Category Archives: Vehicle Operation & Ambulances

Innovation Review: StethoSafe

Have you ever broken a stethoscope on the job? I have. Rode a wheel of the loaded stretcher right over the connection from the tubing to the bell. It was a clean break. Very neatly decapitated my old friend from EMT school. It was one of those clear and obvious signs of death such as decomposition or rigor mortis. I didn’t want to show it, but my heart was crushed too. But it wasn’t like I was without a scope to do my job. There was always the one that hung on the crash webbing at the end of the bench seat. You know the one, it hangs right above the trash can for anyone too poor to have their own equipment to use. I’ll admit that the idea of inserting other folks ear wax into my own canals grosses me out, but the point was that I didn’t have MY stethoscope. So, before I even finished the PCR, I was on the web buying myself a brand new set of ears. While my new and improved (and yet to arrive) stethoscope would have my name engraved in gold letters right on the tubing, I still wanted my old one repaired. To their credit, Littmann offered me an identical replacement scope for less than the cost of the repairs I required. I won’t tell you what happened to the old broken pieces of “my first stethoscope,” but suffice it to say that I am sentimental.

My new stethoscope, a Burgundy Cardiology IV, was an definite upgrade from my previous faithful Royal Blue Littmann Select. Although the price difference made me a little short of breath, I decided my career was worth it. But from now on I would have to be even more cautious. And my new scope had two diaphragms instead of just the one to protect. In the meantime, I began to examine some of those listening devices hanging back in the patient compartment of trucks I’ve driven. I have noticed cracked or bent diaphragms and even some that appeared to be trying to escape their captivity. Knowing that the quality of our assessments can be impacted by the quality of our equipment, I wanted to ensure I was always prepared. But how much can we really do though? Any equipment we use in the field and routinely stuff into bags is subject to damage and there is little we can do to protect our equipment, right? Wrong.

A couple months ago I heard about a nifty invention from Paramedic Greg Sumner called the StethoSafe. While it is not designed to prevent the type of ‘beheading’ I executed, it is made to protect the sensitive diaphragms on your head. As it states on his website, “It’s like a helmet for your stethoscope.

At $9.95 (plus $3.00 first class postage) for just one, I could have some piece of mind. While I don’t consider myself a ‘whacker,’ I do like innovative stuff. I bought one in blaze orange, stuck it on my head and stuffed it in my go bag. After carrying it around a while, I began to wonder exactly how much protection it afforded my equipment. A friend of mine, who knew Greg, asked me to give it a good test. I wanted to, but didn’t want to break mine, so he contacted Greg to send me another to put through some paces. That left me free to really test it out.

Over the last couple of weeks, I have been intentionally abusing my original StethoSafe. This video review on YouTube is only my latest attempts to ‘crack this case.’ There were many, many more before what you see. Even after all of that, I am still using the same case on my shifts. It does have some obvious scratches now and some discoloration near the joints (you can see circled in the photo) that I assume are the precursors to cracking, but no actual cracks yet. Since this is a 3D printed part (correction: only the prototype was printed, my production review item was injection molded), I wondered about chemical abuse, so I poured isopropyl alcohol on the plastic and it eventually all evaporated with no sign of damage.

I have been very impressed by the ability it has to keep my sensitive parts safe. I did notice, however, after constantly clicking my stethoscope into the case that it was beginning to leave some residue on my bell. But this powdery residue came right off with a simple wipe. It was not actually scratching my bell, just wearing the plastic down every so slightly. My scope fits snuggly in the case (even after plenty of testing.) In fact, it fits so tightly that I worried about pulling on my tube to get it to release. I found myself in the habit of grabbing the metal tube connection very near the bell to pull it out. But with a little faith, I have found that the case will release with a tug from further down the rubber tubing without any damage to the equipment. The lanyard would be very convenient if I had a D ring inside my equipment bag so I could just pull it out when needed. My habit, however, is to leave my stethoscope in the cab (often on the dash) or hanging around my neck. My StethoSafe is never any problem regardless of where that I keep it and I can feel confident that it will prevent me from losing another friend any time soon.

 

 

 

 

 

 

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Anatomy of an EMS Kit: The Importance of Case Design and Contents

Editor’s note: Beyond our skills and knowledge, some of the most important assets of the EMT are the collection of tools and supplies they carry. But how often do we really consider the container in which we carry these critical items? The following post is from an invited guest author on the subject of EMS bags. Sam Distefano works with Fieldtex Products, Inc., a supplier and manufacturer of quality custom EMS carrying cases, and a Medical Division that stocks them with life-saving supplies. He shares his insight on what to consider when evaluating and acquiring new bags for the working EMS professional.

 

The Anatomy of an EMS Kit: The Importance of Case Design and Contents

The well-trained medic or First Responder has so much more to offer than what is stocked in their kit, but a well-stocked and intuitively organized kit can make any responder more effective. There are innumerable ‘First Responder’, ‘Trauma’, and ‘Professional’ First Aid Kits on the market in all shapes and sizes, boasting selections of supplies and tools that vary from kit to kit. Whether built, bought, or borrowed, you become acclimated to your kit layout and it’s supplies, and can feel confidence in your ability to utilize the kit in an emergency situation. However, the vast and varying selection of cases raises several questions: what features should your carrying case have, and what supplies will be stocked inside?

Design Priorities

The most effective carrying cases for EMS have been designed with input from field providers in the very early stages of development, starting with the Prototype and Design phases. Oftentimes, the greatest innovation stems from these fundamental conversations. Without this input, the kits may be aesthetically well designed, but rendered useless if there is a negative impact on your effectiveness or efficiency due to any design flaw that was overlooked due to lack of field experience.

There are a few key features that should be consistent throughout all EMS Cases. We will discuss their Durability and Material Quality, Convenience of Transport, Ease of EMS recognition, and (most importantly) the Organization of your contents.

