The Diesel Bolus

My name is Scott, and I’ve made mistakes. There. I said it. The medical world is one where we strive for perfection. That seems to be multiplied ten fold in the world of EMS. We expect ourselves to be perfect. We expect ourselves to be better than nurses and sometimes doctors as we stand back and watch residents and attendings make mistakes that we feel we are immune to making. We can point them out or cite the newest evidence but for some reason when it comes to our own industry, we are prohibited from pointing out those same mistakes. Some think that in the absence of protocol or knowledge, a good ol’ diesel bolus is the answer and should continue to be the answer when reeducation and more training would be far more appropriate. “Do no harm” is significantly different from “no harm was done” and we need to realize that. Just because nothing bad happened does not mean that something good happened. The key to success in this field is learning from the things that don’t quite go as well as they should have. When I hit the streets fifteen and a half years ago I was terrified. I made a lot of mistakes, and when things were not going well my partner’s foot had better be getting heavy. Through the course of my career, I have grown and I’d like to think today that I’m a better paramedic. In all of the intricacies of medicine that I learned, and all of the journal articles I have read the biggest lesson that I have learned is humility and the ability to admit when I was wrong. When things do not go well, the first question that I ask myself, or someone who takes my patient over is “what could I have done better?” how could I have improved my patient’s outcome? Which brings me to my ultimate point in this post. The internet has been on fire lately after a Virginia volunteer fire department was cited for transporting a pediatric seizure patient in the cab of the fire engine instead of providing care and assessment and waiting for a responding ambulance to...

System Abuse

Over the years some great ideas to change how we care for our patients have come from street level providers and their day to day encounters and insight to the challenges that they face.  Others, however, either fall flat on their collective faces or are proven at a larger scale with the use of evidence to be ineffective.  One of the most frequent discussions that comes up on many EMS related internet destinations is the effects of system abuse on our industry.  Some feel that it is the crippling factor that renders urban systems ineffective however I disagree.  While I do not dispute the presence of system abuse, and while these calls might stand out as being memorable, I think that it is less of an issue than we make it out to be in our own heads. But how show we deal with it?  One popular internet author suggested that something needed to be done, but has not present a plausible example of what that should be.  When the concept of increased education for providers to be trained to make non-transport decisions or recommendations for alternative ways of entering a patient into the health care system, he went as far as to state that I was being “negligent” for advocating for more education for EMTs and paramedics because he felt that this was refusing to address the problem.  While he can try and hang his hat on the anecdotal experiences of his career, I will instead choose to rely on evidence which tells a different story. How can we expect EMTs and paramedics to perform assessments and make treatment decisions when our training tells us to stabilize to the best of our ability and deliver a patient to definitive care?  Giving EMS providers the blessing to deny transport or to recommend alternative destinations or treatment options is something that we have received no training to do.  While there are some instances where our assessment can be spot on where we would tell a patient “you don’t need to go to an emergency room, and you certainly do not need an ambulance” this decision making power would need to be universal if granted at...

An Ounce of Prevention

“An ounce of prevention is worth a pound of cure.”  -Benjamin Franklin Throughout my career, I have been to maybe eight or nine critical incident stress debriefings.  I attended my first one when I was 17 years old after caring for a man who self-immolated as a means to take his own life.  Without getting into the details of this confidential event, the outcome for my family, who was on the call with me, and I was a long standing bond with the dispatchers in attendance.  About once a month for many years following, we used to take coffee and donuts down to the dispatch center to catch up with our new friends. I have always been a person who encouraged everyone involved to attend CISM’s, and I think I have spoken about that here before.  To those who have said, “I am not going to get anything out of it” I am quick to remind them that it’s not all about them.  Sometimes the best thing that we can do is offer something in our own personal experiences to someone else in attendance.  Sometimes, knowing that you are not alone is the greatest reassurance that a person can receive which is why I push people to stand together.  I would never mandate anyone to attend a CISM, and neither should anyone else, but I always strongly encourage people to show up. I do think, however, that we rely on CISM a little too heavily as a means to deal with the stress that people in our field shoulder day in and day out.  We sit back and watch people who struggle go to work every day.  We have all watched coworkers whose personal lives are crumbling around them, and have watched those personal issues spill over to their professional lives.  Heck, some of us have been those people.  We sit back and let people deteriorate because we don’t know what else to do.  Until something happens. Until that bad call.  That big call.  CISM is usually tied to major events.   It’s that nasty wreck on the interstate, or that pediatric cardiac arrest that results in a crew begging to take the rest of...

