Category Archives: Command & Leadership

Pass your passwords forward please

At last year’s How to Become a Firefighter Workshop here in Northern (some will argue Central, long story) California, I presented on technology in the job hunt, focusing specifically on the pitfalls of social media.  It is a fantastic all day seminar held at the Las Positas Fire College and includes lunch cooked by the students.  The cost of the seminar? $12. Including lunch and a chance to speak to the people hiring you one on one, let them preview your resume etc.  Where was this when I was getting hired?

The seminar attracts Battalion Chiefs, Division Chiefs, Officers from a number of large metropolitan departments and someone you know who writes a blog.  Our pals Judon Cherry, Chris Eldridge, Sam Bradley and Thaddeus Setla helped film the video for the program and this year Judon and the Dridge were there again.  Oh, and I have nothing to do with the kick ass indexed screen shot BTW.  have a look:

[yframe url='http://www.youtube.com/watch?v=lLltS4TQfIE']

The attendees had some great questions about facebook, twitter, email a whole host of issues, but one comment from the audience stood out and has caught traction recently.

In my presentation I mention that some employers are asking that you friend their HR director on facebook prior to the interview.  When I mentioned that the Chiefs you’re speaking with may want to friend you as well, one of them spoke up from the audience,

“I don’t want to be your friend, I want your password.”

The audience was silent.

If you were one of the final applicants being considered for this job, would you give a prospective employer, or anyone for that matter, your facebook password?

It could be considered an invasion of privacy, but I can’t think of a better way to see what someone does when they think no one is watching.  And with the way that an employee can ruin a department’s reputation with the simple click of “share” I think it is reasonable to ask for it.

So this year, when I gave the presentation, we discussed the privacy settings pages and how to eliminate tags in photos perhaps you wish others had not uploaded, comments on posts that maybe you made late at night after drinking studying, or perhaps something rather inflamatory, deragatory, racist, sexist, heterophobic…you get the idea.

It’s actually a good idea for everyone to visit those pages every few months just to check and see what you look like from the inside of social media.  We make comments to one circle of friends the other circles may find offensive, but is any of that going to be considered immature, dishonest or a misrepresentation of who we really are?  It matters greatly if the three key traits an emploer is looking for are maturity, honesty and trust.

What do you think?

If you got called up for your dream job in the fire service and they asked for your password, what would you do?

Standby to copy code 3 traffic

I recently had the opportunity to attend a great seminar at the local trauma center.  Monthly, the trauma docs get all the trauma residents together to talk through a case from the previous month.  It sounds pretty dry until you realize how they present the case.

It starts with the Doctor playing the initial radio report recording.  Then he looks to his residents and asks “So, what positions are you assigning, who do you page, what are your chief concerns?”

I always knew the thousands of people in the trauma room when we arrive are important, but I never thought through that there was one person in charge of that room that asked them all to be there based on my report.  It makes perfect sense in retrospect.

In this particular case our medic made a near textbook MVIT truama radio report and had an ETA of 8-10 minutes.  A lot can happen in 8-10 minutes.

The Doctors discussed different concerns for maybe 5 minutes, then they went to the video.

In the corner of all the trauma rooms are cameras.  I always thought they were security cameras, but how great to be able to critique in real time referring to video!  The room is packed with gowns and masks, all awaiting the patient and the Doc stopped the video again.  “Who is missing?” He asked and the residents began to identify all the persons and departments in the room.  No one was missing.  Trick question, but I was impressed that everyone knew everyone else by sight.  a good sign of a team that works well together.

The video started back up and here comes the moment of truth for me, the CQI guy sitting on the side of the room:  The medics have arrived.

His tone was clear and even and he began his report with “Hello everyone this is Erma…”  My favorite way to start a report.  Put the team at ease and calmly describe your findings.  He went on to multi-task, describing the patient’s mechanism, vitals, his interventions and treatments, as well as his reassessment after the interventions.  As the patient was transferred and the swarm of gowns came in, the video stopped again and I was beaming with pride.  I know because the person next to me asked “How come all the reports aren’t like that?”

The Doc went on the quiz the residents about what their first assessments should be and he finished that discussion with “What else do you want to know before EMS leaves the room?”  his laser pointer now shows my guy standing in the doorway out of the way and removing his gloves.  They had nothing more to ask, he had covered it all. 22 seconds.  22 seconds was the length of his in person trauma report.  As the video picked back up he states over the heads of the crowd “you have access left AC 16g TKO on transfer and we put her back on the NRB at 15, I’ll be outside.”

