30 years is a long time

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30 years ago today a 16 year old, brand new EMT took his first ambulance call in a small town in Northwestern Connecticut. He was pretty excited and loved being involved in EMS.

30 years later he sits in front of this computer typing this post and still loves being involved in EMS. I remember that call quite clearly, the intoxicated driver of a car who stopped to urinate off the side of a bridge and lost his balance and fell 20 feet into the river, floated downstream for a mile or so and then crawled up the bank to the road and sat there for three hours until the paperboy found him in the morning. Completely uninjured aside from a killer hangover we dutifully did what the books told us to do because of the mechanism of injury, board, collar, treat for shock, oxygen, and took him hot to the local community hospital. State of the art for a BLS ambulance 30 years ago.

EMS is different from back then, lots of things have changed, mostly for the better but some for the worse.

For for the better our ability to care for patients at all levels of certification has become much better. We are, in many ways, better educated than we were 30 years ago and many of us have become "thinking" EMTs and Paramedics rather than the a+b=c EMTs and Paramedics we were back then. Our equipment is better, we have greater treatment modalities available to us and technology, provided it is not used as a crutch, can assist our assessments in being more thorough.

The other major change that I have noted is the involvement of EMS professionals in the development of their own profession. Many more EMTs and Paramedics are involved in local, regional, national, and international organizations working to make EMS better and to change things that don't make sense. There is a growing community of EMS professionals who are working hard to better educate all of us, even me, a 30 year dinosaur, and teach us to think and understand not just what our patients complaint is but the process behind that complaint and how we can best treat the patient. We are starting to develop the ability to see the "big picture" and understand what our place is in it. The explosion of blogs, podcasts, newsletters, email mailing lists has made it even easier for us to exchange information and ideas and made the ability to connect with other professionals easier. The idea that I would be able to tap a paramedic from another county, state, or even another country for advice and information is something that didn't happen 30 years ago and while new media has made our community larger in numbers it has also made it easier to communicate.

Unfortunately not everything has gotten better. EMS is still the "red headed stepchild" in most areas, with limited support, limited funding, and limited career options. Even many of our own people tend to view this as a "stepping stone" to a career somewhere else, be it the fire service, law enforcement, other areas of medicine. Looking around I see very few of my colleagues from my younger days still in EMS. Lost of nurses, PAs, fire officers, but very few primarily employed as EMS providers. It's sad and we lose a lot of very good people that way.

Our own attention to safety has not improved much. Oh we have finally drilled our people to think about their own safety more. We are better about scene safety and visibility but we put our people in vehicles that are poorly constructed, unregulated, and generally unfit for the job we are doing. After all, there are no safety standards for the patient compartment of our ambulances, the manufacturers can do whatever they want and it is up to us to decide if we feel safe enough. Our ambulances keep getting bigger and while the larger ambulance chassis survive crashes better they are not any safer in the patient compartment. The modules we mount on the chassis are not designed for the dynamic loads of a collision. We focus on ads from manufacturers showing huge weights placed on top of a stationary module and the like even though that is not the type of force applied to an ambulance in a crash. We allow ourselves to be lulled into a false sense of safety by manufacturers showing off airbag systems in the patient compartments when we know deep inside that they will only protect us minimally since we are most likely not seat belted and because the box itself is not designed to withstand the forces of a collision. The sad fact is that I feel no safer in my modern Type III Road Rescue than I did on the 1976 Grumman van that I did my first call in.

We still spend way too much time running hot to calls and to the hospital with patients that have no life or limb threat too. We know the calls that we go to regularly that rarely, if ever, end up as a transport yet we still respond hot to many of them because someone dialed 911. I have worked for services where a fall in a nursing home would be a cold (no lights or siren) response while a 911 call for a fall would be a hot (lights and siren) response. The only difference was the source of the call. Responding hot to the intoxicated person on the street corner asking the beat cop to get him to detox? Been there. Responding hot to an urgent care for a patient with a cellulitis? Done that. Why? Services that claim that they must run red lights and sirens to the ED at all times when they have a patient in the back? Seen it. I've also seen ambulance crashes that occurred when we did things like this. Some of them even resulted in serious injuries. Why? Because we can? We need to look hard at each and every transport we do and ask ourselves if the few minutes saved were worth the additional risk to the lives of the patients, crew, and the public at large.

