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? ...

The Educational Crossroads

The Educational Crossroads

Sep 22, 2015

My trip to Las Vegas for EMS World EXPO 2015 was my eleventh consecutive trip to a major EMS conference.  I feel like I have had a front row seat to see the direction that conferences like EMS World EXPO and EMS Today have taken on a number of different levels.  The crowd certainly has changed.  You still have your big names that show up year after year and those faithful attendees who come year after year and take classes.  Many products stay the same, while many “new and great ideas” are here one year, and gone the next.  Ambulance design shows the continued utter lack of advancement particularly from a provider safety stand point, which I continue to find alarming.  My car today looks nothing like the 1987 Volkswagen Jetta that was my first car in high school, so why does the back of my ambulance look exactly the same as the 1984 box truck that I first road in back in 1993? It is interesting the direction that conferences in general have taken.  For a few years there seemed to be a bevy of new content mixed in with the usual trauma, mass casualty and pediatric classes that always seem to populate the convention schedule.  We used to learn about how ultrasounds were going to be the next big thing, and now Mobile Integrated Healthcare has taken yet another conference by storm.  It’s important information about the future of our industry but come on, folks, it’s time to see something new. To JEMS and EMS World, I beg of you, step outside of your comfort zones.  Let’s move away from the same speakers that present year after year, regardless of how many awards that they have won, or how many articles that they have published.  We need some fresh new ideas and fresh new presenters.  I know that might ruffle the feathers of a few people out there who do not like being turned down, in fact I know of one in particular who has already said he is not submitting to a certain conference anymore because they did not want him this time around, but the time has come.  We are...

Becoming Comfortable

Becoming Comfortable

May 18, 2015

With EMS week upon us, I wanted to talk about what this journey through EMS has meant to me, and what it has taken to take some of the steps that I have in my career and there is no better place to start than that first leap. One of the most common questions that I have been asked by new and prospective EMTs and paramedics is “when will I feel comfortable?”  It is one of the most difficult questions to answer and one that I really do not know the answer to.  Truth be told, it took me a lot longer than I ever expected to be comfortable in my skin as a paramedic. When I started medic school I felt confident as an EMT.  I had a strong grasp on what my role was at a scene, and felt that I could effectively perform any of the skills in my toolkit when called upon to do so.  Medic school proved to be a struggle at times, more because of my lack of good study habits but I got through and added that “PARAMEDIC” rocker to my EMT patch.  Once I hit the street as a medic though I felt very overwhelmed. I remember sitting in my car in the parking lot at Springfield College with my door open dry heaving the morning before my first 7:30am shift as a medic.  I was terrified.  Most of it stemmed from the fact that I did not want to disappoint anybody, especially myself.  That first shift went well though, and the first group of shifts did but for the most part, I can fully admit that I was scared.  When it comes to type of air that a medic must carry with themselves on a scene, I tell most brand new medics that they need to be “like a duck.”  Under the water, you might be paddling your little duck behind off but outwardly, above the water line, you need to be cool, calm and collected and just quack your way along with no one any the wiser.  I was a terrible duck. This overall sentiment went on for about the first year or so...

Why I Support Police

Why I Support Police

Apr 30, 2015

I am a vocal supporter of the police in the world of social media and in my every day life.  My stance has gotten me called many different names such as asshole, racist, conformist, and even boot licker by some.  Much of the support that I express for them is derived from my life experiences with people in law enforcement.  I grew up in a small town where every cop was on a first name basis with just about every resident.  I worked for twelve years in a metropolitan area that was recently named the second most dangerous metropolitan area in the northeast.  I have been pulled over a few times in my now twenty years of driving and received two tickets.  Regardless of the offense that I committed or the fine I always treated the officer that pulled me over with respect because you respect. Over the last ten months tensions in this country have hit a new high.  Dumping fuel on the fire, as usual, are people like Al Sharpton or Joe Madison to name just a few.  City Council members in the City of Baltimore have done press conferences standing next to the “leadership” of street gangs.  Their mayor is now back peddling after she talked about her poor choice of wording or justification for the destruction in her city (depending on which side of the fence you are on).  Leadership in other cities continue to stand on the wrong side of the lines that have been drawn, much like Rebecca Lisi has in Holyoke, Massachusetts.  Mainstream news outlets like Fox, CNN, or MSNBC do not try to put a stop it because it gives them things to fill their 24 hour news cycle and the people who suffer are the citizens and the responders.  I will be the first to admit that not every police officer is the most legitimate, upstanding person.  There are bad eggs in every single profession including my own, but the vastly overwhelming majority of those who have chosen law enforcement as their careers do their job because they care.  Sometimes, sadly, they are asked to care for those who could care less about their well-being. Everybody...