I wanted to do the slow clap until I realized that this should be happening each and every time and, judging by the reaction of the room, it doesn’t.

 

The seminar continued to show the entire time this patient was in the trauma room, including the chest X-ray (then we all looked at it on the big screen), the abdominal and chest ultrasounds (interpreted by the residents) and even to the results of the CT.

 

Near the end of the discussion the presenter asked why no one was so quick to intervene on what they were finding.  Their answer?

 

“EMS is calm, we can take our time and see things through.  When the patients are bad these guys start to sweat.  This guy is calm.”

 

Awesome.

Patient kidnapping – The cowtipping of EMS

Kidnapping!

I’ve been sitting on this post for months and recent discussions on the facebook and around the interwebs are leading me to revisit it.

 

In an old You Make the Call we discussed when to take people to a  certain medical facility versus another and, sure enough, the topic of kidnapping came up.

It was reinforced in a (not so) recent story out of Florida about a man who claims to have been transported against his will.

 

Much in the same way Country kids sell the legend of cow tipping to City kids, I believe kidnapping of patients is an urban legend perpetuated by EMS managers and Chiefs alike to keep us from making waves and doing the right thing.  They need transport dollars to survive and taking people to their hospital of choice is an easier bill than not.

Are you confused with the definition, both of the word and the action?

 

kidnapping n. the taking of a person against his/her will (or from the control of a parent or guardian) from one place to another under circumstances in which the person so taken does not have freedom of movement, will, or decision through violence, force, threat or intimidation. Although it is not necessary that the purpose be criminal (since all kidnapping is a criminal felony) the capture usually involves some related criminal act such as holding the person for ransom, sexual and/or sadistic abuse, or rape. It includes taking due to irresistible impulse and a parent taking and hiding a child in violation of court order. An included crime is false imprisonment. Any harm to the victim coupled with kidnapping can raise the degree of felony for the injury and can result in a capital (death penalty) offense in some states, even though the victim survives. Originally it meant the stealing of children, since “kid” is child in Scandinavian languages, but now applies to adults as well.

Gerald N. Hill and Kathleen T. Hill.

Hmmm…

Taking someone to a hospital where they will receive medical care is not kidnapping as far as I can tell.  I’ve been looking at many different definitions of kidnapping over the week and keep coming back to the same definitions at heart.

If you do it for the right reasons, how can it be the wrong thing to do?

If you are doing it to get back to dinner, get off duty on time, or because your manager tells you to, THEN we have an issue since your position of authority could be interpreted as intimidation, but taking someone having an MI to a proper facility instead of local band aid ER is not kidnapping as far as I can find.

This discussion started when we discussed a patient who did not want to be taken to the appropriate medical facility for his presentation.  The discussion that followed revolved around him being “alert and oriented” “not intoxicated” and “I’m not going to kidnap him.”

In that situation YOU AREN’T!

You may do some research and find a term called “simple kidnapping” which appears to cover a slew of false imprisonments, holding without permission, and similar crimes, but in no definition do I find an example of a kidnapping being taking someone to the hospital.

Keep in mind your jurisdiction may have their own definition and you need to be familiar with it, but let me extend this one hypothetical step further.  If a person claims they need a transport and take me against my will, since I don’t think they need to go, is THAT kidnapping?  I’m being forced to go somewhere by fraud and could suffer harm as a result.

That more closely fits the definition of kidnap than taking a person to an appropriate medical facility, conscious & alert or not.

 

We are told not to disobey the patient and do what they say, take them where they want, and 95% of the time that works out just fine.  Your stomach hurts?  Sure we can goto St Farthest.  Your leg itches again? Kaiser patient, not a problem.  Trauma patient wants to goto St Farthest?  Aren’t we supposed to be patient advocates and do everything we can for them?

Isn’t EMS supposed to be patient centric?  So why aren’t we teaching EMTs and Paramedics what the definition of kidnap really is?  Probably the same reason we avoid teaching them what liability really means.

There are a lot of problems that will come bubbling to the surface if we started acting in our patients’ best interests and none of them are ours OR theirs.

A common practice in my jurisdiction is the art of hospital shopping.  A person will identify as a member of a hospital they rarely attend because they believe the doctors there to be superior, or that the nurses are prettier, or the other place “kicked me out” but in actuality they are simply trying to get someplace new, or clean, or where lunch is served at 1 and it’s 12:45.

