What Do You Think We Are Doing?
Let’s talk about EMS for a minute…
There are industry-level publications, internet sites independent from the magazines and countless bloggers out there that have an opinion. I am no different. I pluck away at the keyboard and think that I can provide some insight, using the experience, which at this point, has spanned more than 20 years. Sixteen of that being in a busy(ish) urban department as well as the private sector, volunteer and any combination of the above. I have been in and out of administrations and held several command positions. I try to give my take on issues that I think warrant attention. I just finished my 24-hour shift which consisted of 8 calls. Not a bad shift. A little lighter than normal. I’m used to the double digits. We didn’t get beat up too bad. So anyway, I know you didn’t ask for my opinion, but you are still reading this so you might as well hear what I’m on my soapbox about this time. Have you a few minutes to kill? Or, at the very least, are you wondering if I will say something witty or lay on the sarcasm that is familiar to just about everyone in EMS? Read on to see if your dreams come true.
So today’s rant; pre-hospital emergency care! Shocker, I know!
Ahhh yes, what we all are doing whether we like it or not. What even the busiest departments in the country can no longer ignore. The fire service’s under-appreciated step-child (in most places) and the thing that pays the salaries of a lot of “dragon slaying”, “grievance filing”, “door slamming, when they get a run”, “treating their patients like shit because they have to be on the medic unit” fire service employees. The thing that has kept some departments afloat during hard financial times. That’s what we will be talking about this time, so let’s explore what is rattling around in my head.
What do you think we are doing out here? It’s a weird question to some, simply because I don’t think it is asked too often. When you ask the new guy or gal, he or she will say we are out here to save lives by implementing all of the groovy things they taught us at the learning annex in our emergency medical technological implementation class. If you ask the “salty dog” they will say that we are the ones crazy enough to stay up for 24 hours straight to cart the crazies to the ED so they can jump on the bus and be back home before you are done with your report. My opinion of us is somewhere in the middle, I think. You may not perceive it that way by the end of this post, but who knows.
I can hear you saying, “get to the point” so here we go (you’re not the boss of me by the way). When I was a young, green, two-pager-wearing, CPR mask on my belt, car lit up like a Christmas tree EMT; I was ready to save the world with the 120 hours of training that I received. I was ready to be a “code buster” as noted on the t-shirts of my local squad and ready to snatch people from the jaws of death like I had read about in all of the periodicals stacked up at the squad house. I was “doin it” on the 68 runs I took my first year as an EMT. I was a hero to my family and friends, and my mom couldn’t stop bragging to her coworkers and pointing out the picture of me in my gear that was on her desk. What has two thumbs and drives the ambulance while the medics work in the back? This guy right here! I wouldn’t say I was Johnny and Roy, but I could make a mean cot and restocked the ambulance with 4000 4×4’s because I knew that bus crash would happen sooner or later! Oh, they let me do CPR a few times…….not bragging……….just saying.
Now, when I get to work with a new EMT and their wet-ink Registry card, I find myself wishing I had the same boundless energy to help my fellow man as I did back then. I get a boost from those guys or gals for a minute but find myself spending the day dispelling myths about some of the crap that they were taught in school. At the end of those days, after snatching people from the jaws of mild discomfort, I wonder what kind of Kool-Aid they are feeding them in their training and what they think they will be doing out here on the street. I think back on conversations I had with the senior members of my squad about what we are doing. That’s after the adrenaline wore off from me driving them through traffic with the noise and the cherries activated!
What do you think you SHOULD be doing out here? Do you honestly feel that you are having the greatest impact on your patient’s clinical course, more so than what the hospital will have? Do you believe that YOUR treatments will “make or break” the outcome of the patient’s recovery? Some of that holds true, but there may come a day when you question that, and that’s okay. Some days you will feel like you are just giving people rides or “hauling freight” as someone mentioned to me once, and that’s okay. Just don’t get stuck there!
Or do you feel like I do? Do you feel like you have an impact on the entrance of the patient into the healthcare system at that time in history? Do you realize a greater portion of your patients need to be at the ED more than they need to be with you? Do you try to get as many of your “skills” done before you get to the ED? Do you feel like most of your “skills,” if done well and for the right reasons, will shave some time off of the patients ED evaluation? Do you know, just by looking at someone, that they need services provided by the definitive care facility and not by EMS? Do you feel like what you say in your hand-off report to the ED staff can get the patient what they need more rapidly? I certainly do. I know by looking at the septic, unresponsive nursing home patient with a 518 blood glucose and a 104.5 temperature that I can get them started. They need to be in the ED and ultimately the ICU and not sitting outside the nursing home in my medic unit while I try to get the $35,000 blood pressure machine hooked up, ECG leads on that won’t stay because the patient is diaphoretic and an IV started after two attempts. The patient needs to see the ED
doc, not me. If I get all of those things done on the way to the ED then “YAY” for the patient and me. Don’t get me wrong; we have made leaps and bounds in pre-hospital care with trauma, STEMI recognition and treatment, stroke recognition and pediatrics. We have a direct impact on the outcomes for those patients and need to be excellent at doing those skills in rapid fashion to give those patients a chance at a full recovery. Keep in mind that we are supposed to be RAPID transport. Not everyone needs you to do you. Some of these patients need the ED, plain and simple.
