A Funeral Procession?

Being assigned - willingly - to a double-basic EMT ambulance for a commercial provider, I often find myself being a transfer shuttle. I'm okay with that; after 15 years there isn't a whole lot that I haven't done at least once before, so catching hospital discharges and hospice transfers with a sprinkle of BLS emergencies is just fine with me. Today, though, I found one of my transfers seemed more macabre than simply a ride to another facility.

Mind you, in the past month that I've been back in the company's system status management plan, at least 50%, maybe more, of my patient encounters have been transfers from a home or a hospital to a hospice care center. There are a lot of great places for patients who are in the final transition of their lives in our area. Today, the routine is somber as usual, but there was an unusually high number of family members present at our patient's bedside. They were kind and very helpful in removing the boxes - yes, boxes - of flowers from the room, and even went so far as to help move furniture so we could get better access to their loved one. 

Once our patient was transferred and secured to the stretcher, the journey began. Due to the attention being paid to the patient by the family, we did the best we could to keep them involved in the move, including loading every one of them onto the elevator while I quickly descended a stairway to meet them on the ground floor. One of the children accompanied my partner in the back as we pulled out of our parking space...and three cars pulled in line behind me.

Like most transfers to hospice, this one was considered fragile, and we proceeded as if our patient were made of glass. Our slow procession wound its way to the facility at speeds that would make a snail qualify for the Indy 500. At one point, the cars behind me turned on their hazards, and a thought popped into my head: is this a funeral procession? By all accounts, it probably could have been, considering our destination. With this thought, instead of moving quickly, I maintained my pace in order to ensure the family could stay with me.

After arriving and helping the staff gently transfer the patient, my partner and I took our leave. We were stopped and thanked by each family member for treating their loved one as tenderly as they would have. Between my thoughts while driving and their obvious gratitude at our simple efforts, I couldn't help but feel sad for our patient and the family. In reality, it was most likely one of the last trips their loved one will ever take.

End-of-Life Decisions

Nothing like a hug from someone you don't know to bring you to the brink of tears. That's pretty much how I'm feeling right now: torn, angry, sad.  

I've just been visited by a sweet woman who wanted to borrow some equipment from the loan cupboard. The encounter started off pleasantly, as she was looking for a walker and wheelchair for a family member. Always trying to provide the best service possible, I started talking with her about the File of Life emergency information cards we offer. During the brief overview of the form, she must have noticed the "Advanced Directives" section, because she began talking about her end-of-life wishes. While preparing to provide information on how she could make her wishes known, she told me "oh, I know about them, but my doctor refuses to sign them. She believes they're only for people who are dying."

My frustration must have been evident, because she mentioned "I'm a nurse, and I know what it's like to see the effects of trying to bring someone back." She mentioned that her physician insinuated her thoughts were "selfish," and my frustration grew. This woman was adamant that she wanted specific actions taken (or not taken), yet her physician was refusing to go along with her requests because "she doesn't believe in them." In that moment, I realized that despite our best efforts in educating the public, we're still at the mercy of others, usually those who have much more medical education than we do. I mentioned going the route of medical identification jewelry, and she stated that she owned a pendant but didn't wear it. I suggested that in light of the discussion we were having that she re-consider it, as in New York State the options for EMS crews to follow are limited. 

I cannot count the number of times I've encountered family members who were shaken by needing to execute the duties of a Healthcare Proxy, or worse yet, get angry because Healthcare Proxy documents and living wills aren't recognized as legal advanced directives in pre-hospital settings in New York. The conversations with a physician and family members, when made in advance, don't make end-of-life decisions any easier. But knowing the wishes of the patient beforehand can make these encounters a little less stressful on everyone involved. Additionally, it's usually not physicians who are walking through the door into these situations. With all respect due her station, this physician's refusal to discuss and acknowledge a patient's express wishes was certainly distressing for a veteran EMT.

