up did in fact occur to me; but the other thought that occurred to me was: “I can leave and go to work and when I get home, my lovely fiancé will have cleaned this up for me. She’ll think that the cat puked on the rug *after* I went to work and I’ll get off scot free!”

And so that’s what I did. Yes, I *could* have taken the five or so minutes it would have taken to clean up the cat puke… but in my defense I’m a model employee and I need those extra five minutes of early arrival time at work to drink coffee and to tell everyone what a model employee I am. So if I would have cleaned it up I would have taken the risk of not being such a model employee. So you see, leaving the cat puke for my lovely, beautiful, and remarkably intelligent fiancé (who will probably read this, btw) to clean up was not something that I did because I’m lazy. It was something I did so I could continue to bring home the bacon for my family in the most productive manor possible.

That’s what I thought anyway, until I came home late that night after a hard day’s 10 hour shift off of a hard fought 24 hour shift spent saving lives and alleviating the suffering of the sick and injured and stepped in the same pile of cat puke on my carpet that I had courageously not cleaned up the morning before. True, she had put in a paltry 12 hour shift at the fire department practicing for the recliner racing 500 and had fed, bathed, and put our son to bed; but that didn’t stop my obviously well-earned righteous indignation to the pile of cat puke permeating my pile covered floor. She had decided (although she swears that she did not in fact see the pile of puke) that I should be the one to clean up the cat puke using some amount of flimsy logic that I have yet to understand.

So, to tie the above 646 words back into the title of the piece, “Cat Puke Chicken” is not the new special at your local Chinese Restaurant. It is the battle of wills that solidified between my fiancé and I as soon as my sock made contact with partially digested Kitty Kibble. We both subconsciously agreed to ignore the cat puke for as long as we could stand it in order to have the other person clean it up first. (See also: “Laundry Chicken”, “Last Sip of Milk in the Carton Chicken”, and “Couples’ Counseling”). This occurs a lot, unfortunately, in most relationships between other perfectly rational human beings. We know that we don’t like having cat puke on our carpeting; we obviously know that the cat puke should be cleaned up at the first available opportunity; and we also have continued doing the other things that we normally do to keep our houses from turning into slovenly hovels. In fact, while this has been going on I have cleaned numerous dishes, laundered, dried, and folded at least four loads of laundry, and have started (but not finished) three household improvement projects. I’m at least as good as a housekeeper as the next guy (Read: Not a good housekeeper) and I do indeed do my best to keep my family and myself from living in squalor.

So why, as two perfectly rational adults who um, chose to work in EMS, are we locked into this powerful battle of powerful wills? In a word: “politics”. Not the kind of politics that provide the revenue stream for the myriad of cable news networks, but the politics of household supremacy that truly affect our day to day lives. This isn’t Senator So-and-So bloviating about the fact that pork in the stimulus bill is in fact, not pork… it’s me and the woman that I love and want to spend the rest of my life with deciding who shall be the designated Cat-Puke-Cleaner-Upper!! Pulse pounding stuff here.

And as with everything else, this got me thinking about politics in EMS.

Say you’re in a service way far away from anywhere where I work and you have a small volunteer squad that covers the areas that your service is not jurisdictionally bound to cover. Sure, your service would be glad to come if they called you, but somewhere back in history when the powers that be drew the political boundaries they decided that your service was not responsible to respond to the pleas for help that come from that particular geographic area. Suppose that your service just happens to be a small ALS service with two paramedic ambulances and a BLS ambulance on duty 24/7 and the other service was a BLS squad with volunteers coming from home and/or work. These volunteers are dedicated, caring individuals that want to do the best that they can for their friends and neighbors but work in a system where when a call for service comes out it takes about 20 to 25 minutes for the system to get an ambulance to the patient’s side. Say also that the service that you work for has your three ambulances and paramedics about 6 miles from their patients staffed and on duty but you can’t respond because the political system is such that you would be in trouble if you did so.

You may also relate to having that coworker in your EMS or Fire service that just isn’t up to par. They may be a basically qualified EMS provider through the state licensing body, but you still would cringe at the thought of that person responding to take care of anyone in your group of family or friends. They’re a provider that just doesn’t get it. Their care is substandard, their attitude is poor, and you can’t help but feel that the patients being “cared” for by this individual or crew aren’t getting the best medical care possible from your service. You’d want to say something, and normally would, but you’d become an outcast in your agency and would be looked down upon for blowing the whistle. Besides, even if you did the service is short handed and your management wouldn’t fix the problem anyhow because they need to staff the trucks.

Or maybe you can see that EMS in general is underfunded, underappreciated, and undereducated and you can’t shake the feeling that something has to be done to improve patient care industry-wide. You feel powerless to do so, but you’re angered every time you see a representation of bumbling ambulance drivers on TV, or see the local news completely mishandle a news story involving EMS, or especially when you look at your paltry pay check.

In all of the above cases, you’ve got cat puke on your rug and you’re hoping that somebody else is going to clean it up.

As EMS professionals, we know that there are myriad little political games that play out in each and every little jurisdiction a
cross the map. This service may not call this service for mutual aid because someone’s brother once stole a pumpkin from one of the other service member’s brother’s pumpkin patch. “Jim” may not provide good care, but you let it slide because he’s popular with the other crews. Sure, the local fire department gets a kajillion dollars more in funding than your EMS service does and runs like a tenth of the calls that you do, but that’s just the way it’s always been, right?

We need to step up as a profession and clean the cat puke from our carpet. Ignore the politics. Ignore the personal hurt feelings and the power plays. EMS is about the patient. It isn’t about you, or me, or that person down there. We exist solely to save lives and alleviate suffering in the people that we serve in the best possible way that we can. Nothing else matters more than that. So if you can see that cat puke on your rug, and I’m absolutely positive that you know exactly what I’m talking about no matter where you are, you probably have better things to do than be playing chicken. We all need to stand up and say that we are the Cat-Puke-Cleaner-Uppers and that quality EMS is our responsibility, no matter what little political games of chicken are going on. Our patients deserve nothing less.

(Fiance’s note: As of press time, the pile of cat puke on Chris’s floor is still intact solidifying into the fibers of the carpet)

 

Posted by on January 22, 2010 • Filed under: Administration & Leadership, Ambulance, ambulance humor, cat puke, Command & Leadership, edemse, Emergency Medical Services, EMS, EMS ethics, EMS Humor, EMS Management, EMS Topics, EMT, Ethics, everyday ems ethics, Fire department, Fire Rescue Topics, Firefighter, Paramedic, politics, relationships

Are We the Gatekeepers to the Emergency Healthcare System? – EMS 2.0

13 comments

Did I do good?

The Chronicles of EMS, if you’re living under a rock and you haven’t heard, is a cooperative effort between the Great Filmmaker Thaddeus Setla (EMSmedia.tv), the Remarkably Strong Paramedic Mark Glencourse (Medic999), and the “Ruggedly Handsome” firefighter/paramedic Justin Schorr (The Happy Medic). Their cooperative venture has taught me things that I’ve put to use in my own EMS practice that I believe have improved my care. Mark showed me the UK’s “Front Loaded” model and Justin has been talking about EMS providers being a gatekeeper to the emergency healthcare system. It’s a powerful collaboration. (Be sure to follow #CoEMS on twitter and become a fan of Chronicles of EMS on Facebook as well)

So here’s an example of what I mean. I can talk about this now because it’s been long enough that I can sufficiently muddle any possible trace back to the patient and fulfill any patient confidentiality concerns. I work in two very diverse service areas and cover approximately 35 different skilled nursing facilities at any one time. So in the time since the Chronicles of EMS has come out I’ve transported umpteen-hundred patients from those facilities and the patient I’m writing about could be any of those umpteen hundred. So there’s no way to violate confidentiality, Mmmm ‘Kay? 

Anyway, some time ago I was dispatched as the ALS response to backup a BLS ambulance for the “unresponsive” patient at a skilled nursing facility. I arrived a few seconds after the ambulance did and carried my drug bag and EKG/Defib into the facility with the ambulance crew following close behind with their jump kit, the cot, and a backboard. After a few seconds in the facility, a staff member directed me to the Physical Therapy area of the facility which was a bit of a walk. When I got there, I saw three other staff members huddled around an elderly female patient who was seated in a reclining chair.

The staff members were fairly excited about the situation, as was the patient, who was very much conscious and alert. The story everyone told me at once was that the patient had finished her physical therapy session on her upper body to strengthen her shoulders and had been sat in the chair by the PT Assistant to rest. After a few minutes, the PT asst. came to check on the patient and found her unresponsive to verbal stimuli, by which I mean that the patient would not awake when spoken to. The PT asst. called the facility’s emergency response team and another staff member activated 911. When one of the nurses arrived, the patient awoke to a sternal rub and was quite surprised to be the subject of so much attention. She had been fully alert and cognitive since that time and when I asked her she denied any chief complaint other than being understandably emotional about the situation.