All of these things are true but the thing that disappoints me most is the inability of most of us to maintain professional relationships even when things go badly. Think about it, how many times have you had a call go really well and all services involved and all the members of the crew feel good about themselves and the job that they did? OK, now think about the times when things didn't go well. Did everyone involved look at the call and try to figure out what went wrong and how to prevent it from going wrong in the future or did everybody start looking for someone to blame for things going badly? The fact of the matter is when things go well we are happy with each other and when things go badly we turn on each other. This, unfortunately, is one of those places where EMS has gotten worse. In this day and age of decreasing funding, pressure form the fire service to take over third service or commercial EMS contracts, and the like our ability to view things that go badly as an opportunity to better our overall system we find ourselves trying to point the finger at somebody else so that we personally or our service don't take the hit for being the cause of the problem and that being used against us. In short, none of us want to own our mistakes. It's a pity too, because if we spent half the time figuring out what failures led to the mistake that we do finger pointing and posturing we could make sure that it didn't happen again.

I won't see another 30 years in EMS but I do plan on seeing another 20 years. I plan to continue the positive changes and hope that I that my effort can help to reverse some of the negative things. I also hope that everyone reading this will do the same.
As some of you may know I have been recreating my blog from various backup sources and in the process have run across some entries that were more interesting than others. This particular entry was posted for the first time six and a half years ago. It could stand some polish but it was a concept that got brought up in conversation a few days ago. From where I am in my career right now I'm finding this discussion even more relevant than I did when I first wrote it.

Over the past couple of days I have read a number of articles both about EMS and computer science. One of the common themes of them was how to be the "best" at what you do. One of the articles was by Eric Raymond who, among other things, is the author of "The Cathedral and the Bazaar" which is a collection of essays about software and the open source movement.

For the sake of this discussion it is important to understand the difference between a "hacker" and a "cracker". A Hacker is someone who is adept at his chosen field, delights in solving problems, and continually strives to overcome limits of some kind. A Cracker on the other hand, is one who uses his (or her) skill to break the security of a computer system. In a nutshell, Hackers build things, Crackers break them.

Raymond discusses the "Hacker Attitude" in one part of his book. When I read this I found it to resonate with me professionally. Raymond lists the 5 things that outline the Hacker Attitude.

1. The world is full of fascinating problems waiting to be solved.
2. No problem should ever have to be solved twice.
3. Boredom and drudgery are evil.
4. Freedom is good.
5. Attitude is no substitute for competence.

As one who considers himself to be a serious geek and, when time permits, writes computer software for fun and relaxation I can see how these elements are relevant to the classic definition of a hacker. I can also see how they, along with the entire hacker ideal could work in almost any profession. As I was reading this I was in the company of an ambulance crew who, while I believe they meet the minimum standard, has no desire to surpass it.

When I put the 5 elements of the Hacker Attitude into an EMS perspective they fit quite well and seem to point to how one can assure that they will be "the best" in their field.

In EMS the world is always full of fascinating problems waiting to be solved and EMS folks have been doing this since the beginning. Look at some of the tools we use every day. Initially many of them were not designed specifically for what they were being used for and various EMT, paramedic, and yes even as far back as "ambulance driver" hackers saw the problems and had the vision to find new and unique solutions to them. Some of these solutions involved modifying existing tools and some of them involved the building of completely new tools that had never even been thought of before.

In EMS we should never have to solve the same problem twice. We strive for this and in a larger sense we succeed by finding the general principle that solves the problem and inventing numerous ways to implement it. Even in those things that have multiple procedures and/or multiple devices to solve the problem the general principle of each always seems to be the same. It is our own ingenuity that allows us to apply these principles in different ways to meet the needs of different situations.

