Before I get into the details of a fictional event, let me mention that the Black Diamond X Boot I reviewed did not go through a test I would have imagined until just recently.  I can now confidently say that if I ever have to walk 100 meters in sand, this boot is not bad to have on.

Now into my dream, partially inspired by the Motion Picture Inception, featuring the lovely Marion Cotillard.

The alarms ring and I’m in the new firehouse.  The bells sound different, but the feeling is the same, “Where am I and where am I going?”

Lights flashing, the engine winds it’s way around the access roads until we reach the parking lot of the beach and the ambulance responding with us is close behind.  We pull into the empty lot expecting to see someone looking for us but no one is there.

The screen tells us the person is conscious and able to walk, but has yet to present themselves to where they said they were going to be.  As we sit, lights flashing, clearly visible for at least a half mile, my mind wanders back to the nice warm bed back at the firehouse.  Perhaps I’m still in my bed and this is all a dream?

Just then the PD come roaring into the parking lot, open a locked gate and wave us through.  Even in my dreams we don’t take the engine into questionable places.  Good for us.

The ambulance crew, my EMT and I grab the gear and begin to hike down to the point where a wide staircase awaits us.

Still no one visible despite our flashlight beams and calls in all directions.

We are met with only silence and darkness.

“We’ll go this way,” the officer motions to the west, “You go that way.”

“In your dreams” is what I meant to say and, in fact, deeper I went into this new dream, now walking east, seeing another officer’s flashlight many meters ahead.  I suddenly notice I’m in heavy boots.  Looking down, the reflective stripe on my pants is now blinking and I wonder why.  Looking back up the officer ahead is doing the signature “over here” wave with his light.  It sparkles like a star in the night sky above.

The crew follows as we radio ahead to see if extra equipment is needed.  The response is vague, stating only “He OD’d.”

This deep into the second dream, time is slower.  Each step seems to get me 1/2 step closer to the victim, but we’re all traveling at the same speed.  Almost like when you try to escape in a dream, but your legs won’t respond.

Finally reaching the small bon fire 3 fellows sit, arms on legs, talking to the officer who now uses his flashlight to take notes.

“Someone laced my weed, man, I need help,” one of them says, standing and brushing the sand off of his pants.

Turning to the ambulance crew I mutter, “I have to be dreaming,” and I fall deeper into the dream this man is having, where smoking weed for 3 days straight, running out and realizing it is cold and a long walk home merits a 911 call.  Trapped in his dream I have limited options and have to do what he wants.  It’s his dream.

The walk through the darkness is aided by flashlights and a comforting arm under his, making the trek easier by far.  For him anyways.

We complete the 100 meter walk back to the flight of stairs, when he changes his mind and wants us to leave him alone.  It seems his dream is beginning to unravel at the seams.  The arm he has been leaning on through the sand and up the stairs is now forcing him forward, up to the ambulance.  What began as a simple question and answer session surrounding his health and well being has now devolved into a shouting match.  The beach disappears in a flash of bright light and he now lays calmly on a stretcher in the back of an ambulance, trying to regain the nice dream he had been having, leaning on another and borrowing light to make the trek back to the parking lot.

I’m back in the Officer’s dream now, his hand on his cuffs, ready to spring into the back of the ambulance and restrain the uncooperative man with any means necessary.  From my vantage point outside looking in, he can use all manner of holds, strikes and language to make the situation safe, whereas if I even use colorful tone I could get in trouble.  If this was my dream…

…I’m back in the engine, returning to the station.  The sun will be rising soon and I can feel the warmth of my sleeping bag as if I was in it…

…and then I awake.  In bed.  At work.

It seemed so real, but it was only a dream.

When I took my boots off the engine however, they were covered in sand.  How is that possible?

Just in time for your next meeting, event or shift, an introduction to the initial EMS 2.0 concept is now available for download.

You can print it out and give it to a friend, colleague, supervisor, Chief or just to prove to folks that just because something is online doesn’t mean it doesn’t have merit.

Go have a look.

And while you’re there, get a T-shirt, pin and patch to help spread the EMS 2.0 word!  All profits benefit Chronicles of EMS and EMS 2.0.

