Category Archives: Administration & Leadership

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.

cilais online

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.

Of Blankets and Discipline

A very eye catching story has been circulating for a few days involving everyone’s favorite EMS system to hate, Detroit and a Paramedic who claims to have been reprimanded for giving a blanket to a person who was cold after a fire.

I was waiting to comment until the Detroit EMS Administration commented.  Let’s just say I’m glad I wasn’t holding my breath.

As a Quality Manager I see this differently than most line medics might.  On the surface a medic was doing the right thing giving a blanket to a cold person.  It’s what we do most: Make bad days better.  We all know most of the attaboy letters don’t involve medicine but instead note demeanor and comfort measures.

Seems like a non starter.

However, it seems there were some policies in place, whether you agree with them or not, regarding dispensing agency property.

Take a deep breath…I’m getting to my point.

Most Vice Principles have a list of trouble makers who are just under the disciplinary surface and are watching them like a hawk waiting for a reason, any reason, to bust them on a black and white policy violation.

I don’t know enough of the facts to pass a decision regarding the blanket, but I can tell you that if this was brought to my desk I’d ask how we solved all the other problems to be able to spend time on this.  If there had been a decision to reprimand based on the Rules and Regulations, in my experience, there is more going on than meets the eye.

I wander the halls looking for my borderline crews to screw up on something so I can have a chat with them, sure, but more often I’m wandering looking for any chance to talk with them about how things are going.

This could have been a policy enforcement or the straw that broke the camel’s back.

Let’s just hope the camel doesn’t need a blanket.

A quiet weekend in the City

Some boats in the bay…

America’s World Cup

More boats…
Fleet Week

Air traffic ticks up a smidge…

Blue Angels

Music…

Hardly Strictly Bluegrass

A bit of sport…
Cincinatti Reds at SF Giants MLB Playoff Game

Buffalo Bills at SF 49ers NFL Game

 

Should only triple to population for a few days, all 33,000+ hotel rooms are booked, and I wish my weekend cars luck.

Out of Left Field

Sometimes we forget who we’re up against.

Sometimes the system is indeed rigged against us from the start.

But how can you win if the other party refuses to even play the game?

 

The term “blind sided” was used in a meeting today, much to my surprise.  You could even go so far as to say that I was blind sided by this blind side.

It was a jolt of reality back into my EMS 2.0 world that not all of our enemies lie within.  Some are just skirting along the outside of EMS, providing valuable services, only to pounce on ideas they find threatening.

Only problem is, I don’t see it that way, not sure I ever will.

I’ve had almost a year to figure out this whole politics thing and I still just don’t get it.  I don’t care who had the idea, or who gets credit, I need some things to just happen.

In my role, very few decisions are actually within my control.  I do research and pass the info along.  If it gets rejected, I research more.  I’ve had my preconceptions busted more than a few times, comes with the territory.  But there is this perception that others see my actions as more for me than the system.

I just don’t get it.

 

Some things come from out of left field, but that’s all based on the assumption that what we’re expecting was in left field to begin with.  My surprise came from the bleachers behind left field, caught my on the jaw and knocked me to the floor, blinking, wondering what just happened.  I had a ceiling do that to me once.  Once.

 

I’d love to say “never again!” but when you don’t know what to expect, how can you prepare?

When a complaint is a cry for help

I absolutely LOVE answering the complaint line here at HQ.  Not HMHQ, my real HQ gig.  The complaint line at HMHQ never rings.  :P

 

Many may not want to hear the public rattle on about how we stole tens of thousands of dollars from their wheelchair or lifted a priceless piece of art the last time we were called code 3 for a spoon stuck in the disposal, but I LOVE it.

My pencil jots notes as I listen to the complaint in it’s entirety never once asking for clarification.  I get the entire story out and make sure they say everything they want to say.  90% of their complaint is usually because they want to be heard, not because they have a legitimate complaint.  They want to hear that it’s not cool that they don’t have as much stuff as I do or that spoons fall into my disposal all the time.  The venting is the powerful process here, I should know, right?

 

However, every now and then I get a call from someone unclear on the concept.

