Knee Jerk Management

Your department has a policy that they send two ambulances to reported cardiac arrests.  On one particular busy night two of your trucks are dispatched to a person reportedly not breathing.  The first truck gets on scene and finds a patient beyond help.  Before they can cancel the second ambulance, they are involved in an intersection accident.  In response to this incident the next morning your director releases a memo stating that second ambulances will no longer be dispatched to cardiac arrests. In a labor management meeting, an employee suggests development of an “emergency code” for field personnel to report to dispatch that they are in trouble to help activate a large law enforcement response to assist them at their location.  Your boss says that this will not happen because they think field crews will abuse it.  A week later, a paramedic is seriously assaulted by a psychiatric patient.  The dispatcher on the other side of the radio was unable to make out their calls for help.  Your boss then revisits the policy. Your division uses a non-disposable laryngoscope blades.  A supervisor goes to your boss and suggests following the industry trend and shifting to disposable ones to reduce the risk of infection for patients.  Your boss decides against this since your company has never been sued by someone receiving an infection from this means of transmission.  You are convinced that the only way this policy will change is through some sort of tragedy. All three of these incidents are loosely based on actual events that I have either been part of or have heard about from friends of mine working in different systems throughout the United States.  They are all evidence of the same though, change driven by catastrophe.  We have all experienced it at some point in our career.  We have all been sitting around in a conversation with our friends and coworkers and had somebody utter the words, “Nothing is going to change until somebody gets hurt.”  Some of this attitude from leadership is because of a generalized disconnect from the field.  Some of it is because of the kneejerk, reactive nature of EMS that seems to carry on with people...

The Surfside Beach CPR Debacle

The first time I laid hands on a patient’s chest and did CPR, I was 16 years old.  There were probably close to a dozen total times that I used the skill that I learned at the age of 14 before I was legally able to be the treating EMT by myself in the back of an ambulance, a responsibility that one must be 18 to hold.  On the overwhelming majority of the CPR calls that I have been on in my career, let alone those two years before I was of legal age, I left the patient just like I found them, dead. On January 25, 2015, the Surfside Beach Fire Department in South Carolina rolled a rig with a CPR certified junior firefighter on the truck.  At some point, it was that teenager’s turn to tag in on compressions and do their two minute duty.  Much like nearly 93% of all cardiac arrests worked nationwide, that crew from the Surfside Beach Fire Department left the patient how they found them, dead, much to the dismay of the Surfside Beach town council. Almost a month ago, an “unnamed official” with the town filed a complaint, prompting an investigation by the State of South Carolina’s Department of Health and Environmental Control.  The investigation, concluded earlier this week, found no evidence of wrong doing despite the shock and horror expressed by town officials. These are the kinds of stories that make the news that are related to our industry.  No matter how futile the efforts might be, the loss of a patient is obviously catastrophic to a patient’s family, but blaming a teenager for performing a skill that is taught to kids as young as 10 is preposterous.  Thankfully, there are many who agree with me on this stance. I got my start as a cadet on my first volunteer squad, and I had the chance to mentor a few other cadets over the years.  It takes a special kind of person to handle the responsibilities that an EMT or first responder is tasked with at such a young age, but for every call, much like that junior firefighter in South Carolina, I was closely...

