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.

Treat the Patient?

We’re taking a short break from our series on transfers to discuss a recent post on the EMT-Medical Student blog. One of the issues he brought up is the old saw, “Treat the patient, not the machine.” Rogue Medic struck on this as well.

What do people mean when they say this? They mean that if you attach a diagnostic tool like a pulse oximeter, and it gives you a result that is at odds with the rest of your assessment, then it is probably wrong, and you should not base your decisions on it. It can be broadened to the BLS level, including findings like vital signs, by saying: “Treat the patient, not the number.”

And it’s essentially true. In fact, something I frequently harp on is that diagnosis must always be based on a broad constellation of consistent findings, not on any one red flag. We like red flags, we want red flags, because they’re easy, but it never works that way. The body is an interdependent system, and if a pathology is present, then it almost always has multiple effects detectable in multiple places.

This idea can be looked at differently by asking another question: is it possible to be severely, acutely sick without showing it? I don’t mean long-term problems like cancer; you can’t look at someone and detect that. But if someone’s dying in front of you, of a proximate cause like hypoxia, is it always obvious based on their presentation?

Generally the answer is yes. That’s why it’s wrongheaded to look at a healthy patient with pink skin, normal respiratory rate, calmly denying shortness of breath, but with a low oxygen saturation, and say, “Oh no — he’s hypoxic!” If your oximeter says 72%, what’s more likely — that the number is wrong, or that the patient is somehow hypoxic without any other evidence of it?

Call this the phenomenon of the Hidden Killer. Is it common? Is it real?

It is not common. But it is real. And that’s what’s not recognized when people say, “Treat the patient…”

Why do we take 12-lead ECGs on chest pain patients? Because a clinical assessment alone cannot reliably detect ST elevation, which (simplifying the issue!) is diagnostic for a heart attack.

Why do we take CT scans of blunt head injury patients? Because a clinical assessment alone cannot reliably detect intracranial hemorrhage.

Why do we perform abdominal ultrasounds in multi-system trauma patients? Because a clinical assessment alone cannot reliably detect abdominal bleeding.

Now, some critics will say that all of these will indeed present with obvious, frank clinical findings. The major STEMI patient will eventually enter cardiogenic shock. The head bleed will become comatose and present with Cushing’s Triad and herniation. The abdominal hemorrhage will have guarding, distension, and eventually outright shock.

All true enough. But we’d like to find them earlier than that. It’s true that severe and late pathologies are usually obvious, but our job is to find them when they can still be treated, not after their effects are permanent or lethal. Heck, we could also just provide no medical care and wait until everyone died to make a diagnosis, which would extremely easy to assess, but a little pointless. It is rare that big problems do not have a big assessment footprint, but “small” problems can still be a big deal.

Consider the much-maligned pulse ox. Surely it does not replace a full assessment. But when used appropriately and its role understood, it provides valuable information. A drop from 99% to 94% saturation may not be clinically obvious, but it is potentially significant and surely worth knowing about. What about the patient who is non-verbal at his baseline? Is he going to complain if he drops from 95% to 87%? Will it be frankly obvious from his skin and breathing? Maybe, maybe not. (How about if he’s on a mechanical ventilator at a fixed rate?) If not obvious, does that mean it’s no big deal?

Is the pulse ox always correct? No. But like all things except magic, it’s wrong in predictable ways, ways that can be accounted for, and when it is wrong, that can tell you something too. It requires adequate peripheral circulation, and poor perfusion will make it read low. How is the patient’s distal perfusion? Pink and warm? Good capillary refill? Then you’re probably okay. Carbon monoxide poisoning will make the sat read high. Has the patient been in enclosed spaces with heaters or open flames? Working around engines? Is there any potential source of CO in their history? If not, you’re probably okay. Alternately, does their sat read unusually high compared to their clinical presentation? You might then consider carbon monoxide — something you might not have otherwise have known without the oximeter. It didn’t give you a correct number, but by knowing how and when it fails, it gave us a useful answer.

Here’s a recent example. I picked up a patient with a blood pressure of 54/4. That is a ridiculous blood pressure; arguably, nobody should have it, on the theory that a pressure that low should be pretty close to unobtainable. But, there it was. We diverted to the nearest hospital and I was subsequently chewed out by the receiving nurse.

Do I think that patient truly had a central arterial pressure of 54/4? Nah. Although she wasn’t doing well, her skin was better than that, and although she was altered and combative, she wasn’t comatose. However, her pressure was undoubtedly low, and just how low? If I don’t go with this number, then I’ve got no guidance. The clinical picture was clouded. I couldn’t ask if she knew what day it was; I couldn’t ask what her complaints were; she was non-verbal. She was tachycardic and hypoxic and diaphoretic; she was certainly sick. So, treat the patient, or treat the number? The number may not have been right, but it was concerning enough that it couldn’t be ignored without an assessment that otherwise screamed “no problems here!”, which was not what we had.

