Last month, a group of us created a new Facebook page called Modern EMS Issues. We wanted to give people an outlet to discuss what they felt were the important challenges that we are facing both today and tomorrow. One of the first questions that we asked everyone was to name what they felt were the biggest challenges that we face today. There were some terrific answers, but I feel like the root of much of the issues that we deal with comes down to two things, ignorance and litigation. Far too often, we allow people who do not understand our profession and what it is capable of to make decisions about how we perform our jobs. We allow the general public to believe that response times are more important than high quality care. Some of this is he fault of those who prey on the ignorant, but for the most part it is our fault for not properly educating those that we serve. I cannot count the number of news stories that I have read that either cite what people interoperate as “poor care” that was directly related to response times. Take a look at the situation in Minnesota last week where a family was “outraged” by a seven minute response time to their residence. There was no talk about what happened after the ambulance responded in what many would say is a reasonable amount of time. There was an article that got a decent amount of attention a few years ago when the Super Bowl was held in Dallas regarding MedStar’s response times during that week when they also faced a sizable Texas snow storm. Many responses were made to “emergent” calls in a “non-emergent” fashion with no marked reduction in patient mortality.  The thing that I like about the information that MedStar released was there was no “spin” to it.  It was just straight facts backed up by statistics.  Not many places take that road.  Far too often, they rely on public opinion and speculation of what the public thinks is important. Furthermore, we allow ourselves to continue to believe that while urban responses require someone to be on scene in less...

Last week, actor Tracy Morgan was involved in a serious motor vehicle accident that also killed a friend of his. The pair were struck by a Walmart owned tractor trailer that was being driven by a driver who had reportedly been awake for more than 24 hours. When I heard reports of the accident the circumstances surrounding it, I started to wonder how many responders at the scene were in the same boat as the driver. Long hours are a well known part of our job, however how long is too long? In the system that I work in now, many of our BLS units are staffed by people who are on 24 hour shifts. A number of the people working these units have a number of different shirts in their drawers from the departments that they work part time for. It is not an unusual occurrence to find some people working back-to-back 24 hour shifts in an attempt to cram a good number of hours into their work week to maximize their days off. In the study that Fitch & Associates did of Alameda County back in the mid-2000’s, it was noted while riding with some crews that “many responders appeared exhausted.” They added that one even “nodded off during a midday conversation.” Again, ALCO was a system where people would try to cram their work week into a couple of days. The effects of sleep deprivation and sleep inertia are well documented in the medical industry as well as the transportation industries. This is why medical interns have seen their hours cut, and pilots and truckers are required to have a certain amount of downtime. Here in the world of EMS though, we push forward. Many of us work multiple jobs. For the first time in my career, I do not have one. It was not unusual for me to work sixty-plus hours at my full time job at AMR, and follow that up with a shift or two at my part time job without a second thought. It was natural to me. I remember days as a supervisor where I would encounter certain employees in the same boat as me who...

I’ve been giving a lot of thought lately to what would make an EPCR system perfect for me. Most of these thoughts have stemmed from the last year that I have been using what arguably is the worst EPCR system that I have encountered out of the four that I have used. Yes, I know, four really is not that many when you consider how many products are out on the market still, the thing has a long way to go to reduce the frustration that I seem to consistently encounter. What I decided to do was create a few “Do’s and Don’ts” that might give someone developing or improving an EPCR system some things to think about when working on their product. DO have an open source coding system that will allow different products like cardiac monitors to upload their data to it with the greatest accuracy possible. Make sure that event markers line up with the wording in the monitor and if possible allow the patient information we put into the monitor (name, age, case number) to import into the chart so that it only has to be entered once. Also, allow preferences to be set for each person that can include truck number, crew member, and other information that is the same for every single shift. DON’T try to do too much of my job for me. I have never met an auto generated narrative that I like. It does not matter if it is CHART, SOAPE, or anything else that you can name, things just never seem to add up. Facts get missed, and what I see with my eyes is either left under described or completely missed. Anyone who teaches a PCR writing class will reinforce the concept that your narrative is your bread and butter. It is what will tell you the most about a call if you get called to the carpet for it years down the road. It is what will get you paid if there is a dispute with MEDICARE. Narratives are so incredibly important that they need to be left to the tech to write them, not the computer. DO have a repeat or...

Friday’s post about the now deleted craigslist letter got me thinking about the need for an in depth set of policies and procedures to help in decision making for everyone involved in an organization.  My boss used to like to say that there were so many grey areas in EMS that writing a set of policies and procedures would be exhausting and quickly rendered invalid.  I could not disagree more. I went from a service that had very loose procedural structure to being handed a three inch D-Ring binder filled with my new department’s P&P’s that outlined everything from the procedure to call out from work to how to properly place the pins on my uniform.  It was clear and concise and I loved it. Despite what they might tell you I feel that EMS providers crave structure.  If you want proof of that look no further than standing orders and protocols.  While a single protocol might not fit the mold for every patient and you might find yourself crossing from protocol to protocol.  You might not start at step one and move to step twenty hitting steps two through nineteen along the way but you at least have a framework to work within.  Policies and procedures need to be viewed with a similar mindset. No situation is perfect, and no solution is going to be 100% correct 100% of the time, but I feel like if a policy gives you the answer 50-75% of the time then it is serving its purpose.  A prime example would be something like “ambulance crews are expected to be available in the hospital within twenty minutes of their arrival.”  Is that 100% achievable?  Of course not.  There are so many outside factors like patient condition, decontamination needs and ER backups that might prevent this but it sets an expectation and a parameter for crews that if their patient is turned over they should be available in that time frame. Failure to set expectations for people leads to freelancing and frustration.  Rules are enforced from supervisor to supervisor and dispatcher to dispatcher with little consistency.  I know that this happens because I was guilty of it.  There were...