American Medical Response in DC

As the days tick past American Medical Response draws closer to going “live” with their new public/private partnership with the District of Columbia Fire and EMS Department.  After a story posted earlier this week about a traumatic cardiac arrest that sat for close to 30 minutes without a transporting unit being available, it is clear that the time is now for something to change in the nation’s capital. The coming months are going to be very telling for the future of EMS not only in DC but throughout the country.  From a personal stand point, I am very excited to see in what direction everything goes.  There is a lot of influence in the AMR DC operation from my old stomping grounds in Springfield, Massachusetts.  Their Operations Manager, a guy by the name of Mark Nuessle, was one of my first supervisors when I hit the streets back in 2000.  About a half a dozen people who are being brought in from around the country to help with the hiring and training process of close to 200 new employees have some sort of tie to Springfield as well.  It really speaks volumes about the system that I came from. With the involvement of national resources, I also think that this partnership says a lot about AMR’s ability to strive for success.  Often seen as the biggest of big business in prehospital medicine, when AMR steps up to the plate like they have recently on the east coast, they deserve a lot of credit.  Some critics of private EMS will speak of the “lost jobs” from the closing of companies like Transcare or like Falck’s recent move to pull out of Pennsylvania but AMR has been there to pick up the pieces.  Closures like this do not mean that jobs are going away.  People still have to do the work, it just means that a company with a better ability to operate in today’s health care climate are stepping up to the plate to provide the service.  In fact, AMR is adding close to 200 jobs to the Washington, DC market in particular, and that is a huge step forward for the private sector. I cannot...

Comfort and Failure

In my post last week about the importance of being comfortable with failure, I mentioned statistics and benchmarking.  Last month, I had a chance to present at my first national conference when I spoke at EMS Today as part of the EMS Compass preconference.  I’ve been involved with the EMS Compass project since November of 2014 and while the process itself has had some growing pains, the mission and goals of the project involve some of the most important things to the future of our industry. For example, it is only with a firm understanding of the role of benchmarking in quality assurance and quality improvement that we will be truly able to compare the impact that we have on patient outcomes.  Understanding the impact of our care and being able to compare it to other systems is how best practices are discovered.  It all comes down to asking a couple of simple questions? WHY? The first question is an easy one, and that is simply why?  If another system is seeing better patient outcomes for their STEMI cases, or if they have a higher ROSC and survival rate for cardiac arrest, you need compare your system to theirs and just ask “WHY?”  Do they have a different set of CPR protocols?  Do they have a more aggressive field pronouncement protocol that steers medics to stay and play instead of taking a load and go approach with their cardiac arrest patients? The easiest way to figure any of this out is to work backwards.  Take the example of ROSC and survival rates.  If another system has a higher survival rate, start with where they are delivering their patients.  Are they using hypothermia for their patients prior to arrival or have they omitted that step at recommendation of the AHA?  Are they part of a completely different system with different protocols that might call for later intubation or a different style of airway management all together?  What about their care in the field differs from the care that you provide? After analyzing the care that takes place on scene, look at who is going to those calls.  Are they sending more help than you are? ...

A Challenge for the Industry

Tucked away in the back of the EMS Today Exhibit Hall was a board surrounded by a number of Post-Its bearing the question “What is the BIGGEST CHALLENGE in the EMS Industry?”  There were a number of responses on the board including head scratchers such as the one that stated standards should be lowered for volunteer providers, and no that was not my “trolling” submission.  Mine, unfortunately, did not make the final copy of the board, but I think that it needs to be delved into so what better place to do that than my little corner of the internet? My response was a simple one but an important one for all of us to remember.  My Post-It read “Stop being afraid to fail.”  We are so dead set on our own success that we are content with staying in a safe area of development in our industry.  Why try something new?  What if it does not work?  What if I do it wrong?  What if I cannot do it well?  What if somebody dies?  The answer to all of these questions are simple.  Respectively they read like this: our industry will not progress; dust off and try something else; practice more you’ll get it; again, practice; and finally, people die.  We cannot prevent that. When looking at some of the most successful people and industries one will find that many, many people have more misses than hits.  Take me, for example.  My first choice of where to spend my career, which I thought at one point that I would never leave, was not the right fit for me.  I’ve tried other blog ventures, and had two or three that never got off the ground before I even started writing on the pages that you are reading today.  I’ve invested time in countless projects that just did not work out.  All together though, the things that I put my heart into that have worked are in my eyes pretty successful. Even great inventors such as Thomas Edison, who held over 1,000  patents for his inventions had more than his fair share of failures.  Throughout his lifetime, he tried to invent devices that could project...