As I do with every patient after I rule out any immediate life threats I moved into a more detailed assessment. My lady here had skin that was Pink, Warm, and dry. Her pupils were PERRL and her Cincinatti Pre-hospital stroke scale was negative. Her Lungs were clear, her abdomen was soft and non-tender with normoactive bowel sounds, and her extremities were warm and had good pulses, motor, and sensation. Her blood glucose was well within limits, and so were all of her vital signs. All of my other assessment findings were not indicative of any acute abnormalities other than a complaint of slight shoulder pain and weakness which could have been indicative of either an acute MI or of a rigorous PT session. So, to be even more thorough, I hooked her up to my 5-lead EKG which showed normal sinus rhythm with some peaked T-waves. I then ran a 12-lead EKG which was admittedly probably better than mine is.

I asked the nurse “Has she had a potassium level drawn recently?” She looked through the patient’s chart and found out that the patient in fact had been tested for that two days prior and had been found to have a slightly elevated serum potassium level. Since they had been active witnesses to my assessment we agreed that other than for perhaps a bit too much potassium there was little chance of anything being wrong with the patient.

Since we were here in the US and not in the UK like Mark, where he can treat and release (or “Respond, not Convey”) I asked the patient if she wanted us to take her to the hospital. She didn’t want to go and said that she just wanted to go back to bed. When the staff members weren’t completely convinced that we shouldn’t transport her, I suggested that they call the patient’s primary care physician to ask him what his wishes were. The nurse did so, and called from her cell phone in front of us. She did a good job of explaining in detail the events of the call and our collective assessment findings, I provided my interpretation of the 12-lead EKG and chimed in with my assessment findings that I use in my acute care practice.

For his part, the doctor was amenable to treating the patient at the facility and stated that he was comfortable with us not transporting the patient. He ordered a few stat labs and requested that we leave a copy of the 12-lead for the patient’s chart, which I was happy to do. Bottom line: The patient signed a refusal and was happy not to have to go to the hospital; The skilled-nursing-facility staff members were happy that the patient was in no immediate danger; and I was happy that we had made the best possible decision for the patient and that I wasn’t exposing her to unnecessary risk.

What happened here is exactly one of the things that I and others have been talking about with the EMS 2.0 movement: EMS people having the ability to make an educated and sound decision about the best possible healthcare options for our patients and not simply having to activate the full emergency healthcare system for every complaint. This case had every element of that and I believe that the patient being redirected through her normal primary healthcare pathway was a much better choice than taking her to the emergency room.

Heck, since there turned out to be no adverse results to this, and since the patient was probably on Medicare, I would surmise that I’ve ended up saving the taxpayers thousands of dollars in unneccesary costs… Huh? Can educating and empowering paramedics “save” the healthcare system in the US by creating a huge savings in the most expensive form of providing healthcare?

What do you think? Did I do good?

QGE5GE5AAH4W

Posted by on January 21, 2010 • Filed under: change, edemse, EKG, Emergency Medical Services, EMS, ems 2.0, ems education, EMS ethics, EMS Topics, Ethics, everyday ems ethics, medical ethics, new perspective, patient care, Patient Management, physician, politics, potential, Skilled Nursing Facility, US economy

“CPR Theatre” – Pediatric Deaths, resuscitations, and futility

16 comments

This post is a cooperative joint topic with two widely respected EMS bloggers, Steve Whitehead from Http://www.TheEMTspot.com and Greg Friese, from Http://www.EveryDayEMStips.com – Our topic is supposed to be on why it is that EMTs, Paramedics, and other healthcare providers will sometimes “go through the motions” and continue on with futile resuscitations with pediatric cardiac arrest victims. I’m sure that they will have very insightful posts on the topic, as they always do. Here’s my take.

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Can someone say “emotionally charged”?

One of the truths about where I’m sitting right now is that I’m chained to a lot of potential responsibility. Today, like a lot of days I’m one of two paramedics on-duty in my service area and the next call is mine. No matter what the next call is, it is my responsibility to get up and answer that call… without regard the horror that fate may be sending me to bear witness to and intervene in. All medics have to accept this inherent part of the job. One of the worst of those possibilities is that it may be a call that involves the significant injury or illness to, or even the death of a child.

Mention the possibility of a child’s death to even the most cynical and seasoned of healthcare providers and you will send a very cold chill down their spine. It’s just horrible. For me, the blessedly rare times that I’ve lost a child have been sentinel events in my life, things that are often thought of but rarely spoken of… almost always spoken of only to comfort the pain of a colleague experiencing the same thing. The loss or suffering of a child just burns into our souls and leaves an indelible scar that only someone who has experienced it can have true empathy for.

And I for one, wish that I didn’t have the empathy that I have for it.

Heaven forbid that I ever have to be one of the parents with pleading eyes at one of those tragic and traumatic scenes. I just can’t imagine what they go through when I’ve said “I’m Sorry”. I can’t imagine their pain, and frankly I don’t want to. As a parent myself the thought is blocked from my conscious mind and relegated only to the deepest recesses of my subconscious fears. Losing an adult patient is one thing, as we humans come to know that our lives are fragile and that our price of admission is to be removed from this existence. It’s a knowledge that we get as we progress through life and gain the experiences, both good and bad, that make us who we are and will become. However, the terrible thought that one could be ripped from us in their age of innocence is an affront to everything that almost everyone holds dear… and it’s more than a lot of us can bear to make the last decision of a child’s life. Instead, we try. We try hard and we keep trying. We hold out hope against thought and fight on, sometimes against futility.

But in my mind, I think I know why it is… because no healthcare person wants to be the person who looks into those pleading eyes and says “I’m sorry”. That decision takes an enormous emotional toll upon the parents and family, of course… but also upon the EMT or Paramedic. It’s ultimately easier on us as EMS people, we reason, to fight on. To race headlong into futility and hold out hope that someone else won’t have to say “I’m sorry”. At least we won’t have to.

There are probably psychological studies out there that I haven’t read that deal with the issue of whether “CPR Theatre” is harmful or helpful to the long-term well being of the surviving family.  These studies are probably well-researched. I took a class once that told me that it was better for family members to be in the resuscitation room inside of a hospital to witness the events as healthcare people try to save their loved ones… and I can understand that I guess. Perhaps it is better to witness that “everything possible was done” for your departed loved one. I don’t know.

As healthcare providers, it is our sworn duty to alleviate suffering as best we can using the tools at our disposal. I, like most of my colleagues, realize that the secondary and tertiary patients that we treat are the family members and their grief reactions to the tragic circumstances that resulted in their calling us. I am reasonably comfortable handling their grief reactions and sadness when an adult passes on scene but I am humbly inadequate to be of much comfort to a parent that has just lost their child no matter how I might try.

My guess that futile CPR theatre can be explained as being more for the parents and families of departed children than it is for the slight chance that we might have missed something. We make the effort in the name of showing to the family members that “everything possible” was indeed done, up to and including running their child lights and sirens to a hospital. I’ll even admit that in the back of the ambulance while I’ve done this, I’ve prayed right along with the family that just perhaps this once we would have a miracle. Never once has it happened.

Here’s a mea culpa for you, even though every time I’ve gone through the motions I’ve said it was for the family…  It may really have been for my own benefit as I’ve stated it could be above. I am a paramedic and I’ve seen my share of pain, but I don’t think that I can look a parent in the eyes and say “I’m sorry” ever again. I just don’t want to and as I write this, I can’t imagine that I could do that and then come back and look the guy in the mirror in the eyes without wondering if maybe this time would’ve been the miracle. I am probably selfish for this practice… but is that wrong?

From a completely actuarial perspective, no futile resuscitation should be performed due to safety concerns and the unnecessary costs involved. I agree that with adults, transporting cardiac arrest victims is probably deadly. I also understand that no ambulance should risk a lights-and-sirens trip to transport a body to the emergency room. However, I am not an actuary. In those cases I’m a witness to horrible emotional pain and I want someone else to be the one who says “I’m sorry”. It’s human nature, perhaps.

In my career, I have told parents “I’m sorry, there’s nothing I can do” in cases where it was blatantly obvious that the child was long beyond hope of any intervention. I’ve done it more than once and I can see the places where I’ve done it in my mind to this day. Sometimes it’s completely obvious that there is indeed nothing that anyone can do. However, occasionally I have indeed known this and just done it anyway. Perhaps it’s completely subjective. Perhaps it was my level of experience and intuition that guided me at the times I’ve made the decision. I’ll tell you this, it certainly wasn’t a decision made from the pages of a textbook.

I don’t have the answers to this. But I do want to go home and hug my kid. My only advice to the EMS people out there is to realize that we’re all human, and that all you have to do is your best. Be compassionate, and use your best judgment. For that’s all we can ever do.

For more on this powerful topic for EMS, head over to Greg Friese’s page and also to Steve Whitehead’s page. You also may want to read “Splashed Sadness – A look at Negative Emotions in EMS” where I further explore the sad side of EMS and our reactions to it.

Posted by on January 5, 2010 • Filed under: Ambulance, bad calls, cpr, Emergency Medical Services, emotions, EMS, EMS Blog, EMS ethics, EMS Health & Safety, EMS Topics, EMT, Ethics, everyday ems ethics, Fire Rescue Topics, inside the mind of a paramedic, medical ethics, Paramedic, patient care, Patient Management, psychology, sadness, The EMT Spot, Training & Development

Everyday EMS Ethics – Thoughts on Ethical Behavior in EMS

7 comments

Everyday EMS Ethics? Where do I get my authority to talk about anything ethical? I’m definitely not a perfect person. I’ve made some decisions that I’m not proud of in this life, I’m human, and I’m certainly not immune to the mud that life can sling on a person. How then can I talk about ethics with a straight face, knowing that I’ve made some of the very mistakes that I seem to be condemning?