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...

The Myth of Culture

Over the past couple of years I have read a few articles about the importance of living in the community that one serves.  I have seen articles championing volunteer organizations because “people like being cared for by their neighbors” or implying that those who do care for their neighbors would do a better job because of their proximity both physically and emotionally to a patient. Other articles about fire based systems for example talk about how being part of a community can allow one to know the back roads and short cuts that might shave precious seconds off of response times thus saving countless lives.  Further reading will reveal criticism of private EMS departments that come in from outside of the area and know little about the people that they are caring for.  Some feel that not living in the area that one practices medicine in can result in them caring that much less about the people that they are providing medical care for. Based on some personal experiences that I have had, I fail to see any of these as being an absolute that one should lead an argument with.  My first EMS position was in the town that I grew up in.  Island Heights, New Jersey is small, populated by maybe 1,200 people during the summer months.  It was impossible for me to go into a house on a call and not either know the patient or one of their relatives.  From there I moved some 250 miles away for college, and spent the first twelve years of my career in Springfield, Massachusetts.  I was a transplant, and as a white kid from suburbia, I did not fit the cultural makeup of the city that I worked in at all.  Neither did the vast majority of my coworkers.  Much like the majority of the workforce in EMS, we were Caucasian and majority male. Although I was not from the area I was able to learn the streets, and learn a lot about the culture as well.  Working in Springfield pushed me to improve the quality of the Spanish that I spoke, and learn a little bit about the cultures that I was...

Hey, What’s New?

Hey, What’s New?

Apr 27, 2015

Some of you might have noticed a little bit of a slowdown through the month of April.  There are pluses and minuses to this sort of thing.  The minus, of course, is me putting out less content for those of you who read this blog regularly and for that I apologize.  The plus side though is that with the additional projects that I have recently taken on, I am actually in a position to add more content.  So for anybody who has been wondering, here is where I have been and here is what I have been up to. My time has been divided lately on two fronts.  If you look to the right side of this page you will notice a new disclaimer specifically addressing the EMS Compass project.  About six or seven months ago I was asked by a colleague to be part of a work group that was going to have a hand in developing statistical measures and benchmarks for EMS.  This initiative by the National Highway Traffic Safety Administration (NHTSA) and the National Association of State EMS Officials (NASEMSO) has since been given the appropriate name EMS Compass.  Expect a post about it and what it means for us in the next week. The other fire that my iron has recently spent a lot of time in is a new role as a Field Training Officer at my service.  The way that the system here is setup takes a considerable amount of time and asks a lot of the FTO.  A lot of my writing over the last year or so has been done during some of my downtime and lately I have not had much downtime at all.  My new responsibilities have made me think back to my days of podcasting about being an FTO with Natalie Cavander over at the now defunct GenMed Show, and some of my philosophies of the role.  I am currently developing some content specific to training and educating new EMTs and paramedics. I never thought that being an FTO would take up as much of my energy as it has but its a role that I have been out of for quite some...