Durability and Material Quality: The use of durable textiles for an EMS carrying case should be obvious – you and your kit must be prepared to face some of the harshest elements in the field while safely transporting your supplies to any scene. The use of Cordura (nylon), or other comparable tough woven materials, is the foundation throughout the EMS carrying case industry, and undoubtedly remains the optimal choice for durability. This material is abrasion resistant even after numerous washes (which will be necessary) and continuous uses, providing you with mil-spec durability you can rely on. Other common material alternatives that are frequently used include vinyl and tarpaulin, synthetic non-woven textiles. While not as durable as a woven nylon, these are primarily useful in instances when water and fluid resistance are vital to the design. For example, a case including any sterile items or products that could be water damaged must be kept dry at all costs. Ultimately, there are pros and cons to any textile choices, but Cordura seems to be the most universally utilized – and with good reason.

Closures and other hardware are also a core element of a durable carrying case. YKK zippers are the most durable and reliable choice for zippers. This coil style zipper with plastic teeth prevents rust and corrosion even after extensive use, and every coil size (especially the #10 Heavy Duty) provides a secure and fail-proof closure. While there are other options for zipper brands, YKK is the leading brand in terms of long-lasting performance (there’s a reason you see it on most clothing and bag zippers). Alternatively, opting for durable plastic side-release buckles or high-performance hook-and-loop closures (Velcro being the most widely utilized brand) also provide adequately secure closure, and is simply a matter of personal preference. Some responders will argue these closures grant quicker accessibility than a zipper.

Still, a collection of durable materials and hardware are only the beginning. They must be put together with quality stitching. If you have the opportunity to build your own cases, seek a company with experience in manufacturing for the First Responder community. If you do not have someone that will ensure industrial-strength construction, the most durable fabric won’t matter much when you have missed or broken stitches. Look specifically for “mil-spec” and “industrial sewn” cases which will help reduce the likelihood of failure in the field and will extend the useful life of whatever case you choose. Looking for carrying cases made domestically will also ensure a quality-controlled and durability tested bag that supports American workers.

Convenience of Transport: Getting from your truck to the patient while having everything you need in one trip starts the scene off right. A system that offers more than one transport option (i.e. backpack straps, an adjustable shoulder strap, or handles) assures that your movement won’t be inhibited in any setting whether running through an open space or moving through a crowd. It also allows additional items to be carried separately as needed. Transport options also provide a critical backup in the event that one of the carrying methods may fail on the scene.

Due to the comparative size of some people to the bag they carry, struggling to a patient without being beaten up by your bag can be a genuine challenge. Designing cases with different transport methods also allows you to carry it in a way that won’t inhibit your effective movement or lead to discomfort. Ideally, you should not have to provide different bags based on staff height, strength, or other human variables. While shoulder straps and handles are more common transportation methods for EMS cases, backpack straps allow you to travel without the case bumping against your legs, to distribute the weight evenly across your back, and to keep both of your hands free from the first moment on the scene.

Ease of EMS Recognition: Use of bright colors, reflective straps/stripes or the universal Star of Life logo make it easy for people to quickly recognize you as EMS. Working with a custom case designer and manufacturer that additionally offers ”private label” and ”branding services” also allows you to brand your cases with your county logo, unit icon, or any other recognizable symbol to bystanders on the scene. This is especially important in the event of a motor vehicle accident in a busy intersection or a medical call on a crowded plaza. High visibility not only identifies you and lets people know you’re there to provide professional medical services, but also protects you both indoors and outdoors at any time of day or in situations of low visibility and high risk. Choosing a case that will allow you to easily access and integrate your identification can help expedite access to the scene and effectively reduce response time.

Organization: Last, but certainly not least, is organization of the contents. This is potentially the single most influential aspect of any EMS case in the moment. You never want your supplies to just knock around in the large open space of a duffle bag where they could be damaged. Further, having to dig through dozens of bandages, gauzes, and tapes to find the supply you’re actually looking for leads to delayed action and increased frustration. Buying bags with interior and exterior pockets, or sections, allows the user to organize the case in a way that will increase their efficiency and categorize their supplies in a way that is intuitive. Some bags on the market contain individual “modules” that can be removed. Each component should logically contain products to treat a specific kind of injury or support a unique procedure. Modularization, say for burns or advanced airways, allows these supplies to be quickly accessed and the bags to be easily customized for new situations you may face.

A word of caution on compartmentalization – there is a fine line between organization actually helping and it possibly hindering access. Sectioning products down too much can lead to further stress or added confusion in an emergency situation. Focus on making the case intuitive, not sectioning off products for the sake of sectioning off products. A general rule is that if you have multiple sections containing the same items, you probably have too many compartments. Larger sections should hold bulkier supplies, or supplies that require multiple pieces. While bandages may not be your “go to” on every call, you should always stock several of them in different sizes and compositions – because when you need them, you need them quickly. Storing them in a large compartment near the bag opening ensures easy access on any scene.

If items are placed on top other small equipment, the compartments may be too deep or too few. Another way to store items that need to be accessed quickly could be by attaching them to internal lanyards. One very new idea comes from Stethosafe, a new manufacturer that offers a rigid plastic cover with small lanyard to protect the bell of your stethoscope while also keeping it handy for immediate access.

Another great aspect of teaming up with a contract manufacturer and designing your teams carrying cases from scratch is that you can control the amount and size of compartments based on the inventory that your team regularly stocks. Carrying cases with interior movable/removable dividers (usually fixed with heavy-duty Velcro) also helps with organization and modification of supply compartments as needs change. Your supply stock could be changing as often as the seasons based on accident frequency and type, and your bag should be able to accommodate that. Generally speaking, designing from scratch is more expensive than off the shelf due to prototyping, sampling, and production costs. There could also be production lead times, making it a longer process even after the design is approved. However, designing from scratch is the way to go if you want a bag that is true to the contents your team carries and organization methods.

If you are limited to buying “off the shelf”, seek cases that can accommodate your recurring inventory and have adequate sections. Features like elastic bands to hold smaller items in place can also be an effectual interior design if it is practical and intuitive for the user.