In the pilot episode of Beyond the Lights & Sirens, I had a conversation with a regular named Val.  She presented with chest pain, 10/10, radiating, with history, a mere 10 blocks from an appropriate facility.  Her requested facility, 2 hospitals and 25 minutes away was on saturation divert, or no longer accepting patients by ambulance.  I transported her, per chest pain protocol, to a hospital that was not her requested facility.  No kidnapping charges were filed.

Many of you would argue I kidnapped her.  I moved her from one place to another without her consent using intimidation (My position of authority).  But looking at the situation unfold, I did not kidnap her, but get her to the appropriate facility for her chief complaint, as defined by my Medical Director, County EMSA, State EMSA, Chiefs and Captains.

Don’t default to the stories the Anchors tell you about kidnapping charges being brought against a long lost co-worker for taking Erma to the wrong hospital.  That case likely had a different, more shady reason for leading to termination, not kidnapping.

Perhaps we should spend less time worrying about vague definitions that don’t apply and spend more time in the airway lab?

 

And I hate that I have to remind you of all this, but these words are my opinion and are not those of my employer, a lawyer, an expert, my daughter, the crossing guard or the guy at Sears who stocks the vacuum bags.  Before you act on these words, consult with your local system administrators for the rules and laws applicable in your area.

 

I finally answered the age old question…

…how many Fire Chiefs does it take to turn off a toilet?

3.

 

Doing my usual work up on the third floor of FD HQ, our new Deputy Chief of Operations starts digging through a small tool box near the door to my office.  Not one to let a gold badge do something someone else could do, I offer to help locate the tools he needs.  He’s in a hurry and needs a wrench.  I know where some are.

“Give me those…and come downstairs, we might need you,” he says as he almost runs for the stairs.  My sleeves are rolled up as I exit the second floor stairwell and see a small wave of water exiting the men’s room as the door closes ahead of me where the Deputy just went in.

As I opened the door I learned the answer.

To turn off an overflowing toilet takes 1 Deputy Chief, 1 Assistant Deputy Chief and 1 Division Chief.

Before I could open my mouth to offer help I hear the Division Chief say, “Hey, get out of here, gold badges only.”

Damn executive washroom.

The Ultimate Lifesaver – EMS in the Wall Street Journal

I got a strange voice mail from the Secretary of the Chief of Department asking if I could talk to a reporter about our advancements in cardiac arrest survival.

Um…yes please?

 

Laura Landro from the Wall Street Journal asked the kind of questions I wish more reporters asked.  Not just asking for our survival rate, but the more important question:

“Why is your number improving?”

We discussed continuous chest compressions, training the entire department to AHA standards and ensuring our BLS fleet can anticipate ALS interventions.  We discussed esophogeal airways, CPAP, see through CPR (from ZOLL), end tidal capnography, so many different tools that come together to make a 9% into a 23%.  And that was all before I got my job at HQ.  It’s nice to highlight the work of those who came before including Jeff Myers, Seb Wong, Brett Powell, Pete Howes.

Hopefully this is just the beginning of a conversation with the public about how EMS impacts their daily lives, not just when they, for lack of a better term, drop dead.

 

The Ultimate Lifesaver

 

Report from the Trenches

Only on the front lines can you tell where the bullets are coming from.

 

Everywhere.

 

To say I might be in over my head is an understatement.  To say I thought it would be worse is also an understatement.

This is an entirely different world.  My commute is twice as long as it was 6 months ago when I first tested it, or maybe since it’s an everyday thing now it just seemed half the time before.

I wake at 5 to make the train by 6 so I can do research till 7 and make the office by 8.  Then I have to time my departure to make the train right before the tens of thousands of others exiting the City at closing time.  It’s different than wandering into the fire house after an hour and 20 minute drive.

That’s the only drawback so far.

 

I realized on my first morning of reviewing charts and advanced interventions that I am now responsible for more than my own patients.

To borrow from the meme, “I get ALL the patients!”

Seriously. I am able to act in the best interests of each and every patient this system comes into contact with.  Sometimes that will mean counseling a provider or defending them from an MD unclear on the concepts of EMS.  Other times it will be discovering where we’re not doing enough and finding the evidence to show it, then provide solutions to the command staff.

Some they will embrace, others they will reject.

I am not here to change the world for myself or even EMS, but for each and every person in my City who calls for help.  That is my new goal.  Not a 20 minute intervention, but a 20 week analysis of their experience and outcome.