Video Clip: Bystander CPR

Video Clip: Bystander CPR

Apr 15, 2015

This weekend a number of friends on Facebook linked a video that was making the rounds of a person presumed to be in cardiac arrest in a car in front of a bus stop.  This scene provides with a number of important lessons.  First you see an SUV in the middle of the road with people yelling at the driver asking him if he is okay.  9-1-1 is called and somebody starts doing chest compressions on the person before removing him from the car and placing him in the road.  CPR is continued until EMS arrives.  At the end of the video you see the driver being wheeled to the ambulance sitting up appearing to be conscious on the stretcher. The video itself spans about seven minutes and I encourage everyone to take the time to watch the entire thing from beginning to end.  Some content might be difficult to watch and there is some language that might be considered offensive used by those watching the scene unfold.  Regardless of that though, there are a few lessons that I think both the EMS community and the general public can learn from this. http://medicsbk.com/wp-content/uploads/2015/04/Street-CPR.mp4   There are still people out there who are willing to help – In a world dominated by social media, Twitter and cell phones people seem to either want to record or just call for help and make a potential emergency somebody else’s problem. Seeing this video is reassurance that there are still people out there who will get their hands dirty to benefit another person.  They saw somebody in distress and they acted.  They realized that doing something is better than doing nothing. When you call 9-1-1 help is on the way almost immediately – Confusion is common. People misidentify locations in fact, I can tell you that happened here.  Once a location is confirmed help is on the way but for dispatchers that is not where their job ends.  If there is one place that a dispatcher’s role in providing prearrival instructions can save a life it is in the case of a patient in cardiac arrest.  The bystanders can insist that the caller “just tell them to come!” until...

Words of Wisdom

Words of Wisdom

Feb 3, 2015

Throughout the years, I have received a lot of advice from a lot of people.  I thought now would be a good time to share some of those quotes with you so that you might have the chance to learn from them as well. “If they’re bloody, clean them up.” – John Glowacki I’ve written about Big John before.  He was one of my first EMT instructors and had a major influence on my career, and how I practice medicine even today.  I was on a crash with him that was relatively minor, but the patient that were caring for was fixated on all of the blood covering her hands.  His point was a simple one.  Cleaning her up a bit not only would give you a better idea of where the blood is coming from, but it would also make the patient feel a little better not having to stare at what belonged on the inside that was now on the outside. Put the clipboard down.  Don’t worry about your tablet.  Leave the laptop closed.  Don’t touch any of that stuff until your patient is completely taken care of, and trying to clean them up a bit is part of that. “Rule number 1: People die. Rule number 2: Paramedics can’t do anything to change rule number 1.” – Bob Moore This is something else that I have talked about in the past.  As you may remember, Bob was one of my paramedic instructors and this was part of the speech that he gave us on the first night of class.  A few years ago, I wrote about accepting mortality and quoted Bob.  He commented on the post and shared the origin of it: In the fall of 1983, I was a NU medic student and not to brag but I did very well in class. Near the end of class we had an instructor named Joe Duecy run one of our last mega codes before exams. He put me through each and every rhythm known to man and I hung in there with the correct treatment and got the patient back with a pulse. After 30 minutes of playing with me Joe...

