Lessons in EMS: 11-15

Well, my plan had been to publish one of these each Friday. I’m not sure that’s the best day to do that, so its a work in progress. Also, this past couple weeks has been intense in physical therapy. I had a really significant neck/shoulder/back injury a while back, and the last few months the neck pain has been out of control. In an attempt to avoid another round of steroidal epidurals, or a trip to the neurosurgeon, I’m doing PT a few times a week, for about three hours at a time. While that might not seem like much, it has wiped me out. I’m seeing results, but just didn’t have the capacity to write last week. All that to say, it feels good to sit back down at the keyboard, and if I can, I’ll start to get ahead on posts so that, even if I’m having a rough week, I’ll still be able to publish an entry.

Time to jump back into the Lessons Learned in EMS!

11: Learn to feel the emotions

I think that everyone, whether in public safety or not, that our job is emotionally taxing. No one ever calls us to invite us to a party, at least night for a good reason. The crucible of working in the public eye, of being judged by unreasonable expectations thanks to Hollywood, the long hours and physical strain, and the toll on the body of boredom to extreme stress is not something everyone can do. In fact, I used to be really uncomfortable when people would say that to me, Now, after all these years and time spent as an instructor and preceptor who has had to fail people, I think that is actually accurate. We do a job that not everyone can do, even if their heart is in the right place.

With that in mind, I wanted to talk a bit about how to deal with the feelings that will come up in this job as an EMS provider. It’s not so much a question of if, as much as a question of when. If you want, you can search #itookhome and get an idea of what I mean. This is another mention of the idea of PTSD, and I’m certain it won’t be the last on this blog. My thought today is less typical than you might here. I don’t know if I’ve ever heard it expressed before, so please, if it doesn’t sit well, find someone to process through these moments with.

Some of these calls will stick with you, and haunt you the rest of your life. I have my share, and I’m going to share some of those in later posts. There are some though, that even though people are shocked that it doesn’t bother me, I just don’t have the same emotional response to.

Some of the calls that haunt me are absolutely understandable. They are the ones that we all think of as “the worst call possible”… A bus load of pregnant, hemophiliacs crashes into a glass building and catches on fire. That sort of thing. But a few are just holding a child as they process their illness, or an older man who reminded me of my dad, who was himself on the cusp of entering hospice. There was one call for a child who drowned that didn’t bother me at all, not with nightmares or flashbacks or intrusive sights or sounds. I absolutely felt bad that this had happened to this beautiful girl, but I was actually really proud of my crew, and the firefighters and police officers that responded. We ran as a cohesive team, providing excellent care.

A couple people told me I “should” feel bad about that call. No! I refuse. As a pediatric advanced life support instructor I never told my students that a pediatric call would be more or less stressful or emotional than any other. I prepared them as best I could to handle whatever situation came at them, as calm, cool professionals. I think to some degree, we set ourselves up for struggle if we assume that a certain type of call will absolutely be our triggers.

When you feel bad about a call – ANY call – feel bad. Embrace the emotions. Talk about it. Find healthy coping mechanisms. When you don’t feel bad about a call – ANY call – don’t force yourself into that emotional space, and certainly don’t let anyone else force you into that. Be aware that it may come back at a later time to bite you, and be ready for that. The emotions and the adverse effects of this job are all too real. Don’t run from them, but don’t force them on yourself either.

12. Learn from other public safety professionals

Some of the best lessons I’ve learned as an EMT, then as a paramedic, came from our brothers and sisters in other branches of public safety. In our modern era of responding to mass shootings, cars driven intentionally into crowds, or even the most basic call of a possible intoxicated individual on a bus bench (I’m certain this call is a universal one), our physical safety is most important. Ask a police officer to teach you the proper way to search someone for weapons. Ask them to show you the easiest and best compliance holds for someone’s wrist. Ask the firefighters to show you where they keep the medical equipment in the engine. Learn how they store their gear. Even go so far as to ask them if you can learn how to pull hose, because there is a technique that works.

I know that people have made fun of me for this at times in my agency. However, the numerous knives and four guns I’ve pulled off patients tends to get people to laugh a little less. I also have been enroute to major structure fire and had the winds shift on the cul-de-sac that we were in, and while some firefighters were pulling the hose from the front of the engine, the driver/operator handed me a hose bundle and told me to run it to the hydrant because we needed water for our own protection.

My point is that sometimes, we just don’t have the ability to foresee how quickly a scene can change from safe to not safe. We need to have as many tools, even if they are simple ones, in our mental kit, to help us adapt to those changing dynamics and to overcome them and go home safe at the end of our shift.

