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.

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?

Where's The Common Sense?

New Jersey Governor Chris Christie recently singed a bill into law making it a crime for emergency responders to post photos or videos of crash victims on the Internet without the consent of the family. Violators face penalties of up to 18 months incarceration and fines up to $10,000. While I understand the intention of this legislation, my head screams "where's the common sense!?"

For those of us who began our EMS careers prior to the implementation of "HIPAA," patient privacy was one of the most important topics discussed in EMT classes. The concept of "what happens on a call stays on the call" was well-used and sound advice for the new EMT. I can't remember the number of times I heard this, nor the number of times I have passed it along to new EMTs in training. This is simple common sense, but as we've all heard, common sense isn't so common any more...especially with the explosive growth of the Internet, social networking sites, and web-enabled mobile devices.

Additionally, in the mid-2000s, the Health Insurance Portability and Accountability Act (HIPAA) made it a federal crime to violate a patient's privacy. This legislation introduced the concept of protected health information, better known as PHI, which covers information that identifies or can be used to identify a patient (individually identifiable information). PHI includes health information in any format - paper (written), electronic, or oral; information about the patient's health status or condition; and can include research information and photographs, videotapes, and other images. With this in mind, why was a state statute necessary in New Jersey when a federal statute already existed? All that was necessary was for the patient's family to file a privacy complaint with the responding agency.

Protecting the privacy of patients, whether living or deceased, is one of the highest priorities of an EMS provider, ranking up there with scene safety. However, instead of creating more "feel good" laws, lets all exercise better judgement and common sense. In the rare instances both of these self-policing practices fail, the use of preexisting  statutes to prosecute the offenders should set the example that these lapses in judgement will not be tolerated by those entrusted with patient care.