Category: Principles

The Laws of EMS

One more post about glucometry is pending, but for now, something lighter.

Decades of medical interns have been raised on the Laws of the House of God. The House of God was a cynical and dark look into the world of modern medicine, and its “Laws” were about as uplifting as condensed soup, but they rang true enough that you’ll still hear them quoted in the halls of medicine today (including those of the real-life “House of God,” where I find myself more shifts than not).

In any case, laws come in handy. Although I’m a believer in the nuanced and detailed analysis, as I age and my neurons gradually turn to cotton candy, I increasingly see the value in basic rules of thumb to guide us through the tangled web of life, and especially of this job.

A good law is simple. It’s always true, or almost always, and the exceptions prove the rule. It’s not specific to a certain region or company, but is something you can keep under your hat and carry with you throughout your career. It’s clear and it say something fundamental about the kind of provider you want to be. But most of all, a good law is not just an empty platitude, but rather an actionable guide-post that can answer real questions in real situations. When times are hard or temptations loom, it’ll tell you what to do.

With no further ado, then, here are mine. I believe in them, I follow them, and like good unguent, I wholeheartedly prescribe them for universal application. I am not wise, but whenever I do a good job of faking it, it’s by following these principles.

 

THE LAWS OF EMS

  1. Help your patient in any way you can.
  2. Be nice to everybody. It’s your job.
  3. If you can’t save their life, make their day a little better.
  4. Protect your partner.
  5. Have a reason for everything you do.
  6. Leave the patient better off than when they met you.
  7. It should get calmer when you show up.
  8. Good habits make doing the right thing easy.
  9. Tomorrow, nothing will remain but your documentation.
  10. Everything’s a bigger deal to the person on the stretcher.

 

But that’s just me. What laws do you believe in?

Editor’s note: this post was expanded into a feature piece for EMS World Magazine in the March 2014 issue.

Confidence vs. Competence

 

Do you know what you’re doing?

Do you look like you know what you’re doing?

Although these things are connected, they aren’t the same.

Some of the most common advice a new EMT might hear is to be more confident. And it’s justified: the typical new guy looks and behaves like a scared bunny, and it’s perceivable by everyone around him. You can’t be an effective field provider that way. Other responders won’t take you seriously, patients will decide they’re better off taking the bus, and other medical personnel will mentally delete your input. You won’t make the right decisions, because you won’t have the confidence to commit to them. Plus, your shifts will be nerve-wracking, and your hair may fall out. No good.

Oddly enough, though, this isn’t the worst-case scenario. Worse still is this: you’re supremely confident… even though you’re clueless.

Confidence is a statement. It says to the world, “Don’t worry, I know what I’m doing.” In response, they grant you further responsibility. “If this guy knows what he’s doing, then let him handle it,” they think.

If you project that message, yet are making things up as you go along, you’re telling a lie. You will be given responsibility, only to err terribly. You were trusted according to your level of confidence, but didn’t deserve it; your confidence exceeded your actual competence.

So, you need both. We want EMTs on the ambulance with the ability to assess, treat, and transport sick people. And we want them to demonstrate that they have that ability, by their words, body language, and appearance.

The good news is that confidence tends to grow from competence, which how it should be. As you learn the ropes, you become more comfortable, smoother in your actions, and more certain of your conclusions. Rest assured, you’ll broadcast this difference to everyone around you.

So where’s the problem? The problem arises when there’s an imbalance between the two qualities. Some people are just naturally “nervous-looking” or withdrawn; they may be entirely competent, but you wouldn’t know it by looking at them. These are the folks who need a slap on the ass, and to be told to throw their chest out, strut a little, and say it like they mean it. Even generally mousy people can usually learn to develop a “patient face,” a professional, commanding persona they wear during calls. (Think of your favorite medic… now think of his “medic voice.” Talk about heavy artillery.)

Conversely, some people are either overly confident in their abilities, or have simply been taught to fake it until they make it. (“A commander can be wrong,” as Arthur C. Clarke once wrote, “but never uncertain.”) In fact, some of the most difficult partners to work with fall into this category — the “newish” guy who can perform the everyday basics of the job, but whose cockiness swelled far beyond his actual knowledge, to the extent that he can no longer be educated or corrected. He knows it all, so he’s done learning. These folks need to be taken down a peg, because while ignorance is temporary, wrongness can last forever. If they’re simply afraid to admit when they’re unsure, it helps to reassure them that nobody has it all figured out yet, this is a team sport, and asking for help is much better than dropping the ball.

In the end, the goal should be supreme confidence, clearly palpable to those around you, yet directly built upon a foundation of clinical competence. If you’re good enough, you don’t have to put on a show; you can even hide your moves a little, because they’re going to come out anyway, and a certain amount of humility is professionally appropriate. (Plus, you won’t have to act like a douche all the time.) If you know your stuff but come up short in confidence, that’s your cue to start strutting a little more. And if you lack both, then start by developing quiet competence — not ignorant cockiness.

Dialing it Down a Notch

Bringing order to chaos. It’s hard to suggest a more important skill for an EMT.