I don't know a single person in any field who would not agree that boredom and drudgery are evil. Look at our coworkers who we see as having the bad attitudes, the ones who take no pride in their work, the "bad apples". What do they all have in common? They are bored with what they are doing, they feel that they are doing the same thing day in and day out. None of them started out that way. Somewhere, somewhen, someone or something stifled their ability to think on their own, to expand on what they are experiencing and harness that energy and information to continuously think about the problems and come up with new solutions. I'm not saying that "the best" in EMS never complain, rather that if you listen to them they frequently complain and voice possible solutions to their complaint in the same breath. Their enthusiasm lets them look at the problems as a challenge to be met rather than a limitation that forces them into the same path day after day.

Freedom is good. In general the hackers in any field are anti-authoritarian. Not to say that they fight authority, rather to say that they see that authority for authorities sake is appallingly stupid. Anyone who orders you not to continue to solve the problems that you encounter and are fascinated by for the simple reason that they can and it better serves their purpose fits that description. Authoritarians thrive on censorship, secrecy, and the use of force. The hackers among us believe that reasonable adults do not need censorship, secrecy, and the use of deception or force to compel them to excel. They excel because they want to and because they are given the freedom to.

The last element, attitude is no replacement for competency, is so unbelievably simple that it is amazing that so many people fail to comprehend it. Hackers worship competence, it is their holy grail. Attitude alone will not make one good at what they do just like acting like a professional athlete does not make you one. Respecting people for their competence and abilities and striving to move your own level of competence continually higher is actually enjoyable to the hacker. Learning and the acquisition of knowledge is an ongoing process. The hackers in our profession recognize this and this allows them to develop a healthy attitude, one of confidence in their abilities and in their dedication. There is no disdain for those who are less skilled than they are as long as they continue to strive.

We have hackers and crackers in EMS just like every other profession. It is easy to see the difference between the hackers, who are always trying to make themselves better and do a better job, and the crackers who believe that they know all they need to know and are try to do nothing more than, at best, simply meet the minimum standard, and at worst, try to drag those around them with a hacker mind set down their level.

I am sure that we all can point out people we work with who have the hacker attitude or the cracker attitude and we know how being around them effects us. I know that I revel in being around the hackers in my profession. As strange as it may seem, some of the people I consider hackers, are not the best paramedics I have ever worked with. What they have in common with some of the best paramedics I have worked with is the continuous striving to make themselves and their profession better.
I really had no desire to come to work tonight. I spent the morning at the District Courthouse and didn't get to spend much time with my family today which made me unhappy. I arrived at work feeling like I needed to have an easy day and spend my time getting projects to points where they could be shelved for the week while I am on vacation next week.

It wasn't going to happen that way though. I came in to a storm of problems that needed immediate attention. Right away I had to deal with access problems with our computerized PCR. We have an online PCR that is mandated and provided the state and our billing service is able to directly download our data directly into their billing systems. Unfortunately today they found that they were not downloading our data but data from one of the fire departments we respond with. Some investigation on the part of our general manager and the Bureau of EMS showed it to be a problem with the way the billing company's access was originally set up. I spent an hour back and forth between the billing company and the State trying to get the problem resolved.

FedEx then dropped a package in my lap which led to the next couple hours being filled with work. We use cellular phones to transmit 12 lead ECGs to our receiving hospitals to give them a heads up of patients that might need the cath lab to be activated.The system we have in the receiving hospitals is really antiquated. We use cell phones that depend on technology that the FCC has told the cellular companies that they did not need to support beyond January 2008. Here we are 2 1/2 years later still depending on this technology that allows us to dial into the US Robotics 14.4 baud modems at the hospitals to send the 12 leads. The major problems is that cell phones that are able to do this are few and far between and getting fewer as time goes on.