It’s because that just like everyone else, I have the ability to feel good or bad about anything that happens to me and anyone else, I have the ability to introspect and wonder why my gut feels the way it does about something, I also have the ability to want to be a better, more ethical person. As silly as it seems in this world sometimes, striving to be a better person on this journey we call life is what we all must do as we edge closer to “Point B” in our path.

The omnipresent “they” have always told me that “Being a good person means doing the right thing even when nobody’s looking” and I like that phrase. If a lot more people took that view, I think that the world could improve overnight. Imagine if everyone did the “right” thing all the time? We’d have no crime, no “half-assed” jobs, and everyone would get along, right?

Well no, probably not. Of course things would improve and crime would cut down, but since two perfectly ethical people can have logical disagreements on the same issue, we’d still have discord and differences of opinion. We’re all still human and human beings have different thoughts, feelings, emotions, and standards of right and wrong. Therefore, when one throws out the term “Ethics” it seems to draw a lot of shrugs from people who aren’t looking for the conflict it can generate, or who simply aren’t looking to put forth the effort to debate their positions effectively.

Grey areas abound in any discussion involving ethics, but I think that it can be simplified. Even in an area where lives are literally on the line such as in EMS or other healthcare disciplines, the realm of ethics can be summed up in the above phrase about doing the right thing when nobody’s looking and with the application of the Golden Rule, the one about doing unto others as you would have others do unto you.

Of course, that’s not always easy as it sounds, is it? People are motivated by different things and behaving ethically in one situation may justify behavior that may be considered unethical in another. For example, take the case where a family’s breadwinner has to make more income to feed his/her family at home and that need justifies taking more overtime at work than would normally be considered his/her “share” of the OT and the extra income that it brings. The breadwinner’s coworkers may consider the person to be an “overtime hog” and may think that he/she is behaving unethically whereas the breadwinner may feel that the need to feed his family with the extra OT income justifies his taking more OT than is his/her share. Who would be “right” here? If everyone had a family at home that they were supporting with the extra income from the OT, it wouldn’t be ethical for that one person to take more than their proper percentage of the OT… but would it be right if everyone else was a single person with no families to support? Who would decide that?

We have to be unafraid to discuss the grey areas and tailor solutions to fit the unique situations we face. Discussion among rational adults can help guide the actions of the group towards a more ethical and equitable organization, which makes everyone happier in the end. Some organizations discourage this, and instead make overarching rules that discourage the rational adults within those organizations from free thought that would benefit the overall operations, and some are too lax and instead encourage unethical behavior by never sanctioning those who engage in it.

On political topics, I’ve always liked the words of a country song that state “You’ve got to stand for something or you’ll fall for anything” meaning that a person has got to have a set of values and beliefs based upon their own moral compass and introspection in order to guide their decision making when faced with an overwhelming amount of information.  And we’re all overwhelmed. I firmly believe that human beings can only process so much information and that there is no possible way for any human being to be well-enough informed on every issue to form a truly solid and rational opinion. Therefore, when we hear something, if we judge it based upon our foundation of core beliefs, we have a way to gauge how we feel about it. For example, I’ll bet that if any, only a small percentage of the people who read this post have ever studied the effects of globalization on the food supply in Micronesia. Sure, we could research the issue, but our core beliefs most probably would tell us that anything that decreases affordable food for the majority of the population is bad. My guess is that this opinion on the issue is perfectly fine and I don’t have the time to put in the requisite study to find out otherwise. This can be applied to EMS almost daily. I believe that a thorough assessment and judicious application of treatment modalities benefits the highest number of patients. I believe that any amount of study time that I put in learning about pathophysiology enables me to better assess my patients and judiciously apply treatment to them. Therefore, I can ethically and logically assume that putting in one hour of study time per day on pathophysiology is a good thing.

Of course, if there were to be a study that came out unequivocally showing that 45 minutes per day is the optimal number and that one hour actually causes degradation in knowledge through um, brain fatigue or something, then my opinion would be wrong… but nobody has studied this topic with enough depth to be sure of that.

Here’s what it comes down to for little ole imperfect me: “Shower Guilt”. I usually say that when I make decisions it’s because I have to look myself in the mirror and shave every morning but that’s honestly not where it gets me. My conscience rears its head during my morning shower. If I’ve done something that I don’t feel deep-down is ethical, my “Shower Guilt” kicks in and I beat myself up for it. I usually can tell how I’m doing by how rough my showers are. It’s been that way for years for me and I’m thankful for it. The introspective time has made me a better, more rounded person.

I guess what I’m saying with this post, and with my whole Everyday EMS Ethics series is that ethical issues must be discussed in a positive, adult manner for progress to be made. When people look at problems or violations in ethical standards in a rational and objective manner, solutions come out that go beyond heavy-handed rule spewing and approach the realm of positive resolution and healthy growth. By maintaining an open dialogue, others participating and observing the dialogue can glean lessons that will allow them to make more ethical decisions in their own lives and professional situations. Ethical behavior encourages others to behave ethically. Discussing the ethical standards of a group in a positive and uplifting manner makes people within the group feel good about doing the “right” thing.

Paramedics and EMTs face heavy ethical questions in our day to day work. It’s in our job description.

What does your organization do to encourage ethical behavior?

Posted by on December 2, 2009 • Filed under: Administration & Leadership, Command & Leadership, edemse, Emergency Medical Services, EMS, EMS ethics, EMS Topics, Ethics, everyday ems ethics, Fire Rescue Topics, medical ethics, Paramedic, professionalism, Training & Development

Everyday EMS Ethics – Social Media and “Smart” phones?

9 comments

Today I finally joined The Future™ and got up to speed with the latest technology 2006 has to offer by purchasing myself a shiny new BlackBerry Curve™ “Smart” phone. This thing is SO COOL! I can access my tweets, my facey page, and all of my other online stuff right through it AT ALL TIMES. It’s not an overload, really… I like carrying on 14 conversations at once… at all times. Really I do.

This new addition to my arsenal of cool tech gadgets got me thinking about a story I heard somewhere about a young firefighter/EMT that ran into a bit of trouble with one of these things. Incidentally, this story could have come from any public safety agency anywhere these days, so you probably don’t know whom I’m speaking of here, but if you think you do then go kick that person in the butt for me.

Anyway, this young firefighter/EMT was a full-fledged, “smart” phone carryin’ member of The Future™. Like any good young member, he was fully invested in Social Media. This firefighter/EMT responded to an incident scene and thought that a picture of the incident would make excellent fodder to post on one of the social media sites that he participated in. So, he snapped the picture with his “smart” phone and immediately posted it on the social media site. Appended to the photo he put what undoubtedly was an especially witty and thoughtful comment related to the person(s) who caused the incident.

Thus ensued “all hell” being brought down upon this young firefighter/EMT by the upper echelons of his fire department. Turns out that the Chief, the Assistant Chief, and a number of his coworkers were “friends” of this young firefighter/EMT and were immediately notified of what he’d posted on the social media site. They were not amused in the least and did not find the humor in the especially witty comment that he’d posted with the picture.

I agree with the Chief on this one. Let me be the first one to expound upon the virtues of social media in EMS and Fire. The fact that you’re here reading this is a testament to its potential to positively influence our profession and our interactions with the public and each other. However, its potential to tarnish our image if used irresponsibly is there as well. This case was an example of that.

I never did get a chance to see the picture, but from what I heard of the case the picture did not involve any personally identifiable information. Locals could have seen the picture and identified it, so could those involved of course, but it didn’t violate any laws that I know of.

What it did violate, are the ethical standards in which we operate under. Public safety people respond to incident scenes where we see things not meant for public viewing every day. We’re all familiar, I hope, with HIPAA and the various other privacy laws that we operate under, but we also need to be aware of the ethical standards that guide our interactions with private information.

When I got into this business, the metaphor that we used was “The Coffee Shop”. We were told to keep our shop talk behind closed doors within the service, and not go down to the local coffee shop where people could hear us talk. In the small town I lived in, everybody knew everybody and everybody had a scanner. Even if one of our guys was talking about “This Person” who had had some type of medical condition or had injured themselves in a spectacular way, everyone would know whom he was speaking of. Thusly, we didn’t go talking about what we saw out in the public. It wasn’t a legally mandated standard, it was an ethical standard of behavior that allowed the public to trust us and feel comfortable calling us in their hour of need. People won’t call us when they need us if they fear public embarrassment. Most people, that is.

Nowadays, it’s gotten complicated. With social media sites more popular than ever and showing no signs of slowing down, the impulse for some of our ranks to post information of an ethically non-public nature up there on the interwebz can be irresistible. With my “smart” phone in my pocket at all times, I have an express lane to career ruin right there at my fingertips. All I have to do is act irresponsibly one time with a photo, comment, or post and my career is finished.
And I remember and respect that. 

