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Haaaaaave you met Ted?

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I apologize in advance for the formatting on this post, I worte it on the plane and wordpress’s HTML coding sucks so in the interest of spending more time with my now 4 year old, I give it to you raw.

“Have you met UK Paramedic Mark Glencorse?”

“Have you met Ted Setla?”

I have never before tried so hard to talk to people about something other than getting in the ambulance. It’s not easy to be a barker at these conventions.

Paul, who’s last name I am either forgetting or omitting for my own safety, from Zoll was the leader of the demonstration of the Zoll Rescue net system, who’s presentation was before Mark’s and my own.

He had great one liners and provoking questions that made passersby stop and wonder what the guy in the blue shirt was talking about. That was nice.

Just wandering the aisles at a trade show can seem awkward I’ve learned. As you wander, the folks from all the booths seem to come at you, quickly reading your name badge and asking you some strange question you’d rather not answer.

“What C-Collar does your system use?”

“Well, shoot, it seems to change all the time, why?” and they’ve got you. And they’re good at it, that’s why they’re there.

At EMS Today Baltimore, the Chronicles of EMS team was invited by Zoll to speak about the reality series and where the movement might go.

Charlotte, our Zoll contact, had arranged for a large amount of T-Shirts to be available to conference goers and they were a big draw. Trouble was we didn’t have a space in the booth, or any booth for that matter. Not sure exactly what we were, how we were to interact or what to do, we did what all Paramedics do, improvise and adapt.

A false wall curtain moved, literature stored and a quick ironing of a half dozen shirts up on hangers and POOF! Chronicles of EMS “booth.”

We were in front of the previously hidden storage room for the Zoll folks and they were constantly coming in to get more handouts and materials as they were quite popular.

So Mark and I took position in front of the 5′ wide gap in Zoll products and readied ourselves for the storm.

And this is where the really great part of social media comes in.

As faces approached we tried not to look at the name badges, but just introduce ourselves with a simple “Have you seen the Chronicles of EMS, the new EMS reality series?”

Surprisingly, most folks who wandered by said they had heard of it, or seen something about it, and not in that “Oh, sure I’d LOVE to see pictures of your great grand children” way, but in a “Finally someone can explain this to me” way.

So right there in the booth Mark Glencorse had wrangled a power source and extra monitor to show the episode on a loop. And folks took a look and asked more about it.

A 17 year old EMT student from New York State saw it.

His father, a retired Firefighter and social media skeptic saw it.

And they both wanted to learn more about it.

That is huge.

What else was huge, in my book at least, was the number of bloggers who made the travels to gather in Baltimore for the largest Fire and EMS Blogger meet up in the history of man.

At one point a familiar face wandered over and extended a hand and I shook it. The voice that came with it was none other than Ambulance Driver. Before I had a chance to express my joy in meeting a true beacon in EMS blogging he stepped aside and introduced me to another beacon, Too Old to Work, Too Young To Retire (TOTWTYTR or TOTW). My jaw was on the floor. Having my face all over the show makes me rather easy to spot, but some of the most closely kept secret identities in blogging came forward and said hello. It was amazing.

Even more amazing though was how they stepped back when folks would approach Mark and I and say “I read all the blogs and meeting you guys is so cool.” Mark and I shared an inside glance, then looked 10 feet back and wanted to say “Do you know who is standing right behind you? TOTW and Ambo Driver! Look quick!”

On the morning of the second day I was hurrying through the lobby of the hotel on my way to meet Mark to head for a full day of wrangling folks into the “booth” and share Chronicles. Coming my way through the throngs of high school students gathering for the Model UN Conference was the internet’s Red Headed EMS Stepchild, Chris Kaiser. As I said hello to him an oddly familiar face appeared behind him.

And something happened that would happen over and over again that day:

The second introduction.

You see, we really do live double lives. As I looked to the beautiful (and tall) woman I suddenly realized I was introducing myself to an old friend, Epijunky from PinkWarmandDry. We shared a smile and a hug as if we had not seen each other in years even though we had never met.

Friendships were not made here, they were experienced on a different level.

I offered a hand to a fellow approaching the booth with purpose, another man close behind. It was Fire Critic and Fire Daily, themselves having only met face to face after months of co-hosting a radio show together.

NateEMTB from twitter stopped by to say hello, as did MyrtLife and literally dozens of others who introduced themselves first with their names, then their identities. The names got a polite smiles, the identities a welcoming embrace.

Yes Mrs999 and MrsHappy, we did a lot of hugging. It comes with the territory.

But then there were the other folks stopping by the spot we carved out of the convention floor, a space not even big enough for 3 people to stand, so we stood in the aisle.

It was in this aisle that I had the first of many “Are you freaking kidding me?” moments.

“Hi Justin, Hi Mark. I really like what you guys are doing” said the brown haired man in the striped shirt.

“I’m Bryan Bledsoe.”

I’ve said it in this forum a good deal of times, but this truly was a

blink…blink…

moment.

And I was a fanboy all week. Dr Bledsoe wandered by a number of times during our stay and always had a smile and a handshake to say hello.

It may be a bit late, but if you hate name dropping and fanboyism, you should go read Motorcop because I am about to go 14 year old on you.

I carried my Firegeezer mug on the plane so the baggage handlers wouldn’t damage it. I carried it and a red permanent pen each and everyday on the off chance I would bump into Mike Ward or the Fire Geezer himself to get it autographed. And I did. Both of them. Yup, I’m THAT kind of fan.

Throughout the show, we met people involved in all aspects of EMS and each level seemed interested in what we were doing, both in the show, with the blogs, EMS 2.0 and just saying hello and talking to folks.

I can not select a single moment that was my favorite but I have collected a few that stand out from EMS Today in Baltimore:

Meeting the inventor of the KED, over a beer.

Introducing myself to the Chief of EMS for FDNY who replies, “Yeah I know you guys.”

Talking systems allocation theory with an 18 year old EMT student from New Jersey (I forgot your name but if you read this email me, our talk is not over!)

Being interviewed by THE Dave Statter of Statter911.com who refuses to put me on channel 9.

When a twitter friend, 2 of them actually, accompanied other new friends to an Irish bar in the cold night air near closing time and then not letting me buy them a drink (I owe you squirrel and NJ)

Watching vendors realize the power social media has.

I can’t wait until Denver in April.

HM

You Make the Call…Ladder Drill

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You Make the CallYou’re the boss on the ladder company today and have decided to run the troops through their paces.  The large extension ladder is raised in front of the firehouse.

You’ve sent the young guy up to practice working off the side and locking in when a woman with a clip board casually strolls up and begins to talk to you.

Even though all your member are in their PPE with helmets in place, she refuses to stand back as she makes notes on a sheet on her clip board.

“I notice your ladder is not secured at the top,” she tells you.

“Well No, Ma’am, it’s not, we’re practicing a situation where that doesn’t happen, that’s why this fellow here is holding the ladder,” you tell her while pointing to your foot man holding the ladder as he always does.

She presents credentials from the local occupational safety department and orders your member off the ladder.  She then demands to speak to your supervisor for a violation of safety laws.

What do you tell her?  You make the call.

Layout

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Sunday Fun - Get MotivatedIn my opinion the most important person on a hoseline is the layout man.

Some departments staff 3 to an engine, meaning there is no layout man unless the Officer goes back down the line to make things right.

Not mine.

We run 4 to an engine and for good reason: You need 4 people to mount an effective primary fire attack.

Driver/Engineer: Operates fire apparatus, engages and monitors pump and water supply.  Good so far, we have a way of getting water into the hoses, that’s a plus.

Officer: In command of the team. Calls for type, length of hose and where it is to be deployed.

Nozzleman: Operates the valve at the end of the hose, points it at the fire.  Really more complicated then that, I know, but than again, so is…

Layout: Ensure the hose is properly deployed from the apparatus and unkinked entering the building.  Follow the attack team around corners, untangling and advancing line as needed.  Block open doors and move furniture so that when the line is charged it isn’t trapped under something.  Stay back from the firefight to pull line back so the nozzle team can redeploy to another location without standing on a load of spaghetti in the hallway.  And, possibly THE most important role of the layout position is to slow additional responding companies if conditions are unsafe ahead of you.

Even though the Officer has a good view of the seat of the fire, and a good officer knows the conditions around them, they can’t see what the layout person sees.  From a safe distance, possibly at a corner, ready to pull hose while the nozzle gets the “glory,” the layout can scout conditions in other rooms and maybe even get some ceiling fall on them when the truck cuts a nice hole.

The layout knows all the trouble spots that line may encounter if it needs to move through that area again.  The first two folks through had their attentions elsewhere.

The layout is also the one who will be assisting the nozzle team should the conditions warrant an evacuation.  From that position you know where the exits are, not just where the line goes out, but also rooms of refuge, should they be needed.

When the fire is out and overhaul continues, the layout man needs to make sure that line is still available to knock down hot spots in the ceiling and walls by looping it into an unburnt room and placing the nozzle, with nozzleman still attached in a position to redeploy if necessary.