I have stolen a peak at the new EMT Curriculum and had a chance to go through it word by word.

Unfortunately, there are a few sections missing that I feel need to be highlighted and returned to the standard knowledge base of every EMT in the country.

1.  Understanding Paramedic Humor – Too often I have restocked from an ambulance and when asked if I need anything else replied, ‘Get a cup of hot fat, the Beatles White album, oh, and bring me the head of Alfredo Garcia.” only to be handed a hot pack.

2.  Carrying heavy shifting loads under threat of vomit – Sounds like it should be day 1 to me.

3.  Resetting Life Alert Base Stations – See the big button with the yellow light that says reset?  PUSH IT!

4.  Spelling – When I ask you to copy down the meds list, don’t guess, simply recreate what you see on the bottle right there on the form.  Don’t go rogue and try out some new abbreviations or interpretations.

5. You are not here to save the paramedic – Turns out most of the things you’re reminding us of (C-spine, O2) are actually bad for them anyway.  I’m not ignoring their sat of 98%, I’m 2 steps ahead of you.  Now where is my stethoscope again?

6.  Pens – You carry them, they get tangled in my cape.

7.  Nurse interactions – When we hit triage and no one will make eye contact, block the entrance to the nurses station with your patient.  Don’t try to apologize, try to get their attention by making them look at what they need to be looking at.

8.  Stop pissing off the nurses – We’ll be back here in an hour and they’ll remember.  Unless it’s 6:30, in which case, let’s have some fun!

9.  Social Workers have it lucky – They get to sit in an air conditioned room and do the same interview we do, but 2 days from now, after our client has been to the ER 3-4 times for the same “hunger pains.”

10. When I’m hungry, we eat.

As reported by WPTY in Memphis, Memphis Fire EMT Kenneth Montgomery was assigned to a unit transporting a patient.  Instead of completing the transport he steered the unit to Firehouse 16, parked and went looking for a relief to take the rest of the job.

Kind of a no brainer to me and I hope to you too.

Finish the job you’re sent on.  That’s a letter in your file and in case you thought this would get you off the ambulance, think again.  Unlike many folks on Facebook, I’m not asking for your resignation, your EMT card, or anything else.

Why not?

The video posted at the news website includes certain “details” that got my memory spinning.

You see, I’ve been on this call 100 times.  I’ve even been on the call that is the 1 in a million like this, but I know that wasn’t an actual emergency and I’ll tell you why in a moment.

Using my amazing holistic detective skills I can tell you this was a morning run to a rehab center for chest pains.  I would honestly be surprised if they had to look at the map book for this one.  999 out of 1000 times the chief complaint does not match the signs and symptoms, someone will start to hospital shop, refuse a 12 lead ECG etc.  Treat every job like that 1 in a million until proven false.

I have no details as to the patient care or condition in this circumstance so don’t even comment that I’m not being compassionate.

I do have one set of details that, had it been happening, the press would have mentioned it for sure:

No lights and sirens to the hospital.

We can debate the benefits of playing Paramedic Pinball code 3 to the hospital, but it can tell us a lot about what may or may not have been happening in the back of that ambulance.

Had this been a code 3 return Mr Montgomery would indeed be facing harsher punishment from the likes of me, but having recently taken a promotional exam that dealt with similar situations there are a number of statements I need to gather before passing on a recommendation for disciplinary action:

1. Interview the call taker and pull the E911 tape to confirm the call.

2. Interview persons at the scene as to the disposition of the crew.

3. Obtain admission condition and discharge condition of the patient.

4. Interview Paramedic in charge of patient care.

5. Interview Mr Montgomery as to his thought process and justifications, if any.

and most importantly,

6. Were there actually any rules or regulations broken?

Is there a rule in your system that mentions being required to go straight from the scene to the hospital?  Even something as vague as “Timely Discharge of Orders” might stick to the wall, but my guess is Memphis is about to get one of those rules that can be traced to a name.

Mr Montgomery, what you did may not have been right, but it brings us into focus in a way we don’t need.  I’m sure private ambulance companies will be mentioning this event at the next system bid for sure.

Over the next few weeks you’ll be hearing from me about the Tak Response Conference in San Jose coming up September 14th-16th.

