Individuals and interactions over processes and tools.
The people of the organization are the most important thing, everything else is secondary.
The second highest priority is the delivery of quality healthcare to the community.
Providing good healthcare over profits, expansion, political jockeying, career advancement, or being progressive. Taking people to the hospital and being nice to them is 90% of the job.
Guidelines over strict regulations.
Protocols must be guidelines that allow people to accomplish the goal of quality patient care. Protocols should not be rigid doctrine that must be followed even if the results are deleterious.
Welcoming changing practices based on new evidence and knowledge. Evidence kills sacred cows and dogma – walk away from things that no longer serve a purpose.
Build projects around motivated individuals. This means hiring the right people – ones that you are willing to invest in over the long term. Build a team, not a workforce.
The most efficient and effective method of conveying information is face-to-face conversation.
You must talk with the providers in your system face to face – there is no substitute.
A sustainable work lifestyle.
You can’t successfully provide quality healthcare to a community by forcing people to work overtime for months at a time and burning them out.
Continuous attention to technicalskills. Skills must be practiced regularly or they will atrophy. Skills should not be the hard part of the job; thinking should be the hard part.
Simplicity – the art of maximizing the amount of work not done – is essential.
Get rid of the bullshit; in the documentation program and in anything else that prevents good patient care from happening. Simplify and streamline processes, remove things that suck the joy out of work.
At regular intervals, the team reflects on how to become more effective, then tunes and adjusts its behavior accordingly. Honest evaluations and feedback are needed at the individual and organizational level. When a measurement becomes a target, the value is lost.
I am not one for manifestos. I don’t really like the word manifesto as it has taken on a meaning different than the actual definition, but it is what the original document was called when a small group of software developers that were fed up wrote the Agile Manifesto in 2001.
Make no mistakes here, this is idealistic, hell, maybe it is even unrealistic but it might be what is needed.
Ketamine may do which of the following in a patient with shock:
A) Raise blood pressure
B) Decrease blood pressure
C) Not cause a change in blood pressure
D) All of the above
There are some misconceptions about ketamine in emergency medicine and specifically in EMS. Some EMS providers believe ketamine will ALWAYS raise blood pressure, acting like a vasopressor. Ketamine is a great drug but in some patients it can decrease perfusion.
It began as a beautiful idea but it is almost unrecognizable now. It has become something dirty and impure, a tool for power hungry people to label others and think they are doing something productive.
Just culture has become another bureaucratic policy, another mandatory training that people have to sit through while staring at bad PowerPoints and watching the clock.
“Think about it. 7-Elevens. 7 dwarves. 7, man, that’s the number. 7 chipmunks twirlin’ on a branch, eatin’ lots of sunflowers on my uncle’s ranch. You know that old children’s tale from the sea. It’s like you’re dreamin’ about Gorgonzola cheese when it’s clearly Brie time, baby.”
I spend way too much time on EMS social media. I am fascinated by some of the comments that are posted – the dismissal of science and rational thought, the flawed logic, and the ignorant certainty that abound in the comments section provides a window into the flawed inner workings of the human brain.
I recently stumbled onto the reflective judgment model by King and Kitchener. It seems to be a decent tool for exploring and identifying the behaviors in EMS social media commentary and EMS in general. Reflective judgment is the process of thinking about how you know what you know and how true those facts are. There are seven levels of reflective judgment proposed by King and Kitchener in their 1994 work, Developing reflective judgment: Understanding and promoting intellectual growth and critical thinking in adolescents and adults.
“You have to get ROSC before you get anything else.”
“If patients don’t get ROSC they can’t live, so anything that increases ROSC is giving that patient a chance.”
It makes sense to think that ROSC is an important outcome, at least on a superficial level. Patients need to get ROSC at some point if they are going to have a good neurologic outcome. It is true, but it is a half-truth and unless it is examined health care providers will continue to administer ineffective and perhaps harmful treatments.
Questioning the benefits of stroke ambulances seems to be in vogue lately in certain circles. In the interest of self-promotion these individuals love to point out the perceived shortcomings of others. As an EMS leader and agent of change, I feel I need to bring some clarity to this issue. I will outline the many benefits of having a stroke ambulance in your community below. Continue reading “Why you need a stroke ambulance by Chet J. Reilly (guest post)”→
With absolute certainty the EMS empty suit proclaims that a college degree will fix all the issues EMS faces both today and in the future. Strangely, many of the proponents of a degree requirement do not even have a college degree themselves. They honestly believe it is a simple equation of supply versus demand. Degrees will cause there to be fewer paramedics and therefore increased demand for paramedics, which will fix everything. Complex problems rarely have simple answers.
