Lessons Learned in EMS: Lessons 6-11

Here is the second installment in the series on my lessons learned in EMS… You can find the link to the first post, Lessons 1-5, here.

6: Be consistent

This one has to do with both the professionalism that I believe so strongly needs to be deeply held by those who practice EMS, but also pays huge dividends in patient care. I think it is important to have routines. This applies to preparing to go to work, equipment maintenance, and patient care.

Preparing for work: The day before work, realize that your responsibility to be effective at work means that you act like a responsible adult the night before you have to be on duty. Again, drawing on my friends in the Navy, the rule that they live by is “12 hours from jigger to trigger.” That means that the night before you have to be on duty, don’t go out and get plastered. There is no excuse to come in hungover. When I started, this was more common behavior, but now seems to have fallen out of fashion, for the better! Also, sleep is of critical importance. The US Army includes sleep as one of three components in its “Performance Triad,” with the other two being nutrition and activity. Lack of sleep decreases cognitive abilities, one’s stress resilience, and can even increase one’s susceptibility to post-traumatic stress reaction and disorder. We all do so well running at a constant level of sleep deprivation, but that one night when we know we are heading in the next morning, there really is no excuse to not start your shift rested!

Equipment Maintenance: Create a routine for checking out your bags, your truck, and even your personal kit. If you aren’t consistent, then things get missed. Always take the extra time to open every pocket in the bags. If you need to, create a checklist so that you know that you have all the IV sizes you need, all the meds you need, all the tubes. There really can be zero excuse for not having something on scene that should be in the bag and having to run to the rig to get something. And there should be no digging in the bags in the back of the truck, trying to find something that should be in a cabinet. I heard Ashley Liebig (on Twitter @ashleyliebig), in her talking entitled “The Golden Fleece, The Golden Hour, And The Golden Rule“, telling how on the way to a scene, she touches all the pockets in her flightsuit and vest, just to make sure everything she needs is in there. That kind of routine breeds a confidence in the provider because, no matter what you face, you know you are as prepared as possible.

Patient care: Consistency is so important here. We all learn these little parrot-phrase assessments that we are taught for NREMT, or whichever trauma certification we are trying for when it comes to the physical assessment. Over time, we develop our own questions to ask, but it is always important to ask the same questions the same way. Why? Because, as is well documented, there is a direct link of the release of catecholamines, stress hormones, and an increased heart rate, and a decline in cognitive function. I hear a lot about how calls with a patient with acute shortness of breath are so stressful, such as the patient having the acute anaphylactic reaction, or the crashing pulmonary edema patient. I agree, these can be some of the most high intensity calls. in light of that, I make sure that my assessment on the most benign shortness of breath call is the same as the most critical. I ask the same questions, and listen to the patient’s lungs in the same pattern, every single time. I assess my trauma patients in the exact same way. I take the time to visually asses them, then palpate them, the same way, every single time. Why do I do it this way? When I have the crashing patient, whether medical or trauma, I know that I won’t get distracted from my assessment. This consistency greatly reduces the risk that I will overlook something. If I have a trauma patient with a lower leg that just went through a wood chipper, I know that I will place the tourniquet, then move to my ABC’s, without tunnel visioning extremity or the patient’s screams. I have my priorities, and my assessment allows me to keep them. It’s important to remember we will always fall back on the level of our training. So practice the same way, on every patient, every time.