We should never leave the engine without a tool of some kind, but as the layout we need full flexibility so a sheathed axe can really get in the way.  A pump can can also get in the way but makes an excellent door chock and point of no return doorway device.  That little can can keep an advancing fire from getting through a doorway if teams are retreating behind you for at least 2-3 minutes when used properly.  So what to bring?

Depends on construction, location of fire and your Department’s SOPs.  A cop out answer I know, but the truth.

So next time someone else “grabs” the nozzle, remember that they have it easy, now you’ve got the most important spot on the hose line.  If the fire goes out you did your job right.

Now get those kinks out and feed line up to the third floor!

The Premiere Party is LIVE!

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A Seat at the Table

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Buried within all the excitement of the premiere of the Chronicles of EMS Reality Series is another premiere I’m proud to be a part of.

Over the years EMS has been serving their communities we seem to be finding ourselves out in the cold when budgets are doled out or reimbursement tables adjusted.  The practitioners on the street, in the patient’s bathroom, bedroom, living room, deepest darkest days are largely ignored when industry heads meet to discuss where the trade may go.

They’ve talked of minimizing standards to maintain a constant flow of low paying jobs and EMTs eager to step on the gas and run the lights and sirens.  Study after study showing one way is wrong so another can get a bigger market share.  All the while our pagers are going off and alarm bells are ringing.

If we’re lucky enough to have a voice in the discussion, we are looked at as an afterthought.  A nod and a smile greets our suggestions for improvement, often with a “we tried that before, it didn’t work” which is the EMS version of a pat on the head.

Various committees and organizations sprung up with a spot for us, among dozens of others, making sure we had no chance to be heard.  EMTs and Paramedics were never given a seat at the table.

So we made our own.

Social media has us sharing ideas and concepts in a way they never saw coming.  Research can be done from home instead of at a far off conference of owners and Chiefs all striving to prove themselves as having the best system.  We can now call their bluffs, and they can call ours.

A Seat at the Table takes one element we discovered while filming the Chronicles of EMS Reality series and expands it into a format rare in our industry: Video.  This element was the civil discussion of differences by street level EMS personnel who took the time to comment about what Mark and I were learning from one another.

There are plenty of EMS videos available for viewing online and by purchase, but never before has a filmmaker with a vision and a background in EMS taken up the challenge to document what we’re talking about.

Take a look at this snippet Ted Setla and I shot to explain to investors the power of Chronicles of EMS:

Chronicles of EMS – The purpose from Thaddeus Setla on Vimeo.

The Chronicles of EMS:A Seat at the Table is a table top discussion program filmed in the round and is scheduled to include as many people involved in the future of EMS as we can find.

Each time the Chronicles team travels, A Seat at the Table will be close behind to take advantage of the unique people we might meet and want to hear from.

Not only will we be sharing ideas, but getting answers to questions from those in charge of where we’re all going.  Mark Glencorse and I will be there but you will be as well, following each episode as it is filmed HERE in the ustream chat room (scroll to the bottom). When you listen live to the filming, Mark and I will be monitoring your comments and questions for the panel and including them in where the show goes.

That chair you’re sitting in will now be at the table, a voice in where our young profession leads.

Watch the Chronicles page for updates about filming in your area and if you want to be in studio with us, let me know. thehappymedic@gmail.com.

Bookmark the link to the Seat at the Table page as upcoming episodes, topics and guest lists could change suddenly as we’re sent all over the world exploring how EMS systems operate.

See you there.

Fire and Rescue, UK style

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My EMS adventures in Newcastle upon Tyne had come to an end and I had but one full day left in England.  Swalwell Station Manager Peter Mudie has arranged for me and Mark to take a bit of a tour of the capabilities of the Tyne and Wear Fire and Rescue Service, so we’re up early and he’s taken us for a road safety class.

Not for me, thank goodness, but for a group of young drivers to impress upon them the importance of not drinking and driving.

Many of us have been to these presentations before.  A middle aged expert prepares what to them appears to be a hip multi-media presentation and the attendees seem less than interested.  I was the same way at 16, we all were.

Enter the Happy Medic and UKMedic999 and the class is now wondering what just happened.

The presentation was actually one of the best I’ve seen including some racy videos that in the end have a message about driving safely.  The kids were really paying attention then.  Mark and I had a chance to impress upon the gathered youth the importance of seat belts and driving safely. I think my “accent” kept their attention more than my content.

Even the locals were cold. Mrs HM knit me two hats, so I shared.

Then it was off to the yard behind the station for an extrication drill to show the new drivers what happens when cars collide.

Set up down the hill were two cars and two students were chosen to be the victims.

To say it was “balls cold”, as one student put it, would be an understatement.  I’m a 6th generation Californian, 50 is cold for me.  This yard was cold.  Wind blowing, snow falling and me with no gloves.

The kids watched as their friends shivered in the cold while the fire appliances pulled up and began their task.  I mentioned in passing to the instructor that I would have let the kids go back inside and he suddenly had a point to make to the youth suddenly more interested in each other than the hydraulic tools freeing their friends.

“AYE!” He shouted to the huddled, hooded forms, “You’re here wearing your coats and gloves, hats and whatnot, but what if you were heading back from your mate’s place and were wearing only a shirt and crashed?” He was moving around in front of them, almost pacing like a drill sergeant, “Laying in the snow, cold, tired and hurt?  You wouldn’t last very long would you?”

He had their attention the rest of the morning.

The extrication was straight forward with the only difference being the use of the smaller ladders to brace the car on it’s side.

After a lunch cooked by the station’s french chef (Yes, the chef is not a firefighter) it was off to Tyne and Wear Fire Headquarters.

What an impressive building and training ground they have!

A grand foyer greets the visitor and many small groups of men are sitting in plain clothes discussing this and that.  One of them, the only one wearing a shirt and tie sees my SFFD Firefighter/Paramedic jacket and does a double take.

As I surveyed the enormous complex I would assume candidates are intimidated when they enter to get their employment packets.  Peter led Mark and I on a brief tour of the lower level and the man in the tie wandered over and said hello.  Just a casual greeting, he seemed like a regular guy in a sea of white embroidered uniforms and street clothes.

Chief Bathgate, Yours Truly, Peter Mudie

The man in the tie wandering the lobby is none other than Iain Bathgate – Chief Fire Officer for Tyne and Wear.

blink. blink.

He offered a hand and I shook it.  There I was in my uniform shirt, but buried under a sweatshirt and a jacket.  Had I known I was going to meet the Chief I would have at least donned my cap and tie to show respect.

Turns out he was more interested in the back of my jacket than what wasn’t around my neck.

“You do both then?” he asked me.

“Not often at once, but yes, I am proficient in both skills” I replied, wondering if I should go into further explanation.  As we spoke the other men were taking interest in the fellow with two titles on his jacket their Chief was talking to.  He immediately suggested a tour of the training grounds, something his face glowed about, he was proud of it.

Through the main lobby and out another set of large glass doors was their training facility, easily 5 acres and including a wide variety of props.

11towerThere was a standard training tower that, since once at the top one could peer over to the automobile manufacturer test track next door, was rotated and modified to keep wandering eyes away.

11highangle

Next to that was a high voltage power line tower prop for high angle rope drills.  Under construction nearby was a large two story collapse house that can be dropped and rebuilt quickly to simulate rescues.

A number of burn buildings stood ready for recruits and in service crews alike, one of which was in service when we visited.

But the piece of equipment that caught my eye as special was their train rig.  Over behind the airplane prop and the piles of wood was a full size train car half in a man made tunnel. 11tunnelI wish we had one.

Half way through my tour, Mr Bathgate dismissed himself and went back to running what appeared to be a well funded and well respected organization.

Mark, Peter and I finished the tour and the Department had a photographer come down and snap a few pictures of us in front of some of the appliances.  then a few minutes later she rushed out with a stack of nice photos for me and Mark to remember our visit.

The only comments Mr Bathgate made regarding the wording on my jacket was, “Oh, we’ll not be doing that here” which is something I’m not unused to hearing from the Big Red Machine.

Same System, Different Country.

I’ve got a few more posts worth of observations and anecdotes that I’ll be saving until after the Chronicles of EMS premiere on February 12th.

Meeting the NEAS Executive Team – My UK EMS Conclusion

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chroniclesblogIt all comes down to this meeting doesn’t it.  The entire project, everything I hoped to learn comes down to sitting with Mark’s supervisors and policy makers in the UK and making a solid impression that American EMS is not awash in profit driven patient care.

But then again, we kind of are.

I started the meeting starving hungry from my hours in the dispatch center downstairs and was told this would be a kind of working lunch meeting.

Sandwiches and various appetizer type dishes were brought in and my personal favorite, fresh coffee.  The conference room at the NEAS appeared to have been recently remodeled or redecorated as there were literally dozens of legal sized computer generated signs reminding those reading not to place cups directly on the table.

So what do I do?

Yes, and luckily I had Peter right behind me to place a saucer beneath the cup and shoot me a “Hey stupid” look.  It was in this framework that the rest of the administrative team made their way in and began a presentation on the stats of the NEAS.  Population, call volume, etc.

