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What Do You Think We Are Doing?

 

Let’s talk about EMS for a minute…

There are industry-level publications, internet sites independent from the magazines and countless bloggers out there that have an opinion. I am no different. I pluck away at the keyboard and think that I can provide some insight, using the experience, which at this point, has spanned more than 20 years. Sixteen of that being in a busy(ish) urban department as well as the private sector, volunteer and any combination of the above. I have been in and out of administrations and held several command positions. I try to give my take on issues that I think warrant attention. I just finished my 24-hour shift which consisted of 8 calls. Not a bad shift. A little lighter than normal. I’m used to the double digits. We didn’t get beat up too bad. So anyway, I know you didn’t ask for my opinion, but you are still reading this so you might as well hear what I’m on my soapbox about this time. Have you a few minutes to kill? Or, at the very least, are you wondering if I will say something witty or lay on the sarcasm that is familiar to just about everyone in EMS? Read on to see if your dreams come true.

So today’s rant; pre-hospital emergency care! Shocker, I know!

Ahhh yes, what we all are doing whether we like it or not. What even the busiest departments in the country can no longer ignore. The fire service’s under-appreciated step-child (in most places) and the thing that pays the salaries of a lot of “dragon slaying”, “grievance filing”, “door slamming, when they get a run”, “treating their patients like shit because they have to be on the medic unit” fire service employees. The thing that has kept some departments afloat during hard financial times. That’s what we will be talking about this time, so let’s explore what is rattling around in my head.

What do you think we are doing out here? It’s a weird question to some, simply because I don’t think it is asked too often. When you ask the new guy or gal, he or she will say we are out here to save lives by implementing all of the groovy things they taught us at the learning annex in our emergency medical technological implementation class. If you ask the “salty dog” they will say that we are the ones crazy enough to stay up for 24 hours straight to cart the crazies to the ED so they can jump on the bus and be back home before you are done with your report. My opinion of us is somewhere in the middle, I think. You may not perceive it that way by the end of this post, but who knows.

Credit: Paul Combs

I can hear you saying, “get to the point” so here we go (you’re not the boss of me by the way). When I was a young, green, two-pager-wearing, CPR mask on my belt, car lit up like a Christmas tree EMT; I was ready to save the world with the 120 hours of training that I received. I was ready to be a “code buster” as noted on the t-shirts of my local squad and ready to snatch people from the jaws of death like I had read about in all of the periodicals stacked up at the squad house. I was “doin it” on the 68 runs I took my first year as an EMT. I was a hero to my family and friends, and my mom couldn’t stop bragging to her coworkers and pointing out the picture of me in my gear that was on her desk. What has two thumbs and drives the ambulance while the medics work in the back? This guy right here! I wouldn’t say I was Johnny and Roy, but I could make a mean cot and restocked the ambulance with 4000 4×4’s because I knew that bus crash would happen sooner or later! Oh, they let me do CPR a few times…….not bragging……….just saying.

Now, when I get to work with a new EMT and their wet-ink Registry card, I find myself wishing I had the same boundless energy to help my fellow man as I did back then. I get a boost from those guys or gals for a minute but find myself spending the day dispelling myths about some of the crap that they were taught in school. At the end of those days, after snatching people from the jaws of mild discomfort, I wonder what kind of Kool-Aid they are feeding them in their training and what they think they will be doing out here on the street. I think back on conversations I had with the senior members of my squad about what we are doing. That’s after the adrenaline wore off from me driving them through traffic with the noise and the cherries activated!

What do you think you SHOULD be doing out here? Do you honestly feel that you are having the greatest impact on your patient’s clinical course, more so than what the hospital will have? Do you believe that YOUR treatments will “make or break” the outcome of the patient’s recovery? Some of that holds true, but there may come a day when you question that, and that’s okay. Some days you will feel like you are just giving people rides or “hauling freight” as someone mentioned to me once, and that’s okay. Just don’t get stuck there!