7: Listen a LOT

One of the things that I have always loved about being in EMS is sitting around the dinner table at the station, laughing at stories, hearing how thing were “back in the day.” It took me a couple years to learn that what I was actually hearing wasn’t just stories, it was wisdom. Sitting in a fire station, as a junior medic, I was surrounded by five people who had a cumulative experience of just under 100 years. That is a ridiculous number of EMS calls, fires fought, practical jokes (there’s good to be learned in the humor!), and people rescued. I began listening not just at the humor of it, which was side-splitting. I began to listen to the lessons. “Why do you think you pulled your crew off the roof?” “How did you know that patient was going to crash?” “What told you that line was going to snap and could have killed you all?” Sometimes people gave me a hard time, always asking “hard” questions. For the most part though, they would stop and pause, and everyone would turn and look at the person, and listen. I cannot even express how much i gained from taking the time to ask these questions. The most overlooked procedure on a call, like where to park, all of a sudden became the lynchpin in understanding what kept a crew safe. One of the greatest lessons I learned was that it was absolutely critical that I learn to trust my instincts. So often, I would hear from firefighters, chiefs, senior paramedics, and cops that, “I’m not sure… I just had this gut instinct” or “my gut just told me that..” What a valuable lesson. Be thankful that we work in a job where oral tradition is passed down, senior to junior, and that with awareness of the deeper lessons, we can learn from people’s mistakes and heroic actions.

8: Learn the inside of your apparatus

I don’t care if you work in ground EMS, fire service, or an air service, there are few things more beneficial than this. When things are going to poop in the back of the rig, when there is stress and screaming, and people working hard doing ventilations or fighting with a patient, knowing where things are is almost the most important skill. If you can’t find your surgical airway kit, your glucometer, or restraints, you have done your patient a disservice, and possibly endangered them and your crew. This might blow my cover and reveal my true level of nerdiness that I have at work, but I would sit in the back of the ambulance and close my eyes and train myself to find everything by feel. I could at least get to all of my equipment without looking. This took some time to master, but in those moments with the crashing patient, I never regretted looking like a fool in front of my partner, because I was squared away and it decreased by stress levels dramatically.

9: Understand the concept of “Command Presence”

This is something I learned from my law enforcement sisters and brothers. In my understanding, this means that when someone encounters you, they can tell merely from how you present yourself, that you are someone to be respected. When I was new, I had a partial understanding of this. I thought that it meant that I spoke in a tone of voice that “demanded” respect, and I leveraged the fact that I wore a uniform to back that up. What I ended up learning was something much more subtle, and much more effective. I learned that this kind of presence started with how my truck looked, and even if it meant showing up early, I would wash it every day, if needed. I think seeing a shiny fire engine is much more appealing than seeing a dirty ambulance, and its one of the reasons that the fire service tends to get more respect. That may be splitting hairs, but its my opinion. This also might be me being a bit ridiculous, but I absolutely think that shirts should be clean and tucked in, boots should be zipped, and if possible, polished. Does this mean it’s always fighting a losing battle? Sure. However, the payoff of seeing someone looking sharp in their uniform, and not like a “soup sandwich” (if you don’t know this term, imagine eating a soup sandwich… its just a mess!) is undeniable. In an profession where we walk in and meet someone with whom we have never had contact before and ask them to trust us with their life or the life of a loved one, the more presentable you are, it might give that person or family one more reason to allow us to effectively care for our patient. I also learned that I could do this gently, without the authoritarian attitude I had early in my career. I could always default to that if I needed to, but with so many patients, I found that I could speak softly. If I addressed everyone as “Sir” or “Ma’am” with my initial contact, and then asked what they liked to be called, I could establish an amazing rapport with them quickly. This demonstrates respect, which is the sign of a professional. I addressed gang bangers, professional athletes, transients, and CEO’s all the same way. I also addressed people I worked with by their title, i.e. “Hey there Captain Flores! How can I help you guys today?” By showing respect for the police officers and firefighters I worked with, I gained their respect in not coming in with an attitude, which in turn had them treating me with similar respect. This just made it easier for the patient to see that we were all on the same team, working together in their best interest. I even demanded that my junior partners who worked with me learn to act in this professional way, and understand the concept of command presence. It was fascinating to watch those that might have had an antagonistic relationship with different agencies or hospitals see that dynamic change. They literally would see how people would interact with them change, as they started to address people with their title, and would show up looking professional. One of my favorite partners ever had such a bad reputation, and watching it transform was really a highlight of my career, as it was the first start setting him up for success as he followed his dream to be a firefighter/paramedic. I think had he not changed, his reputation would have prohibited his advancement.


