Professionalism in EMS and why the lack of it is hurting us all

                Oh no, this one is going to hurt. See there is no EMT or Paramedic that is professional all of the time. So in posting this one, I had to look at this from a very introspective point of view as opposed to the usual looking at problems that I see others needing to solve. See, despite my personal crusade to end the lack of information and poor patient care modalities, I have personal flaws. While I am aware of them, it isn’t always easy to fix them. So when you read this, understand that I am working on mine as well.

Professionalism as an EMT or Paramedic

                I have described getting EMS personnel to get on one page to be like herding cats. We are the guys and girls that walk into chaos with the determination that it will conform to our desires. It breeds arrogance and cynicism. We often speak of a patient complaining of neck pain as being a drug seeker. We become irritated when we pick up a diabetic patient regularly with hypoglycemia. The drunk with psych issues that we treat with contempt as being below us. The welfare mom with five children who is pregnant with the sixth, and she calls because her water broke.

We become immune to human suffering and consider ourselves better than these people. Our contempt often bleeds through in our communication with these people. I mean they are just abusing the system right. The person with neck pain should go to his local doctor, pain never hurt anybody. The diabetic should just eat a sandwich. The drunk is worth a couple of laughs at his expense. The welfare mom should have her damn tubes tied. I know you think this. So does the rest of the word. You post it online for the world to see. Then you wonder why people look at you with no respect.

Facebook pages like Paramedics on Facebook and The Most Interesting Ambulance Crew in the World have individuals that post on there in ways that are detrimental to the profession. We put cocky stickers on our vehicles. We wear T-Shirts that advertize our lack of empathy and caring. When people refer to us in terms that we consider derogatory, despite the fact the speaker may have no knowledge of what we do, we often flip out and act like they initiated a hate crime. Never mind that the person has no clue about your ability to recognize a posterior MI and act accordingly, or that you can make a snap decision that can improve their life, the know that you and your partner are coming in an ambulance and one of you are going to drive them to the hospital.

Then there is the condescending attitude we take with coworkers. We all know what we feel like when a new EMT walks in the door. We fear taking them out on the street the first time. We treat them as if they have communicable disease. We laugh when they hold a little old ladies hand or they have trouble working the suction. These people are coming in looking for mentors and they get bullied. I remember starting a job, walking in wearing my new white shirt and BDU pants and the first thing I heard was “Who the Hell are you”. Nice way to start a new job. This was two days after being suspended because I had to be so I could pay for my EMT-I class.  That is enough to make someone not want to work in the career field.

                The only person that catches as much crap as the newbie is the person who actually reads EMS research. The guy who was pointing out that 12 Lead EKG’s were going to be the standard in 1998. You know the guy who gives out pain medication to “obvious” drug seekers, then explains himself by talking about patho-physiology of pain. That nerdy guy who “can’t hack it on the streets” as opposed to the street medic who “knows” what to do.

                Carrying yourself in this way shows the world that you are not a professional. You allow the gallows humor that we use at the station or in the ambulance to cope with the stress bleed out into of pain. That nerdy guy who “can’t hack it on the streets” as opposed to the street medic who “knows” what to do.

                Carrying yourself in this way shows the world that you are not a professional. You allow the gallows humor that we use at the station or in the ambulance to cope with the stress bleed out into your dealing with the public. We also forget to shave and neglect our personal appearance. We yell at our coworkers and management. We look and act like we don’t give a damn. We have reaped what we have sown. We need to fix this. Now, that’s enough on ripping on crews

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Professionalism and management

                Supervisors, managers, and dispatchers, this one is for you. We will start with dispatchers because while they are not actual management, you are part of the office staff and the initial point of contact for both employees and the public. A hateful or panicked voice portrays nothing more than you are too good or incapable dealing with the situation. The public and the crews know that you are their lifeline. If a crew needs help, you are the first person they are going to tell. If there is an emergency and the public calls you, they are going to expect you to keep calm. Be honest with them, and try to help them. When a hospital calls do not give them an unreasonable time that your crew will be there. Remember that whatever is going on is that person’s emergency not yours, and you have the ability to think clearly.