We chatted for a few more minutes, then after I had lifted her wheelchair and walker into the car, she asked "Can I give you a hug? Is that okay?" It caught me completely off-guard, because I didn't think that I'd done anything spectacular besides offer some advice and help with loading some equipment. But apparently, that alone was enough to warrant this spontaneous moment of human emotion from someone I'd met for the first time only a few minutes earlier. I can only hope that she takes the information I provided her with and tries again to convince her physician to follow the wishes of the patient.

"Just a Basic"

Let me set the tone: I've been a basic EMT for 15 years by choice. It's not that I haven't wanted to pursue the "bigger and better" world of wearing a Paramedic patch, and I haven't completely written it off. It's just that I've seen the merit of having well-trained, experienced EMTs complementing the strong ALS system we have in place in our region. 

That being said, I'm tired of the "just a basic " mantra that's haunting our EMS systems. At least in New York State, with very few exceptions, all advanced providers must spend some time learning the ropes before earning a Paramedic credential. What bothers me the most, though, is that this is often used as an excuse by EMTs for not knowing or understanding things that purportedly fall out of the scope of their foundational knowledge. For example: when preparing to teach a transition class on cardiology, I was questioned by a few colleagues as to why I was preparing slides with various EKG rhythm strips. I replied that, in my opinion, EMTs should know the difference between a normal sinus rhythm, asystole, coarse and fine ventricular fibrillation, ventricular tachycardia, and pulseless electrical activity (among others). Their reply: "Basics don't need to know that." I asked them to back up their position; they replied that "we're just basics, we're not responsible for interpreting EKGs." 

The argument was factually correct, but is this information going to hurt? Is learning something that might be new harmful? Some would say that it sets up unreasonable expectations and that EMTs need to "focus on the basics." In my experience, mixing things up a bit and throwing in some new material is a way to get EMTs more involved and enthusiastic about learning. I also find contradiction in the "basics don't need to know that" routine when the material is being provided by an advanced practitioner, nurse, or physician. In those circumstances, apparently it's okay but not when an EMT wants to teach colleagues the same topic. 

The other part of this mantra is "we only really get to work the priority four [strictly BLS] calls alone. Everything else is handled by ALS, so we don't get the experience we need to be better providers." Here, again, I say stop: this is absolutely the best opportunity to gain experience. Truthfully, are we going to "save a life" when transporting a patient BLS? In the physical sense, probably not. But this is where EMTs have the opportunity to hone their  interview, assessment, and BLS intervention skills. These are patients who we should be performing detailed assessments on, listening to lung sounds in multiple fields, listening to bowel tones, fine-tuning our blood pressure evaluation skills and learning as much about the human body as we can. 

Don't use the "it's only a nausea/vomiting/diarrhea patient" excuse to ignore your patient during transport. Get your BSI on, get your hands on the patient and assess him. You might find that what is causing the patient's bodily dysfunction is completely unrelated to what the patient ate last night. Or in the event of the "simple fall," find during an interview that the patient has been falling more frequently and may be in need of a social intervention to rectify the situation. In these cases, you can certainly "save a life" by taking the short time you have to learn as much as you can about the patient and his or her condition then sharing it with others who have other specialized resources at their dispersal.

Don't think of yourself as being "just a basic." Take the time to invest in your education, attend continuing education, and dedicate yourself to being a clinician instead of a technician. In doing this, you may find greater satisfaction in your position and understand that you are a bigger part of the system than you originally thought.

Praise in Public

Like many others, I got my start in my working life in a quick-service restaurant. I was humbled to be asked to join, and eventually lead, the training team a short time after becoming employed. One of the most important lessons I taught our trainers was to praise in public, remediate in private. I had such an opportunity to praise in public the other day when visiting a franchisee of that system.

The young man who waited on me was eager, enthusiastic, and knowledgeable. He was friendly, quick, and professional. He was confident and didn't seem to hang his head in shame or express embarrassment in working in a restaurant environment, a trait I find all too common these days (a la the "turning fries" humiliation routine). Considering my time working in that type of restaurant, I knew their professional standards were high and he was meeting every bullet point on the service attitude training guide. The best part is, he wasn't faking it. 

