What You Need to Know for EMS Today

I know that some of you will be in Baltimore this week for EMS Today, while still others cannot join us. Regardless of which category you may fall into, I have some advice to help you make the most of this week.

First, if you are travelling, hopefully all your arrangements are complete. But even so, you still have an opportunity to save money during this trip. There are many transportation, parking, eating, drinking and shopping opportunities in the Baltimore area that are offering discounts to conference attendees. All you need to do is “Show Your Badge” for discounts at these participating merchants. To help you keep track of all the sessions (and any last minute changes) or just find your way through the exhibit hall, you should download the EMS Today app for your smart phone or mobile device. It is free for your Android phone from Google Play or for your Apple device from iTunes.

Whether you are physically at the conference or not, networking is what any conference experience is all about. And you can do it while you are here, at home, or even between calls. The key is to “be social” during the conference whether you are physically there in person or you can join us only in the virtual sense. Many attendees, including myself, will be active on social networks allowing you to connect with your peers and gain some insight of what is happening through the eyes and ears of others. If you are on Twitter use the #EMSToday2016 hashtag and follow the official @EMSTODAY account or join me, @hp_ems, for the latest updates, comments, and feedback on what is going on at, or even beyond, the sessions. Check out the latest posts on Facebook at the official EMS Today Conference & Expo page or join the conversations on various topics throughout the year at the High Performance EMS page. You can also learn from my own perspectives and the opinions of attendees that I talk with by reading my posts as this years official blogger of EMS Today 2016 at HighPerformanceEMS.com.

Being social can also win you prizes. There will be giveaways for visiting exhibitors in the Expo Hall, but also opportunities to find me at sessions where you can tell me about your favorite experience this week for an opportunity to win a prize from Limmer Creative who can not only help you pass the test, but retain the knowledge you need to succeed at the job. Just look for me, Dale Loberger, or find me by my backpack pictured here, and tell me what you love about this conference. I’ll make it easier to know where I will be by posting the sessions I will attend to my Twitter account at @hp_ems. If you won’t be at the conference, you can still have an opportunity to win by simply retweeting my contest post starting on Wednesday. Reposts of the full tweet will be counted through noon on Saturday in the drawing. Watch my account for more details!

We Deserve Answers Not Just Anecdotes

It certainly appears that suicide among EMS providers is on the increase. All too often we read articles like this one from Canada citing anecdotes and making promises. We know that the work is demanding and routinely exposes providers to critical incident stress. It is also no secret that all too often, the providers who face these incidents are left to deal with this accumulating stress on their own; either because of a lack of effective employer-based programs or due to a culture that discourages disclosure and treatment. When stress is left unaddressed, it can lead to Post Traumatic Stress Disorder. PTSD increases the risk of suicide and can be compounded by an individual’s negative coping strategies. Positive coping strategies and personal resilience, on the other hand, may actually help reduce PTSD risk and even contribute to Post-Traumatic Growth (PTG).

Faith Boldt, a Masters candidate in Public Health at Western Kentucky University, is conducting an important survey, which takes only about 20 minutes of your time to complete. Your time can be pivotal in impacting her study to investigate the relationship between PTSD and suicide ideation. The results will provide data on the prevalence of PTSD along with suicide ideation and will be offered to identify strategies to reduce that risk.

The survey will only be available for a short while, so please take time to click here and fill out this research survey honestly on PTSD and suicide ideation factors affecting EMS personnel. This is an important subject in EMS and it affects us all! So consider sharing the link and encouraging other first responders to participate as well.

The issues of mental health awareness in EMS are only just beginning to be discussed more openly. We can thank the efforts of people like Paul Combs in his illustrations like this sample below or organizations such as The Code Green Campaign , #IVEGOTYOURBACK911 or Heroes Are Human. Please show your support for them as well. But most of all, make sure you have the support you need, because more than anything else, we want you to be safe!

Intolerance is Not a Black and White Issue

Of course “Black Lives Matter.” Just like white ones, red ones, blue ones, and every other color that we place as a ‘label’ on a life. All. Lives. Matter. But that isn’t the end of the story.