Emergencies are chaotic. Heck, even non-emergent “emergencies” are chaotic. The nature of working in the field is that most situations are uncontrolled. Part of our job is to bring some order to it all, sort the raw junk into categories, discard most of the detritus, and loosely mold the whole ball of wax into something the emergency department can recognize. Call us chaos translators. This is important stuff; it’s why the House of God declared, “At a cardiac arrest, the first procedure is to take your own pulse”; and it’s why we walk rather than run, and talk rather than shout.

The thing is, it’s not just those of us on the provider side that need this. Oftentimes patients need it too. Imagine: every other day of your life, you’re walking around without acute distress, in control of your situation and knowing what to expect. Today, something you didn’t anticipate and can’t understand has ambushed you — a broken leg, a stabbing chest pain — and you don’t know how to handle that. So you called 911 to make some sense of it all.

Most ailments are side effects of other problems: the fear of going mad, the anxiety of being so alone among so many, the shortness of breath that always occurs after glimpsing your own death. Calling 911 is a fast and free way to be shown an order in the world much stronger than your own disorder. Within minutes, someone will show up at your door and ask you if you need help, someone who has witnessed so many worse cases than your own and will gladly tell you this. When your angst pail is full, he’ll try and empty it. (Bringing Out the Dead)

With some patients, this is more true than with others. With some patients, there may be little to no underlying complaint; there is mainly just panic, a crashing wave of anxiety, a psychological anaphylactic reaction to a world that is suddenly too much for them. Particularly in those cases, but to a certain extent with everybody, bringing that patient to a place of calm may be exactly what they need. I have transported patients to the hospital who clearly and unequivocally were merely hoping to go somewhere that things made sense.

The burned-out medic likes to park himself behind the stretcher, zip his lip, and allow things to burn out on their own. This may sound merciless, but there is a certain wisdom to it.

We are very good in this business at escalating the level of alarm. Eight minutes after you hang up the phone, suddenly sirens are echoing down your street, heavy boots are echoing in your hall, and five burly men are crowding into your bathroom. We have wires, we have tubes, we have many, many questions. What a mess. So sometimes, once we’ve finished ratcheting everything up, it behooves us to pause, step back, and make a conscious effort to turn down the volume.

Take the stimuli of the environment, of the situation, and dial it way back. One of our best tools is to simply get the patient away from the scene — the heart of the chaos — and into the back of the ambulance, where we’re in control. It’s quiet, it’s comfortable, and there is less to look at. Move slowly, consider dimming the lights, and whenever possible avoid transporting with lights and sirens. Demonstrate calm, relaxed confidence, as if there’s truly nothing to be excited about. Some patients with drug reactions, or some developmental or psychological disorders (such as autism spectrum), may be absolutely unmanageable unless you can reduce their level of stimulation. Just put a proverbial pillow over their senses.

If you’re stuck on scene, try to filter out the environment a little. If bystanders or other responders (such as fire and police) are milling around, either clear out unnecessary personnel or at least ask them to leave the room for a bit. Make sure only one person is asking questions, and explain everything you do before you do it.

There’s a human connection here, and if you can master it, you can create an eye of calm even as sheet metal is being ripped apart around you. Look directly into your patient’s eyes, and speak to them calmly, quietly, and directly. Take their hand. Use their name, and make sure they know yours. Narrate what’s going on as it occurs, describe what they can expect next, and try to anticipate their emotional responses (surprise, fear, confusion). If they start to lose their anchor, bring them back; their world for now should consist only of themselves and you. To achieve this you need to be capable of creating a real connection; it is their focus on you that will help them to block out everything else. Done correctly, they may not want you to leave their side once you arrive at the hospital; you’re their lifeline, and it may feel like you’re abandoning them. Try to convince them that the worst is over, and they’ve arrived somewhere that’s safe, structured, and prepared to make things right. They’ve “made it.”

Applying these ideas isn’t always simple, and learning to recognize how much each patient needs the volume turned down requires experience. But just remember that no matter who they are, no matter what their complaint, most people didn’t call 911 because they wanted things more chaotic. Try to be a carrier of calm.

Because it’s Cold Out There

http://www.youtube.com/watch?v=3pO2mdVpN20

We rarely think about it. If we did, we’d probably lose our marbles.

But it’s true.

The universe doesn’t care.

We are born, we live for a little while, and eventually, we die. In the duration, we will have hopes and fears, passions, desires, successes and defeats, joy and pain. The whole gamut is out there. And as a rule, the inexorable pull of the world is downward — into darkness, into chaos. Scientists call it entropy. We just call it life.

But it means that at any given moment, if we want to be happy — comfortable, fulfilled, free from suffering — we have to be waging a constant battle. If we ever stop paddling, we start to sink.

There’s a certain point in your youth (maybe this is the moment that you become an adult) when you realize this battle is nobody’s but your own. When you’re a child, your parents agree to fight in your ranks until you can walk and talk and drive a car. But once you step out onto the world stage, the only one wearing your colors is you. As self-centered people, we find this hard to believe; we feel like we’re important players in the grand scheme. But the truth is that although everybody else feels the same way about themselves, they certainly don’t feel the same way about you.