It was made clear to me ahead of time that Fiona, the Chief Executive’s aide, had prepared the presentation and Simon Featherstone gave credit where credit is due.

Mr Featherstone, the aforementioned Chief Executive of the NEAS, seemed like any other person I had met on my travels so far and that made it very easy to listen to him discuss his system.

A few slides in he turned to the dozen or so folks in the room and suggested we do more interacting.  This was, after all, common knowledge to all but one person in the room, me, and they wanted to hear from me, not their Chief Executive.

I went into a brief overview of my system in the SFFD and also explained other systems around the country.  Much time was spent, and not surprisingly, with their fascination with the idea of for profit ambulance services.

Each member present asked a number of questions about billing and a person’s ability to pay and I had to remind them many a time that that doesn’t come into play until well after the call, but does drive policy decisions in the end, therefore changing our field care decisions.

Each time I snuck a bite to eat another question would have me or Mark discussing his observations of the system as well as his tales of life in a San Francisco Firehouse.

When it came to Mr Featherstone asking what differences we have observed patient care wise, I brought up CPAP and cardioversion and that those are widely used skills in the US.  Pacing and cardioversion along with adenosine surely more common than CPAP, but it is such a wonderful tool more services should invest in it.

In true executive fashion Mr Featherstone turned to his clinical care person and said, “How soon can we look into doing these things?”

Bang.

Right then and there, slightly leaned back in his chair, the Chief Executive might be moving forward on something that can directly benefit the patients Mark encounters as well as giving him tools to help more people.

The meeting ended with handshakes and wishes of luck, but very little was said regarding the lack of Ted Setla and the Chronicles of EMS team in the room to record all of this fantastic learning and sharing of best practices.

But I understand that.  England is a far less litigious society than the US, but they still have to concern themselves with the appearance of the service and those who function in it.

Everyone reading this post knows Mark and his blog are a source of incredible knowledge and a commitment to improving himself through new pathways.  If Mark wrote a book about EMS I would buy it.  If he had a radio show I would listen to it, but until those things happen (If he had a TV show I’d watch it) I will follow the media he uses to become a better Paramedic.  Right now that is his blog http://999medic.com, twitter @ukmedic999 and on facebook.  All media that is growing not only in popularity but usability and relevance to what we’re trying to do in the pre-hospital care fields.

I don’t expect every service in the world to be open to bloggers sharing patient care and contact stories, regardless of permissions, and the few that value the following some EMS bloggers have are doing so very carefully.

One of the things Mark and I hope to work on in the years to come is acceptance of new media and new ways to share information that still respects a patient’s privacy while allowing those doing the care to share insight and best practices in real time.

A unique airway solution is discovered in Australia, blogged about, read by an ECSW in England who passes it along to their Paramedic who posts a link to twitter where I read it. Suddenly a technique that 5 years ago would wait months to get considered for a trade journal has been seen by thousands of caregivers who are about to share it with their friends and co-workers, and all in minutes, not months.

After a morning of listening to the Pathways system work in the dispatch center, then seeing the openness of the Executives to concepts and treatments, I think Mark is in a good place with the North East Ambulance Service.

In Conclusion-

The NEAS provides a high quality service in a straightforward manner to a well informed population.  Powers rest with the Paramedic at the scene to determine transport, not the patient ahead of time like in my system.  Front loading and getting eyes on a patient is a reliable way to handle system resources and gauge response.

The service is not reliant on insurance companies reimbursing for the services rendered nor are their paramedics passing perfectly capable ERs to reach a certain carrier’s preferred spot.

Mark Glencorse was a gracious host and everyone I met from A&E tech to Chief Executive was welcoming and asked great questions about American systems and I did my best to represent all of us in a professional and knowledgeable fashion.

The food was great, the coffee we can work on in future visits.

Will the NEAS model work in San Francisco?  I won’t know until tomorrow when I get a tour of the Tyne and Wear Fire and Rescue Service by Station Manager Peter Mudie.  Fire readers, this is the post you’ve been waiting for.  But like most of what we do, EMS comes first and accounts for 80-90% of what we do.  Why should my UK story be any different?

“RTB for a cuppa” I’m allocating in the UK

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chroniclesblogRTB means Return to Base.  A cuppa is slang for a cup of tea.  Allocating is something I very much wanted to see first hand.

On this morning in Newcastle, my second to last, Mark has arranged for me to meet with the executive staff of the NEAS at their headquarters.

Before meeting with them, however, I’m downstairs in the bullpens.  I’ve got 2 hours to sit in the dispatch center and do a “Sit-along.”

When you tell a guy who loves talking theory on systems allocation he gets to see the system work from the nerve center, he gets a touch giddy.

My first chair was at a call taker’s desk and I got plugged in.

BANG, less than 10 seconds, not even a chance to introduce myself to the call taker I’m with the first tone is in my right ear.

Before she can answer the call a timer has popped up on her screen 8:00, 7:59… the clock is running.

“Ambulance Service” she answers and begins reading from the screen the pre-ordained triage system called Pathways.  As I’ve mentioned before, this dispatch system makes no attempt to diagnose the problem, but the physician designed questions can dial up or down the response in real time as the call taker asks the questions.

While she is asking and answering, a small red circle has appeared on the screen, then, a bit away, a purple one.  Later I would learn that one is the location of the caller and the other the closest vehicle assigned to the call.  When that vehicle arrives on scene, the timer now passing 6:15 will stop.  This is their target and they take it very seriously.  As I’m listening to the call, it is a very straight forward sick call and the caller is honest about it.  It is then I see the benefits of the flexible front loaded system.  The rapid response car, the closest resource to the caller, has been stood down since there is not an emergency at the caller’s location.

The vehicle, or cot transport capable ambulance, is continuing, however, and the target is no longer 8 minutes, but now 16 from the time the call was answered.

As more questions are answered and the system confirms the lack of life threats, a simple screen gives instructions for the caller until the crew arrives.  The call taker then scrolls around her GPS monitor and finds the vehicle, then advises the caller about how far out they are.  The caller thanked her and the call was terminated.  Less than 3 minutes passed from the answering of the call to the triaging and confirmation of appropriate response.

At no time did a supervisor step in to augment the call taker’s classification, nor did the system err on the side of caution by upgrading the response, putting rescuers’ lives at risk, “Just in case.”

In the hour we were together I learned more about the desk I was at and the number of calls she answers in an average shift.  We took mostly non-emergent calls, details of which would obviously violate privacy, but I can share with you the CALLERS.

When I explained how folks abuse our service by calling from a cell phone miles away about a person they think might have been either unconscious or sleeping, she smiled.  Then, I went on, our criteria based dispatch system considers the caller’s inability to confirm consciousness to be unconscious and their inability to confirm breathing to be apnea, and 7 people are now responding code 3 for nothing.

It was just when the call taker was explaining some of the loop holes used that a care facility called to request an ambulance.

They were not with the patient so unable to observe their mental status, efficiency of breathing or if there was any bleeding.  The system took this information and kept the RRC responding.  Each time the call taker asked a question, the caller was already answering, knowing exactly which question comes next.

She later explained that folks have learned that if they take a cordless phone around the corner and call an ambulance, the crew arrives faster than if they honestly answer the triage questions.

“Same callers, different country.”

It was later in the morning across the room with the allocators that I saw the strength and weakness of the NEAS.

Mark and I spoke at great length about being honest but respectful when offering our observations and suggestions to improve each other’s systems.  Mark was an example of this when he met with SFFD Chief of EMS Pete Howes for a kind of exit interview before leaving.  I hope I can meet that example with the following paragraphs, but each time I write it it comes off preachy, so here goes.

Sitting between the allocators I watched them constantly on the radio with numerous vehicles and cars in various states of service.  Each color on their screens meant something different, from enroute, on scene, RRC, vehicle, on post etc, but it was the clipboard they were passing back and forth that caused them the most frustration and, more than once, delayed allocation.

Not by a definitive amount, we’re talking 3-5 seconds, but it was the constant flipping of pages and radio traffic related to the one thing that I think the NEAS needs to change for the betterment of the system.

No more breaks.

I can hear the UK medics now “Hell no.”

Let me elaborate for my work straight through the shift American friends.

The NEAS, as a portion of their labor agreement, provides their crews with certain breaks depending on their daily activities.  When they have been on post for an hour away from station, they get rotated back to the station.  This was commonly referred to on the radio as “Return for a cuppa.”  The basic premise is simple enough, really.  People need clean bathrooms and a chance to eat since eating is not allowed in the cars or vehicles, nor are they allowed to sit down and eat in an establishment while on duty.  This was evident when Mark was nervous enjoying some Pho in San Francisco.

In the car and vehicle this didn’t seem to be a big deal, we’d get a message to return to base, or that we were clear for meal break.  The meal break can be interrupted, should the allocators need the resources, but they avoid it since the crew interrupted gets paid quite a bit for it and the allocators, although they wouldn’t elaborate, appear to be held accountable.

