Building a strong foundation through training

This should go without saying, but the foundation of any premier service provider is a strong initial and continuing education program. Unfortunately, in emergency medical services (at least in my experience) this seems to be forgotten in lieu of getting bodies on the trucks, not wanting to pay for training hours, or giving in to the generalized demeanor that “I don’t need / want to go to training.” As a result, training budgets are slashed and makeshift programs are developed to “prove” that training is indeed occurring. If we intend to fully prove ourselves worthy of a permanent seat the public safety & health care tables, we need to redirect off this path, and soon.

Initial training & orientation

All states require successful completion of a delineated course before awarding certification as an EMS provider. But does this course offer everything one needs to know to be a competent and successful provider? I would argue no, it does not. These courses provide the bare minimum needed to advance into real-world training programs established by ambulance services.

You cannot realistically expect someone who just graduated from EMT school to understand the nuances in symptoms and treat appropriately. Even if you’re working with a relatively small differential diagnosis schematic, it takes experience in actually encountering and treating patients to accurately differentiate patients with vastly similar, yet minutely different, complaints.

Take, for example, a patient presenting with altered mental status, flaccidity, and slurred speech. Unless you get a complete patient history, or in the absence of that find clues to the patient’s daily insulin regimen, the potential for misdiagnosis is significant. Take it from one who’s done it.

Ambulance services need to review their initial training requirements to be sure the EMTs they’re bringing in exhibit core competencies, obtain real-world experience (more than a couple of patients), and are able to demonstrate clear decision making in complicated situations.

Continuing education

This is much more than the annual blood borne pathogens and HAZMAT refresher courses, which in all truthfulness should fall under recurrent education. Continuing education, when applied appropriately, provides a basic review of the topic, then expands upon that foundation to provide a growth in understanding and application in a real-world setting. In my experience, this includes didactic as well as kinesthetic components whenever possible and always when discussing updates to skill application.

The trick to continuing education is to strike a balance between what providers want to know and what they need to know. For example, many providers will chomp at the bit for juicy trauma pictures presented by a local ED physician but won’t budge when presented with an opportunity to discuss how to incorporate better documentation into their practice.

This is where the imagination of an instructor is key: how to draw in the average EMS provider who is knowledgeable and capable of performing their job, but who also could use a boost to his or her application of that knowledge and skill. An instructor needs to be able to make an enticing presentation that delivers the message while simultaneously assuring the provider that his or her time is well spent.

Conclusion

This is just a scrape of the surface when it comes to developing training programs. Future posts will provide additional detail on the successes and opportunities for improvement based upon my past experiences in this field. Stay tuned!

Terrible news

This morning, I received some terrible news: one of my colleagues, a past supervisor, was found in his home. I don't think I need to elaborate further on what that means. It hits too close to home, coming on the heels of an anniversary of another tragedy in our public safety community. I'm still stunned, as I know many feel when a tragedy of this magnitude occurs.

My public safety friends: you are not alone. You are NEVER alone, no matter how dark or desperate you may feel. We all have demons, and this job exposes us to nightmares regularly. We all have our ways of fending off those nightmares, but never, ever, should you feel like you’re the only one who feels the way you do. You may be stoic and strong with the uniform on, but underneath beats a human heart, the same as everyone else.

As your colleagues, we don’t need you to prove your toughness by shrugging off the same emotions we all feel. You prove that toughness every day when you come to work beside us. It takes a strong person to do this work, and to keep doing it in the face of what we see. What makes you even stronger is facing your own humanity and admitting that, even if only once in a while, the everyday things that make up life get to you too.

We need to remove the stigma of weakness attached to admitting you have a heart, and that it hurts sometimes. It needs to happen now, before we lose another. I’m calling a code green: http://www.codegreencampaign.org

Admit it: EMS stresses you out

A recent story in the Tampa Tribune, available here, talks about the "price" first responders pay for the stressors encountered on the job. My comment to my friend who posted it: "The reality of the job stressors in our environment is becoming more evident. I'm seeing more and more of this come out, and its about time. The public needs to understand that when you strip the uniform off, a human being remains." I caught some flak from another EMSer who read my reply and said "You need thicker skin or you'll never last." Let's see: 17 years as an EMT compared to his five..yeah, I think I'll last.

This isn't about developing "thicker skin." I'd like to think that all of us have a limit, a point where being human overcomes the "superhuman" attributes the general public likes to hang on our shoulders. We all wear different uniforms; some wear SCBA, others wear guns, we wear stethoscopes. But inside the uniform is a human being, someone who (hopefully) still retains the ability to feel raw human emotion in response to a an unnatural situation. We face it all the time, and I challenge you to stand up and say you have never, ever, been affected by at least one patient you've encountered over the course of your career. If you haven't been yet, you will be. Just wait and see.

