Heroes Among Us

Sometimes it takes a horrible tragedy to make you realize just how special your co-workers are.  In the past few weeks, our region has been rocked by two senseless tragedies; the first in Webster and the latest today in Perinton. It's incomprehensible to think of what goes through the minds of those committing these atrocities, let alone the family and friends of those left behind, who have to ask "what went wrong?"

In both scenarios, the men and women who responded to these incidents displayed the utmost professionalism in the face of unimaginable horror. I am proud to consider these people my colleagues, and even more importantly, my friends. They have witnessed something that we're all trained to face, but hope we never have to experience, and did so with the professionalism they are expected to show each and every day.

To Alan, Ben, Dan, Dave, Kyle, Jess, Joe, John, Mike, and everyone else I may have missed, however unintentionally: thank you. Today, you are my heroes.

Excuse me, is that MRSA on your neck?

So after my last post about expecting the unexpected, I was reminded about leaving personal equipment in my car. My four year old grabbed my stethescope, which I apparently had flung into the back seat after an exhausting day, and started playing with it. Granted, he was using it properly, which made me both proud and absolutely terrified at the same time. Nonetheless, after watching him for a minute, I suddenly got this overbearing sense of fear, looked into the rearview mirror to confirm what I'd seen, and shouted "Get that off of you!" It was sufficiently loud enough to cause my wife to cover her ears and give me "the look." You know the one I mean.

I realized that my son was playing with a potentially infectious object. Granted, I try to be cautious with my medical instruments, cleaning them when possible and tossing when not. Considering the recent uptick in respiratory emergencies cropping up (tis the season to be sniffling), I realized not only was the bell of my scope carrying potentially dangerous materials, but while being around the coughing, hacking, and sneezing (oh my!), there was a good chance there were particles all over the tubing as well.  In the heat of everything, I couldn't recall whether I'd wiped the scope after my last shift.

We all know that regular, frequent handwashing helps keep the spread of diseases down. But how often do you clean your stethoscope? How often do your colleagues, the RN that just took your report, or the doctor that walked in to asses the tube placement clean theirs? Your scope should be cleaned after every patient contact. If not, the potential for spreading potentially fatal diseases is considerable. Don't limit your cleaning to just the scope. The handles of your trauma shears, penlight/flashlight, and any other re-usable equipment you touched during that patient contact should also be wiped clean prior to using again.

In New York State, the Department of Health's Bureau of EMS issued a policy statement in 1998 allowing agencies to place limits on what equipment individual providers can carry and use. It states that "Services may issue their members/employees certain items of EMS
equipment such as penlights, stethoscopes, and blood pressure cuffs, or may permit
members/employees to carry their own similar equipment." Okay, so what's the issue?

It goes on to say "Any service which issues or permits the use of personal equipment by its members/employees must have written policies in effect which clearly define which items of equipment are personal issue, and the responsibility of each member/employee for the availability, cleanliness and operational condition of each item when on duty. The service may limit what equipment members/employees may carry." For those who were waiting fo the italics to end, it essentially says that both the service and individual are responsible for maintaining their equipment. And remember...with responsiblity comes liability. Though it is probably near impossible to determine the origin of a community-acquired infection, remember that taking a few extra minutes to ensure the cleanliness of your equipment can save you a lot of trouble in the future.

Expect the Unexpected

Is it just me, or has the use of personal protective equipment seemed to have gone by the wayside? It seems no matter where I go, I see more and more responders conducting patient care without basic protection, including the use of gloves. Ask yourself this: do you "glove up" only when the patient is grimy, dirty, bloody, or puke-y? How about when the patient is sitting in a pristine living room in a house you could only afford after winning the lottery, is superbly groomed and dressed to the nines, and is only complaining of stomach discomfort? Are we letting our eyes deceive us?