Thoughts on Contents

The old adage that “BLS comes before ALS” points out the nature of the type of incidents that most First Responders face. Basic Life Support Kits are stocked with supplies to treat victims on the scene who have sustained life-threatening injuries. In other instances, these cases can be called upon to treat patients while in transit to the hospital. How your kit will be used will determine what supplies are required. Our stocked BLS Kits are designed to manage traumatic injuries (lacerations, burns, other severe wounds), choking, drowning, and other bodily insults that can be treated non-invasively. BLS training is the most common among EMS and Fire personnel, but is also common in lifeguards, police officers, and even teachers.  Advanced Life Support requires further training and certification as Paramedics who may utilize different medical equipment and procedures. These kits are designed to treat underlying medical conditions more invasively. In the case of cardiac arrest, an IV Kit with syringes, and a sharps shuttle allow medications to be administered safely and disposable supplies to be controlled.

It is likely that your organization has a checklist of required items to be stocked – some lists are even dictated by the state or other accreditation agency. While there is no “universal regulation” of what goes in a particular kit, at a minimum, you should stock sufficient supplies to provide life support in the event of an anticipated type of trauma given your location, training and certification level. The amount of supplies is also determined by the number of calls you expect and the length of time away from your base without being resupplied. That being said, there are some things that can be commonly found in these standardized kits:

Wound Dressings: Burn Dressings, Combine Pads, Gauze Pads and Rolls in Various Sizes (2” and 4” rolls are most common), Trauma Dressings, and (a lot of) Bandages of various sizes.

Wound Treatment/Cleaning: Irrigation Solution (normal saline), Hydrogen Peroxide, Alcohol (usually beneficial in a wipe/prep-pad), Antibiotic Ointment, Povidone Iodine solution/wipes, Instant Ice Packs, Pain Management Medication (Ibuprofen, Acetaminophen, Naproxen, and in the event of serious injury, Morphine, etc.). Be aware that while some of these items may be useful, there application may have legal implications. As always, please consult with your local protocols about administration restrictions. “Good Samaritans” who supply themselves and act according to general knowledge in good faith for the best interest of the patient may be held to different standards than certified individuals.

Tape: Transparent, Paper, or Cloth tape

Splints/Collars: Stock Various Size Splints and Cervical Collars (at least 1 child size and 1 adult size)

Personal Protection: Safety Glasses, N95 Face Masks, several pairs of medical gloves, emesis or Biohazard Waste Bags

Tools and Equipment: Utility Shears, BP Cuff, Stethoscope, Flashlight, Nasal Cannulas, Non-rebreather masks, pulse oximeters, Tactical Tourniquet, Thermometer

Drugs: Oral glucose (for diabetics), naloxone (for opioid overdoses), epinephrine auto-injectors (for anaphylactic reactions), or activated charcoal (for accidental poisonings) may also be added based on need and training.

At some point, it’s more likely than not that you will be on the scene of an accident and think “I could really use an (insert medical product here) right now!” Your personal experiences responding to calls in your region will aid in determining recurrent emergencies, therefore helping you stock enough of a frequently used product so you won’t run out prior to resupply. The ability to enhance a common kit with additional supplies gives you the opportunity to further improve your ability to provide emergency First Aid in a crisis situation.

While case design and contents are simply tools, there is no substitution for a well-trained medic. A First Responder or EMT Carrying Case should be designed to help provide the most efficient and effective care, and all play an important role in the layout and organization of supplies on hand.

To learn more about Custom Design and Manufacturing Capabilities, visit FieldtexCases.com.

To learn more about how we can help you Restock and Refill your EMS Kit, visit e-firstaidsupplies.com.

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Split-Second Destination Decisions

This past Sunday night about 2245 hours, a Detroit police officer was shot in the head while responding to a domestic violence call. The Detroit Free Press, in an article identifying the shooter, reported that the incident happened at an apartment complex in the vicinity of the 10000 block of Joy Road near Wyoming Avenue on Detroit’s west side. According to Channel 4 News in Detroit, Rapid Response EMS was dispatched and arrived on scene in less than 60 seconds. The officer was transported, with a police escort, to a level two trauma center,  as reported by another local news source, with the patient being handed over within 22 minutes of the original dispatch. Now, Detroit Police Chief James Craig is asking why the injured officer “wasn’t taken to the closest hospital.”

These are the facts as I have been able to glean them from multiple news reports and summaries. I have no inside knowledge of this particular incident or even any great understanding of Detroit in general, but I believe there are several interesting questions worth a larger discussion here from the perspective of a complete outsider. For those who may have more inside information of this situation, I will point out that I have no interest in any past conflicts that this particular EMS provider has had with the Detroit Fire Department or a memo now resurfacing from an incident last October specifying that injured “Detroit firefighters will be transported by Detroit EMS only.” That is a totally separate matter that relates potentially to medical care, not destination decisions.

A FOX 2 news article made a statement that they are “still looking into why a critically wounded Detroit police officer was taken to a hospital in Dearborn– when there were two hospitals that were closer. At least one of the hospitals that was passed up is better equipped to deal with a gunshot wound to the head [emphasis added].” Another article, updated during my research today, has since made a correction stating, “This story has been updated to clarify that an ambulance driver [sic] did not pass any hospitals while transporting a wounded Detroit police officer.”

The question we in EMS are often forced to answer is what facility is “closest,” however that question does not always have a static answer from every incident. One of the first articles I read on this case printed a thumbnail map (since removed) similar to the image on the left (which you can enlarge by clicking on it.) What immediately struck me was that the shooting occurred at the center of a triangle formed by the three “closest hospitals.”

If we consider distance to be “as the crow flies,” or perhaps more appropriately, “how the medical helicopter flies.” We will get one set of distances and travel times. Here, Henry Ford to the east appears closest in straight-line distance followed by Sinai-Grace to the north and finally Beaumont in Dearborn to the southwest. If we consider road miles of the shortest path, the order changes with Sinai-Grace at 4.8 miles, Henry Ford at 5.6 miles and lastly again, Beaumont at 6.8 miles. However, if distance is measured in drive-time, specific values change (according to my tests using Google Maps) depending on the amount and direction of flow of traffic. In all of my time tests, Sinai-Grace came in dead last due to the number of local street segments traversed and I suspect a large number of traffic signals. These typically narrower streets and signaled intersections are not only slower to travel, but more dangerous when traveled using red lights and sirens (some studies will show this is especially true with a police escort.)