Treat the patient? We always treat the patient. A hands-on physical and history is a vital, vital tool for assessment, but other tools are also useful. Some people lament the downfall of the traditional clinical assessment, from the days when doctors with fingers like pianists made diagnoses from findings like Ewart’s sign, and it is shame, but the reason that the high-tech tools like imaging and labs have become de rigueur is that they work well — they diagnose many problems with a speed, sensitivity, and reliability that is not otherwise possible. Nobody would ever say, “Treat the patient, not the unstable cervical spine fracture,” because we recognize that’s the sort of thing you may not otherwise notice until it’s too late. That’s why we spend big bucks on CT scanners.

It all matters. It’s all useful. We should neither cast aside our individual numbers nor ignore the bigger picture. Data is something that, like money and sex, you can never have too much of.

The Tough Ones

People can be pills.

That is, EMS is the business of dealing with people. Even at their best, some homo sapiens will not be your favorite; you’d have to be a saint to love every single person you’ve ever met. And unfortunately, the patients we’re handed in this job are rarely at their best. That’s why they’re in an ambulance. Expecting someone to present a winning smile while they’re dying may be unreasonable.

The trouble is that showing compassion and doing your very best for people is a lot easier when you like them. It’s just human nature; we’re always nicer to the people we identify with, get along with, and find affable and likable.

. . . a lot of ordinary people look totally uncool, especially in their BVDs. In fact, they’re pretty ugly without their clothes on, or at least a little make-up. Some of them are fairly dim bulbs, actually. And on the worst days of their lives, a lot more have BO, bad breath, wrinkles, loose skin, irregular teeth, big bellies, short penises, hair where there shouldn’t be hair, and no hair where there should be. They’re inarticulate, clumsy and, well, kind of ordinary. They don’t match any of those pictures of perfectly proportioned people you’ve seen in your textbooks or on TV.

And guess what? Their families love them dearly, just the way they are!

. . . What you are is a caregiver. What you’re not is a judge. . . . You can be one or the other, but you can’t be both — not at the same time, anyway. As a caregiver, you can’t let yourself slip into the trap of judging people you don’t know anything about, because it does bad things to you. (People Care, 16)

See, the tough thing is that although it’s very human to treat the likable people better, that’s not how this job works. You’re allowed to like whomever you want; that’s your right as a person. But your responsibility as a caregiver is to do your best for all of them, like or loathe. It’s a learned skill, because it’s not at all natural. But it helps if you remember that your standards for likability are far from the ultimate test of someone’s personal worth. Everyone’s fighting their own battles, and patients shouldn’t be expected to look pretty for you in the midst of theirs. You’re not here to add to their burdens.

We have a built-in bias that tells us that people who are smelly or fat or dumb are overall bad people. It’s hard to overcome it. And because people who are choking, or incontinent, or hospitalized tend to be especially rough around the edges, it’s very easy indeed to file them under the category of “unpleasant objects.”

Special mention should be given to patients who are, to put it simply, jerks. Even those of us who can look past physical and mental defects may have trouble treating the world’s biggest asshole like our own dear mother. Once again, we have to remember that we’re not playing this game on a personal level, and the question isn’t whether the patient will be invited to our birthday party. The question’s whether they deserve our best care — and whether or not that’s difficult, whether or not we want to give it, the answer is “yes.” That’s how this works. If they’re a patient, they get our best. Some nasty physical ailments are harder to treat than others; some personalities are likewise harder to tolerate. But we don’t get to pick and choose, so we just have to suck it up and be compassionate professionals across the board.

Try to develop the mindset that to be human carries an inherent sacredness, value, and dignity. And that even the most despicable and worn-out creature on your stretcher has the same needs and feelings, and likely the same sense of self-worth, as any CEO or socialite. To quote Antoine de Saint-Exupéry, “I have no right to say or do anything that diminishes a man in his own eyes. What matters is not what I think of him, but what he thinks of himself. Hurting a man in his dignity is a crime.” (From How to Win Friends and Influence People, 214.)

All of this isn’t easy. Striving toward it is a constant effort. But if you can take a patient who you truly loathe, and treat him just the same as you would your own child — or your partner — or yourself — then that’s something to celebrate. Because quite frankly, the patient is somebody’s child, or somebody’s partner, and odds are good that their opinions of his human worth may differ from yours.