Count me among those who have trended away from the "I have my BSI on" mentality...until now. A recent encounter left me asking myself why I've been taking these risks, not only for my own health but for the well-being of my family. Let's put it this way...you never know when a patient's condition is going to deteriorate and you end up performing airway maneuvers and suctioning without gloves or goggles. I was lucky that nothing splashed and that my hands were (relatively) unscathed from the coming slaughter of dry skin caused by winter. But the situation still left me wondering "what if?"

Remember this: your agency is required by OSHA to provide you with personal protective equipment necessary to perform your job. There is no requirement that you use it, unless you count common sense among requirements. I typically carry my "blood pouch" with me while I'm on duty. It has a pair of goggles that fit over my prescription glasses, extra gloves, a gown, hand sanitizer, and a MyClyns spray. The day of the crashing patient, it was in the back seat of my car, just when I needed it most. You bet your bottom I won't forget it again.

There's a reason we're taught the mantra about body substance isolation, but I want to take it one step further. As EMS practitioners, we are routinely exposed to contagions of varying lethality on a daily basis. When we come home at night, do we step into a "clean room" to dispose of our work uniform and put on clean clothes before hugging our family? Do our boots lay on the hallway floor where the family dog chews on them? Does your stethoscope lay on the kitchen counter?

Without getting paranoid, think about the potential contagions you are carrying on all of these items. Now think about how you can modify your daily routine to better protect yourself, your family, and your friends. Until next time...glove up, and expect the unexpected.

Handling Complaints

“Marty, I need to speak with you a minute.” Your supervisor’s standing in the doorway to his office when you arrive for work, and your immediate reaction is “what now?”

The next twenty minutes are spent with you seated in a chair, in front of Bill’s desk, while he not-so-tactfully tells you about a complaint that was brought up against you from a group of your co-workers. He proceeds to state this group is concerned with a multitude of problems from everything regarding your hygiene, your driving, your patient care, your PCRs, and everything in between. When you ask who specifically brought the concerns to Bill’s attention, he says “I really can’t say. A letter was left in my mailbox without a signature, but the gist of it appears that there are at least two of your co-workers filing this complaint.”

You’re furious, and tell your supervisor that you’re disappointed with yourself for giving the perception that there is a problem. You also tell him that you’re disappointed your co-workers felt it necessary to leave an anonymous letter instead of either coming to you directly or identifying themselves in the complaint. Considering the grievances being levied against you, you feel it is your right to confront those accusing you of these misdeeds and defend your actions, if necessary.

Bill alludes that the letter mentioned your colleagues didn’t want to speak with you directly because “they feel like you’ll go after them” if they did. He mentions you do have a tendency to come across gruff, which you admit to, but also says those who know you best understand that and don’t take offense to it. He ends the discussion by asking you “stay on your toes” and re-affirms his belief that you are very good at what you do.

Is this situation right? Of course not, but it happens every day. Letters of complaint are filed regularly by people who fear reprisal, whether rightly so or not, and therefore wish to remain anonymous.

Persons filing legitimate concerns against an individual or an entity are protected by whistleblower laws, should use of those protections be necessary. Furthermore, maintaining a certain level of personal and professional integrity exists, especially in cases where accusations are levied that rules or laws have been violated.

Should you ever have the need to file a complaint, do the right thing: stand up in your belief that something unjust has occurred. Sometimes it takes one person making a stand to strengthen others to sit up and take notice.

Documenting Care

I've recently completed a presentation on patient care documentation, and would like to share a few thoughts about the topic. The idea to put on this presentation was born when a member of an agency I work for asked me if I'd be interested in teaching my charting style. I found the request intriguing, primarily because until that point I'd been chided by my fellow providers for "writing novels" and "milking the overtime" when I get a late call and have to spend time thoroughly charting a call. I can also say that has been the sentiment of some of my past supervisors as well. Let's be honest, the notion that a BLS provider's chart should be short, sweet, and done in 20 minutes is so 1990's.

While its true that BLS providers have a lesser degree of pre-hospital education than Paramedics, over the past several years the level of care expected from BLS providers has increased dramatically. For example, we're now using more medications than ever before, and although the number is still small in comparison with the arsenal carried by ALS providers, and BLS providers are needing to become better clinicians in order to effectively deploy these treatments. It's simply not enough to say "patient exhibiting signs of anaphylaxis, mother reports previous prescription of epi-pen, used same."