Martin Luther King, Jr’s vision was not just about ending racism, but about stopping every form of intolerance that denies the basic respect that all life deserves. With his transcending attitude of justice, I wonder just how long King would have made it as a paramedic. Facing people on their very worse; day after day, or night after night, has an affect on your mind. Watching people abusing a system that is intended to provide a literal “lifeline” to the sick and injured eats away at compassion. Seeing what people do to themselves as a result of their over-indulgence, arrogance, or addiction can layer a crust over the heart of tolerance.

I have heard first responders speak openly about those who “do not deserve my compassion.” This mindset justifies the segregation of our patients. It is a segregation not based on skin color, but on some invisible scale of worth. A scale that we try to teach others in order to make us feel better about how we fit upon it. This expression of attitude reminds me, however, to commit myself to practice compassion based on another popular saying instead: “Be kind, for everyone you meet is fighting a battle you know nothing about.�? In my own past, I have easily given my compassion to a drug-seeker who fooled me with an insincere exhibition of pain. More regretfully, I have also withheld some measure of that compassion for a patient who was in real pain and that I had assumed was simply too lazy to drive himself to the hospital. I prefer now not to be a judge of the character of the heart of any patient I treat because I truly do not know their personal pain nor the extent of their real struggle. And most importantly, because the time that I have to make an impact on their lives is incredibly small. I have come to learn that in those times when I do not know what is the right thing to do, I can live easier with the choice of doing what is the best thing.

This morning, I read a story about an EMT in Minnesota who admitted to stealing $120 from the wallets of two teenage brothers killed in a car wreck. Like all of us, she had bills. Like all of us, she was not paid enough for the public service she rendered.  She simply found the wallets lying in the road when she arrived first on the scene. Not a penny of that money could do any good for those teens any longer. She made a bad choice. A very bad choice. I do not know her, or anything more about the situation, but I would prefer to believe the best about her. At least as the woman she was in the beginning of her career. None of us entered the field with illusions about becoming rich. Most of us have a genuine desire to do good for others. Unfortunately, we too often work in a corrosive environment for our souls. But, as Dr. King reminds us, “The time is always right to do what is right.” So today, challenge yourself to go back to the roots of your service. Instead of trying to toughen up the “FNG” who is just getting started in his journey, borrow some of his fire to rekindle your own passion and renew your spirit. I bet your career in EMS will last longer too.

Improving EMS Clinical Preceptorships

A guest article by Caitlyn Armistead

Clinicals are a critical component of EMS education. These dynamic educational environments can be complicated to manage in order to ensure a complete education for each student. Consider these points as you structure your program and develop guidelines for the coming year.

1) Support Strong Mentorships

Formal preceptorship relationships are effective in transferring procedures and protocols to a student; however, the informal dynamics of a solid mentorship are even more effective at conveying not only clinical concepts but positive culture as well. The primary ingredients are time and empathy. A strong teaching environment is built over time in hundreds of small interactions. A student needs time to warm up and build trust; the preceptor needs time to identify strengths, weaknesses, and academic needs. The worst possible way to schedule clinical mentoring is to randomly place students with whomever is available on shift that day.

It is also critical to be selective in whom you choose as mentors. New employees look for role models, and their preceptor is an obvious choice. If mentors are chosen simply from the employees with the most time at your service, there is the risk of jaded viewpoints and out-of-date practices. Mentors should be chosen from among the seasoned employees that you want to replicate within your organization, not simply the one who has managed to hold the same position for the longest time.