In emergency medicine, we have the extremely unique privilege to not only provide transport and care for all of our incredible patients, but we are in the unique link in the healthcare chain that gets to go in to people’s houses, and see the most intimate parts of their lives. While I do not discount our sisters and brothers in the hospital, and their compassion, there is a humanization that is only possible when you see where these patients come from. Our society values our “space” as our own, with each house being our castle. Yet, when the public calls 999 or 911, they allow us in, with unfettered access. This is such a privilege, and its eye opening to see how some people live. It always gave me more compassion, seeing how lonely some were, or what they did to survive. And, we all know, sometimes they do not survive. We all bear witness to being present at the beginning of life and at the end of it. To my mind, these are sacred moments, watching a baby take a first breath, or someone take their last one. Both give me chills, and a sense of awe. The words we speak in those moments to family members will ring in their ears for decades, and they will remember even more how we make them feel. What an honor. We also get to see moments of incredible heroism, big and small, in our partners and coworkers. Sometimes, this looks like risking your life for a stranger. Sometimes, its taking your gloves off and giving someone a hug and crying with them. Never lose sight of the inspiration in the seat next to you in the ambulance, or the simple bravery of showing up. I could write forever about the things I am most grateful for in my career, but it always comes back to deep human connection and interaction. This means that even 23 years in, I still get a huge smile, knowing that I get to do a job that I would do for free. I was talking to a police officer friend of mine, and he said this: ” Some people have to force their life to fit their profession. For us, those of us lucky and blessed enough to do what we do, our profession fits our heart and soul and our life. What a gift!” I couldn’t agree more.

Thanks for reading this! Next Tuesday, I’ll post another part of my story, and maybe start talking more about lessons learned from my patients. Next Friday, I’ll post lessons 11-15.

Sincerely, thank you for the support and feedback I’ve received! It’s been so much fun to write these thoughts down!


I’ve never seen anything like that… (Or how I fell in love with EMS)

It was a dark and stormy night…

Actually, it wasn’t. Not at all. I’ve just always wanted to write that.

I had just graduated high school. I was 19 years old, having grown up in a mostly ideal home in an affluent area in the Silicon Valley. My parent’s had adopted three kids, and we were all growing up into successful and capable humans. I always struggled in school though, mostly because I was bored. I realize now that’s a lame excuse, but I was rarely captivated by any subject, but the ones that I did, I excelled in.

Like most young kids, I had zero idea what to do when I “grew up” and needed to choose a career. There are always the outliers, like a good friend of mine who wanted to be an officer in the Marine Corps since the day I met him in sixth grade. That was not me. I was floating, and had no ideas or direction. Having played soccer and lacrosse in high school, I had spent a fair bit of time with our athletic trainers, and after graduation, the trainer was allowing me to hang out with her and learn basic treatments and therapies. This was great, because it was awakening in me a further desire to do something helping people, something tactile, and something out of a traditional office setting. I loved the anatomy and physiology she was teaching me. I decided to investigate this further, and realized it would be a lot of schooling. Knowing that I would have to pay for the vast majority of college, the trainer made a passing suggestion that changed my life.

“You know, Tim, you should take an EMT course. It’s a good job, the hours would fit around an academic schedule, and its always good to know how to do CPR.”

“EMT? I have no idea what this is. Oh… A quarter of college to get my basic level certification, and then I could work in the hospital or on an ambulance? That sounds fun. Wait. I’ll have to be social? I’m super shy though. Yes. You’re right, if I want to work with athletes and people as a trainer or PT, then I guess I have to learn some time.”

Fast forward almost a year: I had just gotten off of my normal 10-hour shift. I was doing BLS hospital transfers at the time, as there were no EMT basics on the 911 ambulances. One of the paramedic crews that worked out

of the same station had been asking me for a couple weeks if I wanted to do a ride along with them. I had been dodging this for a while, because again, that would have meant meeting more people and talking with more people. As I was heading out to my car, they were getting toned out on a call and asked again if I wanted to join them. I said no, and they basically said, “HEY! Get in the back of the ambulance!” I guess their command presence worked on new kids as well as once scene. I hopped in quickly, and we were off.