Sitting between the two allocators on the desk that morning, 50%-75% of their time was arranging rotation station breaks or ensuring crews got their meal breaks.  These variables also added more color codes to the dispatch screen.  This car is on dinner, this vehicle is on base rotation…etc, etc.

When a call came in they shot a quick look to the clipboard showing who gets a break when and dispatch decisions are based off of that.  I did not witness it make a difference in response times, since that information is streaming in real time on giant monitors overhead, but these folks are scrambling to keep everything running smoothly.

With my limited dispatch experience it seemed like a simple change, since on the days I was on rotation in Newcastle we never had a point in the day where we were unable to reach a bathroom or food.

My head was trying to process all the information these women were basing their allocations on and one of them turned to ask me, inbetween moving a car back to base “for a cuppa,” “How do your dispatchers handle your breaks?”

When I explained we (listen to me, like I’m still in a rig), THEY are gone for 10 hours, no breaks, they froze.

It was passing the clipboard back and forth that I saw the only 2 seconds they both held still: glaring at me.  It was clear I was not to repeat that statement for the rest of my time with them.

“That would make, ‘Go ahead 405′ this so much ‘thanks and to base if you please’ easier.”

Yeah, 2 conversations at once.  I have trouble typing and listening to music or TV at the same time.

Mark had some family business to attend to while I was meeting the voice on the other end of the radio and he returned just before dinner time to collect me.  It was an eye and ear opening experience to see the chaos that a simple concept like breaks caused the folks moving units around.

Something I completely neglected to mention over lunch with the executive team.

Told you I couldn’t screw that up.  My conversation with the folks hopefully getting Mark cardioversion and CPAP, and where to put your coffee when the table is literally covered in signs that say “DO NOT PUT CUPS ON TABLE, USE SAUCER” soon.

Yeah I did.

Shapes and Colors

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I often joke with folks outside the Profession that things need to be made “Firefighter Proof.”  This denotes the fact that my mother was right, I ended up with a job where they put my name on my shirt.  Another variation is that this job is all about shapes and colors.  Why else are the drugs in different color boxes, catheters as well, and we color code hydrants based on flow in some places?

But buried in all the jokes about how simple things need to be are some basic shapes and colors that are out in plain sight in the community that help us do our jobs better.

We visited a local cell phone company’s transfer station to train on a new system shutdown procedure.  it seems that if there is a fire in the server and transfer room, the system will handle it but there will be a need to shut down sections of the system, not the entire system.

Inside we saw reflective taping on the floor leading us to the breaker panel.  The tape said “FIRE DEPT SHUTOFF – THIS WAY —>” and it continued all the way to the panel.  At the panel, each switch had a colored reflective tape.  Each area served by that breaker was marked on the floor in front of it by the corresponding tape.  no more wondering which breaker to hit, just remember the color.

Loved it.

Shapes and colors really does work.

If you’re not really concerned about the switching station in your response area, let’s start with the simple ones found in elevators.

SOL_elevator Here is a shot I took at a local shopping mall.  Many places I go have these markings and few rescuers know what it means when a Star of Life is in the elevator well.  And why does this one have it but the one next to it does not?

Think you know?  Do you know?  Formulate your answer, then CLICK HERE to find out what makes this elevator so special.

star floor

Now that we’re in the elevator, we need to know how to get out at the ground level.  In the City, many buildings are on hills so they have more than one exit to street level.  In this elevator, which floor is the ground floor? This panel is pretty straight forward, being in a smaller building, CLICK HERE for a neat collection of photos of panels from around the world. Be glad we have a uniform building and elevator code. That star will get you out on the street level of the marked address. If the building is 123 Main street, that star will get you out on Main street.

All right, how about this reflective sticker on the electric meter at the street level?

What about the house next door with this sticker?

Find out from an article on FFN from Christopher J Naum.

Keep your eyes open out there.

HM

Hey, Box Jockeys!

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This hose monkey has some questions for you.  Please answer honestly, anonymously if you like, but some things have been bothering Happy as of late.

Question #1

Does your employer discourage you from being honest with your patients when it comes to transport decisions?

Question #2

Has your employer asked you to omit information on your reports that would prevent billing a patient a certain way?

Question #3

If a patient asked your opinion, you told the truth and they refused care, would you be in fear for your job?

Question #4

Does your service encourage starting an IV or EKG monitoring for BLS patients to upgrade the billing?

Question #5

Are you aware that the above situations could constitute fraud?

If you are trying to decide whether to do what is right by your patient or keep your job, email me.  Your employer, municipal or private, paid or volunteer, is wrong and we need help changing their practices.

If you are comfortable and supported by your service when being honest with your patients about their conditions and transport options, please list your service in the comments section, they deserve praise.

ems2point0

HM

On the Ambo in the UK

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chroniclesblog

Subtitle for this post: Can you reach that for me?

Coming off a superb time on the Rapid Response Car, nappy time aside, we’re on the vehicle today.  The vehicle is what you and I would call an ambulance, but since anything that can take people to the hospital is an ambulance, it needs to be narrowed down a bit.

The car is certified as an ambulance since it can take people.

The vehicle can, as that is the main purpose of it.

But hiding around town, and just out of camera range as we drove by were swarms of non emergency ambulances, almost buses in their capacity.  When asked their function, Mark and our ECSW Becky (more on her later) informed me they take folks to their appointments, get tests and from one facility to another.

Collecting my jaw from the floor I explained to them and reminded Mark how many times we activated 6 people to do just that.  Becky shot me a look from the driver’s seat of the vehicle and asked a great question I still can’t answer.

“Why not just give them a ride in a van or bus?  Why send the ambulance?’

Why indeed Becky, why indeed.

I could try to explain to her how, in America, people have become so expectant of lights and sirens whenever they want them that they’re willing to sue if they don’t get them.  Regardless of the condition, reason or outcome, folks will threaten a lawsuit and managers will blink and change protocol. Why inconvenience the few when we can just take them and inconvenience the many, right?

That was the start of my shift on the vehicle.  I’d love to tell you that life on a UK ambulance is so much different than in the US.  But when it finally gets to comparing apples to apples in these systems, having someone in the back is it.

Previous posts have covered my impressions of the ambulance layout and ways I think they can be improved to benefit patient care and provider comfort and safety.

Mark had difficulty accessing most of his equipment from the cabinets.  Everything he needed he got to, but not without ducking around the patient, around the family member, then leaning over.  The trash was also oddly placed, lying directly behind the family member so that to dispose of bloody mess you have to ask them to lean aside.

But that being said, with the current layout based on “safety” there is no other place to put these things.

Mark described to me the regulations in place to protect the persons traveling in the back of the vehicles and it makes perfect sense.  Until we have to actually do patient care.

After my description of the ambulances in a previous post I was contacted by an ambulance manufacturer who wishes to remain anonymous, I’ll call them Box inc.  Box inc wanted my thoughts on what makes the perfect ambulance and I told them I have yet to see it.  But, Box inc had some new ideas about making your ambulance more versatile when on post, more on that another day.  But Box inc will still take a van or pickup truck, rip off the back, slap on a place for a cot and make it flash, there really isn’t another option at this point.

But back to Newcastle and the McDonald’s parking lot.

Yes, we’ve found our way to the parking lot at the McDonald’s, on post if you can believe that, so I snuck in for a coffee.  It’s an addiction, I know.  We had a chance to talk on camera about Becky’s role in the NHS and what an ECSW is.  But as we talk about it, a few points to look for first.

I am sitting on the cot and Mark in the chair for family members.  The pass through to the cab behind him has a small door on the top that leads to the trash bin behind that seat he’s in.

The cabinets behind us and between as as we talk contain all of Mark’s equipment.  Just from the layout you can see how challenging it could be to access them with a poorly patient in the back.

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When I said that Becky was above an EMT, the comments section at youtube went insane.  What I meant was that she can give pain relief without medical direction.  She can do something I can’t do, mainly because I’m told I need more education and training to deliver pain gas to those in need.  Becky is proof I do not.  So when I said she is above an EMT, I was referring to her ability to medicate them in that manner.  An EMT can transport, Becky can not.  Apples and Oranges folks.

Our jobs on the vehicle were similar to what Mark and I saw on Medic 99 in the City, moving folks with this complaint over there and that complaint over here.

It was on the vehicle that we encountered the only person, out of dozens, who demanded transport.

As you all plainly know, my clients demand transport 90% of the time and need it 5% of the time.  Newcastle respects their Paramedic’s opinions, likely because they can get in and get seen outside the A&E in a reasonable amount of time compared to here in the US.

This person activated 999 to report an assault and we entered the house cautiously.  It was quite a bit reassuring knowing that the occupant was most likely not carrying a weapon that could mow us down from 40 feet away.  I’m no ninja but I’ll take a clipboard to a knife fight over a knife to a gun fight any day.

The local police were close on our heels, again, without firearms (hard to get used to) and the scene was more than secure.  Very secure the police confirmed, poking holes in our patient’s story.  Then there was the recounting and description of the event given and none of that matched what we were looking at.

Clearly there were behavioral issues in play and the decision was made to transport based on the inability to confirm normal mental status.  We’ve all been there and trying to communicate with eye movements and physical gestures must have appeared as though Becky and I were flirting.