2) Reduce Power Symbols

Rules concerning student conduct should be well defined in policy manuals and reviewed with students. However, these rules should be reasonable for the conduction of clinicals and not exist solely to create a false appearance of discipline while demeaning and belittling the student. Even when not written in overt policy, many times these mandates exist de facto at a clinical site. These sometimes include:

-students must only sit at a table and study, with no other permissible activity, for an undefined or

  unreasonable amount of time

-students must never sit in comfortable chairs

-students must never eat at the same table

-students must never ride in the cab, never observe driving operations

-students must only ride to calls in the box, in the dark, without air conditioning and/or

  radio contact

-students must never have radio access (at times, this may be a safety issue on scene)

-students must never be allowed the same safety equipment as the personnel

Rules such as these, whether explicit or implicit, send a very strong message to students. The usual response when rules are questioned is that they create discipline in the student and that “students need to know their place.�?

The result of such power symbols varies depending on the student. To some, it is merely annoyance with little gain. Others may be reluctant to engage with a mentor and ask necessary questions. Students motivated by affiliation, however, can be demoralized. This can result in a student losing academic momentum or being more likely to choose inappropriate behavior.

3) Teaching techniques are important

New skills and activities should be introduced, modeled, guided, and supported, just as they are in the classroom. Checking off supplies in the truck is a great activity for a student, but when a student is given a paper and expected to go on a scavenger hunt alone, the benefit is minimal and the teaching opportunity–identifying equipment, telling what it’s used for and why it’s in the location that it is–is lost. If a student is expected to learn efficiently, a teacher needs to be present. If a student is expected to ask questions, the preceptor must be available to provide an answer.

4) Use objective evaluations and rubrics

Evaluations should be clear, precise, and as specific as possible. Students are quick to notice when a critique is based more on their football team preference than their skills in the field, but that can be difficult to prove if the guidelines are vaguely written: “gets along well with EMS staff.�? When critiques are unreliable and yet used determine a student’s grade, students driven by achievement and autonomy, in particular, are demotivated. These students want to earn their grade on their own merit and want concise goals and boxes to check off. This requires not only well-designed evaluations, but also well-trained preceptors.

5) Avoid turf wars

When two or more students are assigned to the same station, truck, or even the same calls, learning opportunities per student are reduced. This can also lead to the student focusing on jumping calls instead of gaining knowledge and building the mentoring relationship. “Nice�? students, who defer calls to others, may end up with sub-par clinical experiences. When setting schedules, attempt to ensure adequate call resources for all students and enforce these guidelines.

6) Choose healthy clinical sites

EMS services with toxic work environments easily infect students with poor work ethic, bad habits, and out-of-date dogma. This becomes critical if laws and standards of care are broken, and huge problems can result if a student is caught in the middle or is forced to become a whistleblower. When all possible, avoid such sites and use other services and hospitals for clinicals.

7) Ensure respect

Female, minority, and older EMS students, participating in FISDAP, reported significantly lower preceptor performance ratings compared to Caucasian males (Page, 2013). While this issue needs further study, in the meantime, it is important that all students be treated with respect and empathy. If uniforms are required, make sure there are options designed for females. Harassment and hazing policies should be easily understood and enforced. Student concerns should be welcomed and anonymous reporting available.

Conclusion

Clinical rotations and field training are expensive for a service; they divert time from the best field personnel to a student or new employee. It only makes sense to make the most of these opportunities. Preceptors must embrace the concept of being a mentor. And the training staff, with the support of administration, needs to provide a healthy environment where both formal and informal education can occur. By constructing thoughtful policies and implementing solid practice, clinicals become a valuable dynamic education experience that pays long-term dividends.

Stop Dissing Response Times and Start Dissecting the Argument

It is not hard to find an article that bashes the industry’s insistence on measuring response time as a performance goal. The latest one I saw was published just today in “Don’t let response times overshadow the role of EMS” by the respected author Arthur Hsieh. The flow of his article follows the traditional pattern of claiming that measuring time is an outdated historical artifact of EMS without any basis in science, followed by the inevitable near-contradiction confessing that time is critical is only a limited number of cases before finishing by imploring future leaders to take a courageous stand against the uneducated politicians who simply fail to understand our modern evolving business. Hsieh is certainly not alone in making this well-worn, if not self-serving and short-sighted, argument.