                Supervisors, you are in a precarious position. When your crew messes up, you have to be able to discipline them while maintaining your composure. Yelling and screaming at people proves that you are not in control. The fact is, whatever the person has done that is wrong has already happened. You cannot make it not happen. But yelling and insulting the person is not a solution. Your crew may also come to you with a problem with a patient, hospital, or other customer. The problem may actually be with the customer. Keeping an open mind will allow you to adjust for this. No matter what, no disciplinary action should take place in a public forum. This leads to belittlement and can lead to a loss of morale, even among the employees that act the manner you want to encourage. Be free with praise and encouragement. It never causes problems to tell someone they did a good job.

                Management, you are the ones that truly worry. You know how much operations cost. Losing a contract might cause you to have to fire people. You have to make the decision whether to purchase new or refurbished equipment. You deal with billing. You know what these people’s actions cause. Everything stated about supervisors applies to you. You should also never seem flustered. Rant and rave behind closed doors, but never let the employees see that side of you. You have to be cool, calm and collected. See from an employee’s stand point our livelihood depends on you. Often employees do not understand that your job depends on them as well. You have to be firm, fair and consistent with employees. You should not reward employees for not doing the requirements of the job. It might make things easier, but rewarding people for not doing the right things sends a message that being a problem is what gets rewarded. This leads to good employees being more likely to turn into bad employees.

Professionalism conclusion

                If this sounds like I am preaching, I am not. I have done most of these things wrong. I probably will again. That being said, I am trying to act in a manner more befitting of my profession. See most of the people reading this are my brothers and sisters. I want people to look at them as the people that come into their lives and make them a little better. I promise you I am trying, and maybe you will as well.

As always, I welcome your comments,

Lone Medic.

Illinois should go modular

                I work in Illinois EMS and I complain about how it is administered. If you know me you know that is not surprising. Illinois EMS has a system where 90% of EMS is administered by nurses. A lot of these nurses are good people who try to perform their job with the best goals in mind. EMS agencies are required to join EMS systems that are administered by these nurses. While there is a physician above them, this Dr. has no real knowledge of the people that work for him or her unless they transport to his or her hospital. So we wind up with cookie cutter solutions that only work for the people they see. Because there is no real interaction, the protocols tend to be designed to hold back the exceptional to ensure that people they never see do not screw up.

                So, how can we fix this problem? My solution is that we require the systems to become modular. Each resource hospital has a set of base line protocols, and then has modular enhancements. These modular enhancements might include mechanical CPR, field clearance of C-spine, community paramedicine, and Critical Care Transport. These are just examples obviously, but it would be a start. Allow the providers to know what they have to do in order to allow these things to happen. Then you allow them to do it. Voila, a simple solution to a real problem.

                The best solution is to allow agencies the option to allow EMS providers to hire their own Medical Director. This would allow for EMS agencies to put into place the protocols that actually serve their patients and communities best.  But the reality is that this is not going to happen soon. Despite this being the reality on all surrounding states, Illinois resists change more than any other state. So we need to consider modular systems. It at least allows us to move in a more modern direction, instead of being stuck in 2002.

                Now this is only slightly related, but I am going to encourage you to join the NAEMT and your state EMT association. The NRA is one of the most effective best lobbying groups out there for a reason. That reason is membership. NRA members donate and teach the majority of the gun safety classes out there. These things raise revenue for the NRA to lobby for gun rights. The NAEMT is that for EMS, yet less than 1% of EMS personnel are members. NAEMT membership pays for its self in discounts and benefits, while allowing for better representation at the Federal level. Most states have similar statewide organizations.  NAEMT also provides AMLS and PHTLS as both an educational and fundraising opportunities. Please take these courses. They benefit you greatly.