My eyes said “Look at the door, the things piled in front of it, it opens inward, no one broke in there.”

Her eyes said “What?”

My body, arms crossed, said ‘Over there, look, the door!”

Her body, arms raised to the side and shoulders up said, “Huh?”

Mark’s eyes said “Stop it!”

Mark does not ring down, or pre-alert, the hospital himself, but relays it through his control center.  When I saw what the control center did the next day, I decided that was unnecessary.  If your service relays patient reports trough a third person you are introducing another player in the telephone game and just another chance for pertinent information to get lost.  I would love to be able to forward my report to that point to the hospital and they can move that information to a bed and await our arrival.

Oh, did I nod off?

Right now my service gives audio radio reports to whichever nurse lost the coin toss that day and has to answer the radio.  I tell them what I have and why, vitals and hang up.

Many Americans may shudder at the idea of waiting 2 hours for an ambulance but I met a woman who disagrees.

Mary, I’ll call her, fell down on a friday afternoon and injured her hip. Being of a stoic generation, she didn’t want to bother anyone with her trouble, so she hobbles through the weekend until her doctor’s office opened monday morning. She called the office and spoke to her doctor who advised her to go into the A&E to be evaluated since his office had no x-ray capabilities.

The doctor called the ambulance and the call was classified as an “urgent” meaning there was no life threat, but still a need for a transport. This call is then put in hold in the system with a maximum wait time and an ambulance is assigned as soon as the system has the available resources.

Mary met us at the front door and walked us in with a slight limp, dressed and ready for her trip to the A&E like many of my lights and sirens patients. We took our time making sure her medications were gathered and the stove turned off, then into the chair and down to the ambulance.

Because this trip was arranged her medical records were waiting at the hospital, as was a bed reserved for her and she was seen as soon as she arrived. I asked her if the 2 hour wait was too long and she looked at me as if I asked her what color the sky was.

“I waited all weekend to call, another few hours wasn’t going to kill me, son.”

I wanted to hug Mary right then and there.

After a day of back and forths on the vehicle and torturing Becky with the American and the camera duties, we were close to finishing our shift when that dreaded job came in.

The late job.

We were planning on meeting some of the rank and file for a social evening and this job would put us over our shift and we’d be late.

We screamed through the streets of Newcastle, pushing old women off the road and opposing traffic wherever we could.  OK, not really, we were sent on a common case that would later bring out our common response “Same patient, different country.”

With the patient on board and her friend safely secured we made our way through the evening traffic to St Farthest, all the while talking and keeping our patient in good spirits.

The day went fast in retrospect.  Traffic still doesn’t get out of the way when you’re rolling lights and sirens, you still have to go hunting for the extra blanket at the hospital and the nursing staff is still often glad to see you when it counts.

The evening was a night out with some of Mark and Sandra’s co-workers, we were fashionably late after some creative dropping off and ride sharing.  I got to talk to them about Mark without him listening and their opinions were high and genuine.  Mark is a respected and admired Team Leader in his station and his system.

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Questions in Haiti

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We’re all following the updates from the 7.0 earthquake that struck Haiti just 48 hours ago.  Our brothers and sisters have been mobilized to assist and there is a pouring out of support in the form of food drives and monetary donations all over the internets.  Before I get into my points to think about, please remember to donate to established organizations.  The American Red Cross is just such an organization that can use the money well, as opposed to your local corner Girl Scout Troop who may have to pay to have things sent over, and even then it may not arrive in time.

In time for what Happy?  Oh I think you know.

Our brothers and sisters mobilized for the search and rescue effort are facing a task they may not be ready for.  They are trained professionals in search, rescue, recovery, everything first response, but there is, by all accounts so far, no framework to support their efforts.  I don’t just mean a place to land, restock and camp, I’m talking about basic disaster concerns.  These folks can get in and get setup, do their thing like no other.

Let’s think this through for a moment.  Estimates show 9 million people in Haiti and at least 1/3 of the country may be injured.  3 million injuries.  From scratches and scrapes to fractures to crush syndrome and major systems trauma.  Many may not survive the night because of their injuries, but let’s look past that.

When the USAR teams use their tech, tools and smarts to rescue the injured, where will they go?  Who will come to transport them to the hospital?  Where are the hospitals?  In rubble.  Each and every resource that can assist in this event will need to be brought in from without.  How long will it take to set up triage and treatment centers to help the ambulatory?  Then the injured but invalid? And finally to the traumatic injuries.  The hospital does not just need electricity, or staff, or supplies, they need everything, including walls.

On all 4 networks I have seen different footage, all of one ambulance traveling the rubble strewn roads.

The honest answer is that definitive care for most of those injured will not arrive within 72 hours of their injury.

Do we remember what happens to internal injuries that go untreated?
I had an image of three survivors still trapped in the rubble set for this post, but have deleted it.  You can see it here, it’s photo number 2.  When these folks are rescued…then what?

What is the plan for when the almost 100,000 estimated dead are still in the streets in 96 hours?  Will they have an adverse effect on what little sanitation remains, what little clean water there may be?  What will happen to those sleeping in the open near the bodies?

I do not  envy the person who must choose how to deploy resources, but it makes me think about my own City when, not if, but when our big one hits.  We will have plans, resources from afar.  We have volunteers trained to help, we have disaster supplies ready to go.  We have folks with phones that can make calls without cell towers, buildings that can generate electricity when the sun shines.

Those things are not common in Haiti.  Cell phones, the ones that still have a signal, will have dead batteries soon.  Gasoline for generators will be running low.  People will become desperate for help.

What do we do then?

I don’t have an answer, nor am I posing these questions in a political framework, just trying to get us all thinking ahead.

If it looks bad now, just be ready for when decomp begins and things get worse.  And each person rescued is another that will need advanced care, food, water, medicine.  Each reporter that arrives needs water, food and shelter that could be used at a temporary hospital.

I challenge each and every news network to pull your crew out of the disaster area and donate what you would have used on your people to the relief effort.

If anyone has a link to updates directly from teams at the site, let me know.

HM

Small fire, small water. Big fire…

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Well, did you finish the statement?

Did you finish it the same way most do? “Big fire big water”?

Is that really the right answer?

I think it is the wrong answer.

Pumping high volumes of water into the 7th floor office complex isn’t going to help us if we haven’t trained with the tools used to knock that fire down. Yes having larger amounts of water on the fire floor will help us, but we must remember the layout of our commercial sites. They are commonly open with organized furnishings, and heavy on false walls and highly flammable file cabinets, records etc.

Training needs to include coordinating multiple lines, finding the seat of the fire, and knocking it down. Sounds simple and straight forward, but when all you hear is, big fire, big water, then train residential and not commercial, things can get tricky.  But even in a multi-residential situation, we need to get our water to the fire, otherwise it will ricochet off the ceiling, fall to the floor and run into the street.  All that big water right down the drain and the fire is still burning.

I prefer to say “Big fire, SMART water.”

Get in there with the large line but use it appropriately. Get your fog nozzle off and gain the distance from a smooth bore nozzle. That will give you a chance to get closer to the seat of the fire, find it and effect a knockdown to facilitate a search.  Defensive fires are no different.  Shooting a line from the street and aiming for the ridge line will direct all that water up and over the fire, not into it.  If you don’t have fire to hit, why are you training a line there?  Use that water to your advantage.  Collapse an issue?  Then get the lines up and out of the collapse zone with aerial pipes and platforms but don’t just “surround and drown.”  Aim for areas of heavy fire.  You won’t be “pushing it” somewhere else, it’s already going there, knock down the bulk of it’s heat and support and it will slow it’s advance.

When it is commercial and you’re trying your best to get as many large lines as you can into the office building, what are we doing?  Each of those lines needs 2 persons on the nozzle, an officer and then a member at each corner feeding line.  That exceeds even the best staffing models I’ve seen.  Take that first line and make a difference with it.  Keep it dry until you absolutely need water, then your layout person and other companies can help you stretch as you go.  Charge that 2 1/2″ line with 2 people at the door and all it will be good for is holding the front door open.You’ll need help getting it where it needs to be, but once there and trained on the seat of the fire, conditions will improve and smaller lines can chase the fire back as you advance, knocking down a lot of fire.  All because of SMART application of water.

Think I’m wrong?  Know I’m wrong?  Show me.

These are my observations and do not reflect the standards and practices of my employer.  Nor is the Department in the image used being singled out, nor were they the inspiration for this post, just a nice shot of an outside defensive line and an officer who appears to REALLY love that tree.

A Tip of the Helmet – Cleveland says “No”

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Social Media in EMS - A Tip of the HelmetIt was reported this morning in the Cleveland Paper the Plain Dealer that Cleveland EMS will start rejecting minor calls for service unless the system is able to handle it. Writer Mark Puente reports:

“This is a huge step for Cleveland,” EMS Commissioner Ed Eckart said. “This is a step back from a long-standing culture in this city.”