I pulled his manager aside and said something to her, told her to keep an eye on this one because he was destined for great things. When I was done, he looked me square in the eye and said "have a great afternoon!" That's when I decided to pull the trigger on some praising. In front of several other customers who were all waiting for food, I said "keep up the good work." I explained my background, told him he was being a model employee as far as I could tell, and that if he keeps working as he did today, he'll go far. I haven't seen as big a smile as the one he gave me in a long time.

What's the point of this little story? We're an industry that has a habit of eating its own, spreading war stories and openly mocking our brethren when they're not present (and even worse when they are). I suggest that instead of continuing to publicly shame our co-workers, we instead praise them for what they do publicly, and often. This is a hard job, and we need fresh blood (pardon the phrase) to keep our services alive. By criticizing in public, we do a disservice to those who would otherwise remain. Even new EMTs and non-certified individuals should be celebrated for their accomplishments when they happen. Taking the time to praise in public leads to better morale, and better service.

Last Shift

Kevin Stubbings drives back

to quarters following the last

call of his career..."for now."

I've been waiting to write this until the shift was over because I honestly haven't been able to find the right words to say. Those who know me well know that usually isn't a problem for me.

I lost a good partner today. For nearly three years, we've been a team, working together on the everyday calls EMSers encounter, interspersed with some really challenging calls that define who we are as caregivers. We've seen some really sick patients, backboarded more people than I can count, and gotten more "thank yous" from people than I can remember.

We worked really well as a team, and I truly believe our patients benefited from our ability to seamlessly provide care with little verbal communication between us. We always seemed to know what the other was going to do. Good teams do that, and anyone who's had a partner like this understands exactly what I mean.

We were certainly at very different ends of the personality spectrum, but my partner had a way of bringing out the best in me. When I was feeling out of sorts, his wit would help put me back in better spirits; heaven knows how often he was able to do that. He's helped me through some difficult situations that I'm sure he didn't even know about, and I can't thank him enough for just being him. That stability was what I needed to continue to persevere. Our differences were just enough to balance each other out. You don't find that very often.

Being in EMS full time for more than 5 years is typically a badge of honor; after 10 years my partner's hanging up his stethoscope today. I hope it's only for a little while, for the sake of the patients who need him.

Kevin Stubbings: thank you for your service to EMS, and for putting up with me. Enjoy your time away, but don't stay away too long.

Follow-up on today's post...

Just thought I'd share this as a follow up to today's blog post!

Thank You, Thom Dick

 I've been fortunate to meet many people who have inspired my career over the years. Some have been partners on difficult calls, others have been educators, supervisors, and members of brother services. But one person who I've found has inspired me most often I've only met once for the briefest moment in time: Thom Dick. Many of you may know him as the author of regular columns in industry periodicals; he's also authored a book entitled "People Care." If you get a chance, pick it up; it's a fantastic read. I had the opportunity to meet Thom at the EMS Today Conference in Baltimore, Maryland back in 2009. He had been honored with the James O. Page award and was signing autographs and meeting EMSers in the exhibit hall that afternoon.

The 45 seconds or so I spent were like standing next to a legend for me. Why? His attitude toward taking care of patients. As he outlines in "People Care" and his regular articles, this job is all about people taking care of people. His manner of describing how to put a personal touch on this job has been a teaching tool that I've used with new EMTs for years. He takes situations that are often the butt of jokes in our daily work and makes you realize that regardless of the types of patients you encounter, they're still asking for help; they're still human. His articles provide an "attitude adjustment," if you will, for providers who have forgotten that the patients we encounter have names, emotions, and lives that are usually bigger than the reason you were called.