Change Through Catastrophe

Your department has a policy that they send two ambulances to reported cardiac arrests.  On one particular busy night two of your trucks are dispatched to a person reportedly not breathing.  The first truck gets on scene and finds a patient beyond help.  Before they can cancel the second ambulance, they are involved in an intersection accident.  In response to this incident the next morning your director releases a memo stating that second ambulances will no longer be dispatched to cardiac arrests. In a labor management meeting, an employee suggests development of an “emergency code” for field personnel to report to dispatch that they are in trouble to help activate a large law enforcement response to assist them at their location.  Your boss says that this will not happen because they think field crews will abuse it.  A week later, a paramedic is seriously assaulted by a psychiatric patient.  The dispatcher on the other side of the radio was unable to make out their calls for help.  Your boss then revisits the policy. Your division uses a non-disposable laryngoscope blades.  A supervisor goes to your boss and suggests following the industry trend and shifting to disposable ones to reduce the risk of infection for patients.  Your boss decides against this since your company has never been sued by someone receiving an infection from this means of transmission.  You are convinced that the only way this policy will change is through some sort of tragedy. All three of these incidents are loosely based on actual events that I have either been part of or have heard about from friends of mine working in different systems throughout the United States.  They are all evidence of the same though, change driven by catastrophe.  We have all experienced it at some point in our career.  We have all been sitting around in a conversation with our friends and coworkers and had somebody utter the words, “Nothing is going to change until somebody gets hurt.”  Some of this attitude from leadership is because of a generalized disconnect from the field.  Some of it is because of the kneejerk, reactive nature of EMS that seems to carry on with people...

The Struggles at Home

The Struggles at Home

Apr 6, 2015

In almost fifteen years in this field I have seen a lot of people come and go, and that does not just go for coworkers but also spouses and significant others.  I don’t know what it is but so many of us in this field are so self-destructive when it comes to our interpersonal relationships, myself included, and I cannot help but search internally for an answer.  I have yet to find one. This job is difficult.  This career is difficult.  The level of depression, substance abuse, and suicide that we see in emergency responders is way too high.  It goes without saying that one occurrence is too many, but we are so far beyond that and the numbers just keep climbing.  I have seen far too many broken homes through the years and it makes me sad.  I just do not know what we can do to make that better.  Do we need an orientation class for spouses when their loved one gets hired into this field?  Should we be sending take home information with our new EMTs and paramedics to share with their families to help them understand the signs and symptoms of depression, and to guide them in better handling all of that time away that they might have to deal with at special times of the year? Or maybe we just need to do a better job of including our work force’s families.  If your service caters Christmas dinner for the staff, why not extend an open invite to your employee’s families to thank them for the sacrifices they have made over the past year?  On top of that, if you are an EMS manager and you are not strapping on an apron and serving your people on holidays I question your commitment to them.  I realize that people have made sacrifices over the years and “paid their dues” but if you run a department and you are not willing to make the same sacrifices as the front line staff makes then that will make you into a “boss” and not a “leader.” A few of us used to have a very quiet and not so funny inside joke that when...

Overworked and Under Appreciated in Baltimore

Overworked and Under Appreciated in Baltimore

Mar 25, 2015

Every day you go to work seems to start the same way.  You clock in on time to the sound of your truck backing in to you station.  Your scope goes on the dash, coffee in your cup holder, and gear in the cabinet.  You pull the bag out of the curbside door and start checking through as the loud speaker overhead crackles to life: “Medic 3 respond. . . “ and you’re off. The next ten hours of your day is filled with fourteen more responses every one of them with lights and sirens to the scene, and lights of sirens to the hospital.  As you wait for a nurse to give you your bed assignment, from your radio’s shoulder mic you hear the dispatcher of the day: “Holding a chest pain on the west side.  Is there anybody available to clear?”  “Medic 3, are you ready to go yet?” You’re rushed.  You’re overworked.  The general public thinks that based on the overtime numbers that your department releases you’re overpaid because that choice group of people who torture themselves day in and day out with two or three calls an hour on the ambulance make more than the department’s chief.  And it’s the same thing, day in and day out, for your two days and two nights as you look forward to your four days off. Until. . . Until your department decides that since the guys and girls on the fire trucks are on 24 hour shifts that you should be too.  That is exactly what is getting ready to happen in Baltimore, Maryland.  According to the Baltimore Sun, BCFD is a department that has nearly fifty of their 232 paramedic jobs left unfilled from last year.  That leaves approximately 185 paramedics.  Those 185 paramedics make up just shy of 15% of their department’s 1,250 person staff.  That’s right: 15% of the employee base is responsible for handling nearly 160,000 calls which makes up the vast majority of the department’s annual responses. Now, those 185 paramedics are on the verge of being forced into 24 hours shifts.  It is not right, it is not safe, and it needs to be squashed before...

