In the early days of EMS, especially in many urban settings, there was a “cowboy” mentality.  Paramedics and EMTs were expected to rush into situations, some more dangerous than others, swoop down, and scoop up their patients and then rush them off to safety.  I’ve heard stories of paramedics carrying everything from mace and collapsible batons on their belts to as extreme as a shotgun under their bench seat. Paramedics from yesterday will tell you “It ain’t like it used to be” I know this for a fact because I say it myself.  As an 11 year medic, I feel I have earned that right.  Newer providers will sometimes try to emulate the “old days” in their own way, carrying black “whatcha gonna do” gloves in their pockets or knives visibly displayed on their belts.  It’s time for everyone to remember that times have changed. While the environment that we work in is still strikingly similar to what it was fifteen or twenty years ago, scene awareness (not scene safety) is taught in a much better fashion.  Thanks to priority dispatch, we are able to deprioritize those less urgent calls allowing us to send crews into certain scenes with more help than they had before.    It is time for us to abandon that cowboy mentality completely and move on to a more patient oriented focus.  As scopes of practices expand, as we are seeing in different parts of the country, the role of the prehospital provider is changing as well and we need to better prepare ourselves for that.  We are asked to solve problems every day, but now we need to use our brains more than our brawn.  A wealth of knowledge and a cool head will take us farther than brute strength and a led foot will. I work urban EMS.  I have for the past twelve years, and I love it.  As someone who came from a calm, cool suburban background, the high volume, potential for high acuity and fast pace keeps me interested in the field.  I have, however, also come to realize that sometimes a safer response comes from either approaching a situation a little more slowly or even...

Most of the time when we see change, our gut reaction is to resist it, and do what we can to poke holes in it.  At least that has been my experience at many EMS services.  I guess I am just not lucky enough to work in an environment where fluid change occurs. Some change is really for the positive, and there is no more positive change in EMS that I can come up with than the new ACLS guidelines prioritizing chest compressions.  The problem though is breaking old habits. For my entire EMS career, it was always drilled into our heads that we “must get the tube” and we must do it well or someone would take the ability to intubate away from us.  Since the beginning of time, paramedics have seen their “right” to intubate patients as this sacred lifesaving skill that they must have and that no one should touch.  Through progressive thinking though, it has become more and more evident that intubation is not a lifesaving skill, but it is actually more of a life sustaining one.  In most instances, intubating a patient will help keep their airway patent and keep them alive, especially when sedated. I have studied up on CPR in Seattle and one thing that they discuss at great length is the importance of chest compressions and the minimization of interruptions.  We all need to keep that in mind and we all need to adopt that.  Nine out of ten times, airway is not important.  Early CPR, early defibrillation, and the minimization of interruptions are what are proving to be lifesaving interventions, not pauses in compressions to get a tube or vigorous bagging of a patient to get oxygen in.  Blood needs to go round and round in order for that air going in and out to be effective and measuring end title CO2 proves that. Have you ever had your APNEA alarm on your monitor go off?  The cause might not be a bad tube; it might actually be inadequate compressions.  Low CO2 output is a sign that there is little to no gas exchange at the alveolar level because there is not enough blood going...

Last Monday, I posted my views on the story that came out of Prince George County, Maryland involving a child who was transported in the back of a fire truck who was in cardiac arrest.  My opinion about the incident ruffled some feathers but it also sparked some terrific discussion not only on my blog, but it also helped fuel the topic at EMS12Lead, and on Facebook as well. I stand behind my statement that I felt the decision made was reckless and absolutely wrong.  While human emotion drives us, sometimes we need to fall back on our training.  When we walk into a scene, we are there to bring order to chaos, not add to the craziness. I have never had as many comments on a blog post as I did on this one, and while I replied to a few of them within the post itself, I thought I would take the time to share some of them here. Tom Bouthilette from EMS 12 Lead wrote: “It’s easy to second-guess the boots on the ground but unless you’re the one there watching a child die you can’t know what it was like.  There is no “absolute.” While I agree with Tom that there is no absolute, I do not think any of us would sit back and idly watch a child die.  We have training, and we would let that training guide us in caring for this individual with the equipment we had on hand.  Also, isn’t learning from mistakes made and dealing with the tough situations to improve care what we are here for?  Isn’t that why we write, and retrospectively look at situations that have happened in the past, whether they are positive or negative? Matthias Duschl asked: “Why do you see a need for punishing this crew?  I totally believe that we create better medics by analyzing what they do, measuring the outcome, and if something isn’t optimal, we should improve it by training not by suspending people who did something that saved a life but wasn’t according to their protocol.” Without protocol, we are nothing more than cowboys running around the streets shooting from the hips.  Policy and...