Professionally Ethical behavior requires that we separate our professional lives from our personal ones. While it would have been no big deal for Joe-Public-Came-Across-An-Accident-Scene to snap a quick pic and send it off, it is a huge deal for a Professional Rescuer to do the same. We were called to the scene to help the people involved. Professional Ethics mandate we leave our personal feelings and personal lives at the station. If the public gets the perception that their personal business is going to be splashed across the interwebz by one of the people who came to help them, then I’ll bet that the public is going to be mad at that.

Just remember, folks. Friends and families of public safety people have always been interested in what we do out there. They always will be. With today’s ultra access into our personal lives that social media can bring, it’s easy for youngins to get carried away and violate the ethical standards on spreading private information. There’s a rule for this and technology hasn’t changed that rule. You don’t use your position of public trust to gain access to and spread private information.

Just don’t do it. Resist the urge and keep your career, and honor, intact.

Posted by on December 1, 2009 • Filed under: Administration & Leadership, edemse, Emergency Medical Services, EMS, EMS ethics, EMS Topics, Ethics, everyday ems ethics, Fire department, Fire Rescue Topics, Firefighter, medical ethics, PR, professionalism, Technology & Communications, technology-communications-ems-topics, whattaya do

The Drunk Responder

5 comments

Greg Friese, over at Everday EMS Tips, has written a post in observance of Drug Free Work Week – Oct 19-25th, 2009 entitled “When a Coworker is Intoxicated” In it, he asks what we would do as EMS professionals and Firefighters in cases where we suspect that a coworker is under the influence. This originally started as a comment to his post, but it went long enough that I thought I could get a post out of it. Here it is:

Ewww, I hate these situations. I’ve worked full-time EMS for a long time, but I’ve volunteered for longer than that. One would think that this is a problem that I’ve encountered more often in the volunteer services, however I’d have to say that the few times I’ve actually noticed it are about equally distributed.

Thankfully, these situations have been few and far between. However, EMS and Fire people like to drink sometimes (ahem) and the potential exists for this to happen more often than you’d think.

In a volunteer service, the classic example is someone showing up for an emergency call after consuming alcohol. Often, these people sincerely did not want to “show up drunk” but thought that the need was great enough for them to show up after having “Just one or two”.

For the paid services, aside from the absolute taboo of consuming alcohol while on duty, the classic example would be spending a late night out at the bar and then showing up for work in too short of a time for the alcohol to be removed from the person’s system. If you’ve ever had a coworker show up complaining of a hangover, this may indeed be the case.

Both are unacceptable. Personally, I know that my career depends on never doing this. I also know that my patients deserve a caregiver who is on top of his (or her) game. I subscribe to the FAA’s rule governing pilots, or the “8 hour from Bottle to Throttle” rule. I take myself out of the response roster for at least 8 hours if I have had one sip of ETOH and I stop drinking a minimum of 8 hours before having to go on duty.

There’s no excuse for a provider having any amount of alcohol on board while performing any aspect of EMS. If the patient smells even a whiff of ETOH on their provider, that provider is drunk until proven otherwise. Even if the provider is under the legal limit the patient loses confidence. Our patients deserve better. If you had EMS come for a family member and smelled alcohol on the responding ambulance crew, you’d think the same thing and would probably become very angry or fearful for the actions of the responding crew.

Remember, each “drink” defined as one ounce of alcohol, raises your BAC (Blood Alcohol Content) by roughly 0.02%. That amount of alcohol takes approximately one hour to be removed from your system by your liver. Each person is different, and other factors come into play… however if you’ve been drinking you need to leave hours between your personal fun and your professional care.

The problem here, of course, is the percieved effect on the person who reports a coworker for possibly being under the influence. In some agencies there may be fear on the part of the coworker who notices the smell of ETOH or other intoxicant that they will be ostracized by the group for blowing the whistle and turning the offender in. In reality, it is your duty to your future patients and the reputation of your agency to turn someone in no matter the percieved ill effects. However, to make this easier I have some tips:

  1. Act immediately – If this person gets activated for a call or otherwise interacts with a patient, they could cause that patient harm. This is unacceptable.
  2. Enlist the aid of a coworker if you’re uncomfortable immediately going to a supervisor – Get someone else to nonchalantly speak to the person or linger in their vicinity to see if they notice what you do. Go together to report the suspicions even if the other person doesn’t notice what you do. It’s that important.
  3. Remember that someone’s life may very well depend on your actions – Friendship among coworkers is one thing, but a drunk firefighter or EMS provider may very well kill someone. You or another coworker may be injured or killed by their actions on the fireground or emergency scene. Your patients may suffer at their hands because their decision making ability and reaction times are impaired. Can you stand that on your hands for not reporting it?
  4. You may be helping the person through a real problem – Is the coworker an alcoholic? Could they be? Being at work drunk, especially in such an important job as EMS and firefighting is indicative of a real problem with alcohol. Turning them in may be the first, and biggest influence in getting that person help or in allowing them to help themselves.

This is a tough situation, but is an easy call. Keep alcohol and other drugs out of the emergency services. Keep yourself sober and sharp while on-duty or responding. It’s just not worth losing everything over a couple of beers. Have your fun and enjoy yourself while off duty but remember, alcohol can be a wonderful servant but is a terrible master. Do yourself, your career, and your patients a favor and leave ETOH in your personal life, far away from your station.

Posted by on October 22, 2009 • Filed under: Administration & Leadership, Command & Leadership, edemse, Emergency Medical Services, EMS, EMS ethics, EMS Health & Safety, EMS safety, EMS Topics, Ethics, everyday ems ethics, Fire Rescue Topics, Firefighter Safety & Health, medical ethics, professionalism, safety

EMS 2.0 & EMS Ethics – How far would you go?

12 comments

Throughout my EMS career I’ve heard a lot of the same complaints from paramedics that seem to be endemic within the system. One of these is the quality of physician medical direction and whether or not theirs is considered “Progressive” or “Permissive” by the EMTs and Paramedics that work within the protocol system. Some systems seem almost regressive. They don’t seem to show any trust in the providers that work within the protocols and end up being putting forth “Mother-May-I” protocols that disallow aggressive field treatment and require hand holding over the radio or cell phone to a base station. Others, are fairly progressive and allow quite a bit of treatment to be provided in the field.

However, even in the more progressive of the systems out there the medics always tend to have their own personal “wish list” of things that they’d like to be permitted to do. I currently work in the most progressive protocol system I’ve ever worked in and yet there are a few things that I would like to be allowed to do further than I can do now. Toradol for pain control, and the inclusion of a paralytic to our Medication Assisted Intubation protocols would be examples.

However, there begs a question here that I haven’t seen explored before: What if this was reversed?

Say tomorrow you head on into work and get there to hear the news that your medical director up and left for Tahiti with a new love interest with whom he or she will be very happy. Incidentally, you’ve now got a new medical director that just graduated medical school after spending 10 years as a field paramedic. There’s a “Get to Know Me” meeting scheduled in a half hour,

In the meeting the new medical director, who emphatically insists that you call him “Dr. Pat”, and then changes it to “Just Pat” outlines the new protocols that you will be functioning under starting as soon as you all can get through the trainings and meetings that are scheduled. These protocols are amazing. For example, your protocols for treatment of severe asthma used to include just oxygen, nebulized albuterol, and subcutaneous epinephrine. Now you’ll be giving Albuterol mixed with atrovent for your nebulizers, Epi 1:1000 sub-q or brethine (terbutaline) sub-q, epi 1:10000 IV for severe cases, Solu-Medrol (an injectable steroid), and Magnesium Sulfate infusions for refractory cases. For pain control, you used to have to call for orders to give Morphine. Now you give Morphine in 2mg increments titrated to effect up to 20mg if the blood pressure is over 100mmhg systolic, Fentanyl 50mcg – 200mcg, Toradol 60mg IM, and/or Nitronox (Inhaled Nitrous Oxide). The protocols are really advanced and have at least twenty new medications, some of which you’ve never even heard of.

Soon after you start reading the new protocols you start noticing things that frankly, scare you a bit. Never mind the fact that you don’t know how you’re going to calculate amiodarone drips and use propofol for conscious sedation, you’re frankly scared that the protocol system directs you to perform emergent C-Sections to save a viable fetus in cases of limb presentations in pregnancy. Really?

Mannitol and induced hypothermia for head injuries? Wow. You also now have needle crics, surgical crics, Needle decompression of the chest, pericardiocentesis, retrograde intubation, and what are those words? Thoracostomy (Chest Tubes)?? Thoracotomy? Holy crap! There’s almost nothing you can’t do! 

After the meeting you head out on the streets with your partner. You’re honestly feeling a little nostalgic for the days when your Tahiti-bound regressive medical director wouldn’t let you be responsible for hardly anything. It’s completely opposite now. You’ve gone from one extreme to the other. There’s nothing that you’ve ever thought of doing in the field that you can’t do anymore.

On one hand this would be very exciting for me (and yes, I went a little overboard with plausible treatment modalities to make a point here) but on the other hand, I’d have to ask the question:

Where would be the line where progressive treatment protocols cross the line? When would be the point where paramedics are given too much responsibility for complex invasive treatments?