Nobody cares about your problems like you do. Not even remotely close. They’re busy with their own battles, which are just as burdensome to them as yours to you. So we learn that if we want to solve our problems, change our circumstances, or just keep from backsliding in the constant undertow of life, we’re on our own. The tools we bring to the table are the only ones available, and our to-do list has only our name at the top. There is no oversight, unless we have strong religious views; no referee ensures that the dice land fair; and if the game proves too difficult, we don’t get to quit and try another.

Isn’t this horrible?

Of course it’s horrible. What could be more horrible than to be utterly alone in an uncaring universe?

So we try to build ties. From the little twirling piece of driftwood we’re clinging to, we throw out ropes to the other flotsam and jetsam. We bring them close and tie knots in the hope of building a raft that can stay afloat during the next storm. Maybe this way, we think, if I capsize, someone will pull me back in.

This is hard work, though. Because our own problems are bad enough, and to tie ourself to someone else means we’re taking on some of theirs, too. It means when they get hit, it’s our job to try and keep them afloat. That’s a lot of responsibility, and our plate was already full to begin with. (Everybody’s plate is full, no matter how big it may look from the outside.) So at the best, we only make a few really strong ties.

Oh, we might have a lot of weak ones. Folks we know, and who will occasionally drift by to exchange favors or chat. Maybe a group that we’ll cruise with for a while. But make no mistake: they might be floating alongside us, but they haven’t tied any knots in that rope. If you start to founder, the best you can hope for is a little sympathy as they sail on ahead, and maybe toss you a spare life preserver. It’s not their problem.

The ones who really throw in their lot with you — who say that in thick or thin, in sickness or health, they’ll be at your side, fighting to keep you afloat — they’re few and far between. Maybe a little family, one or two close friends. A significant other. That’s all.

 

What do you think happens when you get older?

If you have the good fortune to live to a very old age, then a lot of things will change. Life is not going to suddenly become easy; if anything, it will become harder. And where are those ties you’ve built?

Dead. Moved away. No longer capable of anything more than clinging to life.

The luckiest among us will make it to the very last pages of life with our partners-in-crime still at our side. The spouse of fifty years, the close and loving family, the lifelong friend. But for most of us, these lifelines are lost over the years, one by one. And eventually, we may have nobody. Nobody to fight for us, to love us, or even to note our passing.

 

The next time you transport the 80-year-old man with dementia, who never seems happy and complains about everything —

The next time you’re called to the home of the little old lady with toe pain, whose husband died recently after a lifetime spent together —

The next time you pick up the same homeless man from under the bridge, drunk once again —

Try to imagine what it would be like to be truly alone.

Nobody to lean on. Nobody to throw you a rope when you start to founder. Most of all, nobody who gives a damn you exist. Imagine what it would be like to know that you could walk into the sea tomorrow and nobody would even know you’d died — let alone that you’d lived.

We can’t be everything for these people. But one day, hopefully not soon, you might just find that you’ve become one of them. So do what you can, knowing that nobody else is likely to. Knowing that, even when it has little effect, the difference between having somebody to fire a few shots for you, and having nobody — can be all the difference in the world.

Unique, Just Like Everyone Else

A few years back, a video of a lecture by Carnegie Mellon professor Randy Pausch made the YouTube rounds, becoming enormously popular; you’ve probably seen it. He later wrote a book discussing and unpacking many of the points he brought up in the lecture. If you haven’t watched or read them, I highly recommend both.

In any case, in the book Pausch describes the birth of his first child, how a complicated birth (a placental abruption) forced him to rush his wife to the Magee-Womens Hospital at the University of Pittsburgh Medical Center, and how his newborn child was brought into their neonatal ICU. He writes,

At Magee, they did a wonderful job of simultaneously communicating two dissonant things. In so many words, they told parents that 1) Your child is special and we understand that his medical needs are unique, and 2) Don’t worry, we’ve had a million babies like yours come through here. (91–92)

This is an elegant account of the demeanor we should all be trying to strike with the families of patients, and indeed with our patients themselves.

Many beginning providers, understandably unsure, will approach each patient like an antique porcelain vase: precious, delicate, and prone to breakage. This is the right attitude as far as priorities — we should take our care seriously — but that doubt is communicated in our body language and tone, and it’s not what sick and scared people want to hear. Imagine being the patient whose doctor says, “Man, look at that! I’ve never seen anything like that! Can we publish you?” or “Okay, I’m not going to lie, I’ve never done this in my life. But I did stay at a Holiday Inn Express last night…”

On the other hand, it can be very few moons indeed until you’re a “veteran” in the worst sense of the word, dragging your technically skilled but burned-out husk from patient to patient, seeing nothing but a stack of paperwork and a routine litany of tests and treatments. Her? Oh, just another abominal pain. Yawn. Her name? Search me. Is it lunchtime yet?