As always, I value your comments and feedback,

Lone Medic

Proper and Judicious use of HEMS

                Tell me you haven’t had this discussion on the truck before.

911 Dispatcher “Small Town Ambulance Service Call, Middle of nowhere. Small Town Ambulance please respond to a 2 vehicle MVC head on, unknown injuries”

JG “County Dispatch Rescue 51 is enroute do we have any word on injuries”

911 “Unknown at this time 51”

JG “51 is clear.”

RD “JG Should we get F&U to send mutual aid”

JG “RD Why don’t we launch a bird, we know how bad it can be out there.”

       Herein lies the problem. Helicopter EMS is a growing and vital service in rural America. It is also overused, causing increased costs with no benefit to the patient. Helicopters save live, I truly believe that. There is very good evidence that they do in rural settings. The jury is definitely out in urban ones though. So in typical EMS fashion there are some of us that take it to a ridiculous extreme. I mean oxygen helps, so let’s put more people on more of it. Wait, there is evidence that Oxygen has negative effect on CVA patients increasing mortality.

      Helicopters are a finite resource that needs to be used judiciously. There needs to be sensible guidelines for HEMS usage. So in the interest trying to improve this, lets look at some sensible guidelines.

Lone Medic’s HEMS Guidelines

Helicopter should be considered in the following situations:

Pt. requires higher level of care than is available locally.

Helicopter can be at scene before EMS unit can have patient at a local hospital for stabilization

Pt. is suffering from immediate life threatening illness or injury.

Consider ground transport in the following situations:

You are able to arrive at an ER before the Helicopter is able to be on scene.

If you are able to transport a patient to an appropriate facility in less time than a Helicopter can.

If the Patient has non-life threatening illnesses or injuries.

        Now you notice that I stated that if you can have a patient to an appropriate facility before a Helicopter can. I know your ask, LM aren’t Helicopters always faster. Well let me take you through the process of activating a Helicopter in a STEMI situation. Something I think is appropriate, if time is saved.

Upon arrival you find a patient is having a Anterior Infarct after performing a 12 Lead ECG. You know there is a Reperfusion center 35 minutes away. Being a caring medic you contact the Helicopter. 3 minutes later they accept the flight and weather is clear. You give them the GPS coordinates and the backyard is clear enough to be a effective LZ. 10 Minutes later they lift off. They have a Flight Time of 15 minutes. After they land it takes the flight crew 10 minutes to prepare the patient to for lift off. They have another 10 minute flight to the Cath Lab. Diagnosis to balloon approximately 55 minutes depending on where the Lab is in the hospital. You could have had the patient there in less time, saving 13 minutes.

       This does not mean you shouldn't utilize HEMS, like I said they save lives. But use them judiciously. The other problem I have is using them when they are not needed. Mitchell Mightymedic gets called out to a man who fell off of a ladder and has a Tib-Fib fracture. Patient is hemodynamically stable with good pedal pulses. Mitch decides to fly this patient to a trauma center due to a  transport time of 24 minutes to the nearest facility.

       During this time, Gina Ditchdoc is called out to a ATV accident that requires a 25 minute ride on a Fire Department rescue UTV. Upon arrival Pt. is found to have systolic BP of 84 and an unstable pelvis. Gina contacts dispatch and there is only Helicopter available is 1 hour away due to Mitch’s patient being enroute to a nearby Trauma Center.

       Helicopters are also unable to fly during lightning, high winds, or other inclement weather. Do not delay transport to ask for a helicopter that is obviously unable to fly. If it is that time sensitive, they need to be in a Doctor’s care.

Your Feedback is always welcome.

Lone Medic.

Lights, Sirens, Stupidity

It has been a while since I posted. During that time I started a second job. My wife has started the journey that is Paramedic Class. I honestly envy her in this, as her program is far superior to mine. If you have read my posts before you know that I am an advocate for improved education for EMS in Illinois. But there are changes that need to happen on the personal and agency levels as well. Personally, I want to drop at least 80 pounds by June of 2014. I have changed ADD Medication to one I tolerate better, which helps me in this goal.