Or do you feel like I do? Do you feel like you have an impact on the entrance of the patient into the healthcare system at that time in history? Do you realize a greater portion of your patients need to be at the ED more than they need to be with you? Do you try to get as many of your “skills” done before you get to the ED? Do you feel like most of your “skills,” if done well and for the right reasons, will shave some time off of the patients ED evaluation? Do you know, just by looking at someone, that they need services provided by the definitive care facility and not by EMS? Do you feel like what you say in your hand-off report to the ED staff can get the patient what they need more rapidly? I certainly do. I know by looking at the septic, unresponsive nursing home patient with a 518 blood glucose and a 104.5 temperature that I can get them started. They need to be in the ED and ultimately the ICU and not sitting outside the nursing home in my medic unit while I try to get the $35,000 blood pressure machine hooked up, ECG leads on that won’t stay because the patient is diaphoretic and an IV started after two attempts. The patient needs to see the ED

doc, not me. If I get all of those things done on the way to the ED then “YAY” for the patient and me. Don’t get me wrong; we have made leaps and bounds in pre-hospital care with trauma, STEMI recognition and treatment, stroke recognition and pediatrics. We have a direct impact on the outcomes for those patients and need to be excellent at doing those skills in rapid fashion to give those patients a chance at a full recovery. Keep in mind that we are supposed to be RAPID transport. Not everyone needs you to do you. Some of these patients need the ED, plain and simple.

We need to know what we do for our patient affects them throughout their clinical course to their discharge from the hospital. Don’t be afraid to learn as much as you can from the hospital about how your patients progressed through the hospital system and their outcome.

I have had discussions with colleagues about this subject and have been accused of discounting the effect of EMS in the healthcare system. I always argue that point because I don’t feel like I am. (Clearly, otherwise, I would not be arguing!) I am just trying to keep a clear understanding of what I think my role as a paramedic is. I am the initial contact with the healthcare system at any given point, so I feel I should do everything I can to get them to the right hospital for their needs. My department transports to six different hospitals including level one and two trauma centers, a children’s hospital/trauma center and a Veterans Affairs hospital. I am the advocate for most of my patients and have gotten good at tailoring my hand-off reports to get the ED staff to focus on what the patient needs right now, and what they can take care of in a few minutes. I also try to steer my patients to the facility that will best suit their needs. I try to teach that to the new folks, but it is a hard concept to grasp for some.

I tell the new folks to look at it like this. You can be in the ED, or at least half way there, in the time it takes you to sit out in front of the patient’s house fumble f**king around. I understand you’re trying to get IV’s, scrutinizing their vital signs, getting the $98,000,000 monitor to take a blood pressure seven times or putting the patient through the “inquisition” about their past medical history, but you should get going. Put it in drive and get going. Nothing is more awkward than the family sitting in the car in the driveway with the shifter in reverse, waiting for the ambulance to move in the direction of the hospital. I’ve seen thirty-minute on-scene times AFTER the patient is loaded into the unit. That is infuriating to me. What are you doing??? It’s neat to meet new people but Christ on a bicycle, you could have been at the ED by now! Do you think that IV is worth holding up the show? Do you not have the skill level to take a manual BP after your forty-eight attempts with the monitor? I mean really? What do you think we are supposed to be doing out here? Granted, you may need to hold still for a minute to get a clean 12-lead or to do something special before you start bumping down the road. Applying CPAP comes to mind. We have all had that partner that thinks that they are driving a Lamborghini to the hospital and throws you around the patient compartment. Sometimes you need to do a couple of things so you can sit down and not die, but outside of that, you need to get rolling. You need to be good at doing your skills on the move. Surfers don’t win surfing competitions by standing on the surf board on the beach, they ride the waves and do that hand signal thing with their thumb and pinky finger. I have a RonJon shirt somewhere with that on it. Dude. Learn to do your skills on the move bruh!

We need to realize that we are not the wizards of pre-hospital sorcery that they convinced us we were in school. They tried to teach me to be an amateur cardiologist in paramedic school. They tried. I do the best I can. I have dumbed it down to whether the patient is symptomatic or not. It’s cool that I can spot that PAC, but this asymptomatic patient needs to follow up with his cardiologist. I am good at STEMI recognition, but we have dumbed that down to by saying if it sounds and looks and feels like a heart attack, even though you don’t have STEMI signs, you need to treat it as a heart attack. You really never know right? At least until you get a Troponin level……..at the ED. No sir, your properly working pace maker is not going to kill you. Your underlying cardiac disease probably will, but we are all just counting out the birthdays anyway, am I right?? (frowny face emoji)

Photo Credit: Scott R. Rosen

There have been several studies about the effect of rapid transport by the first arriving unit on the scene. One study I read compared the outcomes of patients brought to the ED by the first arriving police unit as compared to the first arriving EMS unit. The outcomes were almost identical, with some outcomes being better when the patient arrived by the police officer. Those results are sobering and will make you wonder if what we do is even worth it. I think that as we evolve, we will continue to examine what aspects of our work do the best and focus our attention on those things. There will be new information, and we will be reactive to it and proactive with it. Hopefully, we will move more quickly to embrace the information; I’m looking at you, departments that are still backboarding! Are you dumb or just plain stupid?? Stop using “standard practice” as a reason to do it. Driving stakes into the brains of “crazy” people used to be standard practice but we quit doing that.