Lately, I have been very emotionally charged at work.  Well, really, that’s a nice way of putting it that I have not seemed happy which has been noticed by many people.  I tend to wear my emotions on my sleeve and frustration is certainly one of those that I do not hide well.  During a “venting” session at shift change a few weeks ago one of my colleagues said to me “maybe you need to reevaluate how you are sharing your message.”  I appreciated those words, and really went beyond that.  I decided to reevaluate my entire approach to how I do some things. It should not be any surprise that I am a control freak, a Type A personality.  That is something from my street paramedic career that I was not able to shake, and it rears its ugly head in my middle management style sometimes.  I am always watching what goes on around me, and often have an opinion about what is taking place.  I tent to express that opinion whether people want to hear it or not.  The first internal struggle that I need to address is I need to come to terms with the fact that I cannot control everything.  My focus needs to be narrowed and more concise during the course of my day.  Putting my energy towards changes that can be made and be productive as a result will make a difference in how I spend my time, and the outcomes that I see from it. I also need to come to terms with the fact that some things will never change, like some people’s beliefs.  People are who they are and I need to integrate myself into the system instead of demanding that the system integrates itself to me.  I need to trust that like me, other people are doing what they feel is in our best interest, and I need to move away from a “my way or the highway” attitude that I sometimes slip into. Finally, I cannot hang my hat on an expectation of praise; you cannot expect that to come whenever YOU want it to.  EMS is a thankless profession, and much like...

Recently, an article was posted about a group of Prince George County, MD firefighters who violated policy and transported a child in cardiac arrest to the hospital in their fire engine with what was described as “limited medical supplies” instead of waiting for an ambulance that was less than five minutes away.  The child, who was reportedly having an asthma attack, arrested in front of the crew.  The paramedic who was on scene made the decision to start transporting in their fire truck after getting what can only be assumed was an unacceptable ETA of five minutes.  According to the Prince George County Fire Department, the patient regained pulses prior to arrival at the emergency room. The firefighters who were involved were not suspended without pay.  Their medical control was not pulled.  They do not even appear to have been reprimanded by their department.  Instead, they have been given valor awards for their life saving actions that day. First, I do not want to overlook the miracle that took place on this call.  A life was saved albeit using very unconventional and potentially dangerous actions.  Effective CPR was done, and the girl lived, without any residual neurological deficits.  I give them credit for their care, but only to that extent.  This does not mean, however, that these firefighters should not stand and explain their actions. As I stated previously, the fire truck that was used on the call had limited medical equipment, and according to the press release, it was not one that was typically used for medical calls.  This leads me to believe that the life-saving actions taken by the paramedic that day was effective CPR which could have been done just as well, if not better, on the patient’s living room floor until a transport capable unit arrived. What about the large amount of departmental liability this crew put their employer under?  The girl had no neurological deficits but if she came out of this with so much as a limp or maybe slurred speech, her family could have owned the entire department, and potentially taken that paramedic for everything he had because of what would have only been described as “gross...

Anyone who knows me or spends any time perusing this blog knows that I feel that scene safety and the wellbeing of those of us who work in this field is the most important thing there is.  As a supervisor, my first goal is to make sure every single one of my employees goes home to their families at the end of the day.  They might not go home on time all the time, but I need to make sure that they go home. This past week I had a chance to attend the EMS1 Street Survival seminar put on by EMS1 and Calibre Press.  The program itself was created from the principles developed as part of their law enforcement scene safety class.  Much to my excitement, the class was taught by Mike Taigman, someone who I have a great deal of respect for. Prior to the class, Mike conducted an online survey that revealed that a quarter of EMTs responding had been involved in a fight or violent altercation with a patient.  75%, however, reported that as a result of those violent altercations they were injured in some way.  These numbers are unacceptable, and the need for training and education is evident.  The focus on the class was not to teach a “rip ’em up, tear ’em up” fight with everyone mentality.  While physical resolution of a conflict was covered, first and foremost, avoiding such a conflict was the priority. Day one dealt with coordinating these scenes and acting as the eyes and ears while someone else makes patient contact.  The focus was awareness: be aware of who is there, be aware of how you got in to the scene (out doors or in doors) and being aware of how to get out of a scene.  The videos and photos, actually and staged, that were shared during this first day were geared towards being focused on those little details that one might encounter.  How would you approach a certain scene?  What windows need to be watched?  How should you enter a house to best appraise what sort of situation you are walking into. When it comes to verbal communication in an escalating situation,...

Some posts are more difficult to write than others.  This is one of them. Coming from a volunteer background, I have seen a variety of levels of abilities in EMTs.  Some can’t hear a blood pressure.  Others just seem to say the wrong thing at the wrong time.  Some are just plain unreliable, and still others are downright negligent.  Sometimes, people tried to make excuses for these people by shrugging and saying “they’re doing this out of the kindness of their heart.”  That argument never seemed to hold much water to me. I came to the conclusion early in my career that not all EMTs are paramedics are created equally.  This should not be anything anyone considers earth shattering, some people is better at things than others.  As an industry though we seem to have taken this “all for one and one for all” mentality and it is hurting us. “A paramedic is a paramedic, and an EMT is an EMT.”  Have you ever heard anyone say that?  Unfortunately, if they don’t say it, many people think it.  There is no differentiation between a good provider and bad one, and there needs to be.  It is time to work with those who might not be cutting it.  It is time for them to get on the bus or move on. How much of the problem comes down to our reluctance to be educated?  Our view that continuing education is the two or three year grind that we have to do.  I think many providers might get a decent education under their belts right out of the gate, but once the reeducation or discovery of new educational opportunities is put in the hands of the “responsible” provider, we fail.  Miserably. But I digress. . . The first step to dealing with someone who is not cutting it is to correct them.  Be blunt about it.  Let them know that they are not getting the job done and show them the right way to do it at the right time: away from the patient.  Let them know what they are doing wrong, and tell them, no, show them how to do it the right way. When...