 

THE EMERGENCY

Not sure that heading still fits, but we’re almost 4 years into this thing, why change now?  A woman has called me requesting the ambulance crew who transported her 2 days ago be fired.

 

THE ACTION

OK…

Her story goes a little something like this:

The ambulance crew was late, rude and refused to help her.  They didn’t carry her into the ER and refused to give her to a nurse.  The ambulance crew then pointed at her and make remarks that I won’t repeat here.  Her language was colorful and hurried while I made notes and pulled up the chart from that day.

When she was finally finished I assured her I would look into her claims and explained the process.  While I was doing so I returned no records of a her being transported that day.

“Could this have been yesterday?” I ask seeing her name pop up on another day, then another.  In fact the software we use turns grey days blue if a patient is contacted on that day.

 

There are more blue days than grey.

 

I also notice that today is blue so I pull up the chart.

While I’m doing so she continues on that after the rude evil paramedics left she collapsed and had to spend 2 days in ICU.  She then described the pile of bills she is already receiving.

I noted her concerns for the file and asked the only question I needed to ask:

“Were you transported to St Closest today at 10 AM?”

“What? How do you know that? That’s a violation of my privacy!  How dare you access my medical record without my permission!” a brief pause… “Well?”

“Ma’am, if you’ll permit me..” and I restated her clinical concerns and her destination concern, and the claim that she was not delivered to a nurse, all of which is directly connected to her medical record.  And although I had no way of confirming her identity, no PHI was exchanged and clearly she knows most of the fleet and they know her.  As I scan a few of the charts looking for patterns of behavior I find what I’m looking for.

Most of the crews are using her statements in quotes and they match almost to the word:

“Patient states she will file a complaint if not transported to Saint Farthest, Saint Farthest is on divert, patient ambulated away angrily with steady gait.”

 

When I asked if she had been transported to her facility of choice and if the Paramedics had actually been rude to her, she began the back track.  She didn’t really want them fired, maybe just talked to, or even just mention that she was not pleased with the level of service she received.  Then we talked for a good 20 minutes about her medical conditions and her use of 911.  I offered a few contact numbers for local resources and even threw in a few breathing exercises for relaxing after a long day as an urban outdoorswoman.  She thanked me and in the end apologized for taking my time.

“That’s why I’m here, Ma’am.  If my Paramedics ever do anything you don’t like you call me right back, OK?”

 

That was in January.

Today I noticed her name on a chart where she was transported for a chronic condition, but the colorful language was gone.  I had to go back and check the name to be sure.

Her blue squares have decreased significantly since and I’d like to think I had something to do with that.  It wasn’t a rapid response car, or an advanced skill set, it was taking the time to listen and offering support.

 

Try it.

Just because it’s right…

…doesn’t mean you can do it.

We’ve had some confusion around the yard as to just what we’re supposed to be doing when it comes to assessing the car rather than the patient.
We all know to assess the patient, not the car, the patient, not the monitor etc etc.

At a recent training evidence was presented that contradicts our current protocols as set forth by our regulators.
It seems a number of folks took that training to heart and are trying to apply it to the patients they encounter in the field.

Problem is, the treatment, or omission of treatment in this case, is causing trouble for me in the CQI office since I now have to talk to folks about doing the right thing and breaking the rules.

First a note on one of our favorite terms: mechanism.

Motor vehicles today are designed to crumple, absorb energy and disperse it around the passenger compartment. This design allows for a great deal of damage to be incurred prior to the passenger, if properly restrained, is injured. This is the reason that recent CDC wording of field trauma triage criteria specifically mentions intrusion into the passenger compartment. Your protocols and policies likely have a similar clause.
The problem is when the protocols and policies start making assumptions about the possible damage to the car and how it relates to possible damage on the patient, then prescribes treatment based on the car, not the patient.

Rollovers used to be a big deal. If everyone is belted chances are they’re self extricating before you get there and strap their curved spine to a flat board. You know…just in case.

Even more frustrating is when you finally convince the patient that the hospital will take careful care of them in case they have a back and neck injury only to arrive to a triage nurse removing the collar, performing the same assessment you did, then removing the board if your treatment was based only on mechanism.