Chronicles of EMS was invited to be a part of this collaborative training opportunity that will bring the best of all fields together to network and learn from each other.

This conference combines nursing, Fire, Haz-Mat, law enforcement, SWAT, EMS, public works and a number of other disciplines together, since when we all arrive on scene we have to work together.

Let’s start to train together.

Tak Response is not only a chance to learn from other disciplines where you fit in at “their” scene, but to network socially with your fellow providers before the you know what hits you know where.

Imagine a scene where the Battalion Chief, Patrol Officer and EMT all already know each other and what each agency expects from the others.  That’s a smooth running scene.

Here’s the episode of Seat at the Table where we meet the organizers of the Tak Response Conference and run the concept by paramedics, firefighters and even a cop.

You all know I am not a fan of little boxes.

I dislike the little boxes we have to cram our patients into to treat them based on chief complaint.

Also on my list is the little boxes we take them to the hospital in.  Bolting a box onto a van isn’t enough.  More on that another time.

On the top of this list in big red letters are the little boxes our call takers are required to fit their callers into.

They must meet criteria in order to be coded, qualified, weighted, and then sent out to the trauma hungry troops on standby all over the City.

Problem is, it doesn’t work.

I do not know Dr Clawson, but I do know his system and that, if a system can correctly act on the information gathered and coded, it works most of the time.

What really gets me going these days is the purposeful miscategorization or non categorization used to move calls out of the call center faster than they need to be.  I am not alone in this experience, getting messages, tweets and emails from folks all over the USA asking me what they can do to improve dispatch.

You can’t improve dispatch.  Not until you improve the callers themselves.

One of my readers described it as GIGO (Garbage In, Garbage Out) meaning, in the most respectful of terms, that dispatch should not be changing anything the caller says and that if the caller is wrong, then I do hope my dispatcher is wrong as well.  If a person calls and tells the dispatcher that the space shuttle has crashed on main street and thousands are dead, maybe it did.  But the problem lies in sending that call out before it is coded.

The two most inexperienced people in the system are the ones guiding the system.  The caller and the call taker.

I have never been to a call that was reported, coded and turned out to be the same thing, mainly for the same reason my patients’ chief complaints never seem to jive with my treatment per protocol:

They don’t fit into your pre-determined boxes.

Many systems run a BLS tier, or perhaps a single paramedic resource to handle Omega, Alpha or even Bravo calls.  Here in mine, there seems to be no rhyme or reason to the assigning of resources on some calls.

A call coded by the system, based on information provided by the caller, to the call taker has been declared a 26A1, a sick call.  Yet in the call classification next to the code is the term BLEED-SEVERE.  And now the call becomes a code 3 and 6 or more lives are at risk.

“Better safe than sorry, right?”  Good thought.  Who is in more danger?  The person who bit their lip and called 911 or the 6 responders using red lights and sirens to respond to the call now thought to be more than it is.

“Then what’s the answer, smart guy?”

Ditch the codes.  Stop the tiny box requirement.

If they call and say “I bit my lip,” Dispatch it as such.  Let the responders apply calculated risk to the situation without being blinded by administrative tricks used to ring the bells faster, improving your call center stats.

If you can send a call out in 30 seconds without gathering all the information, that is not a success.

I am not blaming dispatchers.  That voices that tell me where the sick people are are not the ones in control of the dispatch system, but the ones required to work within it, not unlike me not liking aspects of my treatment protocols.

GIGO.

They relay what they are told and code the call.

It is the trick of changing the code or description that I don’t like.  That is how the cut fingers, bit lips and sleeping people send out a full ALS response and drain the system of resources at a time when we are getting stretched thin.

By changing from a criteria based system to a “plain text” system, two distinct things will happen.

Firstly, crews can use their judgment, ETA and experience to determine their response priority based on what the caller actually said, not what the system thinks they might be saying.

“My back hurts again” is not coded as “Non-Traumatic Pain-Code 3″ so the crews can apply their expert training to audit the dispatches in real time.  I worked in a system like this and it worked.

Secondly, it will become very complicated and difficult to classify and track types of calls for analysis after the fact.