. . . until the curtain was rung down on the last act of the drama (and it might have no last act!) he wished the intellectual cripples and the moral hunchbacks not to be jeered at; perhaps they might turn out to be the heroes of the play. (George Santayana on William James [from Linda Simon’s William James Remembered])

Patient Advocacy

What does it mean to be a patient advocate?

I first learned this term from my original EMT textbook, and since then, it seems like it’s been the favorite buzzword of the medical profession. It’s a little bit like “leveraging synergies”; it sounds surely good while having no clear meaning at all.

I think this is a shame, because to me, patient advocacy is actually a very meaningful concept, and in EMS, a very important one. Perhaps this isn’t true for doctors and nurses, radiologists and cath technicians — although I’d like to think it is — but on the ambulance, it’s more than just a pretty ideal.

This was what the textbook had to say:

As an EMT-B, you are there for your patient. You are an advocate, the person who speaks up for your patient and pleads his cause. It is your responsibility to address the patient’s needs and to bring any of his concerns to the attention of the hospital staff. You will have developed a rapport with the patient during your brief but very important time together, a rapport that gives you an understanding of his condition and needs. As an advocate, you will do your best to transmit this knowledge in order to help the patient continue through the EMS and hospital system. In your role as an advocate you may perform a task as important as reporting information that will enable the hospital staff to save the patient’s life — or as simple as making sure a relative of the patient is notified. Acts that may seem minor to you may often provide major comfort to your patient. (Limmer 11)

Not half bad, really. But raise your hand if your eyes glossed over that paragraph.

You see, as a prehospital provider, you occupy a unique role in a patient’s course of care. Your time with this patient, from initial contact until transfer of care, is one of the only periods when they’ll have the one-on-one, undivided attention of a healthcare provider. Think about that for a moment. Ms. Smith may previously be, or soon will be, under the auspices of a veritable pantheon of specialists — cardiologists, endocrinologists, orthopedists, neurologists, and more. On this occasion alone, she might pass through the hands of an ED physician who stabilizes her, an internist who admits her, a surgeon who operates on her — never mind a supporting battalion of nurses, techs, CNAs, therapists, and witch doctors. It takes an army to treat a patient.

But that army has other responsibilities, too. That ED doc has two dozen other patients screaming for his attention, most of whom have already been waiting for hours. The internist is running a code in the next bed. Those nurses are overworked, underpaid, and really want to get home.

As a rule, they all have the best intentions, and they all want to look out for the patient. True bad apples or apathetic mercenaries are a rarity in this business. But everyone’s simply spread thin. Even when they have the resources to give their undivided attention to an individual patient, it’s rarely their responsibility to do so. The cardiologist is here to provide a consultation on Ms. Smith’s heart — not to champion her care like the Hospitalist Prince of North 6 and butt into everyone’s else’s work. It’s just not his job.

But what about you, the humble stretcher monkey who brings her in? For that brief period of time, you really have no business except Ms. Smith’s well being. That’s why you’re here; that’s what you were dispatched to look after; and it’s your legal, medical, and moral responsibility to do everything you can for her, until such time as you transfer that responsibility into the aforementioned healthcare cloud (or she refuses further care). Assuredly, you have a defined scope of practice, and company policies to follow, but we’re not talking about cutting out her gallbladder or taking her to a dive bar. We’re talking about — say it with me — patient advocacy. And everyone upstairs agrees that’s part of your job.

Your job is to be her champion. Not because you’re Superman. But because she’s so vulnerable right now, she doesn’t need Superman; she just needs anyone who will step up. Anybody who’ll stand there and say, you are not alone. We all need that, and we all deserve it — but many of these patients, after countless years and battles, have no one else to turn to.

Let’s steal a quote — this is from Danielle E. Sucher at Legal Agility, responding to the question of why she practices criminal defense.

I don’t like hurting people. Is that so hard to understand? When I go to bed at night, I can sleep easily, knowing that I fought for freedom, and for less suffering rather than more. That I stood by someone accused so that he would not have to stand alone.

I can’t know whether anyone is truly guilty or innocent, or what they deserve, and frankly, I don’t care. We all deserve at least one person on the damn planet willing to stand there next to us and fight on our behalf.

[Source]

Patients have problems. You can’t help with all of them. You can’t cure their cancer, or pay their bills, or make the world fair and right. But you can do an awful damned lot, because it’s astonishing how large the gap is between what the patient would do and what they can do in their current, largely powerless position.