The travel times in my daytime investigation during a typical work week varied with the other two destination hospitals and probably would still be different from a late drive on a Sunday evening. Of some significance in comparing the “best routes” is the number and direction of turns. As a general rule, right turns are safer than left turns which must cross opposing lanes of travel. The other consideration is the speed limit of the roadways. While I assume the ambulance was travelling above the posted rate going code 3, it is the faster roads that are built to a higher level of safety and will more easily accommodate higher speeds with fewer traffic control devices (lights or stop signs.) The route to Beaumont had the highest number of miles on restricted access highways that have the highest speed limits in any city. Consequently, this may have been a very good choice based on actual travel-time as well as safety considerations.

The call was still a judgement one and I will not defend one or the other as the best choice given my lack of knowledge in Detroit, but I will defer to the judgement of crews that travel these streets regularly both as emergent and routine traffic.

The other consideration in this call was the trauma rating of the hospital. As I understand it, both Henry Ford and Sinai-Grace are level 1 while Beaumont is only a level 2 facility. Given the severity of the wound, some deference would likely be given to the better equipped hospitals. However, the real difference between these levels is typically whether there is a teaching and research program available. The surgical capabilities should actually not be significantly different.

With drive times so close to being similar, I can sit comfortably in the safety of my arm chair typing that the choice of Henry Ford would have been quite practical; however, I may well have made a different choice myself as I place myself behind the wheel (as I will be doing tonight.) That immediate “split-second” decision of east versus south west is much more difficult in the moment. And this is exactly the type of situation where I would be grateful for the input from the MARVLIS in-vehicle client that sorts destinations choices by distance and provides an optimal path based on time-of-day with turn-by-turn driving directions.

 

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What 'Level Zero' Really Means in EMS

Rampart, Medic 13 with an incoming patient report.”

Go ahead, 13.”

I have a patient with a pulse of 120. ETA less than 10 minutes. Over.”

Well, this sort of report certainly leaves something to be desired. What is the age of the patient? For an infant, this may be a normal rate, but in a geriatric person it could be a bigger concern. Has the patient been involved in any physical activity? If the subject just completed a marathon it may not be a concern, but if the patient had been sitting on the couch watching TV and the pulse suddenly spiked, it could be a legitimate emergency. In any of these cases, we still need more information. The patient’s blood pressure would be another good measure along with age. Some OPQRST or SAMPLE would be enlightening too. A treatment, let alone a diagnosis, cannot be advised from this single piece of data.

In a very similar vein to our pulse example, there have been several articles written lately bemoaning the dangers of any particular EMS system having hit a ‘Level Zero’ situation some number of times in the last however many months. For instance, there is an article where San Bernardino firefighters attack AMR. Don’t misunderstand my point, not having any ambulances available can definitely be a serious situation, but how long does the situation last in each occurence? In any significant service area, its bound to happen at some point even with proper planning and normally adequate staff. My concern is the media attention over this single measure of an emergency health system. It may be that reporters finally got the message that response time was not a good defining metric by itself. But just like our bodies, an EMS organization is a complex system of interoperating systems. Performance is not defined by any single measure. Although individual metrics, however, can cause us to want to look deeper to understand the likelihood of potential serious problems.

A case in point is a story last year on Paramedics Plus in Sioux Falls, that revolved around two specific cases where an ambulance was not available for patients in distress. While this is not ever a desirable position, the compliance of the ambulance provider in question was 95% and even the investigative news reporter found that EMS arrived before the fire department’s own ”first responders” in 25% of cases. Perfection is simply not easy to maintain. While not making light of any potentially serious situation, my intention is to place this measure within some context, just as a sole pulse reading is only a singular measure of performance and one that is not meant to be interpreted by itself.

The MARVLIS application, in use by almost every member of the AIMHI (Academy of International Mobile Healthcare Integration) organization (formerly known as the Coalition of Advanced Emergency Medical Services or CAEMS) is often viewed as a tool for improving response times. While it has proven to be beneficial in achieving that goal, that is not the only reason these “high value” systems use it. Improving individual response times also improves compliance. Consistently short response compliance can also have clinical value if the times are low enough in the right situations. Jersey City has correlated a response time near 4 minutes to improved ROSC. But other benefits are improved value in post moves. Not moving ambulances for the sake of changing posts, but in positioning units closer to their next call with fewer moves. This also means fewer miles driven with lights and sirens to improve crew safety. Mobile Medical Response (MMR) credits MARVLIS in their annual report with reducing their costs associated with unloaded miles driven. As a collection, these improvements mean more than any single measure.

The reality is that our profession is fundamentally changing. We are coming from an EMS world where measurements of specific vital performance are evolving into a diagnosis of value. Just as good vitals indicate good health, positive measures of performance will be interpreted as higher value. In the same way that a general impression should guide a clinician in measuring vital statistics, the evaluation of an EMS should also be guided by a broader vision of value rather than a microscope trained only on specific measures.

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Lights and Sirens and Safety

lightsandsirensThe use of  lights and sirens is supposed to clear traffic by warning drivers or pedestrians that a public safety vehicle is approaching in emergency mode. The expectation is that the use of warning devices increases the safety of both the patient and provider by reducing travel time in responding to a scene or while transporting a patient to the hospital. Conceptually, this visual and audible cue is requesting that other nearby motorists yield the right-of-way to the approaching ambulance.

While lights and sirens are a fundamental cannon of every agency’s standard operating guidelines, their efficacy has never been proven to positively impact patient outcomes. To the contrary, there are examples nearly every day of the failures of these warning systems to provide a safe transport. Just last night there was an accident as an ambulance broke an intersection in Orlando and a few days earlier another crash was reported in Chicago. And literally as I was writing this post, an ambulance from a small town in New York was also hit at an intersection. If warning devices worked, why do we see so many accidents?

