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.
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)
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)
So ultimately, we are responsible for our actions and what we can provide to our patients. We need to stay current and proactive. We need 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!
Tomorrow morning, January 5th 2016, a born and raised Texan Paramedic will retire from EMS. Becoming a part-time or speciality paramedic might be in his future, but for now, he will be retired.
This guy has worked his shift and covered other shifts. He took the ambulmace home and parked it in his driveway as that was the way it was done back then. He awoke in the middle of the night, multiple times a night, to respond to 911 calls. He’s laid in ditches with your family members. He’s laid in the summer heated streets on his belly to comfort a child hit by a car. He’s been there when a child was rescued from a storm drain. He’s helped your family member after they’ve had a seizure. He has driven millions of miles in the front seat of an ambulance. He’s crawled into ditches after a tornado to rescue men covered by debris. He’s hugged family members of victims that didn’t survive. He’s carried and “worked” kids that he knew didn’t stand a chance. It’s impossible to count how many people he has touched in his career. A career that spanned for 37 years.
He has created an educational program from scratch as an advanced coordinator and instructor. He taught many EMT-Basic, Intermediate, and Paramedic classes in his years.
Has he done anything that thousands and thousands of other paramedics, emts and firemen do day-in and day-out around the world? No.
He is a Paramedic. A street medic. In my eyes, he is the best Paramedic I have ever seen work the field, (no discredit at all to any of the other EMTs and Paramedics I’ve worked with). You see…this guy I’m talking about is my dad. He’s 63 years old, and he began a career of helping people in 1979.
Tomorrow he will retire. He will hang up his stethoscope (that he never wore because he believes that everything he needs is in the ambulance and doesn’t need it around his neck haha).
Good luck dad. The service of EMS needs more guys that can do this job and see these things for 30+ years.
P.s. I’m proud of you pops.
As firefighters, children look up to us. We are the hometown heroes that are able to save lives during a crisis. Whether it be a fire, medical, or rescue call, we are the people these children look up to. October is Fire Prevention Month. We have an entire month, dedicated to give something back to the local children and teach them ways they could help us. If we make them feel like Jr. firefighters, even just for one day, they will make a big impact on our job.
All too often, we hear of victims entrapped in structural fires. Much more, too often, they succumb to their injuries. Smoke inhalation and toxic gases are the number one cause of death in fire victims during 2010. As firefighters, we have a mission to reach out to these little people, and educate them on their part during these emergencies. Believe it or not, I have seen first hand what fire prevention classes could do to our children. They are little sponges, and retain a lot more information than adults do. Especially if a lesson is delivered in such a way that makes it fun for them.
This year alone, I have seen many repeat faces in my local jurisdiction that are very knowledgeable, in exit strategies, smoke detectors, and fire drills within the home. These children are not just taking away pamphlets and pencils with your department name stamped on it. They are taking away life saving strategies that we hope they will never have to use. But are we always as “all-in” in our teaching efforts as we are if it were our own children? Do we sometimes skimp on the small things, and try move onto our next daily task? Hopefully not. We need to stand in front of these children as the professionals we are. They look up to us. Do it for them. Without them, our job would be a lot harder. Treat them as if they were your own children. They ARE your own children. They are the children in your community, and they are the next generation. They are the future doctors, politicians, firefighters, and teachers of our society. Treat them that way. Let’s make sure they make it to that point. Show them you care, and send them home with the skills they need to survive in a fire situation. Do it for them, do it for yourself, and do it for your community. Nobody looks up to you more than they do.
– The “Irons”
LACK OF PREPARATION
LACK OF EXPERIENCE
Whether volunteer or career, every firefighter goes through a series of phases. The beginning is when they are getting the very basic info (fire academy). Probation provides the means to get on-the-job experience, while still learning the job and how it works. The middle of the career is a slack period where the fireman betters him/herself and gets further education (either advanced fire/EMS classes or degrees). The hardest to cope with is the end of a career. The phase that occurs when the firefighter realizes they aren’t as young as they once were, and how they need to start passing it along to the new, young members. Before every Jake hangs up his helmet and coat for the last time, they need to reflect on their career. It provides excellent training to the membership, and finishes closing the doors to an invigorating line of work.
INABILITY TO FORECAST WORSENING CONDITIONS
INATTENTION TO DETAIL
All in all, every department is different and run by different people of the same title. Our main goal is to provide the best quality of care, in the worst imaginable of times. We all have the same end goal in mind. Stay safe, protect property, stabilize the incident, and make sure everyone goes home. Every single one of us can find something that needs to be fixed along our career path. For the tenth deadly sin, I ask that each of you look at yourself. Find at least one sin that you need to fix, that could potentially ruin a fireground’s production rate. Let’s all take the time, and better ourselves, before something happens that can have disastrous consequences. It’s awfully easy to arm-chair quarterback a fire on YouTube, but it’s all irrelevant if you can’t do the same for yourself. In the end, it makes you a better firefighter, and it gets you to take the time to provide some self-realization in what can be fixed. We can change a lot in the big picture, just by making small adjustments in our own lives. Stay salty.