See, people want to be treated like people, and people are unique, precious (at least in their own eyes), scared, and need to be engaged with on the same human level as when you say “thank you” to your barista or read a bedtime story to your son. But people are also machines, and the trick to fixing broken machines is to fix a lot of them, and treat them all the same. We need to be able to reconcile these paired, antagonistic traits, because otherwise we can’t do what they called us to do. It’s not a matter of nailing one goal but missing the other: you miss both. You can’t reassure anyone if you don’t competently address their actual problem, and you can’t practice sound medicine if you don’t engage with patients as people.

That’s the trick that the obstetrics and neonatal teams at Magee pulled off, and it’s all the more important for us, who have to approach patients without the comforting backdrop (that is, comforting to them and to us) of a bright beeping hospital. It’s the trick of quiet confidence, of demonstrating without words that you know exactly what you’re doing, that you bring tremendous skill and experience to the table — but that those tools are being brought to bear for your patient, for the scared individual you’re kneeling beside. The “all the kings horses” response by fire and EMS, the loud and alarming transport to the hospital, the wires and tubes and countless gloved hands — it’s overwhelming and frightening if you’re thrown into it as an unknown environment, but if you understand that it’s all being done for you, then it’s comforting. It’s like calling for help and getting the Wolf. That’s exactly what you wanted in your time of need.

You may not want to date a cocky lawyer. But he’s the one you’d want at trial.

Oldest Trick in the Book

 

I’ve never been to nursing school. But I like to imagine it goes something like this:

On the first day, you walk into class, surrounded by other bright-eyed, eager young students ready to learn the art and science of nursing. Textbooks weigh down your bag, and your pencils are sharp and ready.

Before you stands your instructor, an impressive-looking MSN whose carriage suggests many, many nights spent awake amidst the cool blue lights and quiet beeps of a MICU. As you watch, she strides to the whiteboard and writes in block letters:

Lesson One: The ID Flip

Lesson two is eye-rolling.

Most hospitals, just like most ambulance services, require that clinical staff wear an ID badge at all time. This identifies them by name and role (nurse, doctor, PA, etc.), and often gives them access to secure areas as well.

Long ago, some canny soul discovered that when patients know your name, they can complain about you. If they decide that they don’t like you, whether justified or not, they can call people — like your boss — and unleash angry, entitled, and very personalized tirades about “Sarah Roberts, that mean witch who told me to shut up and stop smoking heroin.”

“Well,” we figure; “if they don’t know our name, they can’t complain.” So although the powers-that-be did insist that badges be worn, we started hanging them in odd places, like from our belt, or inside a pocket. Or covering them with stickers and other things. But the best of all answer of all was elegantly geometric, made especially easy by free-spinning retractable ID clips: simply twist the card so it faces your chest, and the only thing visible is whatever text happens to be printed on the back. Technically, you’re still wearing the thing, and if the boss notices you can just say “whoops, it got twisted,” but nobody can actually read your name, and, ninja-like, you can move through the ward unseen, a bescrubbed ghost.

The nurses have turned this into an art-form, and in some places it’s like finding a four-leafed clover to see an RN with a visible ID (usually I figure they’re new there). But we’ve become awfully fond of this in EMS as well.

People, I realize that the world’s a rough place, that patients can be impossible to please, and that even the best of us need to take steps to ensure we still have a job tomorrow. I do understand this. But there’s a certain point where you have to stop digging trenches, and realize that if you’re giving great care, following procedure, behaving professionally, and generally toeing the line, then you should be willing to stand behind your work. If you’re employed at the kind of place that’s willing to take any complaint as reason to show you the door, I assure you that no amount of ID-flipping will save you. Your days are numbered. Of course, even a good service will eventually start clearing their throat and looking at you pointedly if your personnel file begins to grow particularly fat, but at that point, maybe you really should consider managing your douche coefficient.

Besides, this should all be moot, because when you meet your patient you’re introducing yourself by name anyway. Because that’s just common courtesy when you greet people. And patients are people. Right?

Strive to do the kind of work that allows you the confidence to stand behind it. When someone points at you with forehead veins a-pulsing and demands to know your name so your supervisor can “hear about it,” tell them and tell them proudly. Sometimes, doing the right thing won’t be a defense against trouble — but you can be sure that playing “who, me?” will run out of rope even sooner than that.

Clip your ID somewhere obvious — mine goes on my shoulder — where patients and staff alike can easily see it, and know what to call you and what role you’ll be playing in this show. When I see somebody with a visible ID, I take this as a good sign about their responsibility and willingness to own their work. And those are qualities we need in EMS.

Russ Reina: Moments in the Death of a Flesh Mechanic

Russ Reina runs one of my “sister blogs” on the EMS Blogs network, EMS Outside Agitator. Although no longer working in EMS, he spent over a decade as a medic, way back in ’70s when the paramedic concept was first being introduced in the US; he later became involved with various other things including writing a film, working with Native American healing arts, and a book — Moments in the Death of a Flesh Mechanic: a Healer’s Rebirth. More recently he’s become active in the online EMS community via his blog, forums (he’s a moderator over at EMTLife.com), and similar venues.