I will never forget that moment. The gate to the station opened, and I was watching the sunset, and the lights starting to reflect off the building in front of us. I remember hearing the piercing of the siren, the first time I’d heard it from inside a moving ambulance. I still can hear the dispatcher advising us of the specifics of the call. “324, Code 3 (lights and siren) for a stabbing at the corner of Second and Reed, scene not secure.” My heart rate must have jumped through the roof, and I remember thinking, “I can’t believe I am actually doing this!”

We got to the scene and it was chaos. Police officers were shouting and running trying to set up a perimeter, and the suspect had possibly been spotted. Firefighters were stressed, as the patient was screaming and was in a lot of pain, but also very sick. He had been stable multiple times in the left upper chest, and was having progressive difficulty breathing.  The two paramedics I was with grabbed the gurney, and the small bag used for rapid treatment of trauma patients. We walked into the fray, and from that moment on, everything else was a blur. They evaluated the patient, rarely speaking to each other, years of working together allowing for anticipation and slow, smooth, steady flow. People fed off of their energy. The patient became more calm, listening to their strong, steady words, describing what would happen and how. The firefighters stress level decreased, knowing that these guys were so good at what they did, and soon this patient would be on their way to the hospital.

They asked me to go spike two 1000cc IV bags, which I did completely wrong, because I was so overwhelmed. This wasn’t school anymore. I could smell the blood and alcohol, mixing together in a unique scent that I would become so well acquainted with over the years. I just ended up sitting behind the patient, thinking over and over, “I’ve never seen anything like this before! And I have no idea what just happened or how it happened, but I want to do what they did and be that good at it.”

That simple thought fueled me over the next twenty years. That hour, watching those two guys respond to, manage the scene, treat the patient, provide amazing care, and deliver the patient to the awaiting trauma team was one of those “before:after” moments in my life.

Before this, I was lost, floating and unsure of myself. After that moment, I felt I found my calling, my purpose in life. I had no idea what that would actually mean, what I would learn, and what it would cost me. I am so thankful for those paramedics, who became friends and mentors, and the opportunities this profession has offered me.

The First Five (Lessons in EMS)

This post was inspired by yet another person on The Twitter – @jessandra111! She’s a new paramedic graduate, heading to start her career in a big and busy city. She had asked the question of what lessons one who has been in the field might pass on to a new medic. While I don’t claim my experience to be definitive, these are some of the lessons about EMS that I have learned in my time. As I keep scribbling more notes to myself, I realize this instillation will be probably the first of four, broken into five thoughts at a time. There are so many lessons that I’ve thought of. Thank you, Jess,  for carrying the torch into the next generation of pre-hospital excellence! Hopefully, I can act as the Sensei above, sharing my learned experiences and things that have brought me success and safety in my EMS practice.

1: Always prioritize your personal health.

The first and most important thing is personal health. This includes the physical, psychological, and spiritual/emotional facets of who we are as complete human beings. There are all sorts of ways to do this, and they’re all intertwined. Exercise and physical strength benefits you both in your capability to do the job (lifting, driving, carrying bags, etc.), but also allows you to burn through the catecholamines that build up over the course of the shift. We have to remember that all of those neurotransmitters and sympathetic hormones affect not only our physical health, but our psychological health as well. This includes better sleep cycles, more stable interpersonal relationships, and helps keep us from compassion fatigue.

This all ties into how we treat ourselves as spiritual or emotional beings. The concept of the “beauty to death ratio” is a great way to look at this. We need to make sure that we build beauty into our lives, so that we don’t become blinded to the fact that our reality isn’t actually real life for most people. Real life, apart from EMS, is full of beauty, happiness, love, and good people. Addressing these three aspects of ourselves will help keep you from becoming jaded or burnt out.