In our current age of evidence-based clinical practice, it is more than fair to question operational procedures as well. Studies have shown full use of lights and sirens decrease hospital transport time by only 18 to 24 seconds per mile when the ambulance trip is less than five miles – and there is virtually no time savings at all when the transport is over five miles. Additionally, studies show that the operation of ambulances with warning lights and siren is associated with an increased rate of collisions.

According to a 2010 report on EMS Highway Safety by the National Association of State Emergency Medical Services Officials, “no evidence-based model exists for what ‘mode’ of operation (lights and sirens) should be used by ambulances and other EMS vehicles when dispatched and responding to a scene or when transporting patients to a helicopter landing zone or hospital. A New Jersey based EMS provider, MONOC, has produced a video that aims to protect EMS providers through creating a culture of safety and limiting the times that warning devices should be used. We do know accidents happen when lights and sirens are used. We also know they save very little, if any, time in transport. But no one wants to completely eliminate them. They are in about the same position as the long spine board. We shouldn’t use them as much as we do, but they seem to still have a proper limited space of operation.

In attempting to limit their use, we can come up with some crazy ideas. A new protocol affecting 15 West Michigan counties calls for the use of emergency lights and sirens only to “circumvent traffic,” primarily at intersections, by ambulances transporting patients with life-threatening conditions. Once traffic has been circumvented, lights and sirens are to be turned off. This seems potentially dangerous  as drivers have less warning of an approaching ambulance leaving less time to react. In my experience, drivers are already confused on exactly what they should do when they finally realize we are in a hurry behind them. My other personal concern would be the impression left with drivers when the lights and siren are switched off after “circumventing the traffic.” Will the public incorrectly view the situation as an abuse of the “privilege” to run emergency traffic just to clear traffic? In researching some of these questions, I ran across a serious question from the public asking “if the guy dies do you turn off the siren?” We have failed as an industry to teach the community what we do and how we do it.

The article, “Why running lights and sirens is dangerous” discusses not only the issues faced, but proposes steps that should be taken to reduce the risks associated with driving ambulances “hot.” One objective for safer operation is to reduce the miles that ambulances travel under lights and sirens. The Michigan protocol attempts to accomplish this objective by requiring them to be switched on and off throughout the trip, but another alternative is to change the starting point of an ambulance prior to responding to a call. Many services already accomplish this through dynamic deployment to hot spots of forecast demand which has shown to be effective in reducing both the distance traveled in emergency mode and reduces the overall response time as well.

Carefully consider, within your protocols, when to use the warning devices available to you. Never assume that they “grant you” any right-of-way, as they can only request motorists yield it to you. It is always your obligation when operating an ambulance to drive cautiously for your own safety as well as the public. You can change the culture of ambulance operations to prevent accidents and be safe!

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Toward a Better Understanding of Dynamic Deployment

I recently had two articles published by EMS1 as a couple of “mythbusting primers” on the topic of dynamic deployment. The articles were Dynamic deployment: 5 persistent myths busted and Dynamic deployment: 5 more persistent myths busted. My intention was not to convince anyone of a position that opposes their current EMS world view pertaining to deployment models, but I had hoped to extend the work Dave Konig began in The EMS Leader defining the terms of EMS resource deployment in 2013 and to have an open discussion about it. My hopes of engaging in dialog fell somewhat short of my expectations. But after watching the presidential debate last night, I understand that the idea of a robust “give and take” may be more difficult to achieve in public interaction than simply setting a stage with opposing actors.

One comment I received the first week after publication of my articles was a posting that basically just left a link for an article by Dr Bryan Bledsoe from 2003 entitled “EMS Myth #7: System Status Management Lowers Response Times and Enhances Patient Care.” The assumption being that the topic was settled long ago. While I have great respect for the man who calls himself “The EMS Contrarian” and his robust body of writings (including by first EMS textbook), I respectfully disagree with the finality of some of his assertions. A great deal has changed in the past 13 years. Some readers may actually recall that MySpace debuted the same year that his opinion was written. For those who do not recall that social media phenomenon, MySpace was a precursor to Facebook that was once the largest social networking site in the world – even surpassing Google as the most visited website in the US. This was also a time when almost every patient was administered high-flow O2 because it was considered safe, even if not always effective. Fortunately, the evidence-based movement in EMS has caused many practices to be re-evaluated both for inclusion as well as exclusion. And computer technology has also made great developmental strides from the 2003 introduction of the first wristwatch cellphone named the Wristomo. At that time, engineers were still thinking of wearable technology as a cross between the 2-way wrist radio device that became iconic for Dick Tracy in the 1940’s comic strip and the modern flip phone of the day. Naturally, the device was designed to be easily unclipped in order to hold it to the ear like a traditional cell phone. It even offered an optional cable allowing it to exchange data with a computer. The development of Bluetooth freed designers to reconsider how a smartwatch could interact in an entirely different way with a user’s smartphone. The evolution of dynamic deployment has followed a similar trajectory.

Gartner_Hype_Cycle.svgThe Gartner Hype Cycle is a graphical and conceptual presentation that describes the maturity of emerging technologies through five common phases. Each year, the organization follows several technologies through this consistent cyclical journey. While EMS deployment was not one of these tracked technologies, I would submit that the initial technology trigger in the case of dynamic deployment would have certainly been the work of Jack Stout on System Status Management in the 1980s. His publications in the Journal of Emergency Medical Services (JEMS) throughout the decade inflated the expectations for performance returns. Implementation issues however, contributed to it sliding down into the trough where many disillusioned system providers left it for dead around Y2K. But the story doesn’t end there. The combination of his economic theory with Geographic Information Systems (GIS) provided a new operational view of both demand as well as current positions of available vehicles reported in near real-time with growing bandwidth. The advancement of computer processing has allowed some of these same Stoutian concepts to now be performed in real-time. With practice in modifying the parameters, the concept of Dynamic Deployment has become, as one comment to the article stated, effectively SSM 2.0. The benefits are no longer theoretical or even limited to Public Utility Model services, but are being realized by both public and private EMS providers climbing the slope of enlightenment or who are content with the productivity gains they have already reached.