Some time ago, Russ sent me a free copy of his book in exchange for my honest review. I read it, and enjoyed it, but it’s been sitting on my shelf since, because I haven’t been sure what to say about it.

To start with, let’s mention the elephant in the room. The stuff Russ talks about makes people uncomfortable. To be sure, he’s walked the walk, spending more hours on the road than many of us, and doing it in a time and place where that meant wielding tremendous responsibility in patient care. It’s hard to argue that he was a skilled and competent medic in his day, the kind of guy you’d be glad to have on scene or sitting beside you in the cab. But since then, he’s gone down a different road, and done a lot of… other stuff.

Tending fires in sweatlodges. Reiki. Personal growth and healing. If you click through his personal website, your first reaction is probably “… huh.” For the typical EMSer this is not really our wheelhouse, and at best, it places Russ firmly in the realm of alternative viewpoints. At worst it puts him in the same cart as the other EMS goofballs who do their job but are universally considered space cadets. (Admittedly this is a large cart, but still, it’s not great company.)

I confess that I share some of this attitude. I’m a simple, concrete guy at heart. But I also think that the things Russ talks about, and forces us to think about, are important — and that the reason we’re uncomfortable with them is the reason that we need to have that conversation.

The basic aim of his book is to weave together the calls he ran, the patients he sat beside, the lives and the deaths he saw, and look for the common threads. Not in the patients, but in him. As a paramedic, what was his role? When you take a step back from this job, when you stop for a moment and consider what it’s all about, what’s really going on?

If we’re diligent, and competent providers, we spend a great deal of time trying to improve the quality of our work: our knowledge base, our hands-on skills, our understanding of medicine and the human body — the how. But very little attention is ever given to the why. Why do we do this? It’s easy to be cynical — “well, the schedules are good, you get to cut people’s clothes off, and I was too dumb for anything else.” We’re professional cynics, and the job tends to beat the mushy stuff out of us. But although we rarely admit it, most of us did choose this job for real, human reasons. Something about helping people.

So we show up at the door wanting to help people. Then, usually a couple years later, most of us leave EMS to become nurses or electricians or vacuum cleaner repairmen. What happened between point A and point B?

You can call it burn-out, you can call it low morale. You can blame low pay and a “revolving door” culture and a million other things, most of which are valid and true. But the fact remains that even though people are coming to EMS with the right intentions, most of them aren’t surviving here for long, and of the ones who do stick around, many are empty shells, long since stripped of any human connection they once sought. This is an ill system. It’s not dying, we’re not end-stage, but we are not healthy or happy: the methods, mindsets, attitudes, and overall “immune system” necessary to keep us all going, to maintain our ideal homeostasis, is missing. Individually and collectively, as time passes we move down rather than up. Some rare individuals do find solid grounding and manage to put in 20 years as fully-functional people as well as caregivers, but they are the exception, and they do it by developing these tools on their own.

It’s not about competence. Many of our “walking wounded” are competent clinicians, adequate or even excellent technicians. Russ calls them flesh mechanics. We master the skills of of patching holes, adjusting rhythms, replacing fluids, and generally repairing the broken parts of the human body, all without ever acknowledging the people inside those bodies. To some extent, of course, this is an essential part of the job — it’s the M in EMS, it’s why we’re called to the scene. We ought to try and be excellent mechanics so we can save the most lives and mend the most harm. But this whole process is entirely separate and distinct from the motivations that brought us to the job to begin with. There’s a fundamental difference between tending to a car and tending to a person, and when we successfully manage to eradicate the human element, we quickly find ourselves unsatisfied and burned-out with our work. (It’s not like we’re getting rich doing it, or otherwise being externally rewarded.) Russ’s own journey of transitioning from a pure flesh mechanic back into someone who worked with people is the focus of his book.

Why do we do it? There are dozens of reasons you might pick. Some folks like to work and play at the boundaries, the liminal spaces between life and death. Some just really like meeting the people. Some, like Russ, have a more spiritual approach. Some find meaning from the teachings of traditional religion.

As for myself, I hate death, and suffering, and I want to guard people from it. And I think that I probably get an ego boost from fighting for the weak, and certainly from uncovering an interesting diagnosis. But most of all — and it’s the mindset I advocate for on this site — I simply adopt a deontological outlook: I believe that when we take a patient into our care, we assume a duty to do everything possible on their behalf. Not the duty to weigh the pros and cons, not to judge their need or worthiness, but simply to do it. Everyone deserves at least that.

But you might disagree. And that’s the key: many of us will disagree on how to handle the “why.” Unquestionably, I disagree with many of Russ’s views, or simply find them alien. However, I still think that it’s absolutely essential that we each find some meaning. There must be some human purpose to our work or we will not be happy, and eventually, we will not do it anymore. That’s the secret that Russ was able to uncover after enough years on the job and enough years away from it. Dozens of answers to the question are acceptable, but we at least have to ask the question; we do have to think about these things and not brush them aside. We have to operate on this level or we will not survive in the long run. Spirituality may or may not underly EMS as you understand it. But people — not just patients, not just broken machines — are unavoidably central to practicing medicine. You can do the job without that human connection, without the “why,” but it’s like showering with your raincoat on. You can’t feel it, and you won’t do a good job, and eventually you’ll give up and stop trying.