You have resources. One’s this big ambulance, and everything in it. But you also have the resource of knowledge: you know how the system works. You know where to go for certain things, you know who to contact to get what you need, and you know what’s available for the asking. These would serve you very well if you should need to visit the emergency room or become hospitalized, or if your mother should, or your child. If Ms. Smith were your mother, you wouldn’t just shuffle through the process of putting Person A into Slot B, ignoring her needs and looking for ways to avoid going the extra mile; you’d fight like hell to keep her as happy, as comfortable, and as looked-after as possible. Because patients can’t fight for themselves, any better than defendants can argue their own cases. And because although other professionals will be involved in this process, they won’t be fighting for the patient either. I have immense respect for the docs and the nurses, but sometimes, you’re standing in a place to do things they can’t. A few of them may go above and beyond, but they all have their jobs to do, and this isn’t it.

But it is yours.

People Care

This is the best book any EMT can own.

I say that as someone with a strong clinical focus, and a passion for improving and elevating the educational standards in our field. I am an avowed nerd, and drip rates, T-wave inversions, and case reviews are what keep me awake at night. Yet I consistently recommend this little “warm and fuzzy” booklet to new and experienced EMS professionals alike, and would place it before any electrocardiographic tome or trauma manual. It should be on the shelf of everybody who works on an ambulance, period.

Thom Dick is a longtime paramedic, as well as an author and speaker on the EMS circuit, and several years ago he collected many of his favorite topics into People Care: Career-Friendly Practices for Professional Caregivers. This is a paperback book of less than 100 pages, written in a personal and accessible style, and it compellingly lays out Thom’s idea of what this job is all about.

It’s not about job skills, or tips for getting through your shift, although some of these are offered. Rather, it’s really about how to understand your job — what lens you should use to view this whole EMS business. This may not seem especially important; after all, no matter what rose-tinted goggles you buckle on, you’re still going to end up bringing the same patients to the same places in the same ways (and making the same dollars for doing it). True enough. But what about you? Will you be happy doing it? Passionate? Driven? If you start out as those things, will you stay that way, or will you join the ranks of the angry, the apathetic, the disillusioned?

There are a lot of things wrong with this job. Depending on who you ask, and what their priorities are, you might get different lists. But certainly, EMS is an industry with flaws, and the men and women working to improve it should be seen as heroes. But even if things do get better, what will we do in the mean time? Hell, even after they get better, will you be happy? The goggles you wear can turn the best circumstances bad if that’s your attitude.

Thom’s work is the prescription. When we talked about Joe Delaney, I was channeling People Care; Thom’s kind of EMT is someone who views their business as helping the people who call for us, and who asks for no more than that (or less). It’s not a complicated outlook, but I think it is utterly, absolutely essential.

A lot of things are wrong with this job, but if you have the right lifeline, you can survive all of it and more. Thom’s been teaching these ideas for years now, and you might be surprised at how many of your colleagues and coworkers know him personally or have heard him speak. But if, like me, you haven’t been so fortunate, buy his book. Read it. Recommend it. Loan it out — it’s been out of print for years now. And see if it doesn’t bring some of your problems into perspective.

(I am indebted to Peter Canning for originally introducing me to this book, via his blog, Street Watch. Also of note: Steve Whitehead at The EMT Spot is an old coworker of Thom’s, and his site discusses many of these topics in a similar spirit.)

Helping

“He always said if there was any way he could help someone, he would.”

Carolyn Delaney

Not too many people know about Joe Delaney anymore.

He was a running back. Played for the Kansas City Chiefs, just a couple seasons — 1981 and ’82. Played high school and college ball before that, and ran track too. He was very good.

Delaney looked like he’d make a real mark in the NFL, but his career was short, and nowadays he’s been mostly forgotten. Sure, he held some long-standing records, but who hasn’t?

His claim to fame was something different.

One day in the summer of ’83, at a park in Monroe, Louisiana, three young children waded out too far into an artificial pond, floundered, and began to drown. Delaney, nearby, heard their cries for help. Although unable to swim, he immediately dove into the water to attempt a rescue.

The situation was chaotic, stories differ, and any definitive account of the events has been lost over the years. Whatever happened, the aftermath found Delaney drowned alongside two of the children; the third had made it to safety. One of the victims had eventually been rescued, but died at the hospital; the other was recovered by divers, DOA, along with Delaney himself.

This is an EMS website, and I’m not retelling this story as a teachable moment. As public safety professionals, we instinctively turn up our lip at Delaney’s actions. “Noble, but foolish,” we quip; becoming a victim, or a martyr, is no help to anyone. Perhaps the American Red Cross tells this same story in its lifeguarding courses to illustrate the importance of safe rescue methods. I’m certainly not recommending diving into pools if you can’t swim, or running into burning buildings without protection, or jumping out of planes without a parachute. This isn’t about heroism.