I keep my copy of People Care close by and sometimes, when I'm feeling off, will take a few minutes to re-read a chapter or two. It will put me back into the proper frame of mind so I can head off to take care of the next patient and give them the best care I can give. I look forward to opening my mailbox and finding a magazine that has an article, anxious to read the next words of wisdom from Thom.

I hope that you will be fortunate enough to find someone to inspire your care the way Thom has inspired mine. He's a rare gem among us, and we're lucky to have this guiding light providing words of wisdom to make us all better. Thank you, Thom Dick!

Public Perception

If it's not one thing, it's another. This week, news broke of a second FDNY social media controversy, this time an EMT Lieutenant who's Twitter handle was "Bad Lieutenant." When confronted by the media about controversial tweets, the Lieutenant broke down, stating "my life is ruined." You can read more about the story here. This follows last week's news of the son of an FDNY Commissioner who resigned after racial, anti-Semitic messages were revealed on his Twitter account; more about that story here.

When I first became involved in public safety many years ago, one of the first pieces of information I learned was that my actions are representative of not only me, but also my organization and my profession. If this is indeed the case, we're all in a lot of trouble, and not just because of the few instances mentioned above. Over the past few years, investigations have been started over molestation in the back of ambulances, drug diversion, certification scams, service delays...the list goes on and on.

We work in a profession where we are always in the public eye, on duty or off. We live in a world where we are connected to the world nearly every second of the day. We have access to social media accounts such as Facebook and Twitter where we sound off on everything from the joys of life to our deepest held beliefs. With the privacy policies of these sites changing frequently, it's often difficult to keep anything truly "private" anymore.

We, as a profession, need to start policing ourselves better. We are expected to provide services regardless of race, ethnicity, origin, religion, sexual orientation, gender, etc. We are held responsible for the safety and well-being of those within our care, and should treat everyone we encounter with respect.

Are there are abuses within the system we operate in? Yup. Are they going to be fixed anytime soon? Nope. Is it fair to heap scorn on a particular "class" based upon the actions of a few? Absolutely not.

"Keep Calm, Carry On"

Surely you're seen various evolutions of the British propaganda slogan, "Keep Calm Carry On." I recently found myself using this phrase after receiving disappointing news on a job opportunity. I realized that repeating this when feeling down  seemed to lift my spirits. You see, I realized that no matter what happens in my personal or professional life, nothing is worth getting overly worked up about, and that sometimes being stopped cold gives us a chance to re-think our approach and outlook on opportunities.

I truly believe that everything happens for a reason. After initially feeling frustrated over the news, I took some time to  evaluate where I went wrong. What happened next seemed unfathomable: I began thinking that sometimes we need doors closed in our faces. We often see the "closed door" as a sign of failure, but maybe we should see it as a sign of success.

This sounds like an odd concept, but think of it this way: did you ever consider that your success in a certain niche is vital to the organization? Have you stopped to consider that maybe you are valued more in your current role than you would be in a larger role? While people are certainly replaceable, sometimes the knowledge, dedication, and work ethic are not. Sometimes, in order to keep moving forward you have to maintain your pace while others sprint past.

Where am I going with this? During my introspection, I found that I have found the most success in an area others seek to avoid. I've re-evaluated my definition of "success" and found that while one door closed, the windows are open and I'm enjoying the view.

Keep calm, carry on.

Loss

Over the past several months, there has been much ado over the loss of life in emergency services. Tragically, in December, two firefighters in a neighboring district were fatally wounded and two others sustained serious injuries in an ambush (read my original blog post on this topic here). But not every loss is directly associated with line-of-duty emergency service activities.

A month ago today, some former colleagues woke to hear one of their own had died suddenly the previous night. He was in his 20s. This loss affected me as well, as I had the privilege of calling him one of my employees for some time. Due to weather and work, I wasn't able to pay my respects to this great young man, and I'm disappointed that I wasn't able to say goodbye. Thankfully, I still have memories to remind me of the time we shared together.