JCMCresponsetimevROSCOne of Stout’s assumptions that has changed since the Bledsoe article is the “20 week” rolling window for analysis. This is too broad of a query that effectively combines different seasonal impacts throwing off focused projections not improving them. Experience shows that just a few weeks backward or forward from the current date for only a few previous years gives the best demand  forecast. Tests conducted at BCS show that MARVLIS correctly forecasts 80-85% of calls in the next hour by identifying hotspots that are limited to approximately 10% of the overall geography. Going back too many years, as Bledsoe was led by a consulting statistician, can actually unfairly weight more established neighborhoods while undervaluing newer communities. The clinical significance of shorter response times is not always in the “37 seconds” that are saved or even in meeting an arbitrary response goal, but in reducing response to a meaningful 4-minute mark. Achieving this milestone has had a proven impact on ROSC in New Jersey for instance. And beyond clinical significance is contractual obligation. Like it or not, EMS is often judged (and even purchased) similar to fire protection – by compliance to a time standard. Software makes a difference in meeting those goals. Running a system so that it performs well in most cases means it is more likely to perform well in the cases where it really does matter to the long term health of the patient.sedgwick_compliance

The increase in maintenance costs of 46% as claimed by Bledsoe has also been disproven with services showing a reduction in the number of unloaded (non-reimbursed) miles driven and even a reduction in the number of post-to-post moves in favor of post-to-call dispatches. By reducing fines for late calls, some services have found significant cost savings compared to previous operations.

In trading station lounges for the cramped cab of an ambulance, there has been a genuine cost to the paramedics and EMTs. However, the argument they make is not about fixing the plan, but rather it becomes an attempt discredit the foundation of that plan completely. Consider the fact that most field providers in a closest vehicle dispatch operation describe a “vortex” that traps them in an endless cycle of calls if they do not escape it in time. They find ways to try to beat the system rather than suggest that recommendations account for the unit hour utilization by vehicle and allow busier units to leave the high call volume area and move to less call prone posts to complete paperwork and recuperate. It is not that the strategy is inherently evil or wrong, but is designed to support a business philosophy that is not properly balanced, so the outcome becomes skewed. It is time to stop challenging the core notion and focus on specific concerns of the implementation that will make the system work better for all participants. As long as we demonize the idea, we will not be able to impact how it works.

Much like the polarization of the presidential debates, I have learned from experience that when we perceive only bits and pieces of the world around us, our minds fill in the blanks to create the illusion of a complete, seamless experience, or knowledge of a system in this case. Sometimes that interpolated information is no longer correct and it can keep us from participating in the crafting of a solution that truly works for everyone.

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Consumer Apps in EMS

The tools used in EMS are constantly changing, but one of the most powerful devices available to nearly every ambulance is the smartphone. However, the vast majority of these devices are owned personally by the crew assigned to any rig. While this may be acceptable to the employee who retains control over the personalization of their own device, it can lead to many potential problems for the organization. The advantage for the agency, however, is not having to purchase or support these devices. A trade that many services are apparently more than willing to take as my own non-scientific Twitter poll failed to discover any services that specifically ban the possession of personal phones while on duty. What did surprise me was that only 15% of respondents stated specific policies were already in place regarding their use.

 

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Over the last few years, the number of medics with personal smartphones has only increased. This is due, at least in part, to an evolving workforce integrating the millennial generation that never knew a world without personal communication devices. Over those same years there have been several good articles that describe the potential of using them at work including “10 Apps Every Paramedic Should Have” or “EMS Apps Make Life Easier“. Many of these apps are focused on patient interactions such as drug identification or calculations, language translators, or a digital version of your protocols. Some, like the Northwest MedStar Alert app, are actually designed for operational improvement at the system level. This particular app allows a GPS coordinate from the phone to be sent directly to the flight communications center and even sets up a secure dialog between responders and hospital staff. (One of the best features to that app may be having an accurate ETA for the helicopter!)

padOther authors are more excited about the near future, such as in “How EMS will benefit from smartphones and connected vehicles“. There are multiple studies currently going on regarding the potential of  bringing a virtual physician presence to the scene in order to evaluate a patient. The article “Mobile Devices Speed and Streamline Pre-hospital Care” identifies one of these telemedicine projects targeting stroke. The evolving mobile eco-system has also given birth to some new private businesses. Medlert is just one example of an app built specifically to optimize patient transport schedules using smartphones.  As EMS agencies become increasingly comfortable with leveraging more cloud-based services, there will be more development in the market.

Use of any of these apps (and the personal devices they depend upon) comes with certain caveats and risks. Many apps commonly state disclaimers about their use, particularly in emergency services, so it is worth reading the fine print.

 

 

According to a recent Pew Research Center study, 74% of adults use a smartphone for directions based on location. Another Twitter poll that I’ve conducted shows that using a smartphone app is fairly common for “ambulance drivers” as well. But how good are these routes when we are in an ambulance, especially one that is driving “emergency traffic”? If an agency can provide its own web service based on road data that it controls, the routing can be very good. With MARVLIS Impedance Monitor, an agency’s data can be automatically modified to reflect the travel times common to a fleet during specific timeframes and on certain days and for different seasons learned from actual emergency traffic experience.

There is less control when a commercial routing service is used through a consumer app. Google Maps has an option to show real-time traffic and Waze boasts being the world’s largest community-based traffic and navigation app where drivers share real-time traffic and road information. Waze is interesting in that it was created as a social navigation tool for passenger cars. So, if you plan to use it on an ambulance trip, it would be best not to “share your route” with friends or other contacts. For that, there is a “Go Invisible” option you must choose in order to keep any potential identifying data private.

wazewindowIs simply “outsmarting traffic” really what we need to be doing, though? Apps like Waze are great to help you avoid the congestion created by an accident that is tying up traffic. But when the traffic accident IS your destination, avoiding it is not a recommended route for you to take. For most vehicles, commercial routing and real-time traffic is hugely valuable. But for an ambulance, not so much. Routing normal cars and trucks is relatively simple because there is a set of rules they must abide by in motion that can be easily modeled. Emergency vehicles, including ambulances or fire apparatus, often break those rules by traveling along the road shoulder or even crossing a median into the oncoming lane of travel. The normal direction of one-way streets can also be ignored at times.  No regular commercial app takes these routing options into account. It requires you to track your own vehicles and learn patterns from those operations only. A final consideration is how you may, inadvertently, influence the decision-making on a social routing app for others by including your behavior with all of the other vehicles on the roadway.