I want to use Joe Delaney’s example to illustrate something else.

“People ask me, ‘How could Joe have gone in that water the way he did?’ And I answer, ‘Why, he never gave it a second thought, because helping people was a conditioned reflex to Joe Delaney.’ ” (Sports Illustrated, 1)

He was fast, and he could handle a ball, but those weren’t the kind of stories people told about this rookie running back. Instead, they talked about how he “… mowed this woman’s lawn in the dead of Louisiana summer…” “… gave this person money to get through a bad stretch…” “… turned this child away from drugs…” And how every time, he did these things without question, without hesitation. Merely out of a basic, instinctive drive to help people.

Our job as EMTs is to stabilize. Treat and transport. Provide field assessment and triage. Activate appropriate resources. It’s medicine, or it’s public safety. Or something.

There’s a lot of somethings, and I’m not sure if I can remember them all the next time the tones drop. For sure I don’t think we’re getting paid enough to do ten different jobs.

But then there’s Joe Delaney.

“He always said if there was any way he could help someone, he would.”

Just that. If there was a way — any way — that he could help another human being, he would. That was only criterion. Simplicity itself.

What if that was the attitude we adopted? What if that was the job of the EMT?

The nice thing about wanting to help is that it’s pretty simple. When that’s all you want, you don’t need much more.

Joe Delaney was known for his thriftiness, for living simply even after going pro.

“Don’t you want nothing for yourself?” Carolyn would ask Joe.

“Nah,” he’d say. “You just take care of you and the girls.” (Sports Illustrated, 2)

And it’s funny. But when you view your job as helping your patients, in any way you can, a lot of other stuff seems to fall by the wayside. Is transporting this sort of patient your business? Do you really need to fluff this pillow? I don’t know; does it help? If it does, does anything else matter?

Naturally, there are things to consider. Because typically, the way we can help is through clinical intervention, through skilled medical assessment and treatment. If we helped in another way, they’d call us something else, like “plumbers” or “dentists.” And if we’re better at our craft, we can help more. That’s why we open the books and palpate the rubber mannekins. Because we recognize that if Joe did know how to swim, more lives might have been saved that day.

But the technical aspect is a means to an end, and just one means of many.

If you ask around the base, and people are truly honest, many will admit they got into this job at least partly from a desire to help people. It’s an organic urge, and a good one, and it brings us to the table, but then the years and the worries and the details of how and why and but… start to muddy the waters, and at some point we find ourselves forgetting that basic passion. Striving towards other goals. Elevating the details. And sometimes that’s okay.

But the next time we roll up those garage doors, maybe we can think back, and remember what matters. Maybe we can take a page from Joe Delaney, and every day assert this simple promise: if there’s any way we can help someone, we will.

Good Partners

EMS today is almost invariably practiced in two-person teams.

The main exception to this is in the fire service, which — even when called in an EMS role — is often built up from crews of three or more. And on 911 calls in many areas, ambulances are routinely dispatched alongside the fire department and sometimes police or other resources, so it’s not unusual to see a half-dozen responders or more on a scene.

Nevertheless, this job is fundamentally one that you perform alongside one other person, and that environment defines how we live and work. In fact, the dynamic between you and your partner can come to resemble the relationship of a married couple, an observation made by many a poor spouse after realizing their significant other spends more time with a mustachioed paramedic than with them.

You spend upwards of 10 hours a day sitting in a small box with this individual, talking to them, listening to them, and sharing all their favorite habits, odors, and bodily noises. You experience the best of their personality, but also their worst, and you learn what they listen to, who they hate, and how they address and solve their problems. To do your respective jobs, you’ll have to find ways to compromise where you don’t agree, adhering to what you think is right but ultimately doing what’s necessary in order to get the task done.

We all hope to work with a good partner when we check the schedule, but what is it that makes for a good partner — how can we be that person to someone else? There are many qualities, and some (such as personality) are heavily subjective, but one I think is universal.

Good partners are reliable. This is a word that doesn’t get much respect nowadays — reliable is boring, 8-track tape and grayscale television, reliable is what your grandparents and Dick Van Dyke were. Certainly, although intellectually we acknowledge that it’s a good thing, “reliable” may not exactly be the byword we’d want on our EMS tombstones.

But reliability is a funny thing. Like good life insurance, it’s something nobody wants, but that we all want in the people around us.