Assuming my readers are familiar with the clinical EMS process of assessment, let me present a reasonable differential in terms we can hopefully appreciate. First, what bothers me in the common debate is the assumption that what we see is the totality of the problem. The ingrained reflex of our ABC mnemonic is only for the initial impression, not the final diagnosis. We must resist the urge to simply treat the surface presenting problem and investigate even deeper for an underlying pathophysiology. Our assessment should probe whether the response time concept itself is really the source of the disease, or is it possibly the uncomfortable idea of a formulaic approach to system “compliance” underlying the measure that makes us protest so loudly? Are we taking our frustrations of prescribed protocols out on one single measure when it is actually any measure that attempts to pit arithmetic against our artistic judgement and the free expression of our healing knowledge? Another idea of an underlying cause may be that we equate good response times with unsafe speeds or the very real growing risk of ambulance-involved collisions from excessive speeds and increasingly inattentive drivers. Or could it be a frustration, often expressed as “running hot to a stubbed toe,” that suggests we are simply expending extraordinary efforts on the wrong cases altogether because current EMD processes are not adequately refined in order to triage our limited response options to the unworthy types of calls we are seeing lately?

Without exception, everyone that brings this topic up recognizes at some point that there are clearly instances where time is actually critical. STEMI, stroke, and anaphylaxis are usually among the list of obligatory concessions. Still, we seem way too willing to just “throw the baby out with the bathwater.” In the fire service, there is a well-known motto that says, “train like you fight, fight like you train.” To me, that translates to always practicing the things that are important even if it doesn’t make a difference every single time. There are often instances when (whatever “it” is) genuinely saves a life (whether your own or that of a patient). Sometimes, the “it” is time. There may not be any magic in “10 minutes” (or whatever your standard may be) or even the “golden hour” itself, but there is inevitably an “expiration” on our efforts. There is a time limit when the value of all our interventions diminish to the point that they can no longer buy back the life of our patient. A short response time gives us more time to consider options. It is no longer a question of “stay and play” versus “load and go”, but always to “think and act.” The anxiety of our patients and their family or friends at the scene are measurably lowered by our professional presence. If that is not your experience, then you may actually be correct in believing that your response time truly does not matter.

Just as we do our assessments, we can’t stop at the first symptom of a problem and treat it in isolation. We must often dig deeper to understand an underlying cause that needs to be treated more importantly than just the first observed sign of it. Hsieh is correct in saying that “It’s really time to move on and get with the times,” but  not by neglecting the value of our response, rather in addressing the underlying objection to having it measured. Politicians are never likely to admit to understanding our disagreement to measuring response times because they do not account themselves to us, but to the public that demands our prompt service that keeps them in office. If we insist on expending energy to attempt change, direct that energy in the most productive way it can be used. This begins by recognizing the root problem and the limitations of our interventions to affect change in it.

EMS Week 2015 Challenge

In 1974, President Gerald Ford declared the first “National Emergency Medical Services Week�? as an annual observance to recognize the critical component that emergency prehospital medicine began to play in the public health safety net. That year was a time of many other significant events. Richard Nixon had become the first president to resign in office. The newly formed OPEC consortium successfully constrained production causing a worldwide oil shortage that skyrocketed the cost of a gallon of gasoline to 55 cents. A national speed limit of 55 MPH was imposed to conserve fuel and save lives. The Sears tower in Chicago was opened as the world’s tallest building. It was also the same year that a 1973 Ward LaFrance P80 replaced the original 1965 Crown Firecoach as “Engine 51” in the popular television show “Emergency!” then in just its third season.

In the 41 years since that time there has also been a great deal of change. Pneumatic Anti-Shock Garments such as the Medical Anti-Shock Trousers (MAST) have come and gone while Nitrous Oxide had gone away and may be coming back. Spinal immobilization is being completely re-examined as long back boards are being sidelined and may soon be joined by the hard cervical collar. CPR guidelines are being extended as we work patients longer on scene and the A&E series “Nightwatch” has been signed for a second season.