13. At some point, start to learn above your comfort level

One of the best things that I ever did for myself, after I had my feet pretty well under me, was to stop getting paramedic-level CE’s. I’ll admit, I was really nervous the first nursing conference I went to. It turned out to be such a great experience! Not only were there incredible opportunities to network and build professional relationships that benefit me to this day, but the clinical education was amazing. I know medicine is a profession that no one can ever learn completely. There is both too much knowledge and too much craft to it. To be honest though, paramedics really only scratch the surface. I choose a flight nursing/ED/critical care conference to attend. The first time I went, I probably only understood 50% really well, and conceptually was able to track at about 85%. I then started buying nursing textbooks. (The one that I love most is called “Critical Care Nursing: A Holistic Approach” and I have no financial ties to that book or publisher.) Now I had a tool – other than the Google and Wiki – which allowed me to cross-reference my notes and dig deep. I also noticed that the nurses who had attended the conference loved having a paramedic there! They were more than willing to answer my questions – and I had a lot of them! – and offered to continue to mentor me after the conference was over. I was now able to do more thorough and in-depth history and physical assessments, and I began to conceptualize what the hospital treatment would be for my patient. This meant I could make better decisions about where to transport a patient.

It’s uncomfortable to surrender what “expertise” you may have garnered and feel like the awkward new kid again on the first day at a new school, but the payoff is absolutely worth looking a little foolish for.

14. Choose who gets to speak into your life

Speaking of those nurses offering to be mentors to me, here’s an important thought about which voices you listen to. In public safety, everyone is a critic. I admit that I am. I will place myself in a scenario and wonder how I would have handled that case. I think people have a tendency to express those opinions also, for better or worse. Actually, its for worse. Armchair quarterbacking can really shake one’s confidence and lead to paralysis-by-analysis. Even more detrimentally, it can cause someone to take responsibility for something that might have been out of their control in the moment, and cause unnecessary mental anguish. (The subtext to this paragraph is: Don’t armchair quarterback!)

To counter this, I found a very successful strategy. I chose five people who are widely respected at work, and who I personally respect a lot. One is a physician, one is a nurse, and three are other paramedics. I have talked with these people ahead of time, and treat them as mentors and our conversations as miniature Morbidity and Mortality Rounds. I will proactively come to them with cases that I struggled on, that I am unsure of how I handled myself, or that I am receiving pushback on from other providers. In my mind, I go into it with the clear goal of identifying if there are any system issues, cognitive issues, or scene issues that contributed to how I ran the call. I do this really informally in the conversation, but these are my clear personal goals.

These five people have a free pass to say anything they want to me. They can critique me, ask any question, offer any suggestion, or any encouragement. They can also ask me to look further into something, and I take that as homework and treat it seriously.

With this team assembled and a phone call away, I feel that I can then ignore the rest of the voices chirping in my ear. Everyone else can say whatever they want. I am not responsible to those people or their opinions. I choose to submit myself though to the opinions of my team, these other well-respected people. This holds me accountable, teaches me, and keeps my inner dialogue and critiques in a healthy perspective. I absolutely credit these people with making me the thinking paramedic I am today, and believe sincerely this is one of the best pieces of advice I can offer anyone.

15. We don’t get to choose the war we fight, we fight the war we are given

Expectations can lead to so much disappointment. I know this sounds kind of cynical, but its a pragmatic approach to working and to the work environment that has kept me calm while others are about to be sent for alone time in a padded room.

We have very little control of our lives at work. We come and go and are sent at the time of another’s choosing. We operate under agency policies, protocols, and state and federal law. Even things such as sleeping and eating are often interrupted because of someone else’s decisions. When we arrive on the scene of a call, we rarely get to control our environment or the people on the scene. When it is time to go home, we all know how disheartening it is to get that late call and be held over.

What we can control is our level of expectation. I am solely responsible for my attitude. The vast majority of the time, I can combat a negative turn in a attitude by realizing this is all out of my control. Maybe this is why I like having a clean truck and uniform, because in those things, I can express my own control. I can choose fun music, I can choose to be a good partner, I can choose to be polite. In doing all of this, I find myself enjoying work more than I did when I was new and got frustrated not being able to do what I wanted, when I wanted. I think that was a huge sign of me maturing as a human being, not solely as a paramedic.
Not sure when the next post will be, but I imagine it will be either Tuesday or Wednesday. Thanks again so much for reading and for the kind words and support! This has been a great experience putting these thoughts to paper!

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.

10: BE GRATEFUL

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!