And indeed a long standing culture in America on whole.  I have a call into the Commissioner to get more details on the nuts and bolts of this move as I would love to know how we all can enact this kind of common sense in our own EMS systems.

Now before everyone starts wringing their hands about what is going to happen, take the time to read through the comments on the story, many of which claim to be written by local responders.

As you start to write your comment about the referred ankle pain that could be presenting as a silent MI, keep in mind that as you transport that “maybe” call, the actual crushing chest pain that IS an MI is waiting longer for a transport.  We need to stop worrying about what might be and focus on what is.

The issue of liability for reducing immediate response is countered by the liability of explaining to the family of a deceased person that their ambulance was delayed because of system abusers.  We call it triage.  No one thinks twice about ignoring minor injuries in an MCI, why is it suddenly an issue when that decision is moved into the control center?  If we let the call taker take the calls and the triage system deems it non-emergent, then let it be non-emergent.

For so long we as an industry have striven for an 8 minute goal only to see the nation expect that 8 minutes for everything.  Cleveland says no more.  Cleveland.  No offense to the system there, I’m learning more about it now, but if you went to a conference and asked which EMS system in the Nation is out ahead of the others, Cleveland is not in my top 3.  Until now.

A Tip of the Helmet to Commissioner Eckart and the Cleveland EMS system for breaking free and doing the right thing.  I hope to learn more about their research and system savings in the near future.  I will most certainly pass that along if I can get it.  Do you have a question you’d like me to ask the Commissioner?  Post it below and I’ll ask him.

The Car, The Wall and The Game – Day 3

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chroniclesblogThe alarm seemed to be timed better this morning and I was bright eyed and bushy tailed for my second day on Mark Glencorse’s Rapid response Car in Newcastle.  The coffee was ready when I got out of the shower and I watched a bit of news while getting ready.  When I was in England a frightening wave of flooding was literally washing away parts of the western side of the country and numerous Fire and Rescue resources had been mobilized.   It was a topic of conversation in passing throughout the morning with the Vehicle (ambulance) crews we saw and hospital staff we talked to.

The check out on the car was much quicker since my first day orientation and away we went to our first post.  On the way Mark asked if I was hungry and I had to remind him I don’t often eat breakfast.  In the back of my mind was another McDonald’s run but in the front of Mark’s was taking my for a proper Geordie breakfast.  The term Geordie refers to the people or speech from the Tyneside region of England, which is where Mark is from and where we were.  Similar to referring to someone as a Lonestar or Southerner here in the US, a dialect of speech and set of stereotypes is set into your mind.

The car weaved through the light morning traffic to a take away trailer in a light industrial park.  The aroma from this man’s trailer was like heaven.  The odor of bacon, along with other smells, changed my long standing no breakfast clause and my mouth was watering.

As with many of our other adventures this day, Mark in the car had folks wondering where the emergency was.  No one thought he was the Police coming to get him…until they saw me in my navy blue.  When Mark ordered my meal and the fellows standing nearby read the back of my jacket, which said “Firefighter/Paramedic SFFD” they were curious to ask all the questions we’ve been asking each other for months.

“Is it true you have to pay to go to the Doctor?” “yes.”

“If you can’t pay do they send you away?” “No, you get a bill later.”

“What about an ambulance? Is it true you’ll leave me to die if I can’t pay?” “No, we’ll help you out no matter.”

It was a great conversation with locals about their neighborhood and town.  Keep in mind this town has been here more or less FOREVER.  It’s not like some guy wandered through 200 years ago and started a farm.  There are castles and churches still standing despite centuries of wars.

It was in the middle of a talk about a nearby castle that my breakfast was ready.  Mark’s smile widened as he handed me what can only be described as heaven with a side of LAD.

Bun, mushrooms, brown sauce, black pudding, eggs, sausage, bacon and it was glorious!  Along with a true cup of coffee and some good conversation it was a wonderful way to start the morning.

But like so many things on this job, wouldn’t you know it a motor vehicle accident has been reported just a few blocks away.  Chomp, gulp, a thanks and away we go to the 2 car accident.  There was an initial need for extrication so Mark called in the Brigade.

The ambulance arrived quickly, as did the brigade and everyone went to work doing their pre-determined roles.  It was refreshing to see firefighters not distracted by assisting with patient care, but simply having a task and seeing to it that it was done.  This scene was more what I was used to.  Ambulance, fire engines, police, a proper job.  Although the injuries minor and the damage to match, the resources in the community worked seamlessly together to get the job done.  After the patient was transported I had a quick talk with the firefighters about their roles and responsibilities on this assignment, since there was not the usual bickering or fighting for the glory of the jaws that I have seen all throughout my career.  The firefighter assigned to cribbing was working just as carefully and quickly as the two sets, yes I said two sets, of hydrolics that were being prepared.  We discussed my role as dual trained and they gave a polite smile.  I think just below that was two distinct thoughts.  First, “That’ll never happen here” and the competing, “Oh God, what if they do that here?”

My photographer for the day obliged for a photo of the brigade that responded drawing my caption, “One of these fireman is not like the other…”

After a couple more jobs we were released from our roll area and directed north to the Arsenal/Sunderland football match.  The trip started as a chance to show a lifelong soccer fan a proper football match in his adopted country, but it would turn out to be an EMS learning experience.

But first, Mark had something special planned for me.  We grabbed our sack dinner, lovingly prepared by Mrs999, and hit the road to see the proper section of the old Roman Wall I was so interested in.  The drive through the countryside was amazing.  Rolling green hills hiding in the fog, unchanged since ancient times, save for the occasional 200 year old farmhouse with it’s trailing smoke from the chimney proving someone still inside.  The park rangers (or the UK equivalent) came out of their warm office to meet us when the RRC pulled up and we got out.  They wondered if a hiker had been hurt on the wall, why else would the ambulance be there on a foggy, rainy afternoon?

After a climb and a brief hike I was able to take some video and one of my favorite pictures from this adventure.  smallerThen I got to do what my Grandmother never did, stand on Hadrian’s Wall, where her hero Arthur may once have stood.  There was a connection with that place I can’t really describe.  I have the book she was reading when she died, Stories of King Arthur, a book she received as a child from her grandmother and I display it proudly in my living room, bookmark still in place and soon a photo of this part of the wall will accompany it.

It was an experience I hope to share with my young girls when they are old enough to appreciate what the wall means to the family.  Folks have been known to walk the whole length, camping as they go, and I plan to do the same in good time.

And now for something completely different.  If you’ve made it this far, I thank you.  Like Mark has said, so much happened on this trip, so many interesting and exciting things we shared with each other and with all of you, these day by day accounts are long winded.  If you skipped this far to read about Event EMS you are truly a Fire and EMS nerd and I salute you for that.

The Sunderland stadium can hold, at capacity for a football match, 45,000 impassioned fans.  The perception of many of you in the US may be “Soccer Hooligan” and the stereotpye is fitting in many cases when it comes to premier league football.  I was treated to not only the game, but a tour of the medical facilities made available for players and fans alike.

The stadium has an impressive command center encompassing the EMS team co-ordinator, Fire safety specialist, CCTV team and the police commander, all in two large rooms.  From this unified command center a response can be co-ordinated and a plan followed by radio.  The CCTV cameras also allow the leader to call in extra security if it appears an EMS fly team has unrest around them.  Help can be on the way before they even notice what is happening.  There were 4 teams on staff, dispersed around the stadium with assigned seats and radios, ready to respond as well as 2 pitch or field teams ready to respond to an injured player or person on the ground level.

Behind the scenes are two levels of care.  The teams have physicians on staff to deal with injuries to their people and outside the stadium, tucked in with the snacks and beverages are a number of doors marked First Aid.  Behind these doors are the service I know little about from my travels there, St John Ambulance.  (Not St John’S ambulance, St John.  I learned that one real quick.)  In these almost clinic areas are basic care givers, EMT’s, Paramedics, RNs and an entire medical community, all volunteering to help out.  While Mark and I sought refuge there to eat our dinner before the game, a woman came in, was assessed, treated, medicated and released, all in the span of 10 minutes, all by the St John staff.  It all happened before I could finish my Dr Pepper.

Upstairs in the control center I had a chance to peek at the emergency response plan and these guys have it all figured out.  I learned later that a number of previous events led to a mandate that each stadium have an action plan and the resources in place to react to those emergencies.  We also talked about rotating the teams if more than 1 fly team was mobilized, the extent of the St John involvement, their ability to staff a team and a number of other things most laymen would have fallen asleep thinking about.

The match was brilliant.  We stood just outside the command center, which was near the visitor’s seats.  Arsenal fans are passionate fans.  When I applauded a good play, which is common in this sport, Mark grabbed my hands just as one of the visiting supporters turned to see who was clapping.  Just what I need 4,000 pissed off drunk football fans chasing the American who clapped because the home team goal keeper made a nice save.  Tragedy averted.  And good too, because we were heading out on the town later.