Late night I was shown a very public reply posted to a very private email circulated by management in a New England ambulance service expressing displeasure with the performance of many of their employees that some have interpreted led to the loss of a 911 contract that they have been given a second chance at.  Although the original email was never posted, the reply made on a craigslist page and signed by an “anonymous employee” called out management for their practices.  I read it, and I cringed. The post itself was flagged for removal within the first eight hours of it being posted online which is fine, because I would not have linked it here as I personally felt it was in poor taste.  While there is a time and place for sharing with the outside what goes on in the inner workings of an organization this was a lot of dirty laundry to hang on the line for everyone to see.  Quite often they are posted too quickly with the thought that “if I let the public know what is going on here things are sure to get better!”  In actuality, all this does is increase the gap between the field and management. As someone who has, in the past, pulled the pin on a grenade and tossed it into the fray, I can testify that actions like this do not help as much as many think that they will.  As my career progressed, I found it easier to write the email or memo and let it sit on the computer for a good couple of hours.  Then, I would come back and take a second look.  More often than not, my opinion would have evolved to an “it’s the same old complaint, it won’t help anyway.  I’ll keep it in my back pocket though.”  The draft would then be saved, and the window closed, as some fights are just not worth it. The anonymous writer of this post clearly was upset, and I doubt that his or her intentions were completely malicious, they should realize that the damage they did might be irreparable.  While it might be fun for some people to...

Back in September of 2010 when this blog was still in its infant stages and living on Blogspot, I wrote a post about STAR CARE, which I described as the “magnetic north of your moral compass.”  In light of the recent events in Washington, DC (say it with me folks: WHICH ONE?!) I want to take a look at the decision made by Lieutenant Kellene Davis that led to her granted retirement and dodging of department discipline. For those of you who have spent the last couple of months living under a rock, or just recently have been introduced to the wonderful world of the internet, Lieutenant Davis was the officer in charge of Truck 15.  To summarize, and keep the story short, she failed to act when 77 year old Cecil Mills had collapsed across the street from her fire station.  He eventually died.  While we cannot be sure that a response by Truck 15 would have saved the man, what we can be sure of there was no action taken. Now, Dave Konig was quick to point out to me that STAR CARE is an EMS tool and not a fire department tool, but DCFEMS is an EMS provider, so STAR CARE can and should apply to them as well.  As the commanding officer on Truck 15 that day, the responsibility ultimately rests on her shoulders, or at least that is what DCFEMS wants us to believe, so looking at her actions seems to me like the appropriate thing to do.  Let’s take a look at this and see how Lieutenant Davis did. S: SAFETY This was an unknown medical, so looking at it from the most positive side of things, she did not send her crew into danger or allow them to cross a busy street. T: TEAM BASED By preventing her crew from acting, she did not allow them to serve the purpose that the crew was deployed to do which is protect the people and property of Washington, DC. A: ATTENTATIVE TO HUMAN NEEDS I doubt that Lieutenant Davis would want a medical emergency experienced by herself or a member of her family with the same disregard that she...

Through my career I have worked in a couple of different style of EMS systems.  I started out in a volunteer system that commonly saw anywhere between 2 and 4 people riding on an ambulance, cramming themselves in back with a medic and a patient for transport to the hospital.  Despite how big our ambulances were (and granted, they were smaller than many of the ones on the street today) things still felt cramped.  I must admit that from my BLS stand point things seemed to run smoothly.  It was all that I knew.  Everyone had their role.  Things seemed to go well, however, now, twenty years later I can certainly see where things could have been frustrating for an ALS provider. Fast forward a few years to my tenure in Springfield.  There was no predicting who I would be in an ambulance with, and more importantly, how much help I would get if I asked for it and it was actually granted to me.  Sometimes I worked with another medic, sometimes an intermediate, and sometimes an EMT.  I did not mind the work load that was generated by not working double medic because such a high volume of our runs were BLS runs anyway.  Admittedly though, there were certainly some frustrating times in the early years of my career as I felt like I could never get enough done.  I was and am my own worst critic.  When things don’t go how intend them to, I beat myself up.  That seemed even easier when I was the only medic there. On most cardiac arrests, we had a fire engine or ladder company with us ready to do compressions, but they were not always the easiest to give feedback to if compressions weren’t being done well enough, or there was something that needed to change.  Don’t get me wrong, many of them were fantastic but it was certainly a barrier we encountered.  Finally, the question of “how many EMTs do you need to run a code?” was a common question that was asked.  A lack of recognition for the evolution of medicine was something that constantly held us back.  My opinion was always that...