We need to know what we do for our patient affects them throughout their clinical course to their discharge from the hospital. Don’t be afraid to learn as much as you can from the hospital about how your patients progressed through the hospital system and their outcome.
I have had discussions with colleagues about this subject and have been accused of discounting the effect of EMS in the healthcare system. I always argue that point because I don’t feel like I am. (Clearly, otherwise, I would not be arguing!) I am just trying to keep a clear understanding of what I think my role as a paramedic is. I am the initial contact with the healthcare system at any given point, so I feel I should do everything I can to get them to the right hospital for their needs. My department transports to six different hospitals including level one and two trauma centers, a children’s hospital/trauma center and a Veterans Affairs hospital. I am the advocate for most of my patients and have gotten good at tailoring my hand-off reports to get the ED staff to focus on what the patient needs right now, and what they can take care of in a few minutes. I also try to steer my patients to the facility that will best suit their needs. I try to teach that to the new folks, but it is a hard concept to grasp for some.
I tell the new folks to look at it like this. You can be in the ED, or at least half way there, in the time it takes you to sit out in front of the patient’s house fumble f**king around. I understand you’re trying to get IV’s, scrutinizing their vital signs, getting the $98,000,000 monitor to take a blood pressure seven times or putting the patient through the “inquisition” about their past medical history, but you should get going. Put it in drive and get going. Nothing is more awkward than the family sitting in the car in the driveway with the shifter in reverse, waiting for the ambulance to move in the direction of the hospital. I’ve seen thirty-minute on-scene times AFTER the patient is loaded into the unit. That is infuriating to me. What are you doing??? It’s neat to meet new people but Christ on a bicycle, you could have been at the ED by now! Do you think that IV is worth holding up the show? Do you not have the skill level to take a manual BP after your forty-eight attempts with the monitor? I mean really? What do you think we are supposed to be doing out here? Granted, you may need to hold still for a minute to get a clean 12-lead or to do something special before you start bumping down the road. Applying CPAP comes to mind. We have all had that partner that thinks that they are driving a Lamborghini to the hospital and throws you around the patient compartment. Sometimes you need to do a couple of things so you can sit down and not die, but outside of that, you need to get rolling. You need to be good at doing your skills on the move. Surfers don’t win surfing competitions by standing on the surf board on the beach, they ride the waves and do that hand signal thing with their thumb and pinky finger. I have a RonJon shirt somewhere with that on it. Dude. Learn to do your skills on the move bruh!
We need to realize that we are not the wizards of pre-hospital sorcery that they convinced us we were in school. They tried to teach me to be an amateur cardiologist in paramedic school. They tried. I do the best I can. I have dumbed it down to whether the patient is symptomatic or not. It’s cool that I can spot that PAC, but this asymptomatic patient needs to follow up with his cardiologist. I am good at STEMI recognition, but we have dumbed that down to by saying if it sounds and looks and feels like a heart attack, even though you don’t have STEMI signs, you need to treat it as a heart attack. You really never know right? At least until you get a Troponin level……..at the ED. No sir, your properly working pace maker is not going to kill you. Your underlying cardiac disease probably will, but we are all just counting out the birthdays anyway, am I right?? (frowny face emoji)
There have been several studies about the effect of rapid transport by the first arriving unit on the scene. One study I read compared the outcomes of patients brought to the ED by the first arriving police unit as compared to the first arriving EMS unit. The outcomes were almost identical, with some outcomes being better when the patient arrived by the police officer. Those results are sobering and will make you wonder if what we do is even worth it. I think that as we evolve, we will continue to examine what aspects of our work do the best and focus our attention on those things. There will be new information, and we will be reactive to it and proactive with it. Hopefully, we will move more quickly to embrace the information; I’m looking at you, departments that are still backboarding! Are you dumb or just plain stupid?? Stop using “standard practice” as a reason to do it. Driving stakes into the brains of “crazy” people used to be standard practice but we quit doing that.
What we do is worth it. I had to put that in there so the new generation of “everyone gets a trophy for showing up” will not throw themselves off a building or be sad. (another frowny face emoji)……(and the one that looks like it is crying)
So ultimately, we are responsible for our actions and what we can provide to our patients. We need to stay current and proactive. We need to check ourselves before we wreck ourselves and try hard to provide rapid, quality pre-hospital care. It is what we do and is what we are supposed to be doing out on the streets.
We are often labeled as “Jacks-of-all-trades” when it comes to what we do. If you don’t feel like you have a broad enough understanding of what you are supposed to be doing, go out and find the knowledge. Work in different aspects of this business. I spent some time in a hospital-based air and mobile intensive care system. The short time I was there was invaluable in my eyes because I learned what happens from the time the patient was brought in by EMS until they were discharged. It gave me a different perspective on how I treat my patients, who gets advanced airways and who does not and what skills I can do in the field to impact the patient throughout their clinical course.
Be skilled and be quick. Get your patient to the definitive care that they need. Get your ego in check and do what is best for your patient. Listen to them. When they sweat, you sweat. Listen to the answers when you ask a question. Do your job and do it well. We are out there to be the first person they see on the day that their world may be crumbling. You should be honored that they trust a stranger to help them!