There is no question that you will be using, or allowing the use of, smartphones for a wide variety of purposes. What you need to do is be sure your staff are using the right apps for the right applications. We often like to think we are different, and in many ways we are very different indeed from most “consumers.”

We are interested in keeping this conversation going with your experience and ask that you share what apps have you found to be useful on the ambulance, or cautions about them, in the comment section below.

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What If We're Wrong About Response Times?

Anyone who follows my posts here, or on Twitter, will recognize that I consistently argue for the value of prompt responses by emergency vehicles to nearly all incidents. However, this post will be different thanks to an inventive challenge through EMS Basics asking bloggers to consider an opposing view to their favorite topic. You can read about the challenge and link to other participating blog posts in The Second Great EMS What-If-We’re-Wrong-a-Thon.

There actually are some valid arguments against rapid responses, so let me begin with pointing out the lack of a recognized national standard. If a short response was really an evidence-based practice, there should be some agreement on exactly what a “short response” means. The NFPA and NIST standards suggest response times for all hazards, but are really focused on requirements for structure fires and have more to do with the central placement of stations than the speed of fire spread in a structure. The nature of this fixed deployment strategy becomes even more problematic for medical responses as there tends to be far fewer ambulances in comparison to fire suppression apparatus.

A shortage of resources is therefore, a compounding problem. Ambulance response time goals often vary tremendously by locality and type of service. Response time goals become a result of compromise matching community expectations with financing – not the science of resuscitation. Often contracts with private services are drafted to simply improve on the current response times rather than meet an objective goal with a defined clinical outcome.

The clock is an easy measurement device that is more easily understood than many other proxy measures of the quality of our service. And pushing for more (faster) response makes a contract negotiator look like a winner. Unfortunately, there is a heavy cost to pay to chase these ever increasing goals. And for services who cannot meet these objectives, there is either embarrassment, financial ruin or the flexibility built in to the start and end times for the clock. In other cases, there are rules for simply ignoring exceptions to the goal as outliers. Without standards on measurement, why do it?

Trends are showing a higher demand for services which translates to an increased demand in resources which in turn raises system costs unnecessarily. Recent studies have also shown that response times do not improve clinical care in the vast majority of cases. In fact, there are a significant number of responses that don’t even require an ambulance at all. Proper emergency medical dispatching through improved triage at the call taking phase can reduce the effective number of emergent calls that demand immediate responses.

Finally, there is also a growing awareness lately to the safety of providers. Studies show that the use of lights and sirens are risking the lives of responders and even the public. Ambulances driving at excessive speeds for most calls is just illogical and unsafe.

I would like to thank Brandon Oto for issuing this writing challenge. Viewing a problem from a new perspective is quite a liberating opportunity. I believe that in this case, there clearly is still a good reason to debate the need for rapid responses. However, I will continue that debate in a follow-up article from my own perspective.

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EMS Today 2016 Review

It was my privilege to have been selected as the Official Blogger of the EMS Today conference for 2016. Like my predecessor, Tom Bouthillet at the EMS 12-Lead blog, I took that role very seriously and visited as many of the sessions, vendor exhibits, and even socials (they are definitely part of the experience) as I possibly could. Throughout the conference I posted my impressions live on Twitter through my @hp_ems account using the hashtag #EMSToday2016. But I know many people either couldn’t, or simply didn’t, watch that whole feed over the four days that I was tweeting live, so I felt a summary blog of the highlights was definitely in order. If you were there, I hope I saw you and that my remarks will echo your own experience. But I would also like to ask that you include your own impressions as comments at the end of this post. If you weren’t there, you missed a lot. And hopefully for you, this article can provide justification for you to make the trip to Salt Lake City next year for EMS Today 2017.

The very first time I attended an EMS Today conference, I arrived on the first day of the show only to discover that I was actually more than 24 hours late. By not arriving early, I had missed tons of great content presented during the pre-conference sessions the day before. While they definitely add an expense to attending the meeting, they also add anywhere from 4 to 8 hours of detailed content (as well as CEH) that you just won’t get in the faster paced 60-minute sessions of the rest of the conference. This year, I opted to attend an afternoon cadaver lab hosted by Teleflex. Training with manikins and simulators is great, but it can only take your skills so far. But flushing a proximal humerus IO access with the chest cavity open, allowed me to witness first-hand the short vascular distance from the infusion point to the heart compared with femoral access. In addition, we had plenty of time to practice ETI with various devices on many different patients. I also had the chance for my very first surgical cricothyroidotomy. While the practice of these skills was highly valuable, the opportunity to simply hold the lungs while they were ventilated and explore the chambers of the heart with my finger were enlightening beyond imagination. Nearby, was another very popular choice for a pre-conference class in the Active Shooter Simulation. It was unfortunate, but just the evening before this shooter simulation class was a vivid reminder of its importance to us in the form of a gunman who killed 3 and wounded 14 more in Hesston, Kansas. Violence leading to an MCI can clearly happen anywhere and we must all know how to respond. Thanks to this timely offering, many more EMS providers are now better prepared.

Moving quickly from the lab to change my clothes, I headed for the formal EMS10 awards ceremony. This invitation-only event hosted by Physio-Control was an opportunity to rub elbows will the people marking their mark to improve the level of care in EMS today. You can always read about the 2015 EMS10 recipients and their innovations, but by being here I was able to run into them several times throughout the conference and even had the chance to speak with some of them to learn their detailed stories.