What we do is worth it. I had to put that in there so the new generation of “everyone gets a trophy for showing up” will not throw themselves off a building or be sad. (another frowny face emoji)……(and the one that looks like it is crying)emoji-sad-face-yesyou-read-that-right-ALoN3i-clipart

So ultimately, we are responsible for our actions and what we can provide to our patients. We need to stay current and proactive. We getty_rf_photo_of_ambulanceneed to check ourselves before we wreck ourselves and try hard to provide rapid, quality pre-hospital care. It is what we do and is what we are supposed to be doing out on the streets.

We are often labeled as “Jacks-of-all-trades” when it comes to what we do. If you don’t feel like you have a broad enough understanding of what you are supposed to be doing, go out and find the knowledge. Work in different aspects of this business. I spent some time in a hospital-based air and mobile intensive care system. The short time I was there was invaluable in my eyes because I learned what happens from the time the patient was brought in by EMS until they were discharged. It gave me a different perspective on how I treat my patients, who gets advanced airways and who does not and what skills I can do in the field to impact the patient throughout their clinical course.

Be skilled and be quick. Get your patient to the definitive care that they need. Get your ego in check and do what is best for your patient. Listen to them. When they sweat, you sweat. Listen to the answers when you ask a question. Do your job and do it well. We are out there to be the first person they see on the day that their world may be crumbling. You should be honored that they trust a stranger to help them!

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What Percent are You?

Note: The bulk of this post deals with fire department EMS, so if you are not in a department that does fire department EMS, you may find it uninformative. Those of you that do fire department EMS, read on!

As you can imagine, I spend quite a bit of time on social media. I have slow shifts like everyone else, and I have time during my off time to decompress and be a couch potato, so I try to read and follow other fire and EMS blogs and social media pages, just to get a feel for what kind of attitude we have as a “business”. As such, I read articles and posts from various authors about various subjects and in turn, hear various opinions about the same topics or subjects. I am no different. I propose my opinion on subjects and try to give some background as to why I feel the way I do. I will admit that I do not get to travel and dine in the finest firehouses across the country like other “bloggers”, but I get a sense, from what I read, that the issues that I deal with are similar to other parts of the country. Granted, we have varying protocols and levels of service, but we all generally follow the same basic underlying methods and practices to do our jobs.

gasper m17
(Image courtesy of the Gasper Township Fire Department, Eaton, Ohio)

That being said, I have read several articles about being part of a percentage of firefighters that “gives it their all” or “trains until the sun comes up” or “they are the salty dogs that you should look up to, seek out and gain knowledge from. Ones to model one’s career after”. I agree with that fundamentally, but I have rarely seen articles about finding the senior EMS guy or gal and learning from them.

I have learned from some senior folks. I soaked up knowledge and learned the tips and tricks that made me a better fireman (at least it felt that way). They made me a better operator and gave me perspective on how to train the new guy, now that I am the “senior” man on many occasions. I have learned from street-wise and seasoned medics as well. I have always valued what I learned and have tried to pass it on as much as possible, but I am starting to wonder what the current “senior” folks think this business is supposed to be like in 2016. My opinion of this job seems to get further and further away from their opinion, and I find that curious.

I read recently that the FDNY and Detroit Fire are in the process of a major “overhaul” of their operations. Namely because of the fire load (the amount of fires they are fighting) has gone down and the EMS load is going up. That article struck a chord with me. Here are two of the busiest fire department in the nation taking another look at how they operate. I can almost guarantee that there are men and women in the FDNY and DFD rallying against changes. It’s what we do, right? Change is scary! From what I have read, the unions are taking what appears to be a “middle of the road” position right now so it remains to be seen how this will turn out, but I began to wonder, as I stated before, what the senior staff thinks the fire service should be like in 2016. Were they surprised to hear that they need to focus more on EMS? I am reading as much as I can about their issues, and it remains to be seen.

There is no doubt that a number of fires have dropped off, and the EMS calls have gone up in almost every area of the country. We are turning out on more and more weird and wonderful EMS related calls and even more that are due to the failures of the public health system. It’s a busy life for the fire department EMT/Paramedic, and it will only get busier.

ems27So what of it. What’s the point? My point is this; it seems like our senior staff members continue to tell our cadets, our rookies, our new hires that “slaying the dragon” should be the highlight of your career. That being the 10% firefighter is what it means to BE a firefighter. That “doing work” and “getting some” are what makes a firefighter a firefighter in the firehouse. That EMS is just something that we have to deal with, as if it will go away in the future. Is it really? In 2016, does that make you the model firefighter? I submit that it does not.

