Category Archives: Administration & Leadership

Paramedics say the Darndest Things

Mutual Aid company Captain Chair Confessions has a new post up that made me laugh, smile, snicker, exhale, then almost cry.

I miss it.

I miss the witty banter between rescuer and patient, between rescuer and pseudo-patient and above all else I miss the banter between rescuer and liar.  Gods I miss that.

I miss the basic interaction of assessment.  I miss Erma Fishbiscuit and her 23 meds prescribed by 24 doctors.  I miss her son Bubba and his drunken insults, the relief on the face of a CHFer on CPAP and the chill you get from hearing the EMT say “I think I feel a pulse you guys” after 35 minutes of CPR.

I miss it.

From my ivory tower at Headquarters I read most of the charts, checking my check boxes that the crews checked all of their check boxes and fielding calls from angry nurses that the crews didn’t check the check boxes.

I turn off the light, close the door and head home, fire up the computer and live vicariously through you all.

Didn’t that used to be the other way around?

The post today seemed like something from 2009, 4 years ago, when I was at the height of my posting, fired up and ready to change the world!  It seems so long ago.

Turns out the world wasn’t in the mood to change.  They never got the memo, so I hand delivered it.

This therapy experiment we’ve been working on together has seen some incredible ups and some devastating downs.  We’ve shared war stories, ideas, concepts and solutions.  We’ve laughed together, mourned together and still cling to this one tiny thing we believe in above all else: EMS.

From PTSD to stress relief, from Chronicles to Seat at the Table, from Baltimore to Houston to Vegas this blog has not only opened doors but kicked them in guns blazing kickin’ ass and takin’ names.  Clinically speaking of course.

And now I wonder what it’s place is anymore.  Most of my frustrations about the system not working come out in written form to Chiefs, Medical Directors and regulators who take them seriously and many are being considered or have already been implemented.  Motorcop and I spar on our weekly video show and I get great satisfaction from that interaction.  I can’t tell even HIPAA cleansed stories because for each one I filter another pops up that fits that description.

Everything that made this forum what I wanted has found another outlet.

 

This forum, this community, you, helped me through a dark time and I came out shiny on the other end.

What’s next?

 

Official Fire Service Ice Cream Rule

To finally dispel the myths, rumors and falsehoods regarding the Fire Service Ice Cream Rule (AKA Steaks, Cigars, etc) I offer the following definitive ruling on the matter:

Official Fire Service Ice Cream Rule:

1.  Purpose

To establish when a Member of a Company owes Ice Cream to the other members of said company.

2.  Scope

This rule applies to all Fire Service personnel, both paid, paid call and volunteer regardless of rank, station or assignment.

3.  Definitions

Company – A unit or similar single resource.  This can be defined as an Engine Company, Station House or Volunteer Post.

Member – Any person in official capacity at the time of the incident in question.

Ice Cream – While an abomination in the eyes of the Lord your God, something with a crap load of ingredients.

4.  Enough with the bullet points!  Onto the rule!

Ice Cream is owed only if a member of a company is portrayed in the media, be it television, print, online or otherwise (social media not affiliated with a media outlet excluded (see rule 8))  portrays the member in activities not associated with the assignment they are recorded at.  Being filmed fighting fire, cutting a car, rendering aid or performing regular assigned tasks on the scene of an emergency response DOES NOT entitle the members of the company to ice cream from the member involved. Also, for rules on double parenthesis, see rule 9.

5.  Who gets Ice Cream

Only other Members of the offending Member’s Company are required to be appeased with the cold Ice Cream goodness.  Depending on Agency or Department, this may include all units assigned to a house or all shifts on that unit.  It DOES NOT apply to other Companies, units, houses or personnel who wander in to mention being “owed” Ice Cream.

6.  Who doesn’t get Ice Cream

Officers above the rank of front line supervisor (Lieutenant/Captain/Sergeant) unless they were at the scene and may have to answer to the activities of the member caught not performing duties relevant to the scene in question.  All other houses, members and companies not assigned to the offending Member’s HOME Company.

7.  Oh yeah, that reminds me, HOME Company

Ice Cream is only owed to a Member’s HOME Company, not the Company where they were assigned when said incident took place.

8.  Social Media not involving media outlet

That doesn’t get Ice Cream but instead a pat on the head for the person trying, because that wreaks of desperation.

9.  Multiple Parenthesis

Nah, looks weird…or like math, which is WAY worse.

 

Show me the Money

Friend of the blog Bill Carey posted on Facebook wondering why so many in EMS think that salary is the one thing holding us back.