Let's also not forget the other vital individuals in our daily lives who face similar, if not the same, stressors: our dispatchers and call takers. I have the unique opportunity to serve in both roles (field provider and dispatcher) on a regular basis, and I can attest to the genuine emotion felt when you see a job hit the terminal that you just don't want to put out: the Dad who OD'd on heroin while his kids napped. The dump truck rolled over on a car with a mother and infant inside. The child who's not breathing. I've dispatched each of those calls, each with the (somewhat) expected end results, and felt absolutely helpless as crews responded. There was nothing I could physically do to help, and hearing the emptiness in the crews' voices when they cleared the job filled me with a sadness I don't wish upon anyone.

It's part of our job, and something that we are trained to handle as responders; at least from a patient care & transport angle. What we aren't trained to do is harness our emotions, call time out, and take care of ourselves after such a traumatic experience. It's high time we, as providers and leaders of the field, take the reigns and start taking care of our own.

Fitness in EMS

Every once in a while, a trend starts regarding the fitness for duty of EMS providers, including a recent story of a fire department mandating fitness while on duty for their firefighters and paramedics. While I'm not on board with departments mandating fitness while on duty, I am on board with EMS providers needing to be held to a higher standard of physical fitness.

Those of you who know me personally are well aware I'm not a well-chiseled physical specimen. For years I've comprised my diet from the likes of McDonald's, Wendy's, and Burger King, with a few other specialties sprinkled in for bad measure. As a result, I've "suffered" the consequences of high blood pressure, high cholesterol, pre-diabetes, and an expansive waist line. The costs have also included being unable to keep up with my seven year old son or go kayaking with my wife...and much, much more.

In the past, I've been openly asked if I made EMS my career because "you're too fat for the fire service." As much as that statement hurt, part of it is true: I'd never qualify with a fire department. There's no "weigh" I'd make it through the rigors of fire training in full turnout, mask confidence, or maze courses. In fact, I will openly criticize any fire service that accepts morbidly obese members and permits them to participate in active firefighting activities, including pump operators and "exterior only" operations. It's not safe for anyone, least of all the people who are unhealthy.

Being overweight has caused me to question at times whether I can still do this job. All the aches and pains I experience on a daily basis are quite possibly related to 17 years of lifting and moving people...or are they? The continuous exhaustion is ridiculous. The desire to eat nothing but junk is damn near impossible to overcome some days.

Where am I going with this? I can't take the negativity, self-imposed or otherwise, anymore. I can't continue to be hypocritical when talking with patients about their life choices when I obviously haven't made the best decisions. I shouldn't have patients asking me if I'm okay after moving them down the stairs. And I certainly can't keep this up anymore. I'm sick and tired of feeling sick and tired.

Hi, my name's Jon, and I'm a morbidly obese EMT. I'm also a father, a husband, a son, a brother, and a human being that's just trying to live my life as long as I can. I'm making a change, starting today, to be healthier. If you're in a similar situation, better or worse, I encourage you to do the same. This is a big step for me, admitting I have a problem and openly sharing the details. I'll keep you up to date, and see how this all works out...I hope you'll follow me on this journey.

Response Policies, or, Responding Red at 11 pm

Only part of the conversation...

I recently participated in a social media conversation started by a former colleague of mine who openly questioned the response to a working house fire. At issue wasn't the emergent response but the manner of the response. I don't normally engage in these types of conversations, because there is rarely any real resolution achieved. However, seeing as I was an unwilling audience to the cacophony orchestrated that evening, I joined in.

Some background: I live in a "planned community" east of Rochester, NY. Not much happens there at night; traffic is generally non-existent after 10:00 pm except for residents coming home or going to work. I've lived there for nearly 9 years, and it's not a bad place to catch some shuteye without the drone of vehicles all night. 

So imagine my surprise when, at 11:00 pm, I hear what can only be described as a "mayday alert" traveling through the neighborhood. Multiple pieces of apparatus were rolling through to the aforementioned house fire using every audible warning device available on the vehicle: siren, Federal Q, airhorn. Simultaneously, and without relief.

Now, I have absolutely no concern with using sirens at night. In fact, state law requires it when lights are activated. However, situational awareness (and a little common sense) might dictate that the usage of all warning devices is overkill considering the hour, historical traffic pattern, and no reports of persons trapped. Needless to say, my statements to these conditions did nothing to appease the supporters of the local departments. One poster continuously pointed to "thanking" volunteer firefighters, another pointed to V&T law (which I had already agreed with), then provided the "kill:" you weren't there so you don't know if vehicles were failing to yield; maybe they did it on purpose; etc.

Therein lies the rub: as a public safety professional, you are held to a higher standard. If vehicles aren't yielding, back off, don't drive more aggressively. If you're raising the dead on purpose, someone needs to be held accountable. These are not the actions of a professional. If it's attention you're desiring, it's attention you will get, though I doubt it will be positive.

I'm going to add my own theory, something I'll call adrenaline. Adrenaline is a funny thing: it makes us go into Sonic mode ("gotta go fast..."). Unfortunately, those in the business of responding to emergencies need to harness that adrenaline and slow down. Making all the noise in the world and driving like a man possessed isn't going to get you there any faster (or safer).