Communication is such a huge part of this job.  We need to be able to communicate with our patients and get information out of them, we need to be able to speak on a radio (which is sometimes easier said than done) and we need to be able to translate what our patients say into medical jargen so the doctors and nurses we give report to fully understand what they are going to be dealing with.  In addition to all of this, we need to be able to communicate with our partners as well. Jamie was my third partner in my career, and she was the one that I worked with the longest.  The two of us were partners for close to two years, working evenings and weekend overnights.  We had some great times, and did some really good calls over the years.  Our styles were completely different.  I was more aggressive medically, where she was quite a bit more on the conservative side, but because of that I learned a lot about holding back, and what to treat and not to treat. We would seem to commonly encounter a problem in the street though: while our silent communication skills, we were not always able to read each other’s minds.  It was on a slow shift that we solved this problem.  Jamie and I decided that we were going to create our own language, one that was spoken by touching different parts of our face to let the other person know what was needed in more of a silent fashion. For example: there is a crying woman sitting on a bed, not talking with her boyfriend/husband looming over her.  Jamie might tap her temple with her index finger which, according to our silent language dictionary, says “let’s clear the room so I can talk to her alone.”  I’d say to the husband, “Sir, can we go take a look at her medicine?”  or “Can you hold the door for me while I get the stretcher in?” At its peak, we had just about fifteen different silent phrases we’d “speak” to each other on calls, covering everything from “This is ridiculous, why are we here?” ...

For the last couple of months, the term Personal Responsibility has become one of my favorites.I think it’s the answer to many of the questions that we ask day in and day out not only on the streets as we take care of our patients, but in life in general. I constantly struggle with how to provide effective QA/QI and where Chart Review falls into that whole mix.Now, I haven’t done a ton of Chart Review in my day, but I’ve read some truly bad ones, and I’m sure I’ve written my share of less than desirable charts in my day, but does it go without saying that a poorly written chart means substandard care was provided?I don’t think that is always the case.A strong argument could be made that the quality of the chart written can be a direct reflection of quality of care, just like the cleanliness and readiness of one’s ambulance could indicate the same, but ultimately, what is a Patient Care Report? That PCR isn’t just the picture that we paint for those that we turn care over to, or those that review our charts in the Chart Review process.Ask yourself this: Do you think James Patterson, Stephen King, or your favorite author could write an effective chart?I’d say they could probably paint a pretty clear picture of what happened.Does that mean they have the patient care to back it up?Absolutely not. Effective documentation shows a person’s ability to tell a story and craft words.Don’t let the term “Craft words” confuse you.I’m not saying that people are not truthful, because I have a lot of faith in the people that work in this field.I think that a majority of the time, what is documented is an accurate account of the call, but we need to start looking at patient care beyond the chart, and beyond the capacity that an English Professor, or a Math Teacher would look at it from. How do we do that?Well, that’s the difficult question.When practicing medicine in the pre-hospital setting, we often act alone, in the back of an ambulance, or with one other knowledgeable person present to help us.Random visits on calls by Supervisors,...

That morning in Dallas, I got to spend about two hours with Chief Skip Kirkwood from Wake County EMS, and boy did it fly by. The interview I posted in that previous post was a pretty good summary of what we covered in the more “formal” part of our talk. From there, the discussion turned to an exchange of ideas and thoughts on where we are at and where we are headed, and if you’re looking for inspiration, look no further than what you can learn from him, and his department in North Carolina. My admiration for Skip Kirkwood started about five years ago. I learned about the National EMS Management Association, and their list serv on Google, and I quickly signed up for both. If you don’t follow the NEMSMA List Serv, what are you waiting for? Its filled with some of the greatest minds in EMS who frequently share ideas and thoughts on the field, and Skip is one of their most frequent and well respected contributors. When he speaks (or in this case writes) people stop, take notice, and listen. I have actually saved many of his emails that I found to be useful, and I’ve shared them with those around me. I’ve closely followed the progress Wake County EMS has made over the years, and I even have a few friends from New Jersey who currently work in his system (who I am very jealous of). To me, Skip Kirkwood comes across as someone who is a fearless, confident leader who expects nothing but the best out of everyone around him, and I don’t see why simply his personality wouldn’t bring that out of people. He also projects himself as a very patient person, eager to share the life and professional lessons he’s gained over the years. I thought the most interesting moment in our interview was his response to the question “What lesson would you like to teach to a new EMT or Paramedic just getting their start in the field?” His response had nothing to do with anything clinical or even operational. It was about their personal well being. “Manage your finances,” he said, “don’t live outside of...