Curious, question for EMS folks on FB: It appears, based on comments to various news stories in the past, that the greatest solution to all that ills EMS is greater pay. Respect is restored, working conditions and staffing improve and the general idea of professionalism is better. Fire-based, hospital-based, third service, doesn’t matter, just pay us more and the service will get better.
Really?

No, not really.

The same issues I had when I got the paid gig for $4.35/hr are here at my current gig where medics average $65,000 to start (according to indeed.com).

EMS in general is paid what the market allows and what we are worth.  Keep in mind that EMS does not require a degree and Paramedics can get licensed in as little as 1 year in some places.  If some kid walked into my office and told me he went to school for something for a year my first question would be “When are you going back to finish?”

Pay is a result of our goals, not our goal.

Increasing our education standards and proving our worth to the industry is step number one.  But of course the stumbling block to education is how to pay for it.

If you think the reason you are not treated like a Professional is the size of your paycheck I think I know where your priorities are.  If your first concern is that you don’t have access to enough education I’ll ask where you live and why you’re still there.

There are high paying EMS jobs out there, folks, I’ve had one for 10 years, but you have to be willing to put the effort into it.  No one is going to wander into the station or yard one day and say “You guys are great, here’s a raise.”  Your employer has no incentive to increase your compensation unless they desire a particular set of skills that bring that kind of salary.

EMTs are entry level and their compensation reflects it.

Paramedics have more responsibility and therefore more compensation.

A flight medic has even more responsibility, so more compensation.

A Firefighter/Paramedic has a different skills set, different compensation.

 

You get the salary you’re getting because that’s what you’re worth to your employer.  If you started off at $10 an hour, got your degree, teach on the side, and are still making $10 you need to talk to your employer about the increased value you can bring to the organization.  Maybe you’re in line for a promotion or reassignment with your increased education and experience.

It all comes back to education.  If you learn more, not only can you increase the care you can give to your patients, but you become a more responsible care giver and show your manager that you’re not just in the seat for a thrill, but to make a difference.  Folks like that make less errors, collect less complaints and are more likely to collect extensive billing and demographic information.

That makes you a keeper and worth more to them.  You increased your value.  That is the only way you will increase your compensation.

 

Let’s imagine that I’m wrong and simply snapping our fingers and giving you more money is the solution.

Now you make twice what you did yesterday.  Now what?  Now will you go back to school?  Teach?  Where is the added value we’re paying for?

The patients are the same, your rig is the same, your protocols haven’t changed and you haven’t changed.  There isn’t much we as EMTs and Paramedics can directly control but our own attitude and education are the easiest to improve in a short amount of time.

Just raising your pay won’t improve your attitude or the attitude of your co-workers.  It won’t help your manager see the worker bees from the cling ons and it surely won’t help your patients.

If you think you’re worth more to your organization than you’re being compensated, tell them, and get ready to pack.  The high paying jobs are out there, but you’ll likely be in a busier system and competing against higher education and higher motivated applicants for the extra money.

 

Case in point: me.

When I left my last job I was a Firefighter/Paramedic serving a suburban area working on both the Engine and Ambulance.  I was making just under $10 an hour on a 24 hour schedule.

When I got my degree in EMS and began teaching I knew I could reach out an look around for something better and have a good chance of landing it.

When I got hired in San Francisco as a Firefighter/Paramedic assigned to a 24 hour Ambulance I had tripled my salary.  Tripled.  But the cost of living was double and my old shifts of sleeping most nights turned into 32 run paramedic pinball sessions that I loved, but took their toll.

I moved 800 miles to get that gig and I have the broken down UHaul story to prove it.

You can get a high paying EMS job.  They exist, but you have to work for it.

What are you willing to do to prove your worth to EMS?

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A new kind of intern

For the last two Tuesdays I have had an intern.

I can hear you now, “That silly Happy, he has a desk job, how can he have an intern?”

Well, a local High School has expanded and offered an EMS Intern position.  One of the local Rescue Captains has assisted in designing the program which will give this student an inside look at not just field time, but supervisor time, administration time, radio time and even a few days with the regulators (Remind me to ask her to ask about proof spine boards are a good idea.)

I am proud to announce she was officially bored out of her skull in the CQI office.  What we do can be distilled down to the high school level, but the finer points of QA (stop laughing already) can be lost.

“We apply the rules, regulations, policies and protocols to each chart and determine if variations warrant review, coaching, counseling or reprimand.  And after completing those reviews we analyze the results to determine trends and act on them.”