Raising the barriers to entry and decreasing the number of paramedics won’t automatically equal higher pay for paramedics, it might just create more bastardized dumbed-down version of paramedic to skirt the regulations- think EMT-Intermediate,* Advanced EMT–Critical Care, Cardiac-EMT, Enhanced EMT, IEMT and all the other alphabet-soup flavors of ALS-lite that exist for communities that can’t or won’t pay for paramedics to be on staff or volunteers that don’t want undertake that much education to help out their community. 
I thought doing quality assurance (QA) at my EMS agency was going to be a simple matter.
I was wrong.
A decade ago the QA person at my agency resigned. Because I was a willing, warm body I got the job. I didn’t get any training on how to do QA, but I also didn’t think I needed any – besides, it was just going to be a matter of reading reports and telling people when they screwed up.
Over the past decade, I have learned many lessons while doing QA; more than a few of them have been about me as a person than how to do quality assurance. Being blinded by ignorance (along with a side of arrogance) I was certain in my approach – treatments could be labeled right or wrong, protocols were followed or they weren’t and providers were either good or bad at their job. If you made a mistake the solution consisted of write-ups, remedial training, and discipline. I made complex flow charts to grade medical errors by the level of harm to the patient. The level of harm dictated the actions that followed. Level 2b yellow was bad but not as bad as a level C3 orange. God help you if you were found guilty of a level 4 red event.
The Dunning-Kruger effect was strong with me. There is nothing simple about doing quality assurance for EMS. From time to time I try to share what I have learned from doing this job. What follows is something that might have been better as two separate posts, or maybe you can view it as a two-for-one deal. The Outcome Bias
The core concept of the book is the WRAP process. In the heat of the moment it can be hard to remember all of this so I made a pocket sized cheat sheet to consult before making some decisions. It is tailored to my needs and some of it may not make sense to you, some of it is a bit abbreviated. You obviously cannot completely avoid some of the biases, but for the sake of brevity I put “avoid” instead of “really try to avoid…”
For example: I am not a morning person, at all. I am cranky until I have ingested about 600mg of caffeine and should probably make as few decisions as possible before 10am. We were having a discussion about our protocols and if we should approach the state to attempt to get a waiver for non critical care certified paramedics to transport patients on levophed on inter-facility transfers. Should we or shouldn’t we ask the state?
I was going back and forth with it internally. No we should just require everyone to get a critical care certification. Maybe we should try for the waiver so that it shares the load among the crew, so yes? No, why should people get to have the standards lowered, they should have to do the work like I did and get an FP-C. Yes, it isn’t rocket science, it is titrating a medication to a BP. No, because then what was the point of me getting a CC cert? No, because it is going to mean we cannot charge the medicare SCT billing rate when they take the transfer. Yes, because we should focus on building people up. I don’t know…
Should we do it or not?
I was still several hundred milligrams short of my therapeutic dose of caffeine when a single neuron somehow fired and I was able to form a cogent thought. I realized I was falling victim to narrow framing and the the trap of “should we or shouldn’t we?” I needed to widen my view and figure out my goals.
The wider view was simply to ask what are we trying to accomplish here? We are trying to get sick patients to the right place in a timely manner. Often the weather shuts down the option of flying and they must go by ground transport for 2-3 hours from the local level IV to a level II or I hospital. It would be tragic to make a patient sit in a ER room or get admitted to a level IV when that is what they do not need. We are trying to get patients to where they should go in a timely manner, does approaching the state about a waiver for non-critical care paramedics to transport vaso-active medications on IFTs align with these goals? I think it does. Can it be done safely with the proper training and education? I would say yes.
“Yes, we should approach the state about a waiver.
And then I slowly sunk back in to the haze that is my early morning and wondered if I should or should not have another cup of coffee.
Feel free to copy this, mock it, edit it, share it or anything else you might want to do with it.
For every EMS provider that understands what a NNT or P value is, there are ten out there that think backboards save lives and that oxygen is somehow a pain med. For every provider that knows the difference between a Randomized Controlled Trial (RCT) and an observational study, there is an army of providers that believe asystole is an indication for naloxone. Show me an EMS provider who knows about what the AHA means with their proprietary class IIb recommendation (see below if you don’t know) and I will show you a hundred providers who are convinced that oxygen is a lifesaving intervention in a normoxic myocardial infarction patient.