It is all too easy to say that we do not have any impact on what is happening in the world around us, that things are just happening and it is out of our control. For those who accept they are powerless, it is true. The future always belongs to those who are willing to shape it. Every fact I quoted above only happened because some individual was inspired to make something happen. This year you have the unique opportunity to stand up and be counted. You can choose to be a part of the solution and make your community a better, safer place for everyone. It all starts by you just trying something new. 

Look for 2015 EMS Week activity ideas by downloading the Planning Guide PDF from www.emsstrong.org.

“We gain strength, and courage, and confidence by each experience in which we really stop to look fear in the face… we must do that which we think we cannot.” – Eleanor Roosevelt

Where is Wearable Technology Heading?

This post is from an invited guest blogger. Andrew Randazzo is the Director of Prime Medical Training and is a Nationally Registered Paramedic. Aside from teaching, Andrew’s faith and church play a big role in his life, and he also enjoys backpacking, scuba diving, competing in triathlons, and international travel.

—

Disclaimer: I am not being compensated in any way for any of the products I talk about in this article.

I find that when people learn about EMS and all the tools we have at our disposal, they are surprised. Even those who are in the healthcare field are surprised, or perhaps just ignorant, about what our monitors are capable of measuring. It may be because so many other facilities have multiple pieces of equipment that do what our one monitor can do.

Now imagine that one monitor being out of date. That’s right, the good ole LifePak 15s and Zoll Xs need to say hello to the Visi Mobile. The Visi is a all-in-one monitor that you wear on your wrist. Not only does it do all your vital signs including respiratory rate, it can also do EKGs.

What I find the coolest about the Visi is the built in accelerometer that detects what position you are in in bed, if you’ve been walking around, fallen, etc. That feature alone makes it invaluable for hospitals and nursing homes.

Another breakthrough is Continuous Non-Invasive Blood Pressure. What you do is put a normal BP cuff on the patient that takes their initial BP. Then you can take the cuff off and the Visi is able to measure subsequent blood pressures without the cuff being on the patient.

Everything that is monitored can also be transmitted wirelessly and displayed at the nurse’s station in real-time. The Visi Mobile reduces injuries for the patients first of all, but it also allows more people to be moved to less intensive floors (which frees up beds) due the fact that the patients need less 1-1 monitoring.

By the way, I almost forgot to mention this device costs a few hundred in comparison to the thousands you have to spend on current monitors.

The company also plans in the future to expand, to allow monitoring patients post-discharge, in order to avoid hospital re-admission.

This is the wave of the future. I’m excited to see it coming and what else is out there. What are your thoughts on the Visi Mobile or other things you see coming? Please comment as a reply below.

In Support of Backboards

“Proper Placement of Backboard”

One of my first really successful posts years ago was “A Short Take on Long Boards” where I found myself piling on the negatives regarding our habitual dependence on the Long Spine Board. I do not feel as though I can take any credit, however, for agencies such as the Palm Beach Florida Fire Department or the New York City Regional Medical Advisory Committee who have since chosen to abandon the practice of its use.  Many others have made their displeasure of the practice clear in endless commentaries on the topic. And the photo above on the “Proper Placement of Backboard” garnered many “Likes” on social media. It is the traditional reliance on the backboard, in an attempt to totally immobilize patients, based predominately on the MOI that has lead some to parody the practice in a clever cartoon episode. As a matter of fact, the only evidence I could find to support the use of the spine board as an immobilization device for transport was this randomized clinical trial setting it up against a vacuum mattress splint in a false dichotomy that I could only hope is a mocking satire. In an even deeper insult to our immobilization practice, Dr. Bryan Bledsoe, emergency physician and EMS textbook author, has also gone on to suggest limiting use of the rigid cervical collar as well. Suddenly, the topic of immobilization seems to be much more fluid.