I’ve never seen the case I’m describing. I love working under a progressive and liberal protocol system. However, in a meeting the other day when the possibility of administering thrombolytics for refractory ventricular fibrillation in cardiac arrest came up I had a thought that I’d never had before:

“I don’t get paid enough to have that much responsibility. I take on a lot of liability and have to put in a lot of uncompensated education time for the meager wage that I get paid now… how much is that going to have to increase for no more money?”

I don’t want to think that way, and I’d have to question the dedication of any paramedic in any of the protocol systems that I’ve examined that would say no to being able to provide potentially lifesaving treatments to their patients. I can’t imagine refusing to do something because I didn’t think that I was compensated enough to take on the responsibility of doing it. I’d be happy to sit through the required education, but I doubt that they would increase the compensation of the medics in the above example.

Could it happen? Has it happened? Will it happen as treatments progress and professional responsibility increases? I’ll firmly say that I’m nowhere near adequately compensated for the responsibility I have today. Where would I be if the above scenario happened to me tomorrow?

EMS 2.0 needs to seek out and find answers to the questions that we haven’t asked yet just as much as we need to find answers to the questions we’ve been struggling with for years.

What do you think?

Posted by on October 18, 2009 • Filed under: Als, change, edemse, Emergency Medical Services, EMS, ems 2.0, EMS ethics, EMS protocols, ems salary, EMS Topics, EMS training, Ethics, everyday ems ethics, medical ethics, Paramedic, paramedic education, patient care, Patient Management, physician, politics, SMG, SMO

The Medics are Revolting

13 comments

Howdy everyone! This pre-script note is my apology for starting off my first post on my new blog site with a rant. Yes… I am indeed ranting here.

“Do you hear the people sing? Singing the songs of Angry Men. It is the music of a people who will not be slaves again! When the beating of your heart echoes the beating of the drums, there is a life about to start when the morrow comes.

Will you join in my crusade? Who will be strong and stand with me? Beyond the barricade there is a world you long to see? Then join in the fight that will give you the right to be free!”

- Jean Valjean, Les Miserables

< rant>

“You’re just a dumb EMT/Paramedic. Know your place. Shut up and take it. Don’t make waves. Don’t question the system. You’re a cog in the wheel. The system is in place for reasons you don’t understand. Stay in your lane. You don’t have to understand, just obey. Don’t overstep your boundaries. Shut up and do your job. Don’t be a “problem child”.”

All of my professional life I have heard the above. All of my professional life there has been the chorus of the negative. The naysayers have been winning and the apathetic have been in control. The dreamers are troublemakers and the innovators are punished for breaking the rules. They must control us, they must hold us within our role and not allow their status quo and their version of where we are, who we are, and the direction that we should be heading to be challenged. They set the rules and we are to follow them without all but the most superficial of questions.

All of my professional life I have seen patients suffer for it. All of my professional life I have felt my peers and myself suffer for it. Patients suffer from poor, outdated care borne from outdated thinking and EMS people suffer from it through pitiful wages, laughable working conditions, and no professional respect. The ones that conform to the status quo are rewarded for their compliance through slightly better wages and working conditions, but their patients still suffer the same. Every service delivery model has it’s problems. There is no unified voice. Every system has it’s limitations and those who seek to limit it.

And I’m mad as hell and I’m not going to take it anymore.

EMS is suffering from apathy. We’re suffering from a distinct lack of the pioneering spirit held by those that came before us. They saw that the lack of a system was causing suffering in their communities and built a system to care for those persons emergently sick and injured. Through their trials, tribulations, work, and sacrifice a system was put into place that we currently function within. Amazingly, our system is functioning well in it’s adolescence and I am proud to carry on under the banner of the Emergency Medical Services. Our blessing and our curse is that we are the ones whom our society has burdened with the responsibility of responding to our fellow humans in their time of need. It is an awesome responsibility and one that we are honored to hold a place within.

But are we honoring the work of those pioneers who came before us? Are we truly accepting the burden of our responsibility to those we’re sworn to care for?

Sadly, no. We’re not.

Here’s the deal. As a profession, we have some decisions to make and some lines to draw in the sand. First off: We all have to care about the right things. Yes, in some cases, it’s debatable what the “right things” are… but here are some that I think everyone can agree on.

  1. Every patient deserves our best
  2. Every patient deserves our advocacy
  3. Every patient deserves the best medical care we can give them
  4. No patient risk harm due to petty political games or power struggles
  5. No patient should risk harm due to ego
  6. Every EMS provider is responsible to ensure the best care possible for patients in their charge

That all sounds simple, right? Unfortunately, you all know that it doesn’t work like that every time. Systems fall through the cracks, mediocre providers coast along providing mediocre care, ego trips by the various health professions engage in endless power struggles using patients, jurisdictions, and policy as pawns in the game. “Uppity” paramedics who question their role are shamed into submission. Patient advocates who stand up for the rights of their patient against apathy and whatever requires the least effort are chastised. We’re called troublemakers. We’re vilified for our pursuit of improvement in the system or our pursuit of the best possible care for every patient, every time.

EMS 2.0 is the maturing of EMS out of the adolescent trade phase into a grown-up profession. EMS people need to take a stand together, casting off our petty differences and realize that we are here for the same reasons. Our awesome responsibility is to the patients who depend on us. It’s something that we can no longer take lightly. We can no longer allow the various outside forces to dictate our educational standards, our standard of care, and our “place” in the medical hierarchy.

I know “my place”, and it’s not where the ER nurses want me to be. I’m not “unlicensed assistive personnel”. It’s not where the fire unions want me to be, I’m not “a firefighter who works on the ambulance”. It’s not where the private companies want me to be, I’m not a “Pulse and an EMT card”. As a professional paramedic, “my place” is dictated by the professional competence and responsibilities earned by the members of my profession as supported by science and as allowed by law.

That’s just it. A true “profession” meets the following criteria, as can be found on our friend Wikipedia:

The main milestones which mark an occupation being identified as a profession are:

  1. It became a full-time occupation;
  2. The first training school was established;
  3. The first university school was established;
  4. The first local association was established;
  5. The first national association was established;
  6. The codes of professional ethics were introduced;
  7. State licensing laws were established.[2]

So does EMS meet the above criteria? Yes, and no. I think that we are indeed a full-time occupation. Even volunteers must put in full-time hours to maintain proficiency. We have multiple training schools that are loosely based on the National Standard Curriculum, but even with that standard there’s a ton of variation throughout states and regions. For example, somewhere on this site you’re going to see a Google ad for a “Guaranteed Pass” online EMT class. My wife, Gkemtp(it), is going for almost 15 months. Is there a University school? Yes, go ask Firegeezer about George Washington University’s EMS degree program. While there really aren’t any degrees above the bachelor level that I know of, at least it’s something. There’s local and national EMS associations, like the Wisconsin State EMS Association and the NAEMT. There’s the EMS Professional Code of Ethics and every state has licensing laws.

So why aren’t we a respected profession? We meet the 7 standards, don’t we? Mostly anyway.

I’ll answer for you, it’s because we’re not united… yet.

Welcome to Life Under the Lights. Welcome to my little piece on the web. I believe that we can unite under free exchange of impassioned ideas about the profession we believe in. I invite you to dig in, saddle up, and help our profession achieve the greatness we know that it can.

< /rant>

Posted by on October 15, 2009 • Filed under: Ambulance Driver, change, edemse, Emergency Medical Services, EMS, ems 2.0, EMS Blog, EMS ethics, EMS Topics, everyday ems ethics, Paramedic • Tagged: , ,

Soapy Demons – Ckemtp is a geek

2 comments

Washing Machine Sta 1Ok, so this post really proves just how much of a geek I really am. Just bear with me for a bit.

This subject causes me a lot of personal grief. I know that it probably shouldn’t and that I am indeed a geek for worrying about this issue because seemingly no one else does, however this issue has plagued me for years and I need to get it off of my chest.

This is about the washing machine at the main fire station where I work. I’m at this station a lot, whether I’m working one of my three weekly scheduled paid shifts, hanging around with my wife who works there three scheduled paid shifts as well, or volunteering my time for call response, training, or work projects. So I have the opportunity to use this particular large, commercial, washing machine quite a bit.

It’s a nice machine. It handles the huge loads that we generate on a daily and nightly basis. It cleans the stuff pretty well and runs pretty quickly and quietly.

The problem is, the soap. It does not rinse the soap out of the clothes, bed sheets, blankets, turnout gear, or anything else that we put in there. The “rinse” water is always white with suds and everything comes out soapier than when we put it in there.

I am well aware that this is not a sexy problem. It’s not a big issue and castles will not fall because of it. It just drives me nuts.

When it comes to be my time to use the machine, I run two full cycles at a minimum to rinse out the machine. The third cycle usually has at least some soap in the water but I use it anyway because all of the residual soap that is left in the stuff that we constantly wash in there. The stuff is full of soap! Our sheets, our towels, our turnout gear… everything. After you run a load in there, even after a second full cycle, the water is white with suds on the final rinse phase.