So to make a long story short, I think the task Russ has undertaken as an “agitator” is a tough one, and he won’t win many fans. Although he often clashes with the Rogue Medic, their jobs are not dissimilar; one is an continual gadfly working to force us toward better evidence-based medicine, and the other is a continual gadfly working to force us toward a healthier understanding of our job. I wouldn’t want to be either one. But I’m glad they’re here, because I also don’t want to watch good people being wasted in the cauldron of cynicism and pointlessness that is much of EMS today.

In any case, I do recommend his book. It’s an enjoyable read, well-written, with plenty of the entertaining stories that all veteran medics collect and that make the best EMS blogs and literature such good reads. It’s also a rare view of the early, Johnny-and-Roy days of paramedicine, and it’s fascinating to see what’s changed over the years and what hasn’t.

But mostly, I think it’s worth reading because Russ’s crusade really does have a vital purpose. If I have a quibble, other than the fact that his unorthodox background may turn many readers away from his message (although fairly little of that is present in the book), it’s that despite raising awareness to the problem, Russ is relatively silent as its to solutions. Of course, this may be the nature of the beast, where each of us needs to find his own answers. But on the large scale, I doubt the endemic disease of EMS will be cured in this way.

We can try, though. Let’s try.

Decision Fatigue and Good Habits

Editor’s note: this post was eventually expanded into a cover feature in the May 2012 edition of EMS World.

There’s a concept from psychology that’s recently made the jump to the world of popular science (that misty realm ruled over by a benevolent Malcolm Gladwell; Bill Nye is his jester) known as decision fatigue.

The idea is that human beings have a limited reserve of willpower. Willpower isn’t a physical substance, something stored in a sac in your abdomen, but nevertheless it’s a real quantity. Every time you’re forced to make a decision, especially important or consequential decisions, it drains a little of this resource. Certain restorative acts, like sleep or eating, can help restore it. But if you start running low, then you start losing the ability to make weighty or difficult choices — you tend to pick the easy option, the default answer, the path of least resistance. Rather than the big picture, the long term, you start seeing only the immediate payoff. That little mental push that lets you do the right thing… well, if you spend all day pushing, by 9:00 PM you just might be out of push.

This phenomenon may ring intuitively true, but understand that it’s not horoscopes or tarot cards — this is a real behavior exhibited by all or most people. This is something you do right now, whether it’s obvious or not.

And this is very pertinent to those of us in EMS. Due to the nature of our work, we carry an unusually large burden of decisions. For the level of training and experience our job requires, we are granted a great deal of independent responsibility; in other industries, we would be working with a supervisor over our shoulder, a hands-on boss ensuring that we toe the line. Not so on the ambulance; we perform our duties on the road, alongside one partner, and typically have no direct oversight for the vast majority of our day. If you mess up badly enough, you’ll hear about it later; but to quote the luminary Peter Gibbons, “that will only make someone work just hard enough not to get fired.” We all know a few EMTs and paramedics who have learned all the hot spots, the danger zones, know exactly what they need to do (and what to avoid) in order to stay under the radar — and as long as they dance those steps, they can otherwise do, or skip doing, whatever the heck they want.

The point is, in this job you can do everything right. . . but only if you decide to.

Many of our decisions are small. When it comes down to it, even Old Man Lazybones, the 400-year-old medic who only wakes up to punch out and sometimes eat animal crackers, will generally mobilize for the cardiac arrest and the multiple stabbing. That stuff comes packaged with motivation. But what about all the little things in between? Do you change the stretcher linen between calls, or leave it? Do you sanitize that blood pressure cuff after using it on your “recent VRE” patient? Are you professional, caring, and thorough in your patient interviews, or are you starting to lapse into taxi driver mode? Do you document thoroughly, or cut a few corners? Is everything on the truck restocked for the next crew, or are you out the door? And so on, and so forth. There’s doing your very best, there’s just barely “not getting fired,” and there are many points in between, but no doubt, each time you’ll have to decide where you fall.

It’s tempting to say that what matters is simply the kind of person you are. The “good” EMT, the true professional, that guy will do the right thing. He’ll make the right choices. And the slacker, the hack, he’ll blow it off. And maybe that’s often true.

But the lesson of decision fatigue is that none of us is a saint, or an infallible machine. Every time we make one of those little decisions, every time we exert ourselves to do the right thing, we use up a little bit of our motivation. And after 8 hours, 12, 24 hours, five calls, ten calls, you’re going to start scraping the bottom of that well. The good medic will last longer, the hack won’t make it past lunchtime, but eventually, everyone starts cutting corners. Be honest with yourself, and you’ll see that it’s true. You can care, and you do care, but at some point, you’ll stop caring quite so much. In the long-term, we call it burnout, but in the short term we just call it “time to go home.”