The next day (which officially began the conference) started early with sessions beginning promptly at 8AM. I was given reasons to consider “Point of Care Testing” by Kevin Collopy who helped me better understand what we can, and cannot, do today based on federal CLIA regulations and why to consider accreditation. Next was Jonathan Washko discussing the success of community paramedicine at North Shore LIJ EMS. The best part of being at a conference with such notables is hearing comments that challenge your work. Jonathan asked “if you can’t manage yourself, or control your own emotions, how can you manage others” and reminded us that it is “the strongest leaders who ask for help.” Then from my virtual visit to NYC, it was on to a global view of self-regulation in paramedicine with Michael Nolan, Gary Wingrove, Becky Donelon, and Peter O’Meara. A couple of great lines prompted a shift in professional thinking, like when being told that “as paramedics it is time to ‘move out of mom and dad’s basement'” and as we argue over the universal meaning of “paramedic” (or “ambulance driver”), “the patient, the media, and your mother should all know what to call you!” Over in the room where Ray Barishansky spoke on “proactive professionalism,” it was crowed as he said “we as a profession have let ourselves down with our behaviors, low pay, and attitudes.” Ray also reminded us that it is “professional EMS providers who own their mistakes, are respectful, and are always advocates for the patient” and asked us to give further thought to the idea that “93% of how you’re judged is based on non-verbal data.”

Plenty of more data was presented at the Prehospital Care Research Forum session hosted by David Page where I am proud to say North Carolina was nicely represented. We also learned interesting tidbits in these lightning talks such as “volunteer EMS services are 27% more likely not to transport (also to accept refusals, or do ‘treat and release’) than paid services” and that the gender differences in the use of restraint (chemical or physical) is not about the sex of the patient, but more likely to happen with male providers even though female providers are the ones statistically more likely to be assaulted. Matt Zavadsky along with Rob Lawrence (filling in for Nick Nudell) also presented plenty of facts in their session on the Data Dichotomy of the current EMS payer landscape. All of these sessions were going on as the JEMS Games preliminary competitions were being held to see who could brag about being the best of the best in EMS. If you want to see how challenging these “games” can be, here is a quick view of the obstacles that participants face to prove they can handle the job.

It was the mid afternoon that the official opening of the conference was held with all of the pomp and circumstance (including fifes, drums, and bagpipes) that you expect at any public safety conference. There was a somber recognition of our brothers and sisters in EMS who have answered their last call due to LODD along with multiple awards and a stirring multi-media presentation by alpinist Brian O’Malley. The prestigious James O. Page award went to NEMSMA for this ground-breaking whitepaper aimed at preventing EMS provider suicide. There was also a brief visit from Maurice Davis to promote his tribute designed to raise awareness and remove the stigmatism that keeps EMS providers, the military, and many others silent and leading all to often to “The Wrong Goodbye“. The video depicting the impact of suicide is something we should all be sharing with our friends.

It is after the keynote presentation that the exhibit hall opens for a brief reception. If you didn’t get to see it, follow along with a bodycam highlight video of the exhibit hall from my friend Jeffery Armstrong. I must also recognize the generosity of Limmer Creative who donated several of their LCReady classes for me to give away during the conference for people who were able to find me and even opportunities for followers who retweeted my post about the contest. Being social is beneficial!

As my friend Bob Holloway put it, “Day 2 was packed with sessions on EMS innovation, MIH (Mobile Integrated Healthcare), and creating value.” And what better way to kick that off than with a cup of coffee and a lightning round called “Ask the Eagles”? If you aren’t similar with the Gathering of Eagles, it is also known less colloquially as the EMS State of the Sciences Conference. This year’s conference was held the previous week in Dallas and consequently the session at EMS Today (always a favorite of mine) is packed with the latest EMS Pearls that will hopefully one day make it into your local protocols. This is where you can hear progressive medical directors from around the country like Bryan Bledsoe busting dogma with comments like “less spinal movement with self extrication compared to backboard extrication.” Unfortunately, I missed it this year to interview Ferno in a video on their innovative iNTraxx system to promote safety, flexible modular design, and increased efficiency. Watch for the interview made in conjunction with my friends from EMTLife later this week.

Over lunch on Friday, I heard Dr. Keith Lurie, CTO of ZOLL Medical, discuss the changing perceptions of resuscitation through “active compression decompression” during CPR and his ResQPOD impedance threshold device that together can increase one-year survival after cardiac arrest by 49%. There was also discussion of heads-up CPR which can significantly decrease ICP during CPR ad many other tips to help us improve CPR survival rates. This discussion was followed up by another visit to the cadaver lab for some hands-on with real human patients. Practice such as this really makes the charts and figures come alive! But what had to be my favorite session of the whole conference had to be the experience of behavioral medicine with David Glendenning and Benjamin Currie. Far from a traditional PowerPoint presentation, we were invited to take a very different look at patients with behavioral issues by experimenting as a group with schizophrenia and delving into the taboo topic of viewing ourselves as potential patients. David suggested that “dealing with PTSD is NOT a rite of passage in EMS and we need to acknowledge it is a real physical condition and begin to talk openly about it.” The session closed with a thought-provoking David Foster Wallace video from a commencement speech explaining how “sometimes the hardest things to see are all around us.” I hope you will take about 9 minutes and watch it. I would also like to recognize the fine efforts of The Code Green Campaign in this same area (as JEMS/Penwell also did.)

Another awesome session well worth mentioning was early on Saturday morning, it was called “Creating a Social EMS Culture” with Carissa O’Brien and Steve Wirth. While there were several good quotes, it is most important to note that “your EMS agency has a legal interest in your use of social media just as you have a professional one.” There are several legal considerations that include the US Constitution, National Labor Relations, defamation laws, HIPAA, harassment laws, and more; but the end game is not “big brother” watching your networking. It must be understood that your agency has a responsibility in “building a culture that breeds responsible digital citizens.” Just as we develop our clinical skills, “we need to train EMS providers in social media just as we would with any other skill.” This discussion is one that can continue even after the conference by participating with the #socialEMS hashtag in your favorite forum.

For those who attended, you can access the conference proceedings with the username and password you received at registration. I also hope you will add your favorite memories below to give others a more accurate record of the whole conference.

I could go on about meeting the paramedics from Nightwatch, my childhood hero Johnny Gage (Randolph Mantooth), being able to sit in Squad 51, or see the original Heartmobile that played a significant role in the development of EMS in America, but I really think it would be best if you just went ahead and registered for your own journey and plan to attend the conference next year.

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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.

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