In the past 3 weeks the crews managed to lose one phone and break another. Fortunately for us, even though the phone is no longer manufactured, our rep was able to locate a pair of phones for us and ship them out. I spent a couple of hours activating and configuring the phones and started the process of mating them to the bluetooth modules in our Lifepak 12s. I didn't get to finish so I have at least one task for tomorrow already.

I didn't get to finish the task because I was interrupted by dispatch sending me to intercept with the ambulance in a neighbouring town for a patient with chest pain. The dispatch sounded pretty promising, chest pain radiating to the jaw, back, and arms, nausea, difficulty breathing, sweaty, and grey. I arrived on scene a couple of minutes after the first responder and before the ambulance. The first responder called me on the radio to make sure I was bringing in my monitor, I already had it in hand as well as my ALS bag and drug kit.

When I entered the room I saw a heavy set middle aged man, ashen, sweaty, seated in a chair. He already had oxygen in place and vitals sings were underway. I set the monitor down and started to put the leads on to get a 12 lead ECG. I got the limb leads on just as the patient went unresponsive and stopped breathing. I quickly looked at the monitor while I was opening the defibrillation pads and slapping them on the patients chest. Ventricular fibrillation, I charged the defibrillator, cleared everyone off, and deliver one shock. Right after the shock the two of us grabbed the patient and brought him to the floor and CPR was started. Less than 30 seconds later we stopped CPR, not exactly what the protocols tell us to do but when the patient started talking we decided it was time to stop.

Excellent! We secured the patient to a backboard just to put handles on him and carried him out of the house to the stretcher and off to the ambulance. I did a quick 12 lead ECG and started transmitting it to the ED even before I looked at it. I looked at the 12 lead while I was getting ready to start the line, Sinus with lateral and septal ischemia. During the course of the transport we managed to get one line started, he was a terrible stick, get him some lidocaine (a rhythm stabilizing medication, Zofran (an anti-nausea medication), and another 12 lead that showed the same thing. 

As the crew pulled the stretcher form the back the patient went unresponsive again, more Ventricular Fibrillation, I told the crew to drop the wheels and let go of the stretcher and delivered another shock when they were clear. By the time we hit the ED room the patient was talking again.

The ED doc and the cardiologist were pretty happy with our treatment and the patient was on the way to the cath lab 10 minutes after he came in.

I had mixed feelings about the call, I was exceedingly happy that we had s significant intervention with what looks very promising for a good outcome. I was less than happy with my own performance, I had terrible time with the IV and just felt off balance through the entire call. I can't help but wonder if it is a result of dealing with a call volume probably 10% of what I used to do before I moved. I need to deconstruct the call and see what I needed to do better and work out some ways to remediate myself.

Still, I made a difference tonight and that makes it all worthwhile.

My Day in Court

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Last week I received a visit from the local police department. They came bearing a gift, a subpoena ordering me to appear in court as a witness in a DWI case. It's not that unusual for EMS to end up in court for one call or another to give testimony. This case was a bit different as this was the DWI case for the driver that almost struck me head on back in April. One of the things that I have still yet to get used to here is that you don't get much warning, 1 week is all you get.

As requested I was in court at 0800 to meet with the prosecutor and as expected nothing ran on time. The prosecutor didn't meet with me until well after 0900. We discussed what my testimony was going to be and he informed me that the defense attorneys (yes, plural) wanted to go to trial as soon as possible and that they had eleven witnesses to call.

I returned to the waiting room with my iPad to read a book and wait to be called. A couple hours later I saw the defense attorneys speaking with the prosecutor. One of the defense attorneys pointed in my direction and the prosecutor nodded. The defense attorneys stepped away and whispered to each other and then came back to the prosecutor. They shook hands and the prosecutor came over to me and told me that the defendant was going to plead guilty. He volunteered that the defense attorneys changed their minds when he told them that I was the paramedic that their client almost hit head on. I was free to go.

