A trend has spread through EMS that is causing a bit of a ruffling of panties in my neck of the woods. If the term ruffling of panties is upsetting to you relax, it’s accurate.

I hear a lot of “We got a late call” both in the yard and online as a reason folks dislike their shifts. Every shift seems to claim they are always held over because of a late call, that the next shift never has to hold over, it’s not fair, IT’S NOT FAIR! Then they jump up and down from foot to foot in a tantrum which causes the bunching panties mentioned earlier.

Complaining in EMS is remarkably easy. We apply anecdotal observations skewed by our own bias and apply it to everyday. Suddenly getting a call 35 minutes before the end of your shift is a late call and being sent to it is an affront to all things holy.

In response to just such a statement recently I was sucked into a common EMS Manager response that had me actually catching my words just before they left my mouth.

“Back in my day…” was how the sentence was going to start, but I was just able to catch it before I lost all credibility.

But then I stopped. It likely looked like a stroke, but the phrase was easy to say, yet lacked the true meaning I wanted to get across.

“You were closest, you got the job. You are assigned to the ambulance until 0300, not until 0230.” I went on to describe methods they could use to check the ambulance and plan their off duty chores in the 106 minutes they were on post prior to the “late call.”

I then told a war story about the call at 825, 25 minutes AFTER my sift was over and when I had been ordered by the Battalion Chief that I was not to leave my post until relieved. That the call ended up being a transport to Saint Farthest and that I didn’t return to the firehouse until close to 10 AM. They were unimpressed and still held on to the belief that they should get some wiggle room at the end of the shift to “wind down and restock.”

The film version of me delivers the speech far better than I do but the point gets across that we are on duty to answer calls for service and make bad days better. Sometimes that means we’re a little late getting home.

Sometimes we have to spend a few extra minutes doing this work that we have chosen, taking the time to do it right instead of half assing it just to race back and disappear, upset that we asked you for a little something extra. Especially when we’re paying you extra to do it.

A late call is a call that comes in AFTER your shift has ended folks, plain and simple. if you are due off duty at 0300 and dispatch gives you a code 3 call guess what? You have another chance to do something for someone who might need it. Be thankful it’s not the other way around.

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?

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

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.

I have always hated 2 terms in EMS but until I can get everyone to agree on just calling us “Paramedics” and assigning skills and licensing on a National level, I’m kind of stuck.

At a recent class a colleague mentioned how he hated the term “EMT-Basic” because it sounded too much like “EMT-Minimum.”  This is the absolute minimum set of skills we think you need to be able to identify a life threatening emergency, intervene as indicated and arrange for a more educated assessment and treatment.

Another term that always dig sunder my skin is when we slap the word “Advanced” on the side of our ambulances.  Advanced compared to what?  To the basic?  To the minimum?  Current Paramedics are the advanced version of the minimum required.  Well, 3 is more advanced than 2, but it will never be a 10.

So how do we achieve the pinnacle of Professionalism with these outdated inaccurate terms chained to our ankles?

How is it that someone can be content with a certificate or license that uses the term basic?

Imagine you have a plumbing problem in your home and call the plumber.  The person arrives identifies themselves as a Plumber-Basic.  Perhaps they are trained and experienced to handle the problem, but what is our confidence level in that person?  Low, right?  Now what if he arrives and says “I’m an advanced plumber”?  We feel better, sure, but what if he simply arrived and said, “I’m a plumber, what’s the trouble?”

As an EMT-Basic I hated having to rely on someone else to come help me with my patients, yet I refuse to seek out additional education above the level of Paramedic because I like where I am.  I get that not everyone wants to raise to the next level, I’m one of those folks, but I wonder if we’re setting ourselves up for most of the problems we’re experiencing.

EMT-Minimum and EMT-More than Minimum.

We need to get one name and stick with it guys, or this stratification will never end.  Paramedic – Level 1?

But Level 1 is basic, no?  Meets only the minimum.

How about EMT and Paramedic for now and we’ll work on the details later.  The National Registry introduced the non EMT Paramedic requirements, that’s a good first step.  Can we do the same for EMT-Basic? Just drop the basic part?  Can we at least do that?  I don’t like the term technician, but in looking at the standards for EMT-Basic in this country, the term is accurate.

What do you think?

-HM

I finally took some trusted advice and put in for an EMS Quality Management class here at the National Fire Academy in Emmitsburg, MD.  Well, it’s not A class, it’s THE class.

And I am loving it.

The different levels of experience and system types in the room lend for a giant melting pot of ideas.  Folks are actively sharing, borrowing and down right stealing ideas.