After a lot of thought and tribulations, I have compiled a list of 10 Deadly Sins that are reasons why there are failures on the scene of an emergency. Whether it be EMS, Fire, rescue, or TRT, if any of these items occur, there could be an absolute break down in progress.
How many times have we been on a fireground Tac-channel, and “Joe” is on scan? Better yet, what about when he hadn’t changed over to fireground operations at all? We all want to smack that guy, just to get his head in the game, but it happens. Now, what if Joe was the OVM, and interior attack is screaming for vent? What if he needs to bump up the pressure on the line? Joe better get his act together! How about the good ole’ fashioned battery chirp. The one that comes at the absolute, most inconvenient time while operating at a scene? Yep, that breaks down communication because not only can you hear the annoying chirp, but so can everyone else on the fireground. Trust me, we are all looking to see who “that guy” is.
TOO. MANY. CHIEFS. (We all know what C.H.A.O.S. stands for…)
FREELANCING & TUNNEL VISION
Most volunteer fire stations have one. You know that one guy? He’s usually found wearing EMS uniform pants with trauma sheers, maybe a roll of medical tape, sporting a fire t-shirt while strolling Walmart’s auto section. He’s equipped with a duty-belt containing a mounted medical glove pouch, CPR mask key-chain, several Minitor pagers, a scanner, mini-Maglite, rescue knife with window punch and… you get the picture. He’s a walking Fire Store catalog.
He’s, sometimes, known to spout off NFPA codes, fire truck specifications, pump calculations and he knows everything there is to know about fighting fires and saving lives. But it’s likely this guy has done little of either. I know you’re aware of the type. This guy is lovingly, and ill-fatedly referred to as Ricky Rescue but may also answer to “Whacker,” “Yahoo,” and the transverse “Rescue Ricky.”
Believe it or not, it takes a special person to be Ricky Rescue. It’s not for everyone, but they fill an important void among people of our kind. Ricky Rescue is usually young and a little green with an over-enthusiastic affinity for firefighting. Ricky possesses the kind of enthusiasm we wish all of our firefighters had for the job but yet he lacks the humbleness of not flaunting the image and ultimately causing eye rolls. Ricky Rescue strongly values the public’s ability to immediately recognize him as a firefighter, and not just any firefighter…the best firefighter there ever was.
There is a sad psychological story that is playing out in the life and mind of Ricky Rescue, and perhaps I’ll cover that in a Part II, but for now… What do we do with him?
I’ve witnessed several of these characters throughout my career, and I’ve noticed avoidance among officer’s to manage these folks. Most leadership tactics I’ve witnessed involve suppressing these individuals, poking fun at them, holding them back from doing things, ignoring them, and basically trying to make them go away. Let’s face it, more often than not Ricky Rescue’s energy level is higher than most people can tolerate.
The short answer is to lean into them instead of shying away. Ricky Rescue needs a patient mentor, but one who will give him a long leash. Ricky Rescue has loads of enthusiasm, spirit, and energy so why not put that to good use? Giving Ricky individual tasks such as polishing everything or simple fire service research may not be enough. Task Ricky Rescue to the hilt. Give him a project or make him responsible for something and see what he does with it. I’m willing to bet Ricky will surprise you. You could make Ricky in charge of chrome, or have him research new extrication tools and present his findings. Ricky would probably love to update the district maps and is dying to help you organize your filing cabinet. If your inbox is stacked with things that can be outsourced why not give them to Ricky. If his product isn’t good enough to use, then coach him a little or don’t use it at all. Would you like to start plugging away at NFPA 1500, Ricky?
I know what you may be thinking here. “This is pretty cruel.” But I know from experience this method is a win-win. A Ricky Rescue needs to be kept busy. The busier he is, the less trouble he is causing or, the less he is annoying everyone. This works because Ricky gets to be a part of the successful operation of the fire department by actually having responsibility. It’s likely that nobody has ever trusted him with anything. This leadership tactic will help Ricky mature as well as fill him with a sense of much needed prideful satisfaction in that he’s actually helping. Ricky will be so elated about being a part of the operation that he wouldn’t dare give you anything less than his best.
Bear in mind, this tactic only works with a long leash. Give him a project and a brief explanation of what you want the outcome to look like and let him run with it. Allow Ricky to work through the particulars in his own way, you’ll be less frustrated, and he will feel like he’s trusted.