Financial Health

Financial Health

Mar 13, 2015

Find me a paramedic who feels that they are adequately financially compensated for the job that they do and I will be shocked.  Pay in this field has always been an issue.  We blame it for a lot of our recruitment and retention problems.  People constantly cite it as a stressor that makes our lives more difficult.  Maybe though, just maybe, we are putting too much emphasis on how large our paychecks are and not enough emphasis on the money that we bring in. When I had a chance to interview Skip Kirkwood about five years ago, I asked him to tell me one piece of advice that he would give to any new paramedic or EMT.  To summarize the points that he made, Skip told me that he would want people in our field to learn to manage their money better.  Learn to live within your means, and you will not have to work sixty or seventy hour work weeks. Sean Eddy and Jason Hoschouer talked about it on a podcast that I did last year, and if you have not read Sean’s series on Money Smart Medics, you are really missing out.  There are lessons to be learned from all of it, and sitting and talking to Jason and Sean inspired me to make some changes in my life. I have always been good with numbers.  I speak them fluently.  The problem is though I have never been quite as good with how I managed my own money.  As long as I had money in the bank, I felt like I could spend it.  I was one of those people who would live from paycheck to paycheck not because I had to but because I often chose to.  It was a vicious cycle and one that I got sucked into.  Sean and Jason were so enthusiastic with their ideas and values that I felt that I should take a couple steps to try and fix myself. I started by charting my income.  Since I work a set rotating schedule, I could predict my work hours out for the entire year.  I started to chart how much overtime that I was working, and...

To Stage or Not to Stage

To Stage or Not to Stage

Mar 9, 2015

While watching an episode of Nightwatch the other night, I got thinking about the concept of staging.  In the call that was presented on the show, the crew of Dan and Titus was sent for a possible stabbing victim.  They responded as normal but shut down and parked a few blocks away from the call to wait for an overburdened New Orleans Police Department to get on scene and report that it was secured for them.  While waiting, they were approached by someone who told them about the stabbing. I have been in this situation more times that I can count.  It was not unusual to be sent for the unknown third party caller for the psych patient or the suicidal person with instructions to stage for police.  The ambulance would be sent lights and sirens so as to maintain the contract’s requirements of having a truck on scene to all “priority 1” calls in under ten minutes.  Without talking to the patient or having someone looking at them and reporting what was going on, the call was classified as being “unknown” which by some determination made in the dispatch center required that it be “priority 1.”  So the ambulance would respond lights and sirens, and in this case, being on scene meant that they were calling out a few blocks away, putting the truck in park, and waiting.  If all of this happened at “shift change” the wait could be as long as 20-30 minutes. I have always been one who was leery of the concept of “staging” within itself.  In my Springfield example, who benefits from having an ambulance driving lights and sirens, which has been proven to be far more dangerous than driving without them, seemingly for nothing, because you will not be going into the scene?  From the example in New Orleans, how far away from a scene is far enough to park?  A crew is always at risk of being found, and as former Jackson, Mississippi city councilman Kenneth Stokes taught us in 2010, if a city official can’t understand the importance of keeping an EMS crew safe, how can we expect the general public to understand it? How...

“Start Us a 7”

“Start Us a 7”

Mar 5, 2015

In my twelve years from Springfield, I heard the words “start us a 7” come over the police scanner more times than I could count. The number seven was the radio code for an ambulance.  Usually what this meant was the cops had found some indigent on the side of the road that they wanted transported to the hospital, or some assault victim who needed a routine transport for a stitch or two. In a somewhat related incident, a friend shared a conversation that they were privy to that occurred between a fire and EMS dispatcher about a person stuck in the middle of the road in a broken motorized wheelchair.  I am paraphrasing but it went something like this: Police Dispatcher: “We don’t have any way to move the wheelchair.  This is an EMS matter.” EMS Dispatcher: “Neither do we.  It looks like a traffic problem to us.” As always, the outcome was as expected: paramedics responded (eventually. . . it was a busy day) and had to deal with something that was well outside of their scope of practice.  Or how about this one that happened more times than I can count in my career: You respond to a college campus for the intoxicated student.  On arrival, you find a mildly inebriated individual who is being sent by the campus police because it is the “campus policy” that intoxicated students get transported.  The student is defiant, and they are told by the police officer on scene that they can make a choice “hospital or jail.”  Mr. Defiant decides that he is going to be daring and he chooses jail. The police officer responds by putting the patient’s hands behind his back and slapping the cuffs on him.  To you and your partner’s surprise though he does not put the patient in the back of his cruiser.  Instead, he marches him straight to the back of your ambulance where he sternly lectures the student, removes the cuffs and sends him off to the ER in your more than capable hands. I am not saying that these people do not need help.  The problem though is their access point for their desired help, whether...