For a few years, I begged, pleaded, cajoled, and bargained to get people to use less soap in the machine. I tried to get the purchasing division to get us a different type of soap that might rinse cleaner. I even went so far as to post up a few memos in the washing room and write a couple of written requests to the purchasing division and the officer above them.

Predictably, nobody cared those times and still nobody cares about the issue now. Everybody still dumps the same big glob of soap into the machine when they start it and then promptly forgets about it. Whomever comes in and removes the stuff from the washer just puts the stuff right in the dryer, still soapy as all get out, and throws another load in the washer. Then, they dump a big glob of soap in the machine and the cycle perpetuates. Honestly, it’s a losing battle for me and I know that I’m the only geek who cares out of the 100 other people on the department. Nowadays I’ve resorted to trying not to care about it so much and also by surreptitiously watering down the soap that we use. I’ve been doing that for years and nobody seems to ever have noticed (until they read this). It helps a bit, but still our stuff is soapy as heck.

Am I crazy? Probably, but consider this: This small issue is hurting my department and the way we function. Really. We spend hours per week cleaning and polishing our apparatus. To do that, we need towels. Lots of them. Now that they’re all full of soap, they don’t soak up water anymore and we have to constantly replace them with new towels that promptly get full of soap and don’t absorb water and leave our trucks streaked with laundry soap and water spots. Then, we replace the towels again and the cycle perpetuates. How much money do we spend on new towels?

Consider this also: Our guys sleep on linens that get washed every day after they’re used. These linens are full of soap and are against our guys’ skin every night. What happens when one of them develops an allergy? Occasionally, some of this linen goes for use on an ambulance… when will we get a patient with an allergy to our soap?

Consider this as well: How much does it degrade our turnout gear to be full of regular laundry soap? Sure, we bought the expensive specialized turnout gear cleaner, but it doesn’t matter because the water we’re using to wash the gear is full of the soap from everything else? Does that degrade our protection? How much are we harming our very expensive protective clothing by filling it with soap? When will the gear fail and someone get burned because of this? Will it happen? When someone gets burned will it be my fault because I didn’t try hard enough to fix an issue that I saw?

Yes, I’m a geek for caring about this issue so much. I feel like an OCD Chicken Little. However, this small, nothing issue is costing the department money overall and could get someone hurt out there on the fireground. After that, I’m sure people will wonder how this could have been prevented. I’m sure also that they’re looking for ways to cut costs now that the economy tanked and tax revenues are down.

And there sits the washing machine, quietly driving me crazy.

How many issues out there do people know about like this? Issues that are small enough so that nobody else cares but that snowball into big problems for the organizations. How many of these issues affect EMS and the fire service industry-wide. How many of them affect everything?

One day I’ll conquer my soapy demon. For now, I have to keep watering down the soap in secret… but as crazy as it seems, I feel that I’m making some small difference. You can too. Be it the way your equipment is checked in the morning, the way you package your lifesaving gear, the way you make sure that the gas tank is full, or the way you do whatever it is you do to make your service the best it can be.

Now get out there and water down your soap. You might just save a life.

Posted by on October 10, 2009 • Filed under: edemse, Emergency Medical Services, EMS, ems 2.0, EMS ethics, EMS safety, EMT, Ethics, everyday ems ethics, fire, Fire department, Firefighter, new perspective, Paramedic, pride, professionalism, soap

Scenarios. A lot of EMS, a little Einstein

2 comments

A while back ago I had a kick where I did a scenario-based EMS ethics piece that took a look at a possible situation that could be faced by some Paramedics and asked readers what they would do in that case.

The response was pretty good. You should add your opinion here.

I use a lot of scenario based training for the EMS people that I teach. I teach a lot. Being the old, grizzled veteran that I am (shameless self plug but looking at the kids these days entering the profession sometimes I feel like shaking my fist at them, hiking my jeans up to my navel, and yelling at them to “Get off my lawn!”) I have the opportunity to mentor a lot of newer providers and precept a fair amount of students. During our slow periods, I find that giving the students an informal scenario helps them to step outside their thought processes and really think about what they would do when faced with a like situation.

I like it so much, that I even do it to myself. I’ve mentioned that I come up with most, if not all of my blogging ideas when doing other, mindless tasks. A great deal of my post ideas come while driving. I allow my mind to wander to imaginary concepts and ideas. Since I’m so immersed in EMS on a daily basis, a lot of those thoughts go right back to EMS, and “what if” scenarios come into my mind. Some of them are about patients that I’ve had, the “what if this had happened” kind of questions. Others are completely random scenarios that I wonder what I would do if I happen to be faced with the situation.

Einstein conducted what he called “Thought Experiments” to assess theories that he could not experiment with in a laboratory. One of the ones that I’m most familiar with is his “Flashlight on a Train” thought experiment. In this well documented case, he hypothesized that the speed of light was a constant and was not affected by outside forces. He imagined himself on a long, open railroad train with himself standing at the caboose, or end car of the train. He imagined shining a powerful flashlight from the rear of the train through the cars to the front engine. Using some logic that I am not familiar with because I’m no Einstein, he was able to theorize that the light from the flashlight would hit the train’s engine at the same time and that the light would travel at the same speed no matter how fast the train, and therefore the light source, was travelling. Unlike a missile fired from a jet plane that’s speed would be affected by the speed of the plane that fired it.

So how do Einstein’s thought experiments connect to EMS?

I equate the personal scenarios that I think of and the scenarios that I use to keep my students thinking outside the box to Einstein’s thought experiments. There are things in EMS that we do not do very often. Skills like synchronized cardioversion, surgical airways, and complicated drug administrations aren’t everyday things. Neither are difficult patient presentation with complex layers of comorbid conditions. These are high-risk, low frequency events that trial lawyers dream about. When you need to perform these tasks or think around a list of contraindications when your patient needs action now, having thought about them prior to having to perform is lifesaving.

One of the things I hear the most from paramedics and EMTs is how they run though a list of possible scenarios, patient presentations, and treatment modalities in their heads when dispatched to what sounds like a particularly nasty call. I do that sometimes too, although less now than I used to. Spending the time thinking about these things when you have the time to really ponder the issues is very beneficial and even fun… if you’re an EMS geek like me.

So next time you and your partner are bored sitting in your parking lot waiting for the next call, toss around a few “way out” scenarios. Your care will benefit from it. You might too.

Posted by on September 22, 2009 • Filed under: Emergency Medical Services, EMS, EMS Blog, ems education, EMS practice, ems scenario, ems scenario based education, EMS training, everyday ems ethics, mental imagery, Paramedic, paramedic education, patient care, scenario, scenario based training, whattaya do

Everyday Ethics for EMS Providers

1 comment


Mike left a comment on the last post I wrote “EMS Politics, Medical Ethics, and… What would you do?” with a good quote that I’d like to bring the forefront of discussion: “Your next call could be your last call”.

That sentence sums up something that I’ve always said about EMS quite nicely. Bravo to you and your old partner, Mike.

I firmly believe that EMS professionals face “No Win” scenarios several times in their careers. There are things that come up and situations we face that would test the most knowledgeable medical ethicist. Often times we have to make terrifyingly difficult split second decisions using woefully inadequate information that will not only affect the very life of a patient but also our careers and our livelihoods. It’s not fair, and it’s not fun. Paramedics are entrusted with huge responsibility for clinical judgment but can be quickly chastised and sanctioned for even stepping a little bit outside of the box. No, we’re not physicians and No, we’re not licensed to perform everything that a patient may need. I understand that there are some things that are just too dangerous to do in the field, and that yes, patients sometimes die in front of us and we are powerless to stop it.

However, in the scenario presented in the abovementioned post, that was not the case. In the case presented, the patient needed a surgical cricothyrotomy and needed it NOW. The paramedic described in the scenario had been trained in the procedure, had the tools available to him to perform the procedure, and the patient was going to die quickly without the procedure. The catch was that the protocol system he was working in did not allow him to perform the procedure.

The scenario gives two choices:

  1. Don’t perform the cric. Use your full airway bag o’ tricks such as first trying BLS techniques (Heimlich Maneuver, abdominal thrusts) attempting to remove the object with Magill forceps under direct laryngoscopy, attempting to intubate the patient with an ET tube and push the blockage into the right main stem bronchus with the tube allowing the left lung to be ventilated (It’s better than nothing), and scooping the patient up and running really fast to the hospital. If all that takes more than 5 minutes from the time the airway got blocked, including the time from incident to the 911 call, the dispatch time, and your travel time, expect brain damage at the very least. If it’s much longer than that, expect the patient to die.

     

  2. Perform the cric. You’ve got the knowledge, you’ve been trained on the procedure, and you have the equipment available to perform the procedure. The procedure is in the standard scope of practice for paramedics all across the country. Unfortunately, even if the patient makes a full recovery, you’re in deep trouble. The Medical Director in the scenario has not authorized the procedure for paramedics under his/her direction and therefore you’re practicing medicine without a license which is a violation of the letter of the law. It may very well be the only thing that will save the patient’s life, but you’re likely to face severe penalties for violating your protocols.

So what do you do?