She was unimpressed (Seriously? Stop laughing.)

So we read a narrative I was reviewing.  It went a little something like this:

“Police activated EMS for man defecating on sidewalk.  Male present alert and oriented, steady gait near pile of human feces.  Male has no chief complaint and has no signs of traumatic injury.  Male states “Just cite me and go away” without slurred speech.  Male does not give consent to treat or to assess vital signs, threatens to pick up and forcibly relocate feces, EMS agrees male may leave area under own power.”

“Why did the cops call if he wasn’t hurt?” She asked.

“We’re working on that, but I expect your generation to get that sorted out for good.”

 

She had a chance to meet the Chief of EMS and talk to him a bit about what it means to be a Paramedic these days and looking forward.  He is of the same mindset as me, that we make bad days better and go home safe to our families who will never know the truth of what we’ve been through.

I told her that the gauge of a good EMS leader is someone who, when asked if they would go back to an ambulance answers “yes” without the slightest of hesitation.  You can be away from the ambulance for only so long I have learned and the farther away, the more you miss it.

 

Next Tuesday is her last day in the Administration track and we’ll stop by the fleet yard and let her observe a World Class System deploy to chaos.

 

Ambulance Facility Must Haves

Many an article looks at ambulance design, Paramedic training, policies and protocols but I’ve been wrestling with a different kind of barrier to quality: The Fleet Yard.

 

More specifically, I was wondering what your must have list is for an ambulance deployment center.

 

Is it indoors, well lit, vending machines, training on site, locker rooms, showers, supply techs, drive through ambulance wash…

Here’s my must haves if I could build a brand new facility:

  • Drive through restocking and shift change
  • Onsite mechanical repair
  • Onsite scheduling, CQI and training
  • Indoor secured fleet and employee parking
  • Vehicle Service Techs for restocking
  • In-unit mobile data gateway repair (after I get them installed that is)
  • Crew lounge
  • Locker rooms with full showers
  • Gym

Let me know what your must haves are, maybe you’re thinking of something I’m not.

 

The hour is late

Recently a close friend asked why we even try.  Why do we try so hard to achieve all the goals we have been chasing?  Who cares?  Isn’t there someone else who can fill in what we’re doing better?

No.

No there isn’t.

If there was something better that could be done, we’d be doing it.

This forum used to be updated every few days, some days even multiple times a day.  My duties have consumed my time, heart and vision.  Previous posts about not being able to change the system have turned into meetings that are changing the system.  For every crazy story I try to tell, I read an actual chart that mirrors my edited version and the tale can’t be told.

We’re on the verge of some major opportunities in my system and that seems to be monopolizing my time.

Go figure.

13 months ago my priorities changed and this therapy experiment has suffered.  It was created for one purpose and one purpose only and that was to serve as a pressure release valve.

Boy did it ever.

But the pressure might be too high this time around.  The troubles aren’t with those in charge of the system, or the system itself, but within myself.  My dreams of an EMS 2.0 world were destroyed by regulators, bureaucrats and the realities of a for profit system only to be rebuilt by a single EMT doing the right thing despite our policies to the contrary.  Our late night discussions in Baltimore, Vegas, Houston and other places all build into a mural of a future for our Profession only to be sidelined by technical issues and personnel conflicts.

We were dreamers.  We looked at a future that was built around quality patient care, not realizing the first question would be “how are you going to pay for all that?”

I checked…the Police Department has yet to post a profit.

It isn’t an uphill battle we in EMS are fighting, it’s an all out war.  There are those who wish to take over, give up, concede, demand even take a seat on the fence and wait to see who wins to declare their allegiances.  We can get frustrated, rant, moan and complain or we can give 100% to the one thing that matters:

 

The patient.

 

My posts may slow, my twitter may stagnate, but only because I have a chance to make a difference for more patients and I’m taking it.

Join me?

 

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Move up or move over

In a recent post I mentioned my service is using CAD data to monitor just how busy the EMS Division is when addressing calls for service.  All of this is gearing up towards a State mandated increase in market share without (so far) an increase in staffing or units available to staff.

 

Knowing how busy you are is crucial in any business, that’s how the supermarket knows how many checkers they should need at 5pm.  Yet you’ve never seen all 24 check stands open have you?  There is a buffer built into most operations, a surge capacity if you will, that anticipates a need for more than the usual compliment of people and supplies.

 

Trying to anticipate that surge is the job of our in house statistician.  Yes, we have one.  She determines the need, designs the staffing models and anticipates surge.  She’s the one who says we need 19 ambulances on Friday night, not 18.  her models are all built on her understanding of how the system reacts to calls for service.

