14 in 13

A 14 gauge IV in a 13-year-old girl

Teresa Forson lost her job as a firefighter because she started a 14-gauge IV on a drunk 13-year-old and then lied about the circumstances surrounding the event.

The 13-year-old girl was alert and ambulatory with stable vital signs. Many people on social media defended the firefighter, feeling that termination was uncalled for, that it was excessive and that really, this was not that of a big deal. In one sense they are right, a 14-gauge IV insertion probably doesn’t hurt much more than a 20-gauge IV does and since no harm came to the patient from this incident, what is the big deal?

Intent is the big deal. Intent is what matters. Either these paramedics need some serious remediation on when large bore IVs are needed, or this was a punitive act. I can’t truly say what occurred in the back of that ambulance between the surly drunk teenager and the firefighter as I wasn’t there and I don’t have all the facts, but it sure sounds a lot like punitive medicine.

Practicing punitive medicine is indefensible. It points to low levels of emotional intelligence and poor impulse control. I certainly have had moments in my career where I have contemplated doing it to patients. When I first started in EMS, I believed that “drunks get 14’s,” and I was more than ready to plug some 14-gauge IVs into the next drunk patient I encountered. It would take a few years of working in EMS before I realized that there might be a better way to learn how to care for patients than teaching via war stories from people who had repeated their first-year twenty times over.

A lack of emotional intelligence training in healthcare education.

Healthcare education rarely teaches about soft skills like emotional intelligence. These skills will be used on almost every EMS call, on almost every shift and yet we don’t talk about them. Time is sent on garbage like the KED and taping people to plastic boards.

Emotional intelligence may not be real form of intelligence, there certainly appears to be a debate about that. It may be more pop-psychology than an actual science, but the skills and attributes emphasized by it are very real and can save or prolong a career.

Increasing emotional intelligence can change how you relate to the bullshit calls. If you have worked in EMS for some time you have probably encountered people that were extremely intelligent in the conventional sense yet had astoundingly low levels of emotional intelligence. These people are smart but they tend to explode over small things or end up doing some sort of punitive thing to a patient that ends their career.

“If your emotional abilities aren’t in hand, if you don’t have self-awareness, if you are not able to manage your distressing emotions, if you can’t have empathy and have effective relationships, then no matter how smart you are, you are not going to get very far.”
-Daniel Goleman

Emotional intelligence has four or five components to it depending on the source you read; self-awareness, self-regulation, motivation, empathy and social skills.  Each component is important but self-regulation  might be the most important when it comes to not getting fired and not fucking up your life in general.

Having impulses to punish a patient is not the problem; not being able to control the impulse is a problem. You can hate your patient, you can get pissed off at them, you can find them annoying, but then you move on and do your job like a professional. I have had more than one fantasy where I tell  my partner to pull over on the side of the road and kick a patient out of the ambulance in the middle of nowhere because they annoyed the shit out of me.

The obstacle is the way.

The impediment to action advances action. What stands in the way becomes the way.” -Marcus Aurelius

The Obstacle is The Way by Ryan Holiday is a short book that might change the way you look at the world. Anyone working in healthcare should read it. It transforms how you relate to all the bullshit encountered in healthcare.

In EMS there really are only two kinds of calls—bullshit calls and good calls.

The drunks, the pointless nursing home runs, the patients with back pain that should just harden up and deal with it, the rambling psych patients who went off their meds, the uninjured person that “just wants to be checked out” in the middle of the night, the repeated accidental life alert alarm activations, a pair of piss soaked pants rubbing on your pants, patients with shit packed under their fingernails that keep trying to touch you, drug-seekers, COPD patients smoking while on oxygen and complaining of shortness of breath, the 25-year-old male with chest pain at the jail, and the morbidly obese that are will blow out your back. These are the kinds of patients that suck the life out of healthcare provider. These are the kinds of patients that on bad day are easy to hate. You might even tell yourself that these patients are the obstacle to your happiness at this job—that if it weren’t for the bullshit calls you would be happy at work.

The bullshit calls are the obstacle and they are the way.

You can still be annoyed or pissed about these calls. I certainly am from time to time, but it happens less than it used to, and it has becme more of a passing thought than anything else. It is not a strong reaction. I may not like the patient, or I might be mad, but it is not a big deal. It does not linger; it does not ruin my day most of the time and it certainly doesn’t cause me to lose control. It is more along the lines of when I want Coke and must settle for the apologetic “is Pepsi okay?” Being annoyed about these calls doesn’t accomplish anything, being pissed off about these calls is a waste of time and energy.

Marcus Aurelius asks, “Does what happened keep you from acting with justice, generosity, self-control-sanity, prudence, honesty, humility, straightforwardness?”
No? Then brush it off and move on. If an asshole patient can control your actions, you probably are not really in control as much as you like to think you are.

Making it a practice.
If I get mad, they win.

When presented with an especially difficult patient I remind myself, I get mad, they win.

If a patient can provoke me to a point where I lose my composure, they win. Don’t get me wrong, I’ll escalate appropriately and professionally when needed; I’ll stab someone in the ass with 400mg of ketamine without a second thought and I’ll fight if I have no other choice. But I won’t act out of anger and I won’t give out punitive measures.

A drunk 13-year old girl certainly could be considered just another bullshit call. Or it could be an exercise in patience and self-regulation; it could be a lesson in managing your emotions.

“I don’t want to be at the mercy of my emotions. I want to use them, to enjoy them, and to dominate them.
-Oscar Wilde

 

The Agile EMS Manifesto

Presentation1

 

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 technical skills.
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.

 

Adapted and/or straight up plagiarized in parts from: https://www.agilealliance.org/agile101/12-principles-behind-the-agile-manifesto/


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: The Sex Panther.

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.

 

sex panther
“Sex Panther by Odeon. 60% of the time, it works every time.”

Continue reading “Ketamine: The Sex Panther.”

Just culture is dead.

Just culture is dead.

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.

If your organization thinks that embracing just culture is using an algorithm to decide if someone can be blamed for something or not, then it has already failed. Continue reading “Just culture is dead.”

A field guide to EMS social media commentary: the seven levels of reflective judgment, plus a story about my roof.

“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.

Level 1: “I’ve seen it work.”
This is the land where anecdote is king and correlation is causation. Continue reading “A field guide to EMS social media commentary: the seven levels of reflective judgment, plus a story about my roof.”

Something About Nothing: ROSC is a Meaningless Outcome (and The 2018 ACLS Update).

ROSC is not an outcome that matters.

“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.

Resuscitation is more than the sum of its parts. Continue reading “Something About Nothing: ROSC is a Meaningless Outcome (and The 2018 ACLS Update).”

Why you need a stroke ambulance by Chet J. Reilly (guest post)

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)”

The Empty Suits of EMS.

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. [1]

Continue reading “The Empty Suits of EMS.”

The one about the outcome bias.

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

Almost every decision you make is a gamble. Continue reading “The one about the outcome bias.”

Wrap It.

I just finished reading Decisive: How to Male Better Choices in Life and Work by Chip and Dan Heath. If you have an interest in making better decisions you should read this book.

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.

decisions