 

Bring it.

A Whole New World

On a summer day back in 1996 I walked into the trailer at the Isleta EMS and Fire Station and began my paid career helping people.  I have worked a variation of a 24 hour schedule ever since and it has become second nature to be away from my family for long stretches in exchange for a few days in between.

 

That will make Monday all that much more interesting.

 

On Monday I hang up my turnouts and late nights without sleep in exchange for a promotion and a reassignment downtown.  That also means giving up that ever so comfortable and vacation friendly schedule.

 

I was bummed at first until I realized that now the HMjrs are in school and we can’t just pick up and go somewhere whenever we feel like it anymore.  When this job at headquarters opened up it seemed too perfect a fit.

 

Monday I will take over the vacant CQI position that has been retooled ever so slightly to now officially include research.  Talk about a perfect chance to mine the data to see what is really going on out there.  I have lofty goals for my service, but it’s going to be a long while of playing catch up and learning the new job before I can start going forward with new ideas.  I also have a new political landscape to consider and will be in direct contact and communication with the regulatory agencies, budget writers and vendors that all have a stake in patient care in my jurisdiction.

 

It’s an amazing opportunity for me both professionally and personally and I am beyond excited to get started.

 

About the blog…

There will be a slow tapering off of 911 stories, I’ve got quite a few more half written and half anonymized just waiting in the wings, but there will likely be a shift in what I share.  My EMS 2.0 rants may well turn into updates about what I’m dealing with in that little office downtown.  I won’t be changing the name of the blog to Happy Captain (or Happy Cappy as MC suggested) since this is about my therapy, not necessarily an accurate mirror to my own life.

I now join the ranks of Sparrow, Morgan, Crunch and Stubing, to name a few.

 

Thanks for all your supportive messages on FB and Twitter.

 

-Captain HM  ;)

MOI oh MOI!

Rogue Medic is in a great mood as of late and this article about the complete joke that is Mechanism of Injury (MOI) hits the nail on the head.  I recently had to triage a car over a patient because of strict trauma guidelines, luckily finding the always available “Paramedic Judgement” to wiggle my way out of it.

 

The simple point is this: Mechanism needs to be a symbol on a map, not the destination.  With cars designed to crumple around our patients, what if it does take 30 minutes to get them out but they are unharmed?  And the pedestrian clipped by the mirror on the arm by a passing car at 40MPH?  Why are they on a board and in a collar?

 

Because 30 years ago when this Profession was still trying to figure itself out we bought into some crazy ideas, that’s why.  Now that we’re actually starting to study some of these ideas and finding them hurting more patients than they are supposed to help, we need to start revamping a number of our “standards of care” which actually should read “That’s what everyone else does…”

Whenever I have to document damage to a vehicle (mainly for my recollection of the run later on, just in case) I try to use some basic terms that at least remain consistent in my own description of vehicles.  Those are:

Light truck, truck, large truck, coupe, sedan, wagon, van and commercial vehicle.

Then I go and describe the damage using 3 terms, light, moderate and considerable.

Those are mine and can be widely interpreted.  Maybe I’ll get Motorcop to jump in on this but…A coupe hitting a brick wall at 40MPH will look differently than a van that hits another van at 25MPH.  One is a trauma, the other not by protocol, even though one may indeed have carried far more force.

And even if I do mention light damage to the front of the vehicle, what does that mean? What kind of car? What kind of impact? Against what? Did the vehicle’s protection systems discharge properly?  If the driver was able to self extricate and has no chief complaint, why am I chasing him down with a C-Collar? Because the folks who wrote the policy are in a committee long ago and far away.

MOI is important as far as it gives us an idea of POSSIBLE injuries to consider.  I consider it as a part of the Past Medical History and weigh it just as heavily.  If it does not apply to the patient’s presentation it will be considered, but not relied upon.

One rollover will have a 17 year old girl sitting on the curb completely unharmed while a minor damage collision could yield significant injuries to the passengers.  We won’t know until we assess them.

I remember long ago in far off new Mexico, some medics would launch the helicopter just based on dispatch information of the reported damage.  And we’re back to the telephone game of one person’s “Oh my God! They’re trapped!” and another’s “She’s just not getting out, but looks fine.”

Assess.  Use MOI as a tool, not a guide.  We always look inside the passenger compartment for deformity, blood, marks, bent steering column etc, but we should not be basing a transport on the vehicle.