Time and time again, I hear senior staff complain that “when they backed the ambulance in this firehouse, we quit being a real fire department” or that we don’t GET to fight fires anymore because we are taking all of these EMS calls. Really?? You have got to be joking! When I was a Chief, I told my staff that if they continued to complain about EMS, I would pay them using the fraction of funds gleaned from putting fires out. Once I broke down the percentage of the money they earned from fire and from EMS calls, they decided to be more proactive about transporting instead of trying to get refusals, and they didn’t feel as salty about not getting to slay the dragon every day.

I don’t see putting fires out as the greatest moments of my career. Yes, I had some great times kicking doors in and throwing water, and I still do. I love being an engine operator even more now and I love working on the truck, but there is so much more I have done that I am proud of. I have touched so many lives over the years. Some of my greatest “holy shit” moments came in EMS. Some of the “jobs” that made my heart pound out of my chest were in EMS. Some of my proudest moments were in EMS, and some of my biggest defeats were in the back of an ambulance. I have made a point to be the one of the 10% that completely changes the mood of an EMS scene for the better when I arrive. I have made a point to know more than the other guys about medicine and the future of our field, and I share that with the new guys. I feel I am part of the 10% but for other reasons that I feel are just as important as knowing how to force a door 29 ways.

Cc_akEUW4AASFx0I am not saying that firefighting isn’t important work. I truly believe in training until you can’t get it wrong. I get just as frustrated with poorly trained firefighters as anyone. I watch the news or videos on YouTube and armchair it with the best of them. I have put as much effort into being a good fireman as I have being a great medic. I will never feel like a bad ass dragon slayer. It is not my nature. I come from a line of lawyers and stamp collectors, not blacksmiths, butchers or bodybuilders. I have never claimed to be macho, but I can think my way through a difficult airway, a confusing medical call or a wicked trauma. Those skills are what makes today’s 10% in my opinion. We are EMS departments that fight a fire on occasion.

I have seen the FTM-PTB (fuck the mutts-protect the brothers) stickers around, and it makes me uneasy. Who are the mutts? Are they the ones that don’t think the same way about the fire service as you do? Are they the ones who think the medic is exciting? Are they the nerds? You should look around. Some of the leaders in this industry are hanging on every word that comes from NIST. The nerds are taking over so maybe it is time for a shift in perspective. I know the usual explanation is that the mutts are the ones who don’t care about training or drilling or working as a team. Can we put those hose jockeys that think that EMS is a stupid waste of their time in the mutt category? They aren’t embracing all aspects of the job, so does that make them a mutt? I mean, they have to stop dropping weights in the workout room or have to stop molesting the forcible entry training prop to take a stupid EMS call so do they have the right attitude about what this job should be in 2016?

The fire service is mired in tradition and therefore mired down in traditional thinking, so I expect change to come slowly. We still don’t realize that the equipment pays our salary, so we don’t take care of it. We are slow to purchase EMS equipment that would drastically change patient outcomes. We are slow to support the part of our business that generates revenue. Big red firetrucks look cool but if the wheels are falling off the rig that supports 1/3 or more of your budget then why would you neglect it? It’s a weird business model that will eventually shift for the better.

(Robinson Kuntz/Daily Republic)
(Robinson Kuntz/Daily Republic)

I rambled a bit on this post, but I hope you can get through that and see my point. It is time to redefine what we see as the “model firefighter” in my opinion. Knowing how to be successful in EMS will carry that firefighter into the future. Making sure they feel comfortable in an ambulance is just as important as them being comfortable climbing a ladder. This is a team sport, so if all of the team members are not trained up, in all aspects of the job, the team will suffer.

I work in a department that, when you promote to Lieutenant, you no longer have to ride the ambulance. I was operating the engine the other day for a newer Lt. and I said: “I trust you with my life in a fire, but I am getting less comfortable with you helping me on the medic”. With a strange look, my Lt. said ” why is that, I’m still a medic”? I said ” it’s because you don’t see patients anymore. Your skills are going to fade”. He agreed, and we had a good laugh, but I was being honest.

So what percent do you want to be? I want to be part of the group that sees past what we are doing today and looks ahead at what we can become. As a Chief, I always was excited about well-rounded employees because I knew I could plug them into any spot and they would excel. Can you excel in every spot? I hope you can!

As I have stated in the past, I am in no way an expert in the field. I am not a professional writer either. I just post my opinions in hopes that it will promote a dialog or get people to think about our business differently.

Thanks for stopping by and stay safe out there!