We’re meeting Mrs999 and Fiona for a night on the local scene to give me an idea what Geordies do when the sun goes down.  Well, a while after the sun goes down.  OK, late at night.  I was treated to some local color and had a chance to talk to Mrs999 and Fiona about the person I was shadowing this week.  We talked, danced, twittered and had a wonderful time.  Mark loved his new iphone, since the old one died in San Francisco and at one point he fell asleep updating all the Chronicles of EMS followers.  OK, not really, but it made for a fun twitter update.

As the evening continued on the famous Millennium bridge over the river Tyne, I had a chance to reflect on where I was and why.  It was a big deal to be where I was, with Mark and the NEAS, learning how to deliver care in the front loaded model.  We should have called it a night there, but we had one more stop.

Bachelor and bachelorette parties in Geordie country take themed dressing to the extreme.  In Las Vegas, the girls may dress in pink shirts with the bride to be in some kind of white head dress and veil, letting all the single guys know exactly what she is celebrating.  But here, the entire group dressed to match.  There was a group of guys dressed as 20’s gangsters, pinstriped suits and fedoras.  Why? Stag party.  Groups of girls wearing matching tight shirts all wishing their engaged friend luck in cleverly worded phrases on the front. Why? Bachelorette party.  In came a group of girls wearing black and their names on he back of their shirts.  One of them we know.  Steph Frolin is the name my co-workers use to alert me to a scene that is not what it seems.  Imagine we are investigating a person who says they just came in from a terrible car crash.  As I’m assessing them my partner discovers witnesses in the next room who can confirm no such thing ever happened.  They will refer to me by my BS name: Steph (Pronounced Steve) Frolin.  as in “hey Steph, can you have her describe the car again?” Now I know something has changed and that I need to speak to the partner ASAP.

So Mark turned on his ambulance charm and talked the poor girl into standing with the only guy wearing a jacket for some reason involving an American and a blog.  No doubt she has erased this moment from her own memory.

As I mentioned earlier, we should have cut the evening short at the bridge.  The jet lag, the drink, Mark’s dancing, a long day and an early alarm clock would spell disaster early the next morning for our last day on the car.

Taking it easy on the drink is a suggestion that carries through all situations and this one is no different.  Not that I went to excess this night, no where close, but the combination of the time change, new diet and excitement of the Project would lead Mark to getting me off the streets the next morning.  And I’m glad he did.  Details on my nap next time.

20 Keys to a Positive Exchange

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The 20 Keys to having a positive, productive exchange in Emergency Services.

1. Agree on your purposes upfront.  if you want to prove another system inferior, they may not be too cool with that.

2.  Observe, note, learn, apply, repeat.  Not everything will work in both places, politics will never allow it.

3.  Know why you’re choosing that place.  It needs to be a balance between person and system.  If neither is 100% it will never work.

4.  Get the third rail conversation out of the way early.  Talk religion, politics, family.  Find your differences and common ground early.  If you see another persons religion or values as an issue you may not honestly see the system they want to show you.

5.  Be honest with yourself and your partner.  If they ask your opinion, give it, but be prepared to back it up.

6.  4 days observation is a fair amount.  8 days away from home yields travel, 4 days on the streets and meetings.

7. Plan to be exhausted.

8.  Plan time between visits of at least 1 week for family time.  Mark and I did 23 days total, too much.

9. Get the support of the local media to showcase your work.  This should draw the attention of the politicians who can enact some of the changes you may want.

10.  Every system has one Chief or Administrator who wants to be involved.  Let them be.  Keep them in the loop, it is handy to have someone upstairs if you need it.

11.  Avoid the unusual or extreme.  Give them an honest average day in your life.

12.  Be respectful if things turn out differently than you thought.  Above all else be honest.

13.  Find alone time during your trip to reflect on why you are there.  Whether it be a meal, evening or part of a day, you’ll need a few hours to reflect on what you’re doing.

14.  Avoid heavy drink.  It can not only impact your next day, but reflect poorly on your partner, you and your service.

15.  Make sure you have permission from your Department to appear in your uniform and make public comments about your system.

16.  Avoid questions that start with “How come you don’t …” like “How come you don’t intubate kids?” The tone could be considered confrontational.  Try making it easier to answer. “What tools do you have to secure a pediatric airway?”

17. Eat the food.

18. Try to understand the culture, phrasing and customs.  Learn the local history.

19.  Remember not everyone has the same set of definitions you do. A rescue here may not be a rescue there.  When there, use their terms, not yours.

20.  Be Happy.  Smile.  Have fun.

You Make the Call…Chili Cookoff…What Happened

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You Make the CallAlas, Fireman88 from Buttasscold, Michigan (A false name I found out) never responded to my messages, nor in the comments, so what they did in this situation remains a mystery, but I know what I would have done.

First of all, I don’t think this needs to even be mentioned to the Chief, unless this department is so small that the Chief is the front line supervisor.  Secondly, I have a responsibility to report unsafe conditions to appropriate municipal agencies, it’s part of that whole swearing to support and defend the constitution part of what I do.

When I was faced with a similar situation I completed my preplan, as required, then returned to the station to INQUIRE about cleanliness standards in our area.  The agency responsible for enforcing food temperatures and the like was out of the office for the weekend but would follow up as soon as possible.  I didn’t make a big deal about it, but since I had enjoyed eating there a number of times, I felt it my civic duty to pass along what I had seen to folks in the know.

The fact that this business owner was involved in the chili cookoff doesn’t even enter into it in my opinion and it is not a Fire Department matter.  But I would also hope that should the Food Inspector see something that they believe is a fire hazard, they simply do their job and give us a call to make that determination.

If you said call someone who knows better, you made my call.  If you’re ignoring me, you made Fireman88’s call.

Anyone for some tater tots or a lime slushy?  Is it me or does this photo seem wildly out of place?

Anyone for some tater tots or a lime slushy? Is it me or does this photo seem wildly out of place?

A bit of side business real quick, I’ve got a couple more You Make the Call situations in the pipeline, but a friend of mine is looking at forming a training specific program for them, so it may be a bit before I let them go.  Until then, you can read about my EMS exploits and other ramblings.

You Make the Call…Chili Cookoff

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You Make the Call

I get a fair number of emails at thehappymedic@gmail.com, most asking me to send them money in some elaborate purchase scheme. Nigerian Prince or not, I’m not even sure where to send a money gram anymore.  But, every now and again someone will write asking my humble advice or just wanting to rant. I like reading those because I know how good it feels to get everything out, even if to a total stranger.

But when I got the following email from a person calling themselves “fireman88″ in “Buttasscold, Michigan” I was curious to read more.
Mr BAC asked me about a situation he found himself in a few years back and wondered since I do a feature about making decisions would I like to give his situation a try. Naturally I decided to ask all of you, so here you go:

We have a traditional chili cook-off every year for the department and it raises money for gear and rigs and training and stuff. We used to have only fire fighters cook chili but some local businesses got into it and they cook too now. One of them a B-B-Q place has won a lot of awards and always wins now. I had to do a preplan of their BBQ place soon after the cook off and it was nasty. I would never eat there anymore. Nothing was unsafe, OK, just dirty and smelly and nasty. When I told my Chief about it he told me not to upset the owner because he donates a lot to the neighborhood.

I read this and imagined myself back in the kitchen of a local fast food joint a few years back doing a similar thing. I won’t say the name of the place, but when the kid told me they never clean out the chili bin, just add more, I have yet to order the chili cheese tater tots again.

But, what should our cold friend fireman88 do in this situation?  He never mentions if he is career or volunteer, but I think the situation is the same regardless.

I’ll give my response on Monday and, if you’re reading this fireman88, check your inbox I want to hear what you did. Email me or post it in the comments section here.

You Make the Call…Abdominal Pain…What Happened

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You Make the CallI didn’t know such a call would cause such a commotion in the comments section both here and on facebook.  THIS is a situation we encounter often in my jurisdiction.  Almost 30 percent of the calls our call center handles require a translator of some kind.

The main thing I was looking for on this one was what options do you have as a caretaker to help this man aside from loading him up and driving away.  Seeing Mark in the UK have access to other options is always in the front of my mind now when I encounter calls like this.

Our patient did not call, his family did.  The family states they were not told what the discharge form said when they left the doctor’s office this morning following his endoscopy of the esophogus.  The paper details a recent diagnosis of liver cancer and colitis and that he should expect the exact symptoms he is experiencing.  We were able to use a 14 year old family member to confirm with the patient he did not want us there and by no means was he going with us or signing anything to make us leave.

They tried calling the doctor’s office but got no answer since it was after hours.  Unsure what to do next, they called us.  There were numerous family members worried about him and willing to bring water, broth, noodles or anything he needed to get back on a normal diet.  He had not eaten all day due to nausea, from the meds most likely.

We were fine leaving him in his home to recover, as directed by his physician.

Whether they were not offered translators or the phone call went unmade or the family simply didn’t understand, it is clear that the ball was dropped long before I walked in the door.  It can be hard to paint the picture accurately for you on these You Make the Call runs, but clearly I painted this man sicker than he was.  Readers on Facebook spoke of MIs presenting as abd pain and wanting to run 12-leads and treat ACLS.  I noted that his regular hospital was on saturation divert, meaning that even if we do transport, he likely wouldn’t be treated until they can confirm his history, which could take awhile on a good day.