Stand Alone EMS

Stand Alone EMS

Mar 16, 2015

With the season finale of Nightwatch coming up this week, I got thinking about the value of EMS based EMS.  This thinking was also fueled by yet another series of perceived response failures in fire-based EMS services on different sides of the country, specifically in San Francisco and Washington, DC.  While I stand by the argument that response times do not matter as much as we allow us to this that we do, I still fail to understand how the general public does not recognize the value of an EMS only service, especially after a certain population and call volume size. As always, I feel the need to point out that there are exceptions to every rule.  There are private services that get it.  There are EMS services that are fire-based that do it right.  But, as I said above, at a certain size there are others in both of these sectors that fail miserably and fall short of their expectations.  The difference between the two though is when a private service fails to meet expectations, they are usually replaced.  Quickly.  When it is a fire service they are given chance after chance after chance.  The vast majority of third service stand alone EMS systems are successful in their missions, and they are successful because they are dedicated to EMS. What could be better than a team of medics dedicated to providing medicine?  How can an argument be made that in a vacuum when you take away any funding issues that might arise from having a standalone department that a stand alone EMS service dedicating themselves 100% to the medical well being of the community that they serve is not the best possible delivery model? Last month, there was an EMS1 article written about priorities in EMS training.  While fire training is usually a lot more extensive than most EMS CEU classes (I am basing this on what I am told by my fire centric colleagues) from the numbers that I have seen reported from a number of different departments the volume of training is not anywhere near to equal or equitable.  In my EMS based EMS service, for example, we schedule around sixty hours...

The Response Time Debate

The Response Time Debate

Mar 5, 2015

Read Justin Schorr’s post by following this link! Everybody loves a good internet debate, right?  This afternoon I engaged in one of those with my good friend and Chronicles of EMS star Justin Schorr about response times and their impact on EMS.  Sparking the debate was an article that Justin shared that discusses the impact of response time compliance on a large city in the United States covered by a fire based EMS system backed up by two private services. In his post, Justin disclosed that he is a firefighter/paramedic and a “card carrying member” of the IAFF.  Staying in the same mentality, I need to disclose that I worked for a private EMS service for 12 years that held a busy urban 9-1-1 contract.  I now work for a municipal ALS only third service that intercepts a number of BLS level fire departments.  Also, as some might have heard, I am associated with the EMS Compass performance measures initiative.  The views in this post are my own and in no way reflect those of anyone associated with the project. The debate that Justin and I had revolved around two topics: the importance of response times, and the importance and relevance of ALS first response.  I am going to break down those two topics separately. Do response times matter? In most EMS systems, response times are king especially when it comes to those serviced by the private sector.  “Just get there, and we have nothing to worry about.”  All that matters is an ambulance shows up, and is most cases stakeholders want somebody on that ambulance to have a paramedic patch on their sleeve.  What happens from there does not really matter unless somebody complains. It is funny that this topic comes up now, because currently sitting on the desktop of my computer is an almost completed blog post about anecdote vs evidence.  The concept that response times matter to patient outcomes is one of the most anecdotal statements that has ever been made.  There are three different arguments that I feel support this. First think about the path that the majority of our patients take when they arrive at an emergency room.  Think about...