But this is not my personal blog. This is for my profession and how to improve it. The subject that I am about to discuss is one I have personal experience in and how it can go bad. I am going to discuss Vehicle Operations. When I first started the culture was based on drive fast, seconds count, and damn the consequences. That was wrong. I hit another vehicle while driving non-emergency. There were numerous close calls. I once made a normally one hour and forty five minute trip in 59 minutes. Folks, I was a menace.

You combine this with sleep apnea, multiple 24 hour shifts in a row, and my ADD, well it is a miracle I never killed someone. I tell this as one of the lucky ones. I now have the ADD and the Sleep Apnea under control. I have my shifts scheduled so I usually am able to sleep an adequate amount. These things improve my safety as well as the safety of those around me.

Now I mentioned a second job, it is with a really large EMS provider. I will leave it at that. Their driver’s safety program is not quite as extensive as I think it should be, but it definitely works. Every EMT and Paramedic should be taught low forces driving. Every EMS agency should have an effective driver monitoring and feedback program. This is something that will save our lives. Driving is without a doubt the most dangerous activity EMS personnel take part in, and we forget it.

Remember this if you are operating an ambulance and you kill someone, you might not be held legally liable. Different states have different laws about this, but you most likely wanted to save lives when you started in this. Do you want to be the guy that has to face the fact you killed someone. That person you kill could also be yourself. Do you want your friends and family to live with that loss?

As always I value your comments and opinions,

Lone Medic.

The Death of the 24 hour shift, I hope.

                

The 24 hour shift is a dragon that needs to be slain. I hear way too many EMT’s tell me that they like 24 hour shifts and prefer that they be scheduled back to back. I mean this sounds great to me, do my 48 and have 5 days off. I mean who cares if it actually risks people’s lives including you or your partners.

              

  A big problem I have with this type of scheduling, and we have to do it at my current job, but we are working on ending it, is that it makes EMS into a hobby not a profession. There are people that do EMS as a hobby. They are called volunteers and many of them d a damn good job because they want to. But if EMS is how you earn your living, you should look at it as a profession and treat it as such.

               

  As someone who is officially a dinosaur, I ask those of you who have done this for a while on 24 hour shifts, are you as good near the end of shift as you are at the beginning? Most of us will tell you no. Think about it, you have either been awake for nearly 24 hour or you were woken up from sleep that was interrupted by other crew’s tones, radios, or telephones. You or your equally tired partner are driving in excess of posted speed limits weaving in and out of traffic, and avoiding obstacles.

  There is a link between sleep deprivation and depression in EMS personnel. Many of the people I work with, including myself, have been on anti-depressants. Most of us consider this due to the on the job stressors, and they do contribute, but getting more rest would improve the situation as well as our overall health. I have a link on this below.

 

   If you were to come in at a set period of time, you do 8 to 12 hours and you go home. You and your partner are well rested and are able to perform your skills in a prompt and effective manner. You finish your shift and are able to leave to go home. No more listening to radios and telephones at night. You an EMS professional, so you goal should be better patient care and outcomes. In the fight for EMS 2.0 remember that we have to be able to perform at a level that ensures we are not making more victims of death by paramedic assistance.

http://www.jems.com/article/administration-and-leadership/studies-prove-24-hour-shifts-unsafe

http://www.fireengineering.com/articles/print/volume-166/issue-02/departments/fireems/sleep-deprivation-in-ems.html

How to change things.