As emergency services providers, we are faced with loss on a regular basis. Despite what we find, we are expected to remain calm, composed, and professional at all times. But how long can you honestly hold all of that sadness inside? There are too many times where we bottle up our emotions, saddle up and take off on the next run. In reality, you need to have a healthy outlet for your emotions, a coping mechanism to activate when the dam's ready to burst.

As professionals, we need to be able to support each other in times of need. What you may consider a tough call may not be viewed the same by others and vice versa. We need to look out for each other, asking "hey, are you okay?" when it looks like someone's feeling lost. Taking someone aside, out of the public eye, and giving them a chance to talk quietly, vent, cry, whatever they need to do, is something we can all do for each other. Telling others to "suck it up, it's part of the job" isn't appropriate. As many wise men have said before, the day you stop caring is the day it's time to find a new job.

What's my point for all this? It's simple: understand that personal loss is an everyday part of our calling. Often we're called to respond to the loss, sometimes it affects us directly. Your ability to keep a healthy outlook and cope with it is what marks you as a true professional.

Until next time, stay safe and look out for each other.

Moral Obligations

In the news yesterday was a story of a "retirement facility" nurse in Bakersfield, CA who refused to perform CPR on a resident (911 Recording Details Calif. Dispatcher's Struggle). Reading this article, I felt the frustration of a Dispatcher who was doing everything they could to urge someone to provide potentially life-saving care. I sympathize with the Dispatcher, because I too was in a similar position.

As a certified Emergency Medical Dispatcher, I am permitted to instruct callers on performing certain pre-arrival instructions for instances such as life-threatening bleeding, childbirth, choking, and cardiac arrest. I've unfortunately been on the receiving end of a similar call with a patient who was reportedly choking, not moving any air, and the caller was vehemently refusing to provide any care. The reason for the refusal? "We're looking to see if there's a DNR on file." I about lost it, informing the caller that a Do Not Resuscitate order is not a "Do Not Treat" order and that choking is not a natural form of death, so the argument was invalid. The caller continued to refuse over my myriad instructions and the end result was as expected. Those emotions came flooding back as I read the headline and subsequent story.

Unfortunately, cases like this are not as uncommon as you may think. Many "retirement communities" have medically-certified staff on location who are not permitted to perform any interventions as a matter of policy, no matter how misguided you may find that policy to be. Lawyers have advised these communities that performing medical interventions is a "significant risk," and therefore the communities establish these rules presumably to protect their staff from liability. However, at which point do we as human beings push policy aside to fulfill what many would call a moral obligation?

As a pre-hospital care provider, I have a duty to act when I'm acting in my professional capacity as an EMT. I also have a duty to act when I'm acting in my professional capacity as a call-taker or Dispatcher. When I'm off-duty and out with family or friends, I no longer have a duty to act, but I do have what I would consider to be a moral obligation to provide assistance to someone in need of care for a life- or limb-threatening situation. Does this mean I stop at every car accident and render aid? No; I don't have the equipment I need to provide care. Does it mean that I would drop and start CPR on a bystander if necessary? Absolutely. I have all the equipment I need to provide several minutes of potentially life-saving care: good, quality chest compressions. Besides, this is a human life we're talking about.

Why can't more people follow their moral compass instead of bowing to corporate pressures of compliance in this type of situation?

Is Your Scene Safe?

The holidays are supposed to be a time of family, friends, and merriment; unfortunately it’s become a time of sorrow. While we were still getting over the horror committed in a Connecticut school, a nightmare unfolded in my own backyard. For some of our colleagues, this struck much too close to home; the rest of us still shake our heads and think, “That could have been me.” And we’re right; it could have been any one of us.

Violence against EMS providers and firefighters is on the rise, and we have to take notice. This latest atrocity was straight out of a domestic terrorism playbook: start a response for a legitimate cause then create a secondary incident. As EMS providers, we’ve had the mantra of BSI and scene safety drilled into our heads since our original certification classes. But in reality, how many of us actually take the time to consider how “safe” our scene really is? Can we ever, truly, consider a scene to be “safe?”