 

She and I have many conversations where I explain EMS systems and she explains stats and we slowly come down to realize we’re using the same word to describe 2 different things.  The wife and I have this problem all the time.

 

We’re both tearing through data looking to find where we can squeeze another 10% of the market share of responses out of an already taxed system.  We’re looking at what we’re calling the logistics gap, or when a rig is staffed but not available for a call because they are getting checked out or returning to base close to the end of shift.

We’re also looking at their posting patterns or lack thereof) to determine if we really are sending the right unit to cover a post.  Maybe we could move someone else and save time, fuel and misery?

We’re also looking at the way we use our non ambulance EMS resources, our engines and Captains to maximize the availability of transport resources.

In a perfect world, my regulator will change one sentence in their policies and I can flex 3 more non emergent transport vehicles already deployed into service.  Change one more sentence and we can better serve the homeless population while simultaneously drastically decreasing ED overcrowding.  I have said before, EMS holds the key to ED overcrowding.  So many solutions are just waiting for the 40 year old rules to change.  But proving that those rules need to be changed has to be supported with data that can be confirmed, recreated, and stamped approved by someone who knows what that means.  I am not that guy.  But I know who is.

 

There is no switch to flip to make it work better, we all know that, but I have a good relationship with the people who do the wiring.  Our dispatch data folks, the Dept data folks, the statistician, everyone has been very receptive when I came in asking for our police designed CAD to spit out EMS metrics.

 

You can sit in the cab and complain and I can sit in an office and complain but until we provide solutions that will work and can be verified, we will continue to stagnate as a profession, content with the status quo because no one is stepping forward to help us.

You are the change your system is looking for.  Get involved or get your bags packed.  I’ve got 18 years left and I’m not taking them sitting down.

Ellerbe may be ahead of his time

DC FEMS Chief Kenneth Ellerbe unveiled a plan for EMS redistribution in the Nation’s Capital and it is getting some nasty comments online and from the local Firefighter’s Union.

I can’t necessarily comment on Ellerbe’s reasoning for his move, since I don’t know what it is, but I can tell you that he’s WAY ahead of his time.  I just think he doesn’t know it yet.

You see, DC FEMS will be down staffing ALS transport units from 0100 to 0700, a time when calls for service are drastically less than the daytime hours.  On the surface, it makes perfect sense.  Cut extra resources when they’re not needed.  If it can be done and still meet the demand for quality ALS transport, great.  If it can be done while still meeting all the guidelines set forth by the local EMS regulatory agencies, great.  (Now our UHU calculations come in handy, don’t they?)

But what happens when your calls for service are ALS?

Ellerbe’s answer is to staff up that ambulance for the transport with one of the 21-25 ALS engine resources and 7 ALS supervisor units.   That also makes sense, until that fire engine is doing something else, like already transporting an ALS patient.  Forget being on a fire or an alarm or rescue, these resources will be BLS as their extra member attends another transport.  now units are scrambling to pick up medics at hospitals or BLS ambulances are out returning medics to their company.

My agency could consider such a move in the future, but it will be doomed for failure because of the high call volume of seemingly ALS calls as defined by the local EMS regulatory agency.  Without decreasing the number of patients, we can’t decrease the number of transports.

If DC FEMS can also flex their ALS Supervisor resources to augment the system of transports, they will also soon run out and someone from the engine will need to return their buggy to the hospital or the BLS unit give them a ride back to their buggy parked back at the scene.  More time will be spent returning units than responding in many cases.

 

Ellerbe’s plan is ahead if it’s time, but as far as I’ve been able to find it will not be as efficient as it needs to be.

Why you ask?

Because it needs to be coupled to a “Respond Not Convey” program, or as we call it on the street, the Paramedic Initiated Refusal.  Refusing transport to certain patients who do not need it is the relief DC FEMS needs to better serve the population.  So long as every stubbed toe and runny nose that wants transport gets it, you will continue to have 4 person ALS engines or ALS supervisors at the scene of incidents waiting for an ambulance.  We call it “Medic to Follow” and it is the number one drain on our system. “But Happy, that’s a BLS run!” Not if they used the magic word “Chest pain” to get triaged faster.  And we all know that NEVER happens…right?

 

With the sudden interest in the Community Paramedic model, many systems will have to address the issue of Respond Not Convey if they want to increase services without increasing resources.  I would love nothing more than to deploy our fleet of ALS supervisors to handle community paramedicine, but we’re dealing with an increase in call volume and market share.  And we have less than HALF the amount of ALS supervisors DC FEMS deploys.