There are a few Ricky Rescues that are merely in it for the T-Shirt. These folks will give themselves away pretty quick. If the work your Ricky Rescue is giving you happens to be less than acceptable or he is slacking, perhaps you have a dud. A dud Ricky Rescue takes a lot of work, and in the end, you can only polish a turd so much.
All-in-all Ricky Rescue needs strong coaching, mentoring, and peer assistance. Turning your Ricky Rescue into a useful member of your department is a thoughtful process and one that takes a little planning but in the end, it’s worth it!
Station Pride had the honor of awarding the Rhea County Fire Dept. with the first ever Station Pride Brother-to-Brother grant! Station Pride Founder and President Riley Amoriello, as well as Vice President Jonathon Jacobs traveled to Wolf Creek Fire Station 740 in Rhea County, Tennessee to deliver the grant items in person.
The Rhea County Fire Dept operates twelve fire stations across the county with over 100 volunteers. Due to the dangerously small operating budget provided for each station it’s very hard for them to buy even basic necessities, like fuel and maintenance. The continued stress of their meager budget has place Rhea County in the position of having 30-35 year old front-line apparatus and out of date breathing apparatus. Even with their financial and equipment challenges, Rhea County Fire Department volunteers stand up and do what they can, with what they have and still accomplish what needs to be done. The struggle they face is not uncommon.
Will Sargent, of the Rhea County Fire Department, wrote the grant in early 2014 with the hopes of bringing a gas monitoring device to the department which only had one gas meter to cover a response area greater than two hundred square miles.
Station Pride accepted their request in mid 2014. Since then, the members of the Station Pride community both company members and followers stepped up to raise funds for gas monitoring devices. On December the 30th Station Pride awarded two “single” gas monitors to the Fire Chief and District Chiefs of the Rhea County Fire Department, the County Mayor was also in attendance. “It is an honor to be able to help these brothers that work so hard to better their department and community and strive everyday to make their community safer”-Riley Amoriello Station Pride’s Founder.
The Brother-to-Brother Grant put much needed safety equipment into the hands of the Rhea County responders. With the help of Station Pride and all of our website followers we were able to award them with, not just one, but two single-gas monitors.
It is our mission with the Station Pride Brother-to-Brother grant program to support those that need it most. Remember, when you buy anything from our online store! Proceeds go directly to the grant program. When you donate directly to our grant program 100% of that donation is applied to the next grant award. One Hundred Percent of Station Pride’s profit is put directly into the Brother-to-Brother Grant Program. The only expenses we have are the cost of replenishing sale items. Nobody at Station Pride earns a paycheck and we are here to better the fire service one firehouse at a time.
For many volunteer fire departments, low manpower is a major issue. Therefore, mutual aid is a necessary piece of equipment in the proverbial “tool box” in order to do the job effectively. However, to maximize the effectiveness of this tool, just like any other one, we must train with it on a regular basis. The benefits of cooperative training with neighboring departments are endless.
Fostering a personal relationship in a non-emergency environment with the members of your neighboring departments builds a level of trust, respect and understanding that is tantamount to effective team operation on a fire scene. Getting to know the strengths, weaknesses and personalities of each member ensures that the scene can be mitigated in themost effective manner possible. Having a pre-existing relationship with them puts cohesiveness in place before you even get on scene.
Knowing the availability and readiness of their resources is another important part of this tool. Being familiar with the equipment your mutual aid departments has available can save time and ensure that the right resources are being requested for the job. Knowing their equipment and procedures ensures the job is done with enough people, without having to figure out who can and who cannot operate the equipment. Even knowing the small things can make a huge difference in scene mitigation effectiveness. Knowing the coupling or thread type for their hydrants can save precious minutes in establishing a water supply.
An emergency scene is not the place to “work out the bugs”. The best place to do this is in regular training sessions with each other. However, just like any other tool, be it metaphorical or physical, it must be practiced regularly. Remember, we don’t train until we get it right; we train until we can’t get it wrong.
Anybody take pride in their bunk rooms? Some places have live-in firefighters with their own rooms while other places have large bunk rooms. Either way, take some time to add some personal flair to the place you lay your head at night. Pictures of your department’s history, action shots, posters, a disco ball – whatever you want to add some character. I particularly enjoy buying funny sheet sets for my house bag. Every six months or so, we’ll go to the store as a crew and buy ridiculous things to add to the bunk room. Most of us have children’s sheet sets and we never buy the same ones as each other. Again, silly things like this add to the character which adds up to having a station full of pride.
What are some goofy things you do? Share below. -1512