People who have read my previous blogs know that I am an advocate of EMS changing. I am a firm believer in EMS personnel becoming the true first line providers they should be. But good reader, I have met the enemy and he is us. We all know that competent medic that looks at new research and blows it off. He is the guy that has a great IV ratio but looked at 12 leads as unnecessary.  He is the guy that says that sounds nice but it will never happen. When it does happen he is shocked. Well that guy is part of the problem

Another problem is the medic that refuses to know anything more than the protocols. He has no desire to understand the pathology of the illnesses he treats. He looks at new advances as a pain because he has to change his routine. This is the guy that probably judges his skills as a medic based on scene time and being able to immobilize a patient so they can’t move.

So how do we change these people? One, engage them in conversation. When doing this, point out things that were commonly held truths in EMS that have been disproven. These guys are like you in that they want to help people. Point out that Performing 12 as well as 15 lead EKG’s and early activation of cath labs do not just save lives, they improve them. Ask them if they remember things like the Oral Screw, rotating tourniquets, and wide open IV’s. These people are your friends, colleagues, and mentors. Treat them as such.

To those of us in states that require EMS services to work with a resource hospital, learn to communicate with your Medical Director. These people probably have to deal with multiple services and can’t tailor their protocols to your service. Some services will actively oppose any change because it will cost the more than they are willing to spend. Your service might have medics that are so opposed to change that these Medical Directors are not willing to allow you more leeway. Look at it like this, if you can’t get all of your medics to perform a 12 lead, how can you expect to argue effectively for high dose nitroglycerine for CHF.

I am speaking from experience. I work as a supervisor for a service that is encountering many of these problems. When working to improve things and move from traditional paradigms to evidence based models people have to accept they can be wrong. This means me as well. I remember when Vasopressin and the new drug that is going to save everybody. It was the new thing, and I couldn’t wait to give it. I never did. Turns out that Vasopressin is no better than Epi and was packaged in a manner that discouraged its use. It turns out that there is no evidence that any antiarrhythmic drug has a positive effect on patients having a neurologically intact return of spontaneous circulation. Early BLS does though, and we should take that into consideration.

Now what I would like to see is a randomized trial of patients being intubated and ETCO2 capnography in place to see the effects on patient outcome. I know that in local experience it has improved the quality of CPR, but that is anecdotal evidence. We need several randomized studies in urban and rural locations. The studies need to be replicated for the new mechanical CPR devices as well. These things show promise, but we need to find out early if these things are good medicine or as another blogger calls it quackery.

 

I value your feedback,

 

Lone Medic

Thinking mans EMS

I recently read an article on EMS 2.0 at www.ambulancedriverfiles.com that point out that the many EMS providers judge themselves by their skills and not their knowledge. I have come to think that a lot of that is due to how we are educated. So I am going to talk about that.

Many Paramedics are taught the skills they need to perform the job. In class there is some glossing over of the processes of the body that allow it to function. Even the programs that are degree based the “paramedic” class takes up entirely too much of the curriculum. So if we are going to move toward a reboot of EMS let’s start at the beginning.

So what should we do. First the Paramedic Program should include a course that is the basis of the basic EMS knowledge. This class should include teaching the physical skills, NIMS training, and Vehicle Operations. You cannot be a Paramedic without understanding these things. 3 hours per semester.

Now First Semester should include a Baseline Anatomy and Physiology class. It should also include a course on Medical Terminology and Report writing. This should be complete the First Semester. It gives a strong basis for a Medics future.

Second Semester should have an actual cardiology Class. Paramedics have more effect on the cardiovascular system than any other. From 12 and 15 lead EKGs to many of the medications that we give cardiology is a large part of what EMS provides and we need the knowledge base to work on. I would include in this semester a pharmacology class as well. Each class would be 4 hours long.

Ok now we have a good baseline. Third Semester should be a Psychology course. It should also include a course on the Customer Service. Finally I would include a course on Computer Literacy. These things will have a major impact on the type of care our patients receive and we should cover it.

Final Semester should include your internship, and an A and P review. This takes paramedics from being skills based to actually being knowledge based. To be honest I would likely include a summer semester that is adds in a philosophy course and some other humanities course. Anything that encourages thought would be good for EMS.