A better way of charting that same situation: "Patient's mother reports history of severe allergic reaction to peanuts and child mistakenly took a bite of a peanut butter sandwich. Phyiscal examination revealed patient audibly wheezing upon exhalation, oropharynx & tongue swelling, use of accessory muscles during inhalation, and hives across chest and upper arms. In accordance with regional Standards of Care, administered high-flow oxygen at 15 LPM via non-rebreather mask as well as 0.15mg epinephrine auto-injector via IM into patient's left thigh." This example, as compared to the preceding, shows a provider who's a clinician and not a technician. They use clinical findings to justify care instead of simply documenting "rote" procedures.

In my service area, BLS providers are, generally, the first to arrive on a scene. That being said, they are now the first set of trained eyes to evaluate the situation and have a very important role in providing a portrait of what they find. Let's take the following example: "Arrived on scene to find a two car crash with an SUV on its side and a person trapped inside. Other driver was out of vehicle and walking around."

Compare those two sentences with the following: "Arrived on scene to find a two vehicle collision involving a white Nissan Sentra and a black Toyota Highlander at the intersection of Walk Street and Don't Walk Road. Nissan Sentra was facing westbound in eastbound lane of Walk Street and appeared to have significant front-end damage, including starring of windshield. A middle aged white female was walking near her vehicle while talking on her cell phone and appeared to be bleeding from her forehead.  The Toyota Highlander was resting on its passenger side in the ditch on the northwest corner of the intersection with impact damage to the driver's door as well as crushing damage to the roof. A teenage white male was seated in the driver's seat, seatbelt engaged, and complaining of head, neck, and back pain." Paints a more thorough picture, doesn't it?

Last but not least, proofread your work before submitting it. In the age of electronic records, "spell check" isn't going to catch everything. Case in point: a major electronic charting software spell check feature found the following sentence to be correct: "Patient reports he feel from a latter while working on a ruff. He says that he landed on his back and that his arm hurts. He doesn't remember felling but no's the day, address, and month."

Obviously this was a farcical example, but did you find all the errors? How about this: "Patient reports he fell from a ladder while working on a roof. He says that he landed on his back and that his arm hurts. He doesn't remember falling but knows the day, address, and month." That doesn't take spell check; it takes proofreading.

The take home message is this: a pre-hospital care record is a multi-purpose tool. It is a part of the patient's medical record, it is a legal document, and it paints a picture of what happened between the time you arrived and transfer of care to hospital staff. This means everything, up to and including how you moved the patient to the hospital bed (two-person sheet draw), what you did to ensure his or her safety in the bed (rails up, call button at patient's left hand), and who you provided a transfer of care report to (yes, including the name). The most important part of documenting a chart is that this is YOUR memory of the call as it happened. Will you honestly remember all the details you left out of the narrative if you ever have the misfortune of being called to testify in court?

Until we meet again, be safe.

"Wouldn't it be nice if they...."

Going along with my previous post about finding balance, you need to know when to laugh at yourself. Today my partner said he'd "never seen someone go through emotions as fast as you." What happened?

Well, returning to quarters from a transport the garage door opener flew off the sun visor and landed on the dash. Considering I'm on an expressway at the time, I just leave it there. Upon pulling in front of the garage door, I pull forward, then line the ambulance up and stop. Reaching for the opener, I press the button; the door doesn't open. No big surprise, could be I didn't press the button hard enough, a low battery, a disturbance in the Force. I press it again; nothing. A third time...nothing. Remember that saying about repeating a sequence expecting a different response? I was well on the way there.

So I continue pressing the button, trying different variables of pressure, duration, angle, pointing it in the mirror, nothing. After several frustrating minutes my partner looks at his mirror, then at me and says "Bay 2 is open." I look down at the dash, back up at where I'm parked...doh! In my admiration of the spring sunshine and a beautiful day, I neglected to remember I pulled out of bay 2 for this call. Meanwhile, I'm parked in front of (and demanding that the door to) bay 1 open. The ambulance we're in ALWAYS goes in bay 2.