Not everyone works this way, but I have a simple system when working on a dual-EMT crew. On any given call, one person drives, one person techs. If I’m the tech, I’m in charge of the call: I do all the history-taking and communicating with the patient; I give and receive the reports; I make the decisions about next steps and the course of care; I stay by the patient’s side from start to finish, and in the end I’ll write up the documentation. As for the driver, he obviously is responsible for driving, getting us from Point A to B and later to C, and related tasks like the radio; but most of all, his job is to help me out. Record vitals, retrieve equipment, start interventions, take heat — whatever is necessary to free me to do what I need to do.

It’s the job of the tech to keep the entire situation in perspective and paint the path that will, when viewed in retrospect, be clearly visible as the ideal course of care given the patient’s complaint. But many obstacles may interfere with that path, and the more that my partner can help clear those away without a hiccup or hesitation, the more smoothly things will go. This means doing what I ask without question, or better yet, anticipating it even before I ask; it means seeing and foreseeing problems and knowing how to pave them over without diverting us from our primary goals. I can be somewhat anal about this division of responsibility, not because I’m a control freak — I’m happy to play the other part when my turn comes — but because the best way to drop the ball and fumble through a run is by having two chiefs and no indians. Although there are times for collaborative discussion, and times to throw up your hands and refuse to do something foolish, the majority of actions and decisions on any given call are simply things that need to be performed by someone, rather than tabled for debate by committee.

Here’s where the issue of reliability comes in. As a crew, we have the potential to do some wonderful things, including pushing boundaries and getting creative in ways that are anything but boring. But in order for me to go out on a limb, I need to know that you are going to be able to back me up — cover your end of the show, pick up the slack and fend off any looming hazards. If I can’t rely on that, then I can’t extend myself, because I’ll need to hold something in reserve to pick up whatever you drop. If you don’t know how to get us to the hospital, then I may not be able to accomplish very much in the back, because I’ll need to divide myself between the patient and helping you navigate. If I need to ask questions, read meds, take vitals, and package the patient all at once, don’t be surprised if only half as much gets done, because I’ll be doing the work of two. I may be able to handle a rough call with the most useless partner in the world, but it’ll be done in the most bare-bones fashion, merely trying to get through it without any disasters and struggling to hold our heads above the standard of care. However, if you manage your end of things seamlessly and effectively, that frees me to step everything up; the more you can do, the more I can do. Reliability is boring if it’s all there is, but when it’s the immutable backdrop of your care, it’s actually the foundation for all creativity and excellence.

(Now, there are crews out there who don’t work this way. Instead, they handle things cooperatively, each member doing what needs to be done and nobody in charge. This works best when they’re very experienced and familiar with each other, in agreement on most decisions and practiced at staying mutually out from underfoot and functioning synergistically. This is not common. However, the important thing is that even on a crew like this, reliability is all the more important, because it has to run both ways — if we each have equal opportunity to drop the ball, then we each have to be absolutely reliable.)

There’s a major interpersonal element to all this, which is trust. Trust is the coin you pay back for reliability. I need to be able to trust my driver to do his job, and likewise he needs to be able to trust that I’m making smart decisions. If I’m sitting in back and tell him to hit the lights and divert to a nearer hospital, I need to be able to trust him to get us there safely and quickly, otherwise I’ll be forced to take time from the patient to monitor and direct him. But he also needs to trust that I’m making an intelligent decision based on a sound assessment, because he doesn’t know what’s going on back here either, and I may not have time to explain. How bizarre of a request can I make without him balking or refusing? That depends; how much does he trust me?

Just like in a personal relationship, the fear of lending this trust comes from a legitimate aversion to risk. Although trust in an intimate relationships puts us at risk of emotional harm, trust on this job places our career and the lives of our patients and ourselves on the line.

If I was wrong to trust my driver, he might get lost, panic, plow through an active intersection and kill us all. Of course, if he was wrong to trust me, our patient might receive the wrong care, die in a trauma room somewhere, and we’ll both be fired and stripped of our certifications. Extreme, but possible. In many jurisdictions including my own, both members of a crew are held equally responsible for all aspects of patient care; this fact alone makes trust tremendously important if we’re ever to divide up responsibilities at all.

For this reason, I feel that trust has to extend to before and after the call as well. Everyone has heard these rules, and everyone has broken them. “What happens on the truck, stays on the truck” is a popular one, mainly because we’ve all confided something to a partner only to hear them later repeat it to the wrong person — either innocently or seditiously. This sort of thing is fertile grounds for drama, which is no fun, but what’s key is that trust isn’t compartmentalized, and if you can’t trust your partner in a personal capacity, you won’t trust him professionally either.