Sound like anything we’ve been striving for?

There are a few anchors in my class though.  Not the anchors that drag EMS down, but the anchors that recently realized they were doing so and are working hard to reverse the damage they have done.  There are young bucks like me, middle managers from the deep south and more than a few Chiefs from the northeast.

I’m referred to as the guy from the Wrong Coast.

Cool by me I suppose.

The lessons I’m learning here directly relate to my current (part of anyway) responsibilities at the CQI office and I am absorbing as much as I can.  And not a single clinical scenario to be seen.  There is something refreshing about an EMS class that, whenever patient care differences arise, we are reminded “That’s later” in this particular process.

This class is all about managing the quality of the system, looking ahead to spot trouble before it happens and realizing that if there is a problem, it is useless blaming the employee.

Yes, it is the system to blame.  The system that let them skate by, let their skills falter, let them hit the streets knowing full well they were ill prepared for what was coming.  All we did was wait too long to do something about it.  “No, Justin, Medic Bob is an idiot.”  Then what are we for letting him still touch patients?

This class is all about designing the processes to do just that, intervene as soon as an issue arises and solve the problem starting with the simplest solution, not necessarily something that has been done before.  A new breed of instructor lives at this level of EMS Admin instruction, one that looks for solutions not in intubation success rates and response times, but quality of a system as a whole.  A 5 minute response time and 99% first pass intubation rate is useless if your average patient in pain goes too long without relief.

But I heard something today that really made me realize that EMS 2.0 is not coming…it is here.

A student was sharing the fact that they were barely able to attend this class because their Chief was worried they would take the class, learn how to do things right and then leave.  The instructor stopped the class and said, “Tell your Chief he should be more worried that you don’t seek out education…and stay.”

I’ll let that marinate.

…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?

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.

I’ve been going about it all wrong.

Here I was scouring the laws, policies, regulations and statutes looking for a way to get alternate transport vehicles, like vans, SUVs and cars classified as ambulances.

Turns out all levels of regulation are quite clear on what an ambulance (the 9 letters, in case you’re wondering) is.

It starts at the State level defining an ambulance (I’m paraphrasing these) as a vehicle modified to accommodate a stretcher and staffed by 2 people, at least one of them an EMT-1 and that meets all local standards for an ambulance.  So that kicks the details to the local EMS agencies.  I’m OK with that, let the communities decide what specifics they need.  Oh, but there is the 2 person standard and the stretcher part I need to change.

The California Highway Patrol has standards for a vehicle to be LABELED ambulance and allowed to violate certain aspects of the vehicle code by using red lights, siren and blocking the right of way etc.  It requires a forward facing red light, distinctive paint, a cot and 2 people.

Dang it.

Then the County Health Code breaks down an ambulance and a routine medical transport vehicle, both requiring cots and 2 people.  This is looking bad.  So far I have to change a state law, a vehicle code and a County Health Code.

The local EMS Agency is specific on the staffing requirements of a BLS and ALS ambulance, equipment for first response vehicles (do all ALS first response vehicles really need a long spine board?) and are also charged with certifying that all ambulances in the system comply to the standards.

I have a huge uphill battle if I want to start transporting people in something other than a 2 person ambulance.

Or do I?

What is surprisingly lacking in all the statutes I’m reading are 2 things:  The definition of a patient, and a definition of what a patient uses to get to the hospital.

It appears the automatic default is that a patient will go via an ambulance and vehicles carrying those 9 letters are well regulated, and for good reason.  But what about when we let folks refuse transport, then they climb in a car and go to a hospital anyways?  Is that drier violating the state law, vehicle code, County Health Code and local ambulance ordinance? Of course not, silly, it’s not an ambulance.

It’s not an ambulance.

I’ve been going about this all wrong.  A complete 180 is in order.  Instead of trying to wiggle my solution into a decades old understanding of 9 letters, we could simply exist without them.

This theory applies only to my pilot project of course, the 9 lettered certified ambulances are still meeting all local, state and applicable laws, but now imagine being able to call the company taxi and send the person who meets criteria in something not labeled ambulance and they get the care they need.

Won’t someone think about the billers?!

Oh, I forgot to mention 1 little law that does go against my idea: Medicare part B.

Medicare part B is the legislation that looks retroactively and decides if the ambulance was really necessary and reimburses accordingly.  This is the main reason so many systems tell their practitioners not to walk patients to the ambulance like I do.  They’re likely not going to pay you for that trip.