 

Ellerbe’s plan seems like a slap in the face to some, but I see it as a new way of deploying resources.  Thing is, it will work.  That is until a second call comes out.  Then a third, then a fourth and next thing you know Engine 99 is sitting on the curb IFO the clinic awaiting a second engine to respond with a medic so the BLS unit idling at the scene can transport.

 

Just a gentle reminder: These views are my own, not those of the SFFD, the City or any one else, just me.

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How busy are you?

How do you measure an EMS system?

Cardiac arrest survival rates?  Profit? Market share?

 

How can one system accurately compare themselves to another?

I was tasked earlier in the year with a seemingly simple question: “Are we busy? How busy?”

 

Um, yes and um, a lot?

 

Many systems use a measurement of Unit Hour Utilization (UHU), or a numerical value of how much time you spend doing EMS stuff.  This number can then be compared to others since it uses two basic measurements.  Those measurements are Hours Staffed and Time on Task.

Let’s say you’re on Medic 99 for 12 hours. 12 is your denominator, since you spent 12 hours on the rig.  Your time on task is defined slightly differently from place to place, but the standard definition is any time you spend responding to, at the scene of, transporting from or at hospital following a call for service.  This total becomes your numerator.  So let’s just say that on your 12 hour shift you ran 5 calls for a total time of 7.25 hours.  That means 7.25(time on task)/12(hours staffed) is a UHU of .60.  Quite busy indeed.

But I learned very quickly this is not a complete picture of the shift.

You see, you didn’t magically appear in service when you came on duty, you had to get the rig checked and fueled.  Then at the end of your shift you had to return to base and try to get the rig squared away for the next shift.

We refer to this time as the “Logistics Gap” or the amount of time we are paying you to do what should have been done already.  On average this can take 30 minutes at the start and end of a shift.  Now your 12 hour shift feels like an 11 hour shift.  That increases your UHU from 7.25 hours in a 12 hour shift to 7.25 hours in an 11 hour shift, or a .68.

That’s even busier.

But STILL not accurate.

What about all that post moving?

We spent months trying to get our servers to spit out CAD data that tracked post moving, but the language just didn’t understand what we were trying to do.  Adding up all the post moving time gives us an idea of how much time we are paying you to drive around instead of sitting still eating, going to the bathroom, studying, etc.

 

Applying that total, let’s say it’s a whole 60 minutes per shift, brings our UHU to 8.25 (7.25 time on task plus 1 hour post moving)/11 hours (12 hour shift – logistics gap) or .75.

 

From a .6 to a .75 is a HUGE difference!  If you are only tracking your UHU Actual, or the Time on Task/Hours paid, you are not getting an accurate picture of how busy your crews really are.

 

The best part of tracking these 3 values is that you can track them separately and add them up in a simple table.  Now when you introduce a new inventory tracking system that reduces restocking time, the impact can be measured and compared to previous days.  Or if a new software program at dispatch makes post moving less efficient, we can track it and break it down.

 

If your reports can be configured properly you can then measure each rig, each hour, each area of your district to see who is busy and how busy they are compared to others.

 

My agency is in the middle of gearing up for an expansion of market share and trying to figure out how busy we will be at different staffing levels is a breeze.  Just add a few rigs to the mix and rerun the math.

Yup, that’s what I do now.

So, how busy are we? That’s a secret. ;P

Control V

We have become a cut and paste society.  Not just us social media savvy kiddos either, oh no, no.  In a time when the conclusion that shapes your opinion has already been authored, why not just copy and paste it as your own?  Who will notice?

 

Probably me.

 

And not just because I can access all the same resources you can when you did the original search for your opinion, but because I have grown up on this technology and can spot certain abnormalities that many don’t.

Yes, I have these powers.

I can see the difference between MS Word 97 Times New Roman 12pt and MS Word 2003 TNR 12 pt when printed.  It looks the same on the screen and had you cared to standardize your document, maybe it wouldn’t have been so obvious.  How do I know this? I’ve done the same thing before, but caught it in time.  When copying references to cite on a page, most folks copy and paste, resize and move on, not even noticing the font is different.

So what does this tell me about your abilities in the field to which you are professing knowledge?  That I should be highly suspect and investigate ALL aspects of your findings.  And that’s when I get frustrated.  Nay, UnHappy.

There have been few documented cases of me being honsestly UnHappy.

 

Trying to trick me?  Try harder.