The discussion ran into pushing pain meds, anti-nausea meds and transporting to remove the discomfort and remove any liability, but the best decision in this situation is to honor the patient’s wishes and do our best to clean up wherever the system has failed him.

But, that being said, without the translator, without the discharge papers or if he was alone, he’s on the hook and we’re on our way.

Because it all came together, he was welcome to stay home.  If you said honor the patient’s wishes and let him stay home, you made my call.

You Make the Call – Abdominal Pain

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You Make the CallSurprise! These scenarios sneak up on you when you least expect it.  Our normal Friday feature has been found on a relaxing Sunday night.

You are the first responder to a small apartment on a cool, but not cold evening, to a man complaining of severe abdominal pain.  On arrival you are met by half a dozen family members of varying ages and levels of English recognition.  As per usual for this particular culture, only the folks under the age of 30 speak clearly, and the closest to that is a 14 year old.

She describes to you that her uncle, who is lying on the bed rubbing his upper right abdominal quadrant, has been feeling sick for days.  When you try to get something more specific she asks the uncle and the entire room erupts in conversation, loudly, and not a one of them talking to the patient, you or the translator.  This is clearly a heated topic.

You are handed a telephone by one of the non-english speakers who simply says “Doctor?”  On the other end of the line is an answering service for a Doctor’s office, so much for that.

Some discharge papers are handed to you which detail your patient’s last 48 hours.  Diagnosis of liver cancer, colitis and an endoscope down the ol’ esophogus this morning.  The papers tell him to expect nausea, vomiting, fatigue and discomfort and to begin eating slowly with clear liquids and broths.

The family demands he be transported, the patient looks miserable but says nothing, seeming almost embarrassed.

His hospital of choice is on saturation divert, so your nearest facility is now 15 minutes away.

What options do you have for this patient?  You make the call.

Highway/Freeway response poll

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I got in a rather heated discussion with a colleague a little while back about highway/freeway responses in our area.  he insisted that an emergency vehicle should never use lights or sirens on the freeway because we should not be exceeding the speed limit.

I countered saying it depends on the type of call or why we are on the freeway to begin with.

My definition, for this polling, of a freeway or highway is a median protected paved roadway with 2 or more lanes in each direction and limited, marked exit lanes, speeds often 55-65 MPH.

So, what do you do?

How do you respind to an accident on the highway/freeway?

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How do you respond to a location not on the highway/freeway, but responding on it?

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If you recieve a call for service while on the freeway/highway...

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New School, meet Old School

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I was sent this video by a friend on facebook and had to make sure it spreads as far and as wide as we can get it.  Maybe you’ve seen it before, maybe it’s been on other blogs or outlets, but this video from almost 80 years ago could be dubbed over modern video and be just as important.  It is about 12 minutes long and comes to us thanks to the folks over at flashovertv.com, a site I will spend most of the day wandering through and suggest you do the same. But first, a company film.

Please to enjoy the Los Angeles Fire Department training film “Company Response”

You Make the Call – Command Vehicle – What Happened

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You Make the CallThis tale comes to me from another co-worker and his old department.

It turns out he chose to approach his own supervisor, one not involved, and mention what he believed to be an inappropriate situation.  He brought up the use of the command vehicle and the possibility of an inappropriate on duty relationship.

And wouldn’t you know it, he was officially reprimanded for spreading rumors and falsehoods.  Both parties involved denied the vehicle had been seen there, especially since one of them was married at the time.  The write up was one of the inspirations for his leaving to another department.

A few years later, the two parties who denied their relationship were married.

Regardless of the end result here, bringing this to the attention of your front line supervisor is the right thing to do.  Approaching the parties individually could get messy.  The main point I drew from this situation is that the supervisor is using his duty car on duty to partake in a personal endeavor of questionable appropriateness.

Instead of command vehicle, replace it with Fire Engine or Police Car and see if you feel the same way.

If you said report it, you made his call.

You Make the Call…Restaurant…What Happened

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You Make the Call...Line UpThis was the situation I gave you on friday, standing at the top of the stairs, no smoke, no fire, only an odor of burning paper.

We had all our PPE, including air of course, and multiple companies arriving behind us, so we took our pump can and went in search of the odor.  Back under the stairs in what likely passed for a store room 100 years ago, we found a small section of charred drywall at the floor level.  Opening up the wall led us to a large section of brick which likely went all the way up the inside of the building, but all the drywall was clear.  Oddly enough the other side of the brick wall had a large amount of trapped smoke so the Truck went to work opening it up.

In the end the conditions were such that having a charged line before going down there would have gotten us knotted up for sure.  Turns out the source of the smoke may have been above us, at the street level in an alley where a man was seen smoking prior to our arrival.

If you said have a look, but be safe, you made the right call.

Report from England – Part I

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I’m not sure how many parts this report will have.  I’ve been writing pages and pages of observations, recollections of discussions, talks with patients, staff, Doctors, other Paramedics, all in the hopes of learning something from the 23 days that I so hoped would open my eyes.  We can occasionally get caught up in the details of what we do without seeing the broader picture, the entire system, with all it’s players and pieces.  I found that visiting other systems around the US helped, but the same obstacles presented themselves.

When blogger Mark Glencorse an I dreamed up the Project, it was initially partially for fun.  Then we began to talk even more about what we did differently and I had to see it first hand.  And I did, for the most part.  Just as with Mark’s visit to San Francisco didn’t show him everything we do, I know I missed a lot of the problems with the NHS system.  That being said, I was able to burst many of the myths of socialized medicine and an ambulance service run by bureaucrats.

My experiences with Mark here and also in England taught me that there are all the same people in EMS no matter where you go.  There are the flirts, the nerds, the jerks, the dirty guy and the OCD fellow.  Some want to be there, others are on the way somewhere else, but for the most part people were genuinely curious as to what we might learn from the Project.

What did I learn, you might be wondering?  It boils down to this:

We are two countries separated by a common language.

Not sure who said it first, certainly not me, but it is true.  For example, in the North East of England a Chips Buttie is a nice afternoon snack.  Here it is called a french fry sandwich with butter.  There things are made with sugar, here High Fructose Corn Syrup.  There the EMS system is seamlessly joined to the hospital and clinic care, here it is a fight to get triaged in a timely manner.  In both places family means family, I now have a new one 9,000 km away.

Looking over my notes from this Project, I have a boat load to tell you about and a lot I hesitate to tell you about since it may appear my mind was made up before I went about socialized care.  I do have some suggestions how to make that system more efficient, but things there are so completely different when it comes to health care, it will never work here.  Not because of the administration, or government, or labor unions, but because Americans have come to expect instant gratification from their EMS systems.  They refuse to believe their sprained wrist can wait more than 4 minutes for a fire engine and ambulance.  It is this basic understanding of what EMS is that is lacking in America and I know who is at fault.

We are.  Anyone who has been in this business more than 2 years is responsible for the complete lack of understanding that grips the common American about their emergency medical systems.  It is time we recognized this fact and did something about it.  Exactly what that is will depend on those above us in this machine to recognize their part and help us educate our “customers” (I hate that term in this business).

For my short career I’ve been repeatedly discouraged by people using EMS as their free taxi service when more appropriate, far less expensive methods of treatment are available.  I did see, in my short time there, EMS abuse in England, but not nearly at the rate I see it here at home.  I believe it stems from the belief that people have a “right” to an ambulance whenever they want.  And not just the entitlement generation, but those who have paid into the system and want something, anything, back from it.  We need to show these people that they are entitled to help when they need it and an honest discussion about what is best for them.

I also learned from my experience that my system is not being as efficient as it could be, nor is Mark’s.  Believe me when I say that each of those statements could have their own volume, and likely will, since most of the things I want changed there, labor will never allow and the same here.

Before I start boring you with the countless posts about what I did, saw, learned and learned to avoid, I want to take a moment to thank a few people that made this trip everything it turned out to be.

To Mrs HM – The woman who sat next to a burnt out EMT on the tailgate of the rescue truck  in rural New Mexico and said, “You don’t belong here.”  She is the reason I got off my ass and got serious about going back to school full time.  I graduated 3 years later.  She’s been right here with me this entire time and made this whole thing work.

To Mrs 999 – Who I’m sure had just as many headaches as my Mrs while mark was away, you welcomed me into your home each night for tea and made me feel at home.

To Firegeezer – For noticing a little blog about the joys of 911 abuse.

To Lt Talmadge and her UK counterpart Fiona – Meetings, dinners, etc, all went to plan.

To anyone and everyone who donated to help make the Pilot episode of Chronicles of EMS.  Having the cameras along was unlike anything else I have ever done, I hope you all like it.  And I hope that Ted mentions I hit every IV first try with three witnesses and three cameras rolling.

And finally to Mark – Thanks for being so easy to get along with, bad jokes aside.  and sorry all the nurses liked my uniform and accent…wadda ya gonna do?

I’ll get more specific on my observations over the coming weeks, keep an eye out here and at Mark’s blog.  Thanks for following along.