So why are we still making the trip in the most expensive, regulated manner possible?

Because of 9 little letters.

Medicare has strict definitions as to what makes a BLS and ALS ambulance and gives subscribers guidelines as to what is and is not covered for reimbursement, even being as specific as to where you are when we declare you dead.  Another reason some agencies transport all cardiac arrest patients.

Turns out the folks who would meet criteria for a retriage to alternate transport wouldn’t be eligible to have Medicare cover the bill anyways.  So why not arrange for alternate transportation at far less cost?  It’s a cost more likely to be recovered and freeing up the ALS ambulance to find another paying customer patient in need.

I was always told there was a big law somewhere telling us we had to do things a certain way.  And there is, if you want to keep doing things the same way.

There’s still a lot of research required and permissions to get, but the biggest blockade to my desire to introduce alternate transport options is gone.

Just leave out those 9 magic letters.

In one of the opening scenes of the disliked NBC series TRAUMA, the medics responding are wearing their headsets and suddenly begin speaking to the 911 caller.

“Oh, yeah…right…” was my first response too.

But think about it.  Imagine being finally able to put the caller in touch with someone other than the call taker.  What if the Paramedic or EMT responding was able to apply their education and experience to decide how the system will react to this patient.

It might become more efficient.

The call is received, the unit assigned, then the caller transferred to the practitioner assigned to respond.  They begin assembling facts that the little boxes of the priority dispatch and the untrained ears of the call taken can’t identify.

“OK, so you have asthma, but this doesn’t feel like an asthma attack, you just want some albuterol?” There is no code for that other than an asthma attack, but now we can downgrade the call and possibly save a life and time.  Who’s life?  Not the caller’s they’re fine.  But the responders now travelling with traffic reduces the risk of accident.  The call that may come in with CPR in progress can be triaged ahead now that we have a more accurate idea of what’s happening at the first call.

We’ve spent so much time designing systems to categorize, prioritize and automate dispatches we forgot to upgrade the callers and the call takers.  Instead of staffing dispatch with practitioners, why not just let me talk to the patient you’re about to hang up on anyway to meet your target time.

I can begin to establish if that little code even matches what’s going on, gage my response based on what the caller is telling me and save time in patient care for being ready for exactly what’s going on.

OR

We could ditch the codes and just dispatch based on their chief complaint.

I was asked this question by a rather influential law maker recently and my answer surprised me.

Being someone who used to hate the term “First Responder” thinking it dumbed us down, I realized we had to be dumbed down for the general public to grasp what we did day in and day out.  The term is not accurate, but then again, when has the TV and radio ever been given the opportunity to learn why we are so secretive about what we do?  Be it HIPAA or a desire not to owe steaks or ice cream, we avoid the press like the plague, then reprimand them for not knowing what we’re doing.

So there I was, being asked what a “First Responder” was.

“A neighbor coming to another’s aide,” I started, “A father seeing signs of distress in a friend’s child, a teacher noting the early signs of an allergic reaction in a student, a college professor noting a suspicious package, today, we’re all first responders.”

I gulped, thinking I had just sold a generation of actual “responders” down the river, discounting them to be equals with a school teacher who deploys an Ei-pen.

But we’re not, are we?

In a community that looks out for one another, we are not needed.  We are a footnote in the history books of when people used to need emergency care via tiny mobile hospitals.  EMS becomes a truly unneeded service, except for the rare true emergency.  Not unlike the Fire Service has found themselves, all full of budget and not sure what to do with it.  How did they become so successful at putting themselves out of business?

Prevention.

It is my goal to put EMS out of business.  It should be every Paramedic and EMTs goal to do the same.  We may have the occasional emergency, sure, but the day to day BS we deal with needs to go away.

And perhaps if neighbor started helping neighbor, friend started helping friend and we all realized the sweeping epidemics of obesity, diabetes, heart disease and cancer and did something about it maybe, just maybe, we could actually see our call volume start to drop.  See our stress levels start to decline, and see the eventual funeral not for another neighbor, friend or family member, but for EMS as we know it.

Get involved in your own community.  Be a first responder to those you meet by chance, not by dispatch, and become a positive force for change in your own community.

If Uncle John is able to lose weight and exercise, maybe he won’t need Medicare so soon.  If your neighbor recognizes his need for asthma care and to quit smoking, he lives another 20 years to contribute to the community.

We can make a difference in our communities, EMTs or Paramedics or just regular folken.

Get involved, be the force for positive change you’re waiting for.

It doesn’t take a badge, look below it.  It takes heart.

-HM