I firmly believe that medical direction should not hold paramedics back and that there has to be some leeway in the standard operating procedures that paramedics function under to allow for these situations. Every protocol system and EMS service that disallows such procedures that are allowed under national accepted scope of practice can have situations where patients have poor outcomes up to and including death. In these systems, the EMS provider bears the brunt of the negative result. If he allows the patient to die, it could be argued that he withheld lifesaving care and violated a duty to act. If he was protected legally by the letter of his protocols and the fact that he followed them, he at least could be committing a moral and ethical violation that will haunt him for the rest of his life. I would suspect that the medical director and/or the authorizing body would not be sanctioned in this case… if they were even aware of it. By performing the procedure and saving the patient, the paramedic will be punished quite severely. Even if the patient survives but has residual morbidity resulting from the prolonged anoxia, the medic could be sued for and be held liable for the damages.

In any case, the paramedic carries the burden. It’s a no-win situation.

For the record, I didn’t actually have this happen to me, but I have worked in two systems simultaneously where one is more progressive than the other. In fact, I do right now. Fortunately, both of these systems allow surgical cricothyrotomies, but they carry different medications and have different dosages. One of my services uses CCR (Cardiocerebral Resuscitation – http://www.callandpump.org/) and the other follows an older version of the AHA guidelines. While both are acceptable and I follow the protocols for the system that I am working at when I am working there, I can see the potential for ethical conflict. I’ve been a full-time paramedic for a long time and I’ve flexed the rules occasionally when it was in the best interest of the patient. Luckily (and yes, I know I’ve been lucky) the patient has always had a good outcome when I’ve had to do this.

Here are my rules for “bending” the rules:

  • Above all, always act in the best interest of the patient – If you can show that you acted in the best interest of the patient, disregarding any other potential motives, you’re well on your way to vindication. However, remember that ‘rule bending’ must be for the patient’s best interest, not your own. Something like not placing the shoulder straps on the patient during transport because it makes it more comfortable to care for them is in your own best interest, not necessarily in the best interest of the patient. Taking a patient to a hospital closest to your next errand and not to the most medically appropriate is also in your best interest and not in the patient’s. The cric scenario regards whether the patient will live or die at great peril to the paramedic.
  • Know what your protocols are and why they are the way they are – Knowing your protocols inside and out is essential to being a good professional provider. Knowing WHY they are the way they are, i.e. the reasoning behind them is essential as well. Be able to show that you know them inside out when you’re questioned, to show that you’re not negligently ignorant of the rules you have to function under.
  • Be able to prove what information you had available for you to consider – In these situations, you’re working with incomplete information. However it is your professional obligation to gather as much information as possible as quickly as you can gather it. Do a thorough assessment, and talk to the patient and any bystanders, if possible. When questioned about the incident later, you need to be able to present the information that you were presented with to the people who are going to play armchair quarterback. Be able to put them inside of your shoes.
  • Be able to prove what options you had available to you, how you considered them, and why they did not or would not have
    worked – In the previous airway control scenario, I laid out possible options that the paramedic in the scenario considered. I also laid out why they would not work as the situation unfolded. Be able to show your thought process and how you ruled out options that were within the letter of the rule book.
  • Be able to prove why you thought that the option you chose was absolutely necessary – If it was a “do or die” call, be able to prove it as best you can. You should be
    able to show why it was necessary that you chose the option you did. In the cric scenario, transporting the patient to the hospital so that a physician could perform the procedure would most likely have resulted in the death of the patient. In that case, the best interest of the patient, obviously, would be to continue living… which he would not have done without the paramedic violating the rules. BE THAT SURE of yourself.

I would love for people to jump in and offer their takes on this topic. Please comment away. If you haven’t read the great comments on the previous post, left by such people as Medic999, HappyMedic, and TOTWTYTR you can find it here.

I use scenarios like the one that I wrote out in the previous post as a teaching tool for new EMS people and students that I precept. I think that scenario-based teaching is a great way to promote critical thinking skills and to evaluate what a person would do when faced with the situation presented. In the future, I’m going to be featuring scenarios that challenge ethical standards as a way to educate ‘Everyday EMS Ethics’. Look for the “Featured Areas” to showcase these and other interesting articles.
And thank you for reading.

Posted by on August 26, 2009 • Filed under: edemse, EMS ethics, EMS paramedics, Ethics, everyday ems ethics, medical ethics, scenario, whattaya do

Follow up to The Shine Factor: What makes a great Ambulance Service

2 comments
This is part 2 of a 3 part series on “The Shine Factor”

Part 1 of this series can be found here – The Shine Factor

Part 2 of this series can be found here – What Makes a Great Ambulance Service

Part 3 of this series can be found here – The Shine Factor – Grunts

——————————————————–

Perhaps I really am an EMS geek. I do EMS tourism. No, I don’t find new and interesting ways to hurt myself enough to require emergency services but when I’m travelling I usually stop in to EMS and Fire Stations along my way and go look over the service. This has been a lot of fun some times (Thanks MAST in Kansas City and Sedgwick Co. EMS in Wichita! I had a great time) and has been somewhat less fun in other areas. If you’ve ever done this, you’ve probably noticed some things like I have.

First, there are services out there that are average. They run ok equipment, they have an ok group of people working there, and they appear generally competent.

Then there are services that are not so good, the kind that leave you shaking your head at in the car when you leave after politely pretending to be impressed.

And finally, there are services that really, truly do impress you. They’ve got this stuff down to a science. Their rigs are clean, well taken care of, and in great shape. Their equipment is top of the line and well stocked, their uniforms are cool, their people are really friendly and seem more intelligent than your coworkers, and their facilities make yours look like a single-wide trailer. Heck, the place even smells like freshly squeezed awesome. These services are so much of a class act that you find yourself wondering why exactly you work where you do and aren’t working there with them.

I’ve seen these services along my path and I have noticed a few things that seem to characterize all of them. Sure, some do these things better than the others to different extents however you will find a healthy mix of these things at all of these services. I’d like to share some of these things with you.

Things I’ve found out about awesome EMS Services:

  • Their people are proud of the organization: You’ll find that the people who work at awesome services sincerely have pride in where they work. They’re there for a reason. They enjoy working for a service that has a good reputation in the community and the wider region. They think that their service is cool; they think that working for their service is cool; and they are respected by people from other agencies because of the position with the agency that they have. There’s a general feeling among the people that work for the service that it takes hard work and performance to earn a position within the agency. A service earns self respect the same way a person does, by having high standards and meeting their own challenges. A service that earns the respect of its people earns the respect of the wider community. Their Shine Factor is high.

     

  • Their people truly care: “Apathetic” is not an adjective you would use to describe these people. The culture that they’re in allows them to know that they make a difference in everything the service does, not only in the lives of their patients. They know that they are an important part of their service and that they would be missed if they were gone. They care about their coworkers and are as much friends as they are colleagues. There is mutual respect and a feeling that everyone there has to pull their weight in order for the service to meet its goals and thrive. Have you ever seen something wrong in a truck and haven’t spoken up because it was someone else’s fault or someone else’s job to take care of it? These people care enough not to do that.

     

  • Their community cares about and supports them: Community support is absolutely essential if an EMS agency is going to thrive. The best services have proven their worth to their communities and constantly work to prove why they need, deserve, and responsibly use the support they receive. The community supports them because they see the benefit in supporting them. You can see the community’s support in the newness and quality of their equipment and facilities as well as in the salaries that the employees are paid. You can see how responsible the service is with the support they get in how well they treat the equipment and the community in return.

     

  • The culture of the service just ‘feels good’: The culture of the organization defines the way everything runs. Bad organizational cultures breed discontent and apathy in everyone over time. Good organizational cultures breed people who feel comfortable coming to work and handing the responsibility of being an employee. People that work in a bad culture form cliques and get angry a lot. People that work in good cultures come up with ideas that get judged on their merits. People that work in bad cultures fear mistakes because of the punitive measures that will come down from on high. People that work in good cultures acknowledge their mistakes and are allowed to learn from them so that they grow as a provider and as a person. People that work in bad cultures hate coming in to work. People that work in good cultures have friends at work and feel comfortable, if not happy, with being there. I think that you can get what I’m talking about.

     

  • Their people are experts in what they do: Paramedics and EMTs are experts in Pre-Hospital medical care. They have to be, there is nobody else who could or should be. The people in awesome EMS systems have great protocols that are challenging to learn and require advanced skills to perform. Their protocols evolve with emerging science and keep on the progressive edge of medicine. The training, quality review, and quality improvement programs are tough and demanding. People take pride in being the best at what they do and earn their own self respect by doing it well. They respect themselves for their efforts and respect their coworkers for earning their respect every bit as much as they do. Ever been scared that you or a family member or friend would get hurt while so and so’s on? These people don’t have to be.

     

  • The organization respects and supports the employees: This relates to the organizational culture but deserves its own point. Employees will not respect the employer unless the employer respects the employees. In awesome EMS services, the employees and management function in an atmosphere of mutual respect. The management provides the employees with adequate, functional equipment and facilities even when asking them to do more with less. They strive to promote fairness in corrective actions and policies, knowing when to cut someone slack when appropriate. The employees are treated like adults and are encouraged to innovate and take ownership of their areas.