I recommend these basic rules:

Never relate any personal information told to you by your partner, unless you either request permission first, or “HIPAAfy” it so it can’t be linked to him (“one of my partners was telling me…”).
Never tell any stories that could paint a past partner in a bad light, unless you either request permission or HIPAAfy it.
Never involve supervisors or management staff in personal or operational problems, unless critical and intractable patient care issues are concerned.

These are pretty simple rules to understand, although harder to consistently apply, because we’re all blabbermouths at heart and don’t realize when something innocuous to us is private and personal to someone else. The gist is simply that there is a bond of trust between your partner and yourself, regardless of whether they’re a close friend, a hated enemy, or a total stranger; and that bond should not be violated except in extreme circumstances, generally involving the safety of yourself or others. Even in cases like that, every effort should be made to resolve the situation without violating their trust, which isn’t always the easiest method, but it is the best for everyone involved.

Again, this serves to reduce drama and maintain personal relationships, but we’re talking about it because it directly impacts your work. You must be able to trust your partner, or you will be a dysfunctional crew. (If I know you can’t be relied on, I can’t trust this blood pressure you took, can I?) Moreover, you will never be able to help your patients in any but the tightest, most minimal and conservative way, because you don’t know if anything else won’t come back to bite you. You’ll move through your day tense and fearful of being under the eye of someone you don’t trust. Bad news all around.

I’m not suggesting that these ideas are easy, because they aren’t, and dealing with their results and fallout is what makes up a lot of our daily troubles. But this is a team sport, and it can’t be done right any other way.

How and Where? The Cornerstone of BLS

It’s common to observe, and not wholly off-base, that the EMT-B has only a limited toolbag at his disposal for the field treatment of his patients. There are literally only a fairly small number of interventions he is trained and permitted to perform, and most of those are for the trauma patient; for the typical medical patient, he can do very little unless they are actively trying to die. Now, it’s true that for those dying patients, he may have everything he really needs; BLS is the backbone of life support, no matter if you’re a doctor or a lay responder. Still, it’s easy to feel powerless as a Basic with the many distressed or ailing patients for whom we can do very little except transport them and set the stage for their eventual definitive care.

The first and largest clinical skill that the EMT needs to master is undoubtedly patient assessment, but if we’re talking about interventions — that is to say, actions you take that directly change the course of the patient’s care — I believe that limited or not, he has at least one very important role to play. The most important BLS intervention is decision-making.

No, we don’t push drugs or relieve pneumothoraces, but we still make decisions. These can be treatment-related, such as the decision to assist respirations or splint an extremity; they can be logistical and somewhat banal, such as how to best maneuver a stretcher into a home or where to park the ambulance. But with every single patient, we’ll repeatedly make one particular group of decisions — decisions which, at the least, will play some role in their care and eventual outcome, and at the most can determine whether they live or die. Foremost among these decisions are three:

Where does this patient need transport to? What facility or point-of-entry will be most beneficial, given his presentation and suspected diagnosis? Would it be appropriate or acceptable for the patient to refuse transport?
In what manner should this patient be transported? How quickly does he need to go? Is there no hurry, or does every second count? Do we need lights and sirens? Does the receiving facility staff need to be notified of special circumstances (such as trauma, stroke, or cardiac alerts)? After arriving, what information and what degree of urgency do you convey in your report?
Would the patient benefit from any additional resources? You may be the only eyes and ears on scene; if fire or police are needed for safety reasons, it is your responsibility to call for them. Furthermore, would the patient benefit from ALS-level care?

It may be true that we generally can’t cure the primary cause of a patient’s complaint, and in many cases can’t even offer meaningful supportive care short of true life support. But these decisions are still central to the care the patient eventually does receive, and most of all how quickly. Of course, some decisions are made for us by our policies and protocols, and other decisions are patently obvious, but that still leaves substantial room for wisdom or foolishness.

Consider a critical trauma patient extricated from a MVC. In one case, we arrive and direct the fire department’s rescue, setting up the scene for safe and easy access. The patient is rapidly removed and assessed, loaded up, and transport is begun emergently to the level I trauma center 10 minutes beyond the closest community hospital. As we depart, we call ahead and notify the trauma team, relaying our status and ETA. En route, we are able to intercept with a paramedic crew, who hops aboard and jump-starts the patient’s care with IV access, pain management, and other measures. We quickly navigate through traffic and arrive in good time, bringing the patient directly into a trauma room, where staff are waiting and immediately assume care. The report is handed over, including several critical findings, and the patient is stabilized and rushed into surgery.