I had to laugh a little, I never considered myself to be that much of an imposing figure so I can only suspect that whatever they expected me to say in my testimony was going to make their defense of their client difficult. No matter, I'd take it any way it came. Probably a good thing that they were asking about me since the prosecutor had spoken to me a few minutes before to tell me that they may need to ask for a continuance since they had yet to locate the arresting officer.


Recently a paper was published in the journal Prehospital Emergency Care entitled "

Alcohol-Associated Illness and Injury and Ambulance Calls in a Midwestern College Town: A Four-Year Retrospective Analysis.". Some people have already started to criticize this research just on the abstract as being useless, irrelevant to EMS and a waste of time and resources.


Interestingly I am not going to be one of those people. I say this for two reasons. 

First, while I agree that this seems foolish to research and publish this paper I also understand that before we use any data for further research we much have more than anecdotal evidence to work with. Even common sense needs to be verified to protect the integrity of research based on those conclusions. My hope is that is foundational research and the author is going to use the data and conclusions for further research that is relevant and useful.

Second, I work for a regional service in New England that covers a college town and we actually need to perform a study such as this to prove to University administration (who pay a subsidy to support our service) that alcohol is a much bigger problem than their staff epidemiologist is saying. He says 1 in 4 students drink alcohol yet I have data from Halloween last year that had 21 calls in 9 hours and 19 of them were alcohol related. He's using data collected form questionnaires administered by the Health Services Office, my practical data shows something else. Admittedly Halloween may have been aberration but the fact remains that anecdotally our data still does not match with that cited by the epidemiologist even for other, non-holiday shifts.

A study like this can help us prove the extent of the alcohol problem on campus, influence the administration to act on it, and mean that my EMS units are tied up less frequently taking intoxicated students to the ED and are available for other calls. In my mind, improving EMS availability is definitely a worthwhile goal and research that supports that goal may not be as silly as it seems at first glance.

Your milage may vary but from my view this may not be as frivolous as it appears. 

What do you do?

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The Happy Medic poses an interesting question over on his blog today. What do you do when, off duty, you come across someone in uniform drinking in a bar?

It's an interesting question and a bad situation. Here's my response:

That is an interesting question that does not appear to have an answer that is a really good answer. Certainly I would strike up a conversation and try to determine if they were on duty. Drinking on duty is just wrong no matter what the situation. If he was on duty I'd have to tell him that it was wrong and that he shouldn't be here. Contacting his supervisor would probably be in order if I could determine who that was.

Beyond that I guess it depends on how talkative the guy is. I'd try to get some idea of why he was there. Did he have a bad shift and needed to decompress? Could I help even just by listening? I've had those days. I'd certainly consider, as politely as possible, suggesting that he consider taking off the uniform shirt and stethoscope so as not to attract as much attention. I usually have a spare shirt in my car to wear after work if I'm going somewhere besides home, perhaps I'd offer it to him.

If he told me to bugger off I would just go back to my seat, not much else I could do at that point. I would have made a good faith effort to try and help.

I guess my point is that just like Police and Fire we in EMS need to stop eating our young and try to take care of each other a little better.

What would you do?

Research

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I taught at our EMT-Intermediate class last night and while the class itself went very smoothly and I felt that the students got a lot out of it. I was a little disturbed when I spoke to them about EMS Research. We had been talking about CPAP, Intraosseous Infusion, and Capnography, and I mention that it was through clinical research that these skills were added to the prehospital scope of practice in our area and even more research that showed that they could be brought into the EMT-Intermediate scope of practice. I went on to a little tangent talking about how much of what we do in EMS today is not backed up by any actual evidence and how there needed to be much more research done to justify what we did today and determine what we should be doing in the future. I closed the tangent by saying that it was our obligation to assist as best we could any research project going on in our services or area so that EMS could continue to advance.

I was a little taken aback when one of the students responded with "What's research going to do for me on my shift tonight?" and when I replied that research takes time and effort. He snorted and stated that we'd be better off focusing on what we needed to do now and leave the research to the "eggheads" elsewhere. Having fallen behind schedule I was not going to be able to have that debate with him at that point in time.