Department leaders need to start stepping up and reviewing their response policies. This is already happening with the agencies I work with: all BLS responses and many ALS responses are now "green." There's just no data to support the usage of lights and sirens to be a time-saver in all but the most extreme cases of medical severity (think choking, cardiac arrest, or stroke) or distance. Before I get heckled for my lack of knowledge of fire behavior, I get it: fire doubles in size in seconds. But again, unless it's the most extreme cases (such as people trapped), there is zero need to make yourself look foolish to those you ask to support you.

Has it really been five years?

Five years ago today, I experienced what to that point had been the most frightening situation I’d ever encountered. It actually still ranks up there in the top two or three in my mind. At 30 years old, with young family and the bulk of my professional career with the company, I lost my job. No explanation, no “thank you,” just an abrupt “your services are no longer needed,” and out the door. It was a cataclysmic fall from a meteoric rise…and probably the best thing that ever happened to me.

I can’t blame the company. I mean, I could, and I did, for quite a while after my “meeting” that morning. I’d never been dismissed from a company before, and to have it happen without as much as a reason why shook me to my core. After all, I’d done everything that had been asked of me. I took every position asked of me, dealt with the “slimming down” of the management team, took on tasks once handled by three supervisors. To an extent I saw it coming, especially since I was asked to come in on a day I wasn’t scheduled. But regardless of how much I prepared, the result was still shocking.

I spent many hours (okay, years) brooding over this, feeling as if I’d never accomplish anything ever again. Being the personality type that I am, that many of us in EMS are, I needed a reason why. Why, after so many years of success, was I suddenly un employable by the company I’d been at the longest? Why, after doing everything I was asked to do (and more, in my opinion), was I put to the curb? Where did I go wrong? I still don’t have an answer, and I probably never will.

In the end, it was a rude awakening that nothing in life can be taken for granted and that I was way too comfortable in my position. Looking back, I see now that I was ignoring warning signs that probably started almost a year earlier. I was getting subtle messages that things needed to be changed, yet I did nothing to heed those warnings. I’m much more attuned to those little messages now, though sometimes I need to hear them a couple of times before reacting.

I also learned that feeling sorry for yourself for any great length of time isn’t going to change things. It isn’t going to get your job back, and it isn’t going to help you move forward. It’s only going to make you more miserable and restrict you to seeing that which you have achieved, not what you can still accomplish. It took me way too long to learn that lesson, and I probably lost more than one job opportunity due to my state of mind. Since then, I’ve doubled down on my chosen career field, made decisions to pursue certain opportunities while letting others wait. I’ve opened myself to more opportunities, especially ones that are outside my comfort zone. And while I haven’t achieved the rapid successes that I had in the past, the victories are considerably sweeter because I’ve opened myself up to something new.

Are You "Facebook-Proof"?

If you're local in the Rochester area, you've probably heard of the Greece high school teacher who resigned a picture of her using some questionable language in the classroom was posted to Facebook. Regardless of who was right or wrong in this case (there are questions surrounding the intentions of the student, the student's mother, and the teacher), it is yet another glaring example of how the proliferation of smart phones and cell phone cameras can lead to someone's undoing.

The damage isn't limited to just cell phones and Facebook however. You may recall my posting last year of the FDNY EMS Lieutenant who resigned over comments made on his Twitter account. There have also been cases in the media of fire and EMS personnel behaving badly toward those who were seeking to record their actions for whatever reason. Before the claims of "HIPAA violations" are heard echoing across the nation, remember that HIPAA laws do not apply to the actions of every day citizens. Sure, there are personal privacy laws, not to mention social norms and mores that may be at play in the decision of someone to record those who are receiving medical attention. Unfortunately, there are still some who are going to do their best to catch you at your worst.

We, as a profession, must work our way to becoming "Facebook-proof." What exactly does this mean? Situational awareness is one phrase that comes to mind. Unlike many others, we work on a very public stage at times. Being wary of those around you should come as second nature, especially when it comes to the safety of you, your partner, and your patient. If you happen to look up and see someone recording, catch your tongue and your thought process before going off like a firework. Calmly explain that the patient deserves privacy and respectfully request the individual stop recording the scene. If they refuse, drop it, expedite your packaging and move the patient to your vehicle. If the individual is truly recording you, and chooses to make the tape public, your behavior (if they choose to show it) will show you as recognizing the situation, attempting to address it, then taking action to protect the patient. I would also suggest that you write an addendum or report to be filed with your supervisor attesting to the events should anything be posted later.

Demonstrating competency is something else altogether. Though we all would like to think that we do the right thing every time, there are times that we deviate from "standard practice," sometimes due to unforeseen circumstances...sometimes for other reasons altogether. If you catch yourself taking liberty with standard care for the latter, stop, gather your thought process, and do it the proper way. If you absolutely must deviate, explain what you're doing and why to the patient, then document it appropriately. If someone is present and recording, again this information will be captured. Remember that Hollywood has some very different ideas of what EMTs do, and public perception is often based upon what they see on TV, not in real life.

Last, but certainly not least: don't let Facebook tell your life. Choose your "friends" carefully, secure your page, and share wisely. You may think the photo of your buddy being passed out drunk in the front yard is humorous, but he may not. In today's connected world, all it takes is one misstep to bring someone else's world crashing down.