2: Look out for your partner.

As much as our society tries to tell us that we’re not our brothers’ or sisters’ keepers, in this job, I think we have to be. This doesn’t mean imposing our worldviews or moral values on people, but it does mean looking out for people. It means saying, “You’re important, your life matters, and therefore your safety and health matter to me.” I’ve been in the situation two or three times where I’ve had to put a unit out of service, or call a supervisor even when I’m off duty, if I hear about a friend or partner who is potentially depressed or suicidal. While those have made for some very difficult short-term relationships, the long-term benefits of gratitude that have been expressed when someone knows that they are cared about unconditionally is absolutely worth the uncomfortable moment. When you spend as much time as we do with our partners, we can learn a lot about them. Keep an eye on them after a potentially hard call. See if their mood is changing, or if they are more easily irritable. Don’t be afraid to ask them point blank, “Hey… are you doing alright? I’m worried.”

3: Reputation is earned every day.

It’s amazing how subtle and profound this one can be. Reputation is formed from the moment you show up to your very first shift as a student. It means being on time, ready to work, with a good attitude. It means not dodging the annoying work around the station, but being a team player. It means addressing superiors by their rank or title. It means addressing patients by proper names or “Sir/Ma’am”, until given permission to do otherwise, regardless of who the patient is. It means checking your equipment every day, showing up in a clean uniform, tucking your shirt in and having clean shoes. It includes taking pride in your appearance, and the appearance of your truck (if its dirty, wash it, its not that hard!). It means not complaining, not getting angry, or at least knowing when to have those moments. And it certainly revolves around your clinical care.

The most important thing to remember about reputation is that the community that we work in is small. Your reputation follows you wherever you go. Reputation has to be earned, just like respect. In the public safety community, your reputation does not start 100/100, and then work your way down. People look at you skeptically until you prove yourself, so be willing to put out the best effort possible in every situation. And, in the blink of an eye, reputation can be lost. Everybody is watching, making judgements, and filing away how you handle yourself, practice your medicine, and how you treat people. Be willing to work hard and fight passionately to maintain yours!

4: Slow is steady, steady is smooth, and smooth is fast.

Public safety, like the military, is built on lessons learned, and those lessons are usually learned how from failure and not successes. I’m fond of studying military and medical axioms, because in a profession with a strong oral tradition, we can learn much from witty little sayings our seniors dole out like candy that actually hold decades or centuries of experience. One of my favorite is in regards to clinical care. I first heard this years ago well reading about the United States Navy SEALs. The idea is this: slow is steady, steady is smooth, and smooth is fast.

Breaking it down, “slow is steady” means to consciously slow your breathing, slow your speech, and be decisive about your actions. I usually start this on the way to a call if I know that there is going to be the potential of a lot of stress. I’ll give an example: I responded to a call of a two year old who drowned in a toilet. We had updates enroute from dispatch, and then police on scene, stating that they were starting CPR, and that the airway was compromised. I remember sitting in my seat, slowing my breathing, and telling myself, “I am cold. I am steady. I am not going to panic. I am in control, and I will feel nothing.” I said this to myself over and over, until I physically started to feel colder. That was the clinically best run pediatric call I’ve ever had. I never raised my voice, never got out of control, and brought a sense of calm to the scene that my new parter and new firefighter stated later that they fed off of. It’s a cheesy thing to do, but that kind of zen state enroute to a call is something I’ve always done, and works for me. “Steady is smooth” means that as you slow down what you can control such as breathing or your mental space, your physical actions become easier to control. There’s excellent evidence that once one’s heart rate increases past 120 beats per minute, it becomes more difficult to have situational awareness and fine motor control. This is incredibly important in a job with as much cognitive strain and absolute need for fine motor control as we do as advanced prehospital providers. Whether it’s intubating someone, working out drug dosages, starting IVs on your patient… All these will benefit from a smooth approach, not stabbing someone blindly with a needle or bullying a tube into a hole that you’re not sure is their trachea.