My partner looks at me and says "Wouldn't it be nice if they put the ambulance number in big letters on the dashboard," pointing at the 3" Scotchlite numbers pasted on the dash in front of him. He and I shared a laugh for a good five minutes before I could muster the ability to park the ambulance in the correct bay.

Finding Balance

After joining the first agency in my career, a small outfit with two ambulances, a pole barn base, and about 20 active members, I jumped in with both feet. I wanted to be a part of everything, wanted to do everything to help out my hometown Corps. This “dedication” drove the other three new members (and most of the vets) nuts. “You need to slow down, or you’re going to burn out.” 18 years old, full of….yeah, those two things…and ready to save lives. After all, that’s what this is all about, right?

Many years later, I often find myself reflecting on those sage words spoken by the elders of my first Corps. At the same time, they were people I admired and utterly despised because I thought they were holding me back. I knew the stuff on the State exam. Even more than some because my father was an EMT for most of my childhood, so I was always around it. I knew what my job and responsibilities were. But what I didn’t know was that I didn’t know it all. The wise elders at my first Corps tried their hardest to tell me, but I was too bullheaded to listen.

My “dedication” drove me out of that first agency in less than a year. I couldn’t find a balance between the “book stuff” and the “real world” stuff.

It wasn’t until a few years later that I finally understood the need to balance my EMS passion with the rest of my life. Yes, I’ve chosen to make EMS my career. No, I don’t make much money doing it. But when you look past the financial part and understand there is so much more to life than “saving lives” and “true emergencies,” the real essence of this job comes out.

A quality professional provider learns to recognize this job is not “all action, all the time” and that a good deal of down time will occur. They learn to take advantage of this time to enhance their knowledge, catch up on a favorite novel, or just kick back and enjoy a few minutes to breathe. In essence, they understand the need to balance the “go” mentality with relaxation and recharging for the next call.

The last, and arguably most important aspect of balance, is that between EMS and the rest of your life. A quality professional will understand that when the day’s over, it’s time to turn off the pager, hang up the scope, and take some time for you. For those who volunteer and respond to calls from home, this can be applied by understanding that you alone are not responsible for handling every call. There are other members of your Corps for a reason. I’m not saying turn off your EMS brain entirely; there’s a chance you could be in the right place at the right time to help someone in need.

This was one of the hardest lessons for me to learn, and I’m sure I’m not the only one. But you have to do it; otherwise the things we see and do in this job will consume you. Spend time with your family, or with friends who aren’t in the fire/EMS/police scene. Start a new hobby…or catch up on an old one.

Establishing a balance between your emergency services life and the rest of your life can be one of the hardest things to do, especially when you’re passionate about the job. But believe me, once you’ve established that balance you will certainly come to appreciate everything you have in your life and how precious life really is.

The Trademarks of a Professional: Accountability, Appearance, and Attitude

Accountability, attitude, and appearance may not be the first three hallmarks that come to mind when considering what makes a “great” pre-hospital care provider. However, should a provider master these three ideals he or she should consider themselves at a good starting point. All three provide a solid foundation to build upon in the journey that is EMS.

Accountability means accepting responsibility for your actions and the consequences of your actions. This means admitting to scraping the side of the ambulance while backing it, leaving a piece of equipment in the (now locked) patient’s home, or forgetting a clipboard with all of your paperwork on a chair at the receiving hospital (yup, I’ve done ‘em all). It also means being proactive in reporting these breaches of responsibility, no matter how minor they seem, instead of waiting for the inevitable call from a supervisor or saying “I don’t know how it got there.”

As bad at it may seem to report these instances, unless you have developed a habit of these lapses, often the worst that happens is a reminder of how to avoid recurrence in the future and a request for written documentation. This is not to say other, more significant action won’t occur, but in my experience unless the error was grievous or repetitive, it will be attributed to “accidents happen.” Taking immediate responsibility for errors, reporting them as soon as practical, and accepting the consequences are hallmarks of upstanding moral character.