One of the valuable observations from the research on decision fatigue is how the most successful subjects tended to cope with it. By and large, those with the best self-control didn’t survive by being the most stoic, just standing there and weathering a stream of decisions that would shake the best of us. Instead, what they did was set up their lives to minimize the drains on their self-control. They recognized that if they have to spend all day consciously choosing to do the right thing, eventually they’re going to start slacking. So whenever possible, they arrange their circumstances so that no decision needs to be made. When they grocery shop, they don’t just “buy what looks good,” because that’s a constant barrage of “cookies or carrots?” They go in with a list, and they buy what’s on the list, and that leaves no decisions to be made. And then, on the way home when they have to decide whether to yield for the slow-walking granny in the crosswalk, they aren’t already worn out from the battle of the cookies.

Good habits. Good habits will save us.

You can’t go through your shift constantly deciding to do the right thing. But you can create good habits, wherein you do the right thing automatically. This may sound like you’re creating work for yourself, but in fact it’s the opposite. “Work” is choosing to do it. Habits just happens. Waking up, brushing your teeth, driving to work, you don’t complain about having to do these, you just do ’em; they’re things you do, not things you decide to do. If every time you drop off a patient, you change the linen, then this stops being an “issue”; it’s just part of the call, part of your routine.

Setting up habits takes work, but maintaining them takes none, and you’ll quickly find that the type of EMT you are is defined by your habits as much as your decisions. Although I’m a huge proponent of good judgment, critical thinking, and wide leeway for field providers to make good decisions, the truth is that much of our work is routine. And the more of your routine you can manage by habit, the more willpower you free up for the tougher stuff. This doesn’t tie you down. It liberates you to think bigger, and aim higher.

Job Stability in EMS

Let’s just get it out of the way. As a Basic EMT, and to a slightly lesser but still very similar extent as a Paramedic, you are typically viewed as unskilled rank-and-file. You are more like the kid flipping burgers at Burger King than a nurse or a doctor. This is a consequence of supply vs. demand, low barriers to entry in this business, and minimal labor and political representation. I don’t think it’s right, but it is the way it is.

(Note: those working for fire departments and other public services may find that this information does not apply. If that describes you, I applaud you for your good fortune. But for the thousands employed with private services, read on.)

This is a difficult and personal subject for me. I’ve been employed with several ambulance providers, and I’ve been fired from more than one. There were various reasons, but in the end, there was one overarching reason, which is that I didn’t understand how to be the kind of EMT that employers wanted. The lessons that follow may not apply everywhere, but based on my experiences with numerous companies in two different geographical areas, they are generally more true than not, and if you’re newly entering this industry in a field position, they’re worth holding close to your heart.

First, understand that, as we noted, you are not a high-value employee. In fact, you are essentially a low-wage service worker, and you are largely interchangeable with anyone who holds the same certification. Moreover, the job market is currently Bad, and even when it was better, there were people out there who would do this job for free; in other words, even though demand for your skills is still reasonable, supply is very high. Although your service needs a certain number of EMTs and/or paramedics, and although they may perform some amount of screening or testing to find the best candidates (better employers will do more of this), as a general rule there is a limitless supply of people standing behind you, all holding the same card. And your company is just as willing to pay them instead of you.

Second, your employer is in the business of making money. Just like BK needs someone to flip their burgers, ambulance companies need someone to drive and tech their ambulances, so you are a necessary part of their business model. But you are far from unique or irreplaceable. Since it’s not very difficult to hire an EMT, it’s never very difficult to fire one and hire another. So if you ever become more trouble to keep around than you’re worth, you’re inching towards termination.

Third, and most importantly, the money is in the money. A principled and respectable private service will try to drive their financial success through clinical excellence, but whether they do or not, their financial success remains the bottom line. Your Lifepaks and MDTs may or may not get upgraded, but the marketing and PR is never in question. So if by your actions, inaction, or even by association you’re ever involved with something that jeopardizes your company’s revenue stream, you’re absolutely begging them to reconsider taking their chances on a fresh hire.

So, do you want to keep this job, be it briefly or for a long career? (Whether you should be taking advice from me is a fair question, but at least you’re hearing it from experience at the wrong end of every error.) Job stability in this field depends on three skills, and you don’t need them all. Pick any two and you’ll do okay. You might even sneak by with just one. But when the day comes that you don’t have any to protect you, your days are numbered.

 

1. Protect the Money

You can kill patients, break equipment, curse like a sailor, and drive rigs off cliffs, but if you can avoid impacting your employer’s bottom line, you’ll probably be fine.

Billing is big. Try your hardest to help generate billable runs, because getting paid for your calls is how money is made, and consistently interfering with this will bring you the wrong sort of attention. Whatever documentation hoops they ask you to jump through, as long as they’re not unethical or detrimental to patient care, just do it.

Furthermore, your company’s continued existence is predicated on maintaining certain contracts that it holds with cities, counties, hospitals, and other facilities. These contracts give your company the right to transport some or all of their patients, and that can mean many calls and many dollars per year. If you look unprofessional to someone important, piss off a staff member, or make a clinical error that comes to the wrong person’s attention, you are making the Powers That Be at that organization wonder if they shouldn’t be handing their patients and dollars to a different ambulance company. And that is numero uno on the list of ways to lose your job. Don’t think that the facts will save you, and don’t think that they’ll be reasonable or go to bat for you, because if being able to say “the people responsible have been terminated” is good for business, then nothing else will matter.