In this case, we “did” very little for the patient, in the sense of treatment. But consider if things had gone differently. We arrive on scene and bungle things, parking in the wrong spot and jamming up the access routes; it takes us many minutes to assess the situation and call for heavy rescue. The extrication is slow and belabored; when finished, we evaluate the patient incompletely, with a medical rather than a trauma approach. He is loaded and transported to the nearby community hospital, driving with the flow of traffic, and no entry notification is given. When we finally arrive, we sit in the triage line, give a minimal report to the nurse, and the patient is placed in a secluded hallway bed. We head out for our next call, never realizing that the patient sat there for many minutes until a doctor finally assessed him more closely and realized his severity, at which point he called immediately for ambulance transfer to the trauma center. The transferring unit took 10 minutes to arrive, 10 more to assume care, the transport itself took another 20, and the patient finally arrived in surgery an hour and a half after we first arrived on scene.

Although the eventual treatment might be identical, the difference in the timelines for these parallel patients could very well have a profound effect on their outcome. There is some debate currently as to whether time-to-care for many EMS patients could be far less important than we traditionally assume, but even if it is, there is no question that some subset of patients still exists for whom time is critical.

For a realistic illustration, consider the following, a true story of a call I ran:

You are dispatched BLS and non-emergent to a rehab facility for the complaint of “cellulitis.” On arrival, you take a report from a nurse, who explains that the patient has been with them for a week and has been experiencing inflammation of his arm for much of that time. He is severely demented but otherwise has a minimal medical history.

While you talk, your partner comes out of the patient’s room, informing you that she was unable to obtain his blood pressure. Curious, you head in, finding an elderly male accompanied by his wife. He is cheerfully confused, oriented to self only (baseline per his wife), but in no distress. He appears generally well.

His respirations are unremarkable, but his radial pulse cannot be felt, and he has a thready, barely palpable brachial pulse, 90 and regular. With several attempts, you are able to obtain a BP at ~84 systolic. His skin, however, is warm and slightly red — not overtly hot, but certainly not cool. (Your service does not carry thermometers.)

You speak with the nurse, who checks the chart and confirms the patient is typically normotensive, up to and including his last vitals check earlier today. You begin loading the patient onto your stretcher while you obtain a detailed history from the wife. Eventually, you learn that during his recent hospital stay, he had developed a seemingly minor infection of the arm due to an infected IV site.

Although the patient is still presenting well, your assessment is challenged by his poor cognitive baseline, and you are very concerned about the possibility of a developing sepsis. The seeming rapidity with which the patient’s blood pressure has dropped is especially troubling. You load up the patient, giving him some supplemental oxygen for good measure (pulse oximetry is not available), and obtaining further details of his history.

His requested facility is also the closest, a community hospital 5-10 minutes away, and the same hospital at which he was recently an inpatient. If an ALS intercept were available, you would attempt to meet them, as early goal-directed therapy for the treatment of sepsis has been shown to significantly improve outcomes, and some of those milestones are achievable in the field (such as fluid bolus). However, the nearest fly-car is several towns away, and an intercept would take much longer than direct transport. You elect to head straight for the emergency department. You attempt to call in an entry notification, but are unable to raise the receiving staff prior to your arrival.

Upon arriving, you wheel the patient into the busy ED. A harried nurse asks if this is the cellulitis patient (the facility had called previously), which you affirm. She tells you to put him in an overflow hallway bed. Pulling her aside, you mention that you have some concerns about the patient’s hypotension and the possibility of sepsis, painting a brief clinical picture. She has one of the techs clear out the critical care room near the entrance, and you move your patient there instead. After a detailed report to another nurse, you transfer over care, shake hands, and clear out. As you leave, the patient is in the process of having blood drawn.

This was ultimately a simple call, with neither sturm nor drang, and the prevailing emotion was an orderly calm rather than any frank emergency. But consider: supposing this patient were indeed septic (I was unable to obtain any follow-up), there is a clear correlation between time to definitive care and eventual morbidity and mortality. (The best practices of early sepsis care are still evolving, but most would agree that the condition should be treated as a time-critical life threat just like stroke or acute MI.) The fact that the patient seemed to be in minimal distress or extremis does not entail that he was not at a critical juncture. If he had been treated as a simple cellulitis patient going in for evaluation and non-urgent care, he would have — at best — languished in a hallway bed until eventually funneling through the facility’s triage process and being stepped-up to a higher acuity of care.

This, to me, is the central clinical skill of the EMT, on top of basic life support and trauma care, and of course patient assessment. Skilled assessment with the knowledge of pathophysiology and best practices to understand the meaning of your findings is the first half of the puzzle, and making the appropriate decisions to streamline the patient’s continuity of care is the second. This is something that can and should happen with every single patient, and it’s the most basic of BLS tools.