“We don’t know how many CPR calls went out last quarter because we have to go back through each call instead of just pulling the codes.”

A recent study by UCSF and SFFD Medical Director Karl Sporer celebrates the finding that 1 out of 7 reports of a rescusitation in San Francisco turned out to be just that.  You can’t find stats like that celebrated outside of baseball.  1 in 7 was a success.  I see the 6/7 mis-reported or mis-coded calls as room for improvement indeed.

All the studying, testing and nervousness has paid off and you got that paid spot!  Only problem is the commute, 1.5 hours each way 3, towns over.  But, it’s with a good company and you hear great things about them.

Your first day comes along and you arrive at the ambulance yard, clean new uniform and gear, only to discover you were hired over many of the senior part time folks who also applied.  Needless to say they aren’t thrilled by your arrival.

During morning check out you are assigned to a brand new EMT-Basic, ink still wet on his card, who is not familiar with the roads, equipment or hospital locations.

Gulping your coffee, you decide to head into the supervisor’s office to see about a reassignment, at least until tomorrow.

“Nobody else wants the new guy, or gal, so make do.”  Is what you’re told.

Back to the rig and gear is checked but your narcotics are low.  Back into the office the supervisor tells you they don’t have a license for narcs, you’ll have to restock with the FD in the next town.

Something is off for sure.  Is this a test?  Some kind of cruel first day prank?  At the end of the first shift you feel like tossing in the towel but a friend reminds you that their are no other companies hiring anywhere nearby.  2 local ambulance companies recently went under and the remaining one isn’t hiring.

Keep the job and most likely the house and the car payments relying on it, or get out while you can?

You make the call.

There will be no Monday follow up to this week’s situation, it was sent as a request for advice to thehappymedic@gmail.com.  If you have a situation and you’d like to ask for a wide variety of insights, send it in, no name needed.

I was taken aback by this guy at the bar in a T-Shirt with a 8″ EMT on the back and giant star of life.  Add to that the stethoscope around his neck and I was just confused.

My fire and PD buddies were making jokes while I was trying to make the decision whether or not to approach him.

I could start the conversation by asking if he really was an EMT, which I’m sure he is hoping someone will ask, hence the shirt, but it was really the combination of the pants, shirt and especially stethoscope that had me thinking this person is clearly not “one of us,” US being the profession.

He managed to wander over to a table of ladies with his friend who said, “Make room for my EMT buddy,” at which point I had to cover a laugh.

No matter what I said or how I approached the situation, this was not the time or the place to address his lack of professionalism.

He was not in a uniform, but as far as the public knows, he was.  He was not doing anything “wrong,” just not the best thing at that moment.

Mark can tell you that when coming home from riding with him and purchasing an adult beverage at the store, I turned my jacket inside out.  I looked odd, but even in another country I didn’t want to let folks know about that association.

So in the end, I let it go, mainly because I am convinced he would not have understood.

My buddy then, after we left, asked why I didn’t give him a Happy Medic card, then blog about it.

Also not “wrong” but maybe not the best way to approach it.  So in the end, I only did one of the two.

If you said stay out of it, you made my call.

Ah, a day off! You’ve decided to head out for a few quick drinks with friends and meet at a little restaurant/bar in a quiet suburb. As you try to describe to your fire and PD buddies about the culture at an event such as EMSExpo, they ask if folks wander into area bars in uniform.

Replying in the negative, they laugh and ask if folks wander into bars in uniform wearing stethoscopes.
When you glare at them they laugh and point over your shoulder to the other side of the bar.

Seated at a stool and drinking a beer is a fellow in EMS pants, a blue shirt with a large “EMT” on the back and, sure enough, a stethoscope around his neck.  The shirt shows no company or department name and he is wearing no ID you can see.

While you try to make sure you are seeing what you are seeing, your PD buddy says, “Well, are you going to say something?”

You make the call.

One of the Chronicles of EMS earliest followers Sascha Fehr, who I had the pleasure of meeting in San Francisco months ago, arranged for a Hungarian Paramedic to travel to his system in Germany.

He recently uploaded this video:

Find more videos like this on Chronicles of EMS

Tell me again how we’re not changing the world?