Even worse is when you convince them to be seen at the trauma center based on damage to their car, only to see them moved to the hallway prior to your chart being completed…no board, no collar.

I asked a few of my crews to think of the worst Paramedic they had ever seen and if they would want that person “clearing” C-spine injury in the field on them. The point set in that most of us can barely get our noses out of the cookbook long enough to do a complete assessment now. Those folks have no future in EMS if I have anything to say about it.

So what to do?

Attend the meetings of the groups that make the rules. Get on the agenda and speak. Bring research, evidence, examples from other systems already doing what you want to do.
You get a lot more attention when you bring in a multiple page presentation on Community Paramedics rather than complaining in the yard that we need more training to be able to do more.

Follow the policies. If they aren’t what your patient needs, lobby to change them. Don’t ignore them in the field or your next patient may suffer when you’re on suspension and that medic you despise has to treat them.

Which is worse?

Summertime in the City – Why does hypothermia have to be therapeutic?

brrrrrrr…

“Coldest winter I ever spent was a summer in San Francisco” – Mark Twain

“Don’t believe everything you read on the internet” – Abraham Lincoln

“Quotes are stupid” – Some idiot

 

Summertime is here and I for one am glad.  Glad that I get into my car in the high 70s and get out in the City somewhere in the high 50s.

At home it’s shorts and flip flops, at work it’s jackets and glad we wear wool pants.  When I return home, however, to temps in the 90s we rethink the wool.

In a recent conversation with a respected hospital administrator the term “therapeutic hypothermia” was tossed around rather freely, as if saying it for the 500th time would win them a set of steak knives.  It seems the powers that be are interested in bringing some active cooling measures to the only recently mostly dead.  This was the result of a series of meetings I somehow never made it to.  Laziness one possibility, apathy another, or I could have been reading charts and yelling at people.

In our discussion of the merits of the term “therapeutic” we wondered if having to mention a treatment is good in the title is a red flag we’ll look back on in the future.

“Try this therapeutic oxygen, it’s amazing, but avoid that passive oxygen, it’s no good.”

Making people cold can apparently help them recover from a cardiac arrest.  I guess some papers have been written and some friends looked at it and agreed so it became the thing to do.  Trouble I have is the recommended window of initiation of treatment.  It seems that if we can get their heart beating on it’s own again, then make them slightly cold within 4 hours and keep them there for 12-24, we can improve their chances of survival.

4 hours.

Our average transport time hovers in the teens and tack on a few minutes to get pulses back…let’s call it 1 hour.

One full hour, 60 minutes from when the heart stops to when we hit the doors of the ED with pulses and a BP.  That leaves 3 hours to initiate CONTROLLED cooling in a CONTROLLED environment.

My conversation with the hospital rep then turned to the process that will be used to monitor the cooling efforts.  Thermometers perhaps?  Maybe, we’ll see.

On a side note, we also have a problem with a little something called passive hypothermia wherein Erma Fishbuscuit drops a few tenths of a degree just by sitting in her drafty bay window, then we carry her out to the rig on a cold chair with a single wool (wool again!) blanket.  Then we have to get her all tucked in and cozy warm.  Makes sense.

But for her the hypothermia is not therapeutic, had she suffered cardiac arrest, then yes, but late for her dialysis, then no.

So what to do?  Hypothermia seems to be the next big thing, but I’m not sure the effects it will have in my system.  Could we get more people leaving the hospital without deficits from cardiac arrest if we focus on the weakest links of the chain of survival?  Bystander CPR, Public Access Defib and ED CPR quality? (See how I threw that in there?)

 

The conversation ended with a desire to see all policies and protocols require footnotes showing the research that supports the contents.  Then we realized half the manual would need to be discarded and laughed.  It wasn’t a triumphant laugh, but more the kind of laugh when you realize your car was stolen.

As Clinical Supervisor I am tasked with ensuring my crews follow established policy and protocol while acting in the best interests of their patients.

But Justin isn’t sure what kind of an impact making the recently deceased shiver will have.  On a cold summer’s day in the City we could probably just leave the blanket off and get good results.