I wish I had time to discuss just how important research is to the future of EMS and how we need to justify every single thing that we currently do and prove that works and is what is best for the patient. I know this and I think, given some time, I could prove this to my students and colleagues who don't believe it.

That being said I have to say that we do not spend enough time exposing our students or current providers to research, research procedures, and the importance of peer reviewed literature to making decisions on the future of EMS. I am finding that the amount of EMS research being done is so small compared to other areas of healthcare and some of what is being done is reaching conclusions that are painting EMS nationwide with such a broad brush or so specific that it is only relevant to a handful of systems that EMS providers just can't get a handle on the importance of it.

Several years ago I used to subscribe to the EMS Journal Club. The EMS Journal Club was a group of 3 EMS physicians and a paramedic who got together quarterly and picked a handful of articles published in peer reviewed journals and discussed how they were important (or not important) to EMS, how well (or not well) the research was done, and generally gave me my first exposure to research, research procedures, and really cemented home the importance of prehospital research in my mind.

In the days of easy access to programs such as these in the form of podcasts it is about time for something like this to make a comeback.

The Next Big Thing?

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On Thursday I turned 46 years old and with middle age having arrived at some time when I wasn't looking I have been giving some thought to my career, where it is, where it has been, where it is going, and what mark I am going to leave on EMS after I am gone. I know that there are a few people that are walking about because of interventions I was involved in, I know that there are a few EMTs and paramedics that are better because I precepted them in the field or taught portions of their class. These are good things and let me know that I did make a difference.  I feel like it is time for something new to happen.

In September I will mark my 30th year in EMS. That is a long time for anyone to be in a career and while some of my colleagues are considering retirement or moving on to other careers I still have a passion for EMS and no desire to leave it. I do, however, want to do more than I have for the past 30 years. 

I feel like it is time for "the next big thing" in my career. I am not exactly sure what that "thing" is but I have some ideas that are coalescing in my head fast enough to be scary. Ideas are a great thing and they can, if I listen to them, guide my EMS career in an entirely new direction. A direction that I find both intriguing and frightening all at the same time. To make some of these ideas happen I will be gathering advice from other experts in the EMS community, leveraging technology to my advantage, and pushing my comfort zone. It's exciting and frightening all at the same time.

As my plans start to solidify I will share them here. In the meantime I am just looking forward to spending a long time still being passionate about EMS.
I'm on Cape Cod for the weekend. It's good to get away even just for a weekend. After chatting with a colleague here I am finding it good for me when it comes to work too. As much as I have been lamenting the dramatic drop in call volume we have had I realized that some people have it much worse. I work in a college town where we have a drop in population and call volume in late May through the end of August. My colleagues here on the Lower Cape have the exact opposite problem, they have a low call volume from September to late May and then go like crazy for the summer. While I appreciate their dedication and all that they do here protecting the community where my wife's family lives I would much rather be busier for 9 months out of the year instead of just 3.

I guess I'm realizing that it could always be worse. The college comes alive again in a month, I'm looking forward to it.

Dichotomy?

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Interesting comments from 2 students today that left me wondering about the seemingly diametrically opposed messages I got from them.

Student number 1, this morning, teaching him about the cardiac monitor in the back of the ambulance. When he finds out that I have been in EMS for almost 30 years looks at me and blurts out "Are you retiring soon?". Umm, no, not if I can help it. I really like being a paramedic and plan on staying a paramedic as long as they will let me. I'm not THAT old.

Student number 2, this afternoon, after finishing talking about capnography and how we can use it with patients that are not intubated tells me "dude, you should have a blog or do a podcast or something. That was excellent.". Well, thank you.

Interesting.

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0. The opinions expressed here are mine and mine alone. They do not and should not be considered to represent the opinions of anyone else.

1. This weblog represents my life as I see it. Others may, and probably do, see the same incidents differently. I can speak for myself and nobody else.

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