Play the game. If you’re asked to wash the truck with a toothbrush, wear a tie and a monocle, and give all of your patients free backrubs, just do it. Play the game, or someone else will.

 

2. Be Liked

They never taught you this in school (and school was where you’d have found many of us just before we became EMTs), but if the right people like you, nearly anything is possible. If not…

You don’t have to be universally popular, but you should not be “that guy,” because when push comes to shove, somebody with an office and a salary is going to have to decide whether you should keep working here, and if they never liked you to begin with you’re not going to have any armor.

Here’s the big, big secret. You may think that life should be fair, or at least employment should, and if you do your job and don’t screw up too big, there’s no grounds to fire you. In other jobs, you might be right. But we just saw that you hold no sway in these parts, cowboy. Moreover, in most places you were hired under a contract that included the words “at will,” which means they can get rid of you for no reason at all. (Wholly legal? Maybe, maybe not, but most of us won’t be bringing any lawsuits, because it’s a lot of trouble and being “the dude who sued” is not great for your future employability.) So here’s the way it really works: they can terminate anyone, or they can keep anyone. It all depends on what they want to do.

If you’re well-liked by the people who have a say, then you can screw up, and it will be water under the bridge. It may be documented and recorded, or it may simply be swept aside, but nothing will come of it. On the other hand, if you’re someone they’d rather no longer worked there, then you don’t even need to screw up to find your way to the chopping block. Because the fact is, nobody is perfect; even if you think you’re a company man, in the 40+ hours you punch each week, they can find a violation here, an error there, a complaint, a concern. If you ever start getting called to the deck for driving 26 in a 25 MPH zone or parting your hair left instead of right, update your resume, because this is known as “building a paper trail.” (If you’re lucky, maybe they have no problem with you yet, and they’re just preparing a case for the future. Some places are optimistic like that.)

 

3. Stay Under the Radar

This is the master key of maintaining your employment. Many people lack one or both of the previous virtues, but still keep their job for 10 years because they’ve got this one down pat.

If you’re hired today, and starting tomorrow nobody ever hears your name again, then your job is safe. Your name has to cross someone’s desk before they can tie you a noose. So if you’re ever going to screw up, just make sure that it’s never in a way that draws attention.

EMS is rife with uniformed men and women who show up, clock in, work their hours, and go home. They may be interesting people or boring ones, smart or dumb, up-and-coming or cheerfully stagnant. They may be loved or hated by their coworkers. They may even give bad care, write bad documentation, and draw ire in every ED they enter. But so long as it’s never the kind of thing to make anybody complain to the supervisors, then they’ll do just fine.

On the flip side, they might be a Super EMT, aces in every category, but if their name and face are constantly attracting the eye of the bosses, then they’re at best one or two steps from seeking new employment. Because being a bother is not a good virtue if you’re not valuable.

Truth be told, if you’re wise, then you’ll probably stay off the radar even for the most harmless reasons. No attention is good attention, not even asking to change a shift or replace a shirt, and while some of that is obviously necessary it should certainly be minimized. It’s a fine, fine art you’ve mastered when you’re hired as a new medic, and five years later nobody upstairs knows you beyond a vague sense that might work there.

 

There you have it. The big three.

You will notice that nowhere in the above list do I include clinical competence. For a long time, I believed that if you were a good EMT, that was enough to keep you safe — and if you were an exceptional EMT, that would even make up for a few things. This couldn’t be further from the truth. Possibly in a few cases, such as if you assist with training and continuing education, your knowledge and skills can be a feather in your cap. But as a rule, nobody in charge knows or cares about how good you are. You’re just one of the many EMT-Bs or EMT-Ps from the big group of identical licenses on the payroll. So if you think that being the fastest intubator in the West will protect you from violations of the Big Three, then you are sadly mistaken.

Indeed, this is yet another reason (you know, beyond the basic moral ones) to treat your patients and facility staff with respect and compassion. By and large, they don’t know if you’re any good at medicine — the patient in particular — but they know if you were a dickhead, and dickheads are the people they call and complain about. You can nearly kill someone, but if you smile, hand them a warmed blanket, and shake their hand, they’ll go away thinking you were the nicest young man they ever met. For all the great ideas on kindness and empathy in our favorite EMS book, Thom Dick’s People Care, it’s worth noting that its subtitle is not “How to Get into Heaven,” but “Career-friendly Practices for Professional Caregivers.” Career-friendly indeed.

It may sound like I’ve become a terrible cynic, but in truth, I think I’ve just come to understand the basic realities of the field we work in. We may wish the world were different, but we may also wish for a pet unicorn and world peace; things are the way they are, and the truth is that you should be able to maintain a long and successful career, providing the most outstanding care you can offer, if you simply learn how to stay employable.