 

Then again, try documenting that you let a driver refuse transport who had moderate damage after a head on collision into a guardrail, deploying front airbags with a non-complete recollection of events.

Now if I tell you they hit the guardrail head on after sideswiping another vehicle at 40MPH and spinning around, coming to rest in the slow lane and is avoiding telling the police they cut across 6 lanes of traffic to make an exit…now can I let them go home?  Or should I be chasing him down with a collar?  We all know the answer to that one.

 

Looking forward to more, Rogue!

Tip of the Helmet – Lady in the Flip Flops

It’s easy to see an accident and keep on walking, but something in some people kicks in to make them want to learn more. At a recent accident we’ve all seen on video by now a motorcyclist collided with a car and, surprisingly, they caught fire.
As random folks come to the car and look inside a woman in flip flops does what EVERY rescuer needs to do at EVERY roadway incident:

She looks under the car.

Seeing the unconscious body of the motorcycle rider she tries to lift the car off of him. Others seem interested and when she confirms again “there’s someone under there” the troops are flocking to the scene to lift the car.

You can give credit to the worker who pulled the rider out of harms way, the cops and their interesting fire attack or even the firefighters and paramedics who magically appear, but the real credit goes to flip flop lady and her desire to answer the burning question she had inside: “Where is the rider?”

From NPR: According to the Salt Lake Tribune, Wright suffered a “broken leg, a shattered pelvis, bruised lungs and burned skin,” when he and his motorcycle collided with a car. But, thankfully, he is “well on his way to recovery, his doctors said.”

 

10 House “Still Standing”

Each year I choose 1 story to share in an effort to keep alive the memory of those who died. Buying a sticker or a T-shirt that says “Never Forget” isn’t enough, heck it’s nothing. Learning about the lives of those who went into that morning not knowing if they would be coming out and sharing their stories with others is the only way to remember and keep them alive in our hearts.
I used to think the ancient Egyptians were foolish for claiming they were going to live forever, yet we still speak their names and honor their traditions in our museums and textbooks. They truly did accomplish living forever and if we want these men to be remembered in the same way we must continue to share their stories and speak their names aloud.
In my search for a story to share about those who died on September 11th, I kept coming back to a number: 10.  10 years, 10 Engine, Ladder 10…10 House…

A firehouse is much like a family and when a member of a family dies it can have an impact on the survivors. But what if more than 1 dies? Or 2. What about 6?

This year I share the memories of 10 House and the day she lost 6 of her children.

 

10 House is the quarters of Engine 10 and Ladder 10 who, in 1984, adopted the logo of a firefighter straddling the tops of the twin towers on fire reading “First due at the big one.” And they were.  Reports from survivors say that even as they rolled out the door there were already bodies in the street.
The firehouse is on Liberty Street directly across the street from the World Trade Center. The house survived the collapse and was re-opened after getting fixed up, but her family is still healing.
Both companies were established in 1865, later moving to the same house.  It is one of the few houses where the engine and ladder companies happen to have the same numbers. For almost 150 years she saw only 3 deaths in the line of duty, on that September morning the number would triple.

Lt. Gregg Arthur Atlas – Aged 44 years, Lieutenant Engine 10

Firefighter Paul Pansini – Father of 3 children, Firefighter Engine 10

Lt. Stephen Gary Harrell – Age 44, Member of 10 House assigned to Battalion 7

Sean Patrick Tallon – 26, Marine Reservist and only weeks away from completing Probationary status on Ladder 10.

Jeffrey James Olsen – Age 31, Firefighter Ladder 10

James J. Corrigan – Retired Captain from 10 House, oversaw Fire and Safety Operation for the WTC complex

 

The house was a gathering point for those wishing to visit the FDNY to offer their condolences.  Like many houses it was covered with patches and shirts from visiting firefighters, letting the members know they were in others’ thoughts.  A beautiful memorial was erected inside dedicated to the 6 members who died and included was a newer plaque honoring the 3 that had fallen between 1867 and 2000.

10 House became the site of a 56 foot bronze relief sculpture donated by Holland & Knight , a Law Office, who lost  employee Glenn J. Winuk, also a volunteer firefighter, when 10 House lost her children.  The relief was dedicated in 2006 and is the only 9/11 related site on my list of things to see when I visit New York later in the month.

I don’t want to see where 10 House lost, I want to see where she lives on.

You can learn more about 10 House on their excellent website.

2009′s memory

2010′s memory