Mary Baker Eddy authored the book of magical Christian Science nonsense, “Science and Health with Key to the Scriptures” in 1875. I find myself consulting a somewhat similar book with some frequency, “EMS Protocols Version 10.” Both books deal with raising the dead and treating the sick and injured and both books are far from being what one could consider science as they rest on a large foundation of anecdotal evidence and appeal from authority.
The 2015 AHA Emergency Cardiovascular Care Guidelines (AKA ACLS) which sort of forms a default standard of care* in our industry are mostly based on opinions and limited data. Shockingly, 46% of the recommendations in the guidelines are drawn from studies with limited data sets and 23% of the recommendations being based on “expert opinion.”
Much of what we do in the name of ACLS either does not work or does not work and might be harmful. Instead of asking if a medication works we have entered some sort of weird “the emperor has no clothes” paradigm. We now have to prove things do NOT work before we stop subjecting patients to out “treatments.” Painting with a broad brush here, for the average patient some of our treatments are about as effective as Reiki.
Some examples of what I mean:
Amiodarone in cardiac arrest: No better than a placebo in terms of increasing CPC scores.
Epinephrine in cardiac arrest: Not helpful in cardiac arrest in terms of increasing CPC scores , likely harmful
Saline in trauma: harmful in large doses
Backboards: No benefit in terms of immobilization, possibly harmful
C-collars: No benefit in terms of immobilization, possibly harmful
Lasix in acute pulmonary edema: No benefit, probably harmful in acute pulmonary edema
High flow oxygen in the normoxic patient: No benefit, harmful in some patients
Lights and sirens: Little benefit, high risk.
TPA ambulances: No benefit (except marketing)
Lucas devices: No benefit over well performed CPR with adequate rescuers, may be harmful
Surviving sepsis guidelines (30ml/kg for ALL patients): May be harmful to some (most?) patients
Some Supraglottic airways in cardiac arrests: No benefit in most cases, may be harmful
And let’s not forget a laundry list of our greatest misses involving things like MAST, high dose epinephrine in cardiac arrests, Therapeutic hypothermia following cardiac arrest, sodium bicarbonate in cardiac arrests, stacked shocks, treating “malignant” PVCs, and whatever else lurked in the drawers of the Plano box that you would give during cardiac arrests. The issue is all of these things made sense at the time; they all seemed like good ideas at the time.
The problem is the trend continues in EMS.
We simply refuse to learn from the past.
In the name of being a “progressive” agency, EMS is yet again engaging in alternative medicine. A small study on anesthetized pigs shows promise in performing heads up CPR and suddenly an EMS agency is being progressive and performing heads up CPR. If the science does not pan out and patients end up getting a treatment that made them worse, please accept our apologies in the name of “progress.”
But what is a bit of human sacrifice when things like marketability and JEMS articles are at stake? All those dead patients are just grist for the mill, casualties in the war against the status quo.
I fully support well done randomized controlled trials in medicine and many of our current practices need to be placed under the magnifying glass of an RCT; but an agency simply rolling out a new unproven, poorly researched treatment and touting their “results” does not equal an RCT. As providers, we have very little skin in the game here, we have all the upside if the new hotness works and we have none of the downside. If the treatment turns out to be causing harm we simply wash our hands of it and talk about it in blog posts like this a few years later. We don’t consider the countless dead we left behind when the next new shiny thing comes our way.
Another disturbing trend that is emerging is that of the “compounding resuscitationist” phenomenon. I agree that standard dose epinephrine either has little meaningful effects or is somewhat harmful. If I were to suffer a cardiac arrest I do not want any epinephrine given to me, and a sort of DNE form (Do Not Epi) might need to be created. I think a drug without any proven benefit and an association with harm should not be given to patients. Unfortunately many people are playing mad scientist and coming up with their own proprietary dosing regimens: adding a milligram to a liter and running it in over 20 minutes, spaced out dosing, giving some random dose of epinephrine, dosing based on etco2, giving only one or two doses, or a number of other alternative dosing regimens. This is not science, it is alternative medicine. It does not clarify anything; it only muddies the waters further.
Should we even discuss the madness that stroke ambulances are? Perhaps that is topic best left to a separate post.
There is a certain satisfaction one may get from being progressive. It feels good, it strokes the ego a bit when you have new information and do things other agencies are not doing. It may even generate some attention for you and your agency, especially if you are good at self-promotion. As long as you continue to employ the confirmation bias and only remember the few times the progressive movement was correct it is easy to continue this dangerous trend. We owe it to the dead to proceed with caution and diligence and avoid the seductive power of progressiveness.