With the general public clamoring for help, the debate over Narcan and who should have it rages on.  Recently, I read a post by EMS and fire author and blogger Captain Michael Morse from Rescuing Providence.  Michael relates some of his own personal experiences as well as those as a paramedic firefighter with the Providence, Rhode Island Fire Department to shape his opinion that making Narcan available to the public will allow drug users to “push their high to the limit and then return from the brink of death trough the judicious use of the miracle drug that they can now get as easily as they can their drug of choice.” While I respect Captain Morse and his willingness to share his personal experiences with the community at large, I think he is missing the mark here. There comes a time in medicine when we have to weigh the risks of the care and medications that we provide against its benefits and that is exactly what we need to do with Narcan.  I am sure that somewhere in the United States the scenario that Captain Morse has shared with us could happen.  Heck, I’m sure it probably has already happened, but we just don’t know about it, but making this argument is as absurd as saying that someone who is allergic to shell-fish would want to try lobster just once, Epi Pen in hand, ready to bring them back from the “brink of death.”  While I am sure that it has happened, it is the exception to the rule. “What if the drug is given too fast and the patient vomits?” “What if the patient is actually speed balling and comes up violent?” There could be a million and one “what ifs” that we throw out there, much like we could for C-Spining patients, or putting a patient on CPAP.  The medical world is full of “what ifs” which is why every drug commercial on TV is followed by a long list of side effects that I am pretty sure include spontaneous combustion. Rogue Medic will tell you that the problem with an opiate overdose is not Narcan deficiency, and that effective ventilation can...

Friday the Washington Post published an opinion article by Toby Halliday.  Mr. Halliday is apparently the son in law of David Rosenbaum, the New York Times reporter who many feel died because of the inactions of the Washington DC Department of Fire and EMS.  Rosenbaum’s death in 2006 prompted the formation of a committee in 2007 that shaped DC’s EMS system today.    Mr. Halliday was part of that committee. The restructuring that took place in 2007 has been a far cry from an effective solution of the problems that plague DCFEMS.  Some of them were not even addressed, for example, mismanaged ambulances that caught on fire, ran out of gas, or were out of service when they were needed.  While the 2007 study addressed some operational issues it completely ignored many cultural issues the likes of which resulted not only in the death of David Rosenbaum, but also Medric Cecil Mills Jr who died on a DC street while firefighters from Engine Company 26 refused to go across the street and see what was going on. It seems like the article posted by Mr. Halliday is one that is attempting to address and defend the findings and still unfollowed recommendations of the committee that was convened seven years ago in the face of criticism that DC should adopt an EMS system similar to that of Boston, which, arguably is the most effective metropolitan EMS service in the country.  While different systems might be more effective at different levels, I think Washington, DC is a strong testament to the needs of large municipalities when it comes to prehospital medicine.  In Friday’s article, Mr. Halliday shares the “key task force recommendations” from the 2007 committee. 1.  Elevate and strengthen the EMS Mission – While Halliday cite leadership failures and a lack of patient-care experts in leadership positions, if they are searching for an effective mission statement they should look no further than the EMS based EMS system in Boston.  Boston EMS’ mission statement reads as follows, “Boston EMS, the provider of emergency medical service for the City of Boston, is committed to compassionately delivering excellent pre-hospital care and to protecting the safety and health of the...

This post can also be found at TheEMSLeader.com With EMS Today right around the corner, I got thinking the other day about the past conferences that I have been to.  This year’s gathering in Washington, DC marks my ninth consecutive major conference that I have attended.  I’ve been to Baltimore three times, this will be my second appearance in DC, Las Vegas twice, New Orleans, and the first conference that I attended back in 2010 in Dallas. That year in Dallas, Had quite the opportunity drop in my lap.  One morning, I had the chance to sit down and interview a person who I very quickly came to admire because of his involvement in the National EMS Management Association, Skip Kirkwood, who at the time was the chief of Wake County EMS.  Even before I had a chance to meet Skip the words “Well, in Wake County. . . ” were a constantly used phrase in my vocabulary.  I admired the changes and strides that they had made in their quest to provide the best possible patient care for the residents of Wake County. More than that though, I admired Skip’s approaches to problem solving.  For years to follow, presentations that I have given have involved little pearls of wisdom that I have obtained at the hands (and fingers) of skip over the years from e-mails and posts that I have received from him, so while I had a long standing admiration for Skip, having the chance to sit down with him as a captive audience and pick his brain was quite the opportunity for me. One thing that stood out to me was how he approached change and progression in Wake County.  As I read about his service it was clear that things always seemed to progress quickly there.  Skip’s answer to me was that he always promotes an environment that is comfortable and welcoming to change.  He wanted his people to be ready to walk in one day and find a new piece of equipment, or a new policy change.  By doing this, when major changes were rolled out his staff was more welcoming and willing to adapt. I cannot tell you how...