By being slow and steady, you actually do things much more quickly and efficiently than if you rushed through the process. Not only will you be more accurate and successful in your first attempt at a procedure, recalling a protocol, or communicating on the radio, but with that effectiveness, you won’t have to repeat anything. Your scene times will be faster, and you’ll be able to accomplish more in the back of the ambulance. People always thought it was crazy that in a 6 block transport with a major trauma patient, I could still have oxygen, monitor, oxygen saturation, capnography, blood glucose, two large bore IV’s (barely running, but able to be used at the trauma center – permissive hypotension people!), a complete physical exam, and two sets of vitals done.

It may seem like a cheese-ball of a saying, but it has been tested in the harshest of environments and stood the test of time, and is worth ingraining into your soul.

5: Everyone can hurt you, but its not about “us vs. them”

One of the first things that I was taught – maybe the very first conversation I had with my preceptors on day one of my field internship – was them telling me to always remember that everyone can hurt you. This Sobering message that actually kept me from significant physical harm or even kept me alive in some very sticky situations.

It is true though, that everyone has the potential to hurt you. The first time as a paramedic on my own but I don’t with a firearm on scene, it was an elderly patient in her early 90s who was altered and septic, and kept reaching for something over her head. I assumed that she was about to start seizing her that this was some kind of repetitive motion due to her altered mental status. My partner, who is much more seasoned and situationally aware, looks to see where her hands kept going, and found a small 25 caliber handgun, with four rounds in the magazine and one in the chamber. I will never forget Andrew pulling the magazine out and pulling the slide back on the weapon, and watching that round of ammunition fly into the air. My heart stopped. it never occurred to me that an altered elderly patient might actually be trying to defend yourself from people she had no concept of, and had she found her firearm, it wouldn’t have mattered the reason why she pulled the trigger. One of us would’ve been just as hurt or dead.

This experience stuck with me. I learned to wake up the apparently drunk patient after patting them down gently to check for obvious weapons, and then putting their hand and a wrist lock so that I could control them should they become violent. One night in about two in the morning, this kept me from getting stabbed with the switchblade. I could share more experiences, but I think this demonstrates my point.

Working in an urban environment where there was a lot of gang violence, I was always checking people for weapons. Many times people were under the influence of alcohol or chemicals. The repeated exposure to this kind of violence, both directed at other people and directed at myself, definitely hardened my interior. I came to a dangerous place where I realized I had a very much “us against them “mentality. and I actually do think that, to a degree, there is an us/them component to the world. No one understands what we do, and no one looks out for us like our brothers and sisters on the ambulance, our firefighters , or police officers. we always try and watch each other’s backs.

The danger those assuming that everyone is out to hurt you. The perspective I gained with some wisdom, demonstrated to me that I had been completely wrong. Most people, regardless of socioeconomic standing, just wanted to live and work in love and raise families in peace. A small percentage of the population created the rest of the problems. I think we all know the districts in our area of operations that most of the violence and chemically altered patients come from. It becomes easy to stereotype and generalize anyone from that area as being a troublemaker. But they aren’t, not the least.

So well it’s easy to feel like it is us against them, remember that everyone deserves to be treated with respect. You can defuse most of the fights by treating people well. You can still look after your coworkers without falling victim to the cognitive biases that accumulate over time if you’re willing to recognize the fact that they exist.

But never forget: it is an incredibly dangerous job. And yes, some people will want to hurt you. Talk to your police officers in your area. Learn how to search people well. Learn how to look at people’s hands and eyes and body language. Do right along’s with local lawn force meant and have them teach you. That kind of knowledge can literally save your life.


So that’s the first installment. I think I’ll be posting these in five point posts, and mix those up with some stories from my career. I hope this helps my friends at any point in their career! Thanks again to Jess for the inspiration to write this post, for my other friend Jess (@jkwillettmd) for convincing me to start this blog, and my friend Ginger for proofreading. Life is a team sport! Be safe out there, my people!