In a profession that can be characterized as “messy” even on the best of days, maintaining one’s appearance can be difficult. If you’re on duty right now, take a look in the mirror and ask yourself, “If this person was coming into my home, how would I feel about them?” Uniform codes in EMS are rapidly changing. When first beginning my EMS journey, many of the members of my first Corps still wore white pants. Today, there’s a variety of options being used, from t-shirts to “Class A” uniform shirts complete with badges and name tags. Regardless of how you feel about a particular uniform code, your decision of what to wear should be in compliance with that code and paint you as a trusted provider of medical care. Uniforms should be clean, free of holes and stains, pressed (if needed), and boots should be polished. It’s also a good idea to have a spare uniform available for changing into if needed.

Attire is only one part of your appearance, however: hygiene is also important. This is dirty, smelly work, and we often become dirty and smelly doing it. Consider it collateral damage. However, reporting to work showered and well-groomed will help delay some of that damage and prevent your colleagues from wearing respirators while working with you. Consider this checklist of details: are your fingernails clean? How’s your breath smell at 3:00am? Does your shirt bear witness to the hot dog cart lunch you wolfed down? Are your boots covered in mud while walking across a new carpet? Before going on duty, take a minute to look in the mirror. Looking professional goes a long way toward acting professional. Oh, and one more point: appearing calm and composed even though you’re racing inside goes a long way to instilling confidence in your patients.

How’s your attitude lately? What about that of your friends and colleagues? Spending more time complaining about the problems of this job than trying to do something about them is about as productive as bailing out a boat with a fishing net. Everyone likes a good gripe once in a while. In fact, a former mentor of mine used to call it “pulling the vent card.” But venting and complaining too much gets you one thing: a bad reputation.

All professions have their problems, and EMS is no exception. Instead of griping about the “BS lift assist” or nursing home call, consider the reasons these calls occur. At the present time, who better to respond to persons who fall in their homes and need help getting back up? Why not send personnel trained in recognizing and treating injuries that may have occurred during the fall? As for nursing homes, did you realize that most of these facilities have policies in place that require their patients be sent out for evaluation, no matter how minor the complaint may seem? Regardless of how you feel about the facilities, they have rules and regulations to follow, just the same as us.

It is also important to recognize that not everyone you encounter is going to be having a peachy day. In today’s current environment, nearly everyone you meet is stressed, whether or not they admit it. Long hours, multiple jobs, financial difficulties, or just having a general bad day are all reasons the triage nurse might roll her eyes when you walk in for the third time today, or why your partner has a really sour look on his face. Remember: when you’re performing your duties, you’re on stage. One podcast I follow called this “act one, scene one,” meaning you put on a new performance each time you respond. Regardless of how you feel, putting on your game face and adjusting your attitude to be as positive as possible will present you as a caring, competent professional.

These are only three attributes that make up a good professional, and we’ve only scratched the surface. Your comments and suggestions on what other attributes make a good provider are welcomed by visiting journeysinems.blogspot.com or e-mailing journeysinems@gmail.com.

Welcome

Welcome to my little place on the net. As the statement below the header indicates, my goal is to promote the sharing of ideas and concepts that make an impact in the everyday world of emergency medical services. Before I go any further: as stated in the header posting of specific scenarios, no matter how de-identified, will not occur. If that is what you're looking for, then I'm sorry to disappoint you but hope you will find the discussions here informative and enjoyable.

I would like to mention that while this blog is EMS-themed, not everything here will be related to our jobs in uniform. Our families, friends, and sanity are paramount; without them we would eventually collapse from the weight of the stressors we encounter on the job. Some of the topics will be non-EMS related and I hope you will also participate in those as well.

In closing, welcome again and thank you for stopping by. Regardless of your role in EMS (or affiliation via marriage, family, or frienship), I hope you enjoy your stay!