Think about the homes you’ve been inside in just the past month. Did anything raise the hair on the back of your neck? Did anyone in the home, not necessarily the patient, become angry, start pacing, or appear threatening? Did the kitchen have utensils in the drawer?

I know that last one seems silly, but think about it: there’s easy access to weapons in the kitchen. When I was a law enforcement Explorer, one of the Deputies I was assigned to told me “anyone who says there’s no weapons in their house is either lying or they don’t have a kitchen.” I’ve never forgotten that piece of advice, nearly 20 years later. I’m always wary of scenes that take place in a kitchen, especially those with patients who are experiencing emotional or behavioral emergencies.

Years later, I was instructed in the concept of situational awareness during FAR part 135 training for an air medical program. Obviously, the particulars of situational awareness in that type of environment are much different than those in a ground EMS program, but the reasons for it are the same: the loss of situational awareness creates an exponentially greater risk to those involved. It is my belief that we have become so comfortable with the mantra of “BSI on, scene is safe” that we fail to look at the bigger picture and understand any real threats that exist. This is where we, as EMS providers, must spend some quality time in training, as soon as possible.

Before anyone gets the wrong idea, by no means do I think the Christmas Eve tragedy could have been prevented through better situational awareness. In fact, I believe the fire service is ahead of EMS by leaps and bounds in this area. Why? Because they’re trained to go into situations we stay out of. Working fires, vehicle rollovers, low-level HazMat incidents, you name it: they have the knowledge and resources to properly handle these situations. When fire apparatus roll up on house fires, they typically roll past the scene to get a better picture of the overall situation. Why? Their work is inherently dangerous, and they want to gain situational awareness as early as possible.

What do EMS providers do? We stage for law enforcement for clearance into scenes with the possibility of violence. But remember, the information disseminated from Dispatch is only as good as the information provided TO the call taker. How often is the information provided to you close to the situation you encounter? Do you ever suspect the person with the “head injury from falling down the stairs” to be a victim of domestic violence? Do you treat unattended death scenes as potential crime scenes? How about the “altered mental status” patient who is really experiencing an emotional or behavioral emergency? If you do, good for you; if you don’t, you should. You don’t need to be paranoid, but you should never let your guard down.

Agency leadership, training officers, and senior personnel need to set the example and promote the concept of situational awareness among EMS providers. We need to completely re-think how we assess scenes from the cab, how we approach scenes on foot, be aware of entrances, exits, and people in the home. That’s another tidbit I learned during my instructor internship: asking “are you the only one here, or is someone here with you.” It’s a nasty surprise to find another family member, neighbor, or someone else standing behind you while you’re working a patient in their home, especially when you surmise he or she is alone.

So how do we do it? Immediately, concisely, and thoroughly. Start integrating safety briefings into shift changes, having personnel choose from a variety of topics, then working their way through the handling of a particular situation. A topic that’s been hot in local circles here is emergency radio codes and “trouble” buttons on radios. Integrating personal defense classes into regular training periods so that personnel have a basic understanding of how to mitigate threats from patients who turn against them. Even “verbal judo” classes to attempt “talking down” subjects who are deemed to be verbally threatening. This is only the start, and I’m sure that there are many out there who can add to this list.

We as EMS providers take a risk by the very nature of what we do. We exist specifically to take care of the sick and injured, thereby exposing ourselves to the very cause of our patients’ illnesses or injuries. We transport those who are considered threats to themselves or others. We work in weather extremes, are exposed to emotionally charged situations on a daily basis, and ride unrestrained in the back of our vehicles as they barrel down the road.

When are we, as EMS providers, going to start truly taking the steps to mitigate the risks we face? Though we can never truly consider every possibility, as has been tragically pointed out, we need to start somewhere. The time for talking about our safety is over; the time for action is now. Will you be courageous enough to take a stand on safety?