The Sixty Cent Question

The Sixty Cent Question

Jan 7, 2015

A couple of years ago I read a great article by Kelly Grayson on EMS 1 that talked about patient refusals and more specifically a person’s ability to refuse.  I liked it so much that I adapted parts of it into a refresher lecture that I did for a couple of years up in Massachusetts.  Now, almost five years later when I am back on the street, I still use portions of it as part of my refusal assessment. Kelly talked about orientation, memory, cognitive ability, and recall as ways to expand upon the old adage of “alert and oriented to person, place, time and events.”  On every patient that is going to refuse my care, and often on almost every patient that I do any sort of orientation assessment on there is one simple problem solving question that I ask them: “If I gave you two quarters and a dime, how much money would you have?”  The answer, of course, is sixty cents.  Easy, right?  I’ve run into patients though who were able to tell me who they were, where they were, and when it was, but were not able to answer that question. It also gives me another leg to stand on if someone misidentifies “time” for whatever reason.  I’ve found through the years that time is the one that is most often missed.  How many times have you asked a patient, “can you tell me what day it is?” and had them giving you a correct answer that had you looking at your partner for confirmation because you are not completely sure what day it is?  I’m a forgetful person, and it happens to me quite often. Take, for instance, a retired patient, or a patient in a nursing home.  Days might blend together for them and while they might be able to correctly identify the year, or tell you what holiday we just had or are going to have, correctly identifying the day of the week, date, or month might not be as easy as one might think.  Of course, you might ask a patient for a recent holiday, and have them answer “Christmas” and then ask them the month and...

A Reminder About Being a Professional

A Reminder About Being a Professional

Oct 30, 2014

This morning I saw a video come across pretty much all of the major EMS related news sites about a fire crew from Glendale, Arizona who were filmed while restraining a patient.  I fired up the video and sat there watching saying to myself over and over “it looks fine to me. . . still looks fine. . .” and then one of the firefighters opened his mouth, and lost his cool.  He informed the patient that he was “dead meat” and began swearing at the patient and the family.  Have a look at the video, but be aware that there is potentially offensive language used in it.  It might not be suitable for work. The backstory on the call is sketchy: a patient who had a “seizure” after overdosing on medications who first punched his father and then assaulted the crew.  During their restraint of the patient, the stretcher ended up on its side, and at least two firefighters ended up on top of the patient.  Operating in a vacuum, and putting the video on mute, the crew did a pretty good job retraining the patient.  He was being held down by an adequate number of people leaving other responders to watch the scene, and monitor bystanders.  If two people can effectively hold a patient down, then there is no reason to have five people on top of him, so kudos for that.  Keeping with the desired online theme of not armchair quarterbacking this call, I feel that this is a good time to touch on a couple of different points that we can remind ourselves of after watching this video. In the world of power stretchers, we no longer have to lift it to its highest level right off the bat to prevent repetitive lifts. Keep your stretcher at a manageable level especially when you have a patient on it who might become combative.  If you start off at a level higher than your patient, then they will be easier to control, and while you might put yourself at risk for strikes to some areas that men specifically might be more protective of, you will prevent yourself from being struck in the...

Anonymity

Anonymity

Oct 29, 2014

Anonymity on the internet is a powerful tool.  Some use it for good, and some use it to put their coworkers, colleagues, and services on blast.  When I started writing almost five years ago, I first started perusing blogs like Kelly Grayson’s and Justin Schorr’s.  Justin had recently gone public with where he worked with the release of Chronicles of EMS right around the corner.  I always looked at Justin as one of the lucky ones because his service so openly embraced his writing. When EMS in the New Decade was started, I had hopes that I would get it to where it is today, but looked at things more realistically in that so many blogs are started on the internet but not followed through on.  While my name was made public i did not mention who my employer was, and i did not talk about my writing at work.  I maintained this stance for more than a year, mentioning it to some people here and there but for the most part I kept my social media life divided, not discussing my writing very heavily on Facebook, and promoting the heck out of it on Twitter.  Once I did start letting people know what I was doing, the response to me was overwhelmingly supportive.  It is not that I doubted my friends and colleagues, I just did not know that the response would be so overwhelmingly positive. If you met me, it was not very difficult to figure out who I worked for, but I never said it, keeping my description of my employer to “a large national ambulance service in the United States.”  Heck, it was not until I gave my two weeks’ notice that I stated publically that I worked for American Medical Response.  I did not do this out of spite or disrespect for the people that I worked for.  Truth is, if you did know who I worked for, or figured it out, it was pretty easy to put names to a lot of the examples that I gave.  I used this blog to arm chair quarterback a lot of what I saw as failures in the system that I worked...