I’ve been to these services and I can honestly say that I left their station with the feeling that I wanted to be a part of their organization. Then, I’ve gone back to my service and taken an inventory on what we needed to do to emulate them. It’s all about being able to enjoy coming to work for the right reasons where you work with people who care, respect, and strive for the same things that you do. EMS people who are passionate about EMS who are allowed to shine build great organizations no matter where they happen to land. EMS people who aren’t build organizations that fall into the other two categories. I suggest that you take some of the suggestions below to help get your service to where you want it to be:

  • Read “The Shine Factor” – One of my previous posts and the predecessor to this one.

     

  • Realize that your community won’t care about you u
    nless you tell them why they should – EMS organizations need to market themselves just as any other business. No matter what your classification is, you need to market yourself to your community every day. Your constituents are your customers and they won’t think about you unless they either need you or you put your message in front of their faces. Tell them what you do, tell them why you do things the way that you do, and tell them what you need to do what they do. Let them know how you strive for quality. Let them know how well you are stewards of their hard-earned dollars. Let them know who you are and what you stand for. Trust me, PR saves lives and EMS budgets.

 

  • Right now, resolve to treat everyone else in your organization like a professional. Try to earn their respect. Someone has to take the first step here, it should be you.

 

  • End any secrecy in your organization – Sure, direct personnel actions are one thing, but unwritten policies and issues directly affecting all employees are quite another. Allow people to become involved in the organization in any role they want to. Organizational secrecy builds “Silos” where people tend to stratify themselves based upon their own perception of what is most important to the group and allows individuals to worry that anyone with a new idea is there to steal their position within the silo. Allow people to participate and collaborate on decisions affecting the organization.

 

  • Encourage innovation. Encourage participation and new ideas – No idea is a bad idea. Business these days thrives on the economics of ideas. Don’t shoot down any idea without a collaborative review of its merit. Employees come up with new and better ways to do things every day, let them develop those ideas and test their effectiveness. If those ideas are repressed in an organizational culture that resists change, the whole organization will suffer when people begin to feel that their contributions never matter.

 

  • Encourage people to take ownership of their roles and responsibilities – I work for my ambulance service because it would miss me if I was gone. Why would anyone ever go to a place where it didn’t matter if they were there or not? When people begin to feel that their time isn’t valued or their efforts aren’t appreciated, they stop putting forth any time or effort above what it takes to avoid being fired. That’s it.

 

  • Never let anything stagnate – If you haven’t reviewed a system in over a year, you’re lagging behind. If your protocols haven’t changed in over a year, you’re not keeping pace with medical science. Even if something is working very well, that doesn’t mean it shouldn’t be reviewed and measured regularly. Make systems prove their worth. Don’t let anything get stagnant. Pull ineffective policies or programs and replace them with another idea. Review those ideas and see if they’re better suited to your goals. Set lofty goals and try hard to reach them.

 

  • Reevaluate why you do what you do – Why are you in the organization? Are you there because you care about what you do? Are you passionate about it? Once you remember what it was that brought you to EMS and to the organization where you’ve happened to land, evaluate if you still see your organization fires your passion. If it doesn’t, work diligently to make it meet your design. Earn your own respect. Forgive and forget past grievances and collaborate on new solutions. Bust silos and build bridges, not fences.

 

As always, I welcome comments and e-mails: ProEMS1@yahoo.com

——————————————————

 This is part 2 of a 3 part series on “The Shine Factor”

Part 1 of this series can be found here – The Shine Factor

Part 2 of this series can be found here – What Makes a Great Ambulance Service

Part 3 of this series can be found here – The Shine Factor – Grunts

 

Posted by on April 17, 2009 • Filed under: Administration & Leadership, Ambulance, Command & Leadership, edemse, EMS, ems 2.0, EMS ethics, EMS Health & Safety, EMS Management, EMS rant, EMS Topics, EMT, Ethics, everyday ems ethics, Fire department, Firefighter, new perspective, Paramedic, professionalism, technology-communications-ems-topics, The Shine Factor

Oh no you didn’t…

12 comments

Really? Did you just?? Oh come on now… you don’t really think??

Seriously…

Did you really just call me an “Ambulance Driver”?

An Ambulance Driver? Oh come on… Four years of college level classes, hundreds upon hundreds of hours of continuing educations, a veritable alphabet soup of certification acronyms behind my name, and this nifty Star of Life disco ball patch on my arm and you STILL just called me an Ambulance Driver? Really? Oh come now, do you know that calling me an ambulance driver is like calling a High School Teacher a “Nanny”, or calling a Police Officer a “Police Car Driver” or calling a Nurse a “Bedpan Jockey”, or calling a Firefighter a “Fire Truck Driver”, or calling a scientist a “Microscope Looker-Inner” or calling a Congressman a “Pork spewing bloviator” (I could go on, but I won’t… although that last one might be right)

EMS is an acronym for “Emergency Medical Services”. EMT stands for “Emergency Medical Technician”. Nationally, there are three levels of EMS professionals. Each level signifies to the public that the person holding the Title and the requisite license or certification has met stringent educational and training standards that allow them to take care of people. These levels are EMT-Basic, EMT-Intermediate, and EMT-Paramedic. Some of the states have expanded on this by offering additional levels of certifications between the levels, such as the EMT-IV Tech in Wisconsin (an EMT-Basic that can start IVs and give some limited IV meds), or the EMT-Paramedic Specialist in Iowa that is above the NREMT-P a bit but still below their Critical Care paramedic.

A paramedic these days has a college level education, takes over 1000 hours of didactic (classroom) time and can spend anywhere from 6 months to a year in clinical rotations. We can poke, prod, cut, inject, bandage, stabilize, evacuate, and care for you sixteen ways from Sunday. In my ambulance I carry 48 different emergency medications that I have to know how to use REALLY well or I can kill you. (I do know how to use them really well, trust me, so do my peers). I can intubate your trachea so you can breathe, reinflate your collapsed lung with a needle, surgically open your airway if I need to in order to save your life, and do a whole host of other things that you wish that you never ever need. My ambulance is a critical care unit on wheels that can be at your curbside in under 8minutes flat twenty four hours a day seven days a week. Today’s ambulances bring the emergency room right to you and begin advanced medical care right away. This care saves lives and improves your medical outcome greatly for a whole host of medical complaints.

And you, Joe public, still call me an “Ambulance Driver”. Which, if you hadn’t noticed, somehow irks me a bit.

Unfortunately for me, and for the members of my profession, it’s not your fault that you call me that, dear Joe Public. It’s my fault. It’s the fault of each and every EMS professional out there that you know so little about our profession and our industry that you resort to calling us that detestable term. It is our responsibility to get the word out. It is our responsibility to educate you about our life saving services, and our responsibility to let you know just how and when to use us properly. If we don’t do it, and therefore let the responsibility fall to others, we EMS people aren’t going to be happy with the job they do. We’re not going to be happy with the popular representations of paramedics in the popular media. We’re not going to be happy with the results of our public health education campaigns.

The American Heart Association has recently released a campaign entitled “Mission: Lifeline”. It’s a marketing campaign aimed at increasing public awareness of heart attack symptoms so that Joe Public calls us first when they start having the big one. If you’ve been reading this, you know that my all time biggest pet-peeve is when the people having conditions where they need us and need us now but aren’t dramatic like a car accident or cardiac arrest don’t call us. I can’t make a direct quote, but I read a study once where like 60% of people call a friend or family member first when they think they’re having symptoms of a heart attack. Calling EMS for these 60% or so of potential patients whose lives may very well depend on the early interventions we can provide them seems to be an afterthought. I can’t tell you how many people I’ve transported from small hospitals to big hospitals that were having the big one and DROVE THEMSELVES INTO THE ER without calling us.

Please, Joe Public, know that the VERY FIRST CALL you should make when you have pains in your chest is 911. Do NOT hesitate. Do NOT worry about the cost. JUST CALL US!! Do you know that approximately 1% of cardiac muscle tissue DIES AND CANNOT BE SAVED per MINUTE in a bad heart attack (myocardial infarction)? The difference is simple. You call 911 and usually (depending on where you are located) an ambulance arrives within 10minutes and starts lifesaving interventions and gives you medications to help slow or stop the damage in progress and salvage heart tissue that is being damaged. Please remember that “Time is Muscle” and that the extra expense of an ambulance is more than covered by the quality of life that we’re keeping for you. Really. Please call. Don’t wait. You can call your family AFTER you call 911. Please, I’m begging.

I’m also telling you EMS people out there to get the word out. Go market yourselves! If you want people to know what we do, it is YOUR PERSONAL RESPONSIBILITY to tell them. Go, do it now. If you want my help to write something, e-mail me and I’ll help. For free even. It’s that important.

Ambulance driver….. Seriously.

Posted by on March 31, 2009 • Filed under: AHA, Ambulance, Ambulance Driver, American Heart Association, ckemtp rants, Command & Leadership, edemse, EKG, Emergency Medical Services, EMS, ems 2.0, EMS ethics, EMS Humor, EMS Management, EMS rant, EMS Topics, EMT, Ethics, everyday ems ethics, funny, grumblemedics, inside the mind of a paramedic, Mission Lifeline, new perspective, Paramedic, Public relations, rant, STEMI, technology-communications-ems-topics
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