Still, I fear some may have gone too far in calling for the removal of the LBB from ambulances everywhere. In general, we are often all too willing to jump from one bandwagon to another in an “all or nothing” dance to be more “evidence-based” than the next medic. I have heard colleagues suggest that the KED is the rightful heir to the immobilization throne, but in my mind that is like replacing the standard stretcher with a stair chair. In some cases one may be more appropriate than another, but the recognition that a tool has limitations does not mean it should be replaced in every instance. We simply need to become more aware of when to use it, not just remove the tool from the toolbox altogether. I feel we have done the same thing with response times, if they don’t ALWAYS matter, then they NEVER matter (but that is a topic for another post.)

The backboard remains a flexible extrication tool that is widely available and already well understood by first responders. Furthermore, it can be adapted for other uses. Another topic that is hot in EMS right now is High Performance CPR. While the basics of CPR have been around for decades, we are learning better ways to apply it and even understanding more about the science behind the mechanics of how it works. We know, for instance, that the patient must be on a firm platform for effective compressions and the backboard fits that need very well.  More recent research also suggests that tilting the compression platform to a semi-fowlers’ position decreases ICP for better brain perfusion. Instead of introducing a new device, the backboard can be adapted to this use by raising the head about the height of your bag.

It is great when we can improve the efficacy of our work without adding anything to the expense of it! The most difficult change is in our attitude.

What is CAEMS and Why Should I Care?

Two weeks ago, we started a Community of Practice to discuss EMS Deployment. The larger issue of deploying resources is all about efficiency and effectiveness in care, those are also the aims of any High Performance EMS group. However, that message is too often confused with meaning simply “better, faster, cheaper”, when in practice it must be rooted in “doing what is best for the patient” in order to be anything of lasting value.

In the following episode of ‘Word on the Street’, an EMSWorld podcast hosted by Rob Lawrence, representatives of the Coalition of Advanced Emergency Medical Systems (CAEMS) chat about the professional association and exactly what makes EMS systems “high-performance.” Give it a listen (or even download it) here: http://www.emsworld.com/podcast/11327832/word-on-the-street-coalition-of-advanced-emergency-medical-systems.

We Need Some New Stories

We always hear that EMS is still a relatively new discipline. And in the scheme of medicine, or even public safety, that is certainly true. But we shouldn’t let the fact of its youth keep us from acknowledging that it has already been around long enough to accumulate some of its very own antiquated dogma. If you have any doubt, consider the reaction to changes in protocol – even those with good evidence to support some new practice. Working cardiac arrests on scene, for instance, was not met, at least in my experience, with enthusiasm at the prospect of improving patient outcomes. What I heard were excuses for why something different wouldn’t work. I thought about that exchange this week as I was listening to a recent Medicast podcast on an entirely different topic. Near the end of that recording, Rob Lawrence remarked that we really need to do away with the old stories that start out with “back in my day…”

The stories of some grizzled professionals include not just memories of MAST pants or nitrous oxide, but the idea that tourniquets take limbs, not save lives. More recently stories have been spun about the movement away from the long-held reliance on the long spine board as an immobilization splint during transport or even the value of therapeutic hypothermia for cardiac arrests.

While there is no denying, or even stopping, a rapid state of change in EMS, we must be sure that it is not just change simply for the sake of change or even resistance for the same reason. Change must be meaningful change that is guided by reasoned thought and scientific evidence, not personal anecdote. And new practices should be carefully modified to address current issues or new understandings of the problem.

Another sacred, yet unjustified, belief among too many providers is that the dynamic deployment of resources (commonly referred to as “SSM”, or System Status Management) is an unmitigated failure of cost-consciousness that actually leads to increased expenses and provider dissatisfaction. The evidence, however, from many of the services who now employ some facet of dynamic deployment has proven that while it can be tricky to implement well; the savings in time, money, and lives are definitely real. And those savings need not come at the cost of provider safety or comfort either. Whether you have had bad experiences in the past, or just heard about it from others, it is time to set aside the old stories and take a new look at the current technology and practice in every aspect of EMS that leads to improved performance.

To advance our profession, we must completely ban the expression,  “but that’s how we’ve always done it” and look toward “how we can do it now!”