Talking Green

There’s a secret behind this job.

You go to work. You run the calls: the boring, the exciting, the obnoxious, the weird. Occasionally, the terrible. You see, you do, you move on. Like everything else, it runs off our backs. Like rain off a tin roof.

At least, that’s what we tell ourselves. But there’s a secret.

The secret is that hidden beneath the uniformed cowboy swagger of no-problem, we-got-this, no-big-deal, a thick vein of psychological stress is flowing. You don’t see it in your coworkers, because they hide it away. When it reaches you, you do the same, because it’s not okay to show it. Our professional image is unflappability, and you can’t be unflappable if you let things get to you. So we push it under the rug.

Until one of us takes their own life.

PTSD, depression, anxiety, substance abuse, and yes, suicide, are a fact of life in EMS. But we never talked about it. At least, not until a few of our colleagues were brave enough to start shining light upon the problem, in an effort called the Code Green Campaign.

Code Green collects anonymous confessions from our brothers and sisters who can’t speak them out loud, reports the (all too frequent) suicides, collates the research exploring first responder mental health, and performs outreach to build awareness.

Explore their website for more information about their basic mission. After that, come back, because I asked them to unpack a few of the subtleties behind this problem and how they’re trying to solve it.

Question: While most first responders agree with the need for the Code Green Campaign, most of us haven’t actually done anything about it. You did. How and why did it first come about? What was the impetus and how did the early days take shape?

Answer: In March of 2014 one of my co-workers died of suicide. After his death I was talking about it with a group of friends, and we realized that even though we worked for different agencies in different states, we all knew someone that had died of suicide or had a serious attempt. We knew that this couldn’t be a coincidence, so I started looking into it further. I couldn’t find a lot of data, but what I did find told me that this was a much bigger problem than anyone realized.

Once we established that there was, in fact, a mental health problem, as well as a stigma problem, we started discussing what could be done — particularly about the stigma. It occurred to us that if there was one thing first responders like doing, it is sitting around telling stories. We thought that if we could come up with a way for first responders to share the stories of their own mental health problems, other people could read them and realize they weren’t the only ones struggling. We started collecting the stories and posting them on social media every Monday, Wednesday, and Friday. Things blew up from there.

In the early days things moved fast. My co-worker died on March 12th, and on March 16th we came up with the story sharing idea. We came up with our name a couple days later, and I think it was by March 23rd that we had our Facebook page up and running and stories being shared.

Q: Let’s get down to the elephant in the room. Why is this a problem for us? Why do EMS providers seem to be at higher risk for mental health issues in general, and for suicide in particular, compared to bakers, librarians, and schoolteachers?

A: I’m going to preface this answer with the warning that this is a lot of supposition, extrapolation, and educated guesswork. PTSD has most extensively been studied in the military population, so that is the best info we have. This is also a simplified answer, since the long answer would probably beat a doctoral dissertation in length.

We are frequently exposed to known risk factors for PTSD, such as seeing people hurt or dead, feeling helplessness or fear, having poor social support after a traumatic event, and having extra stress outside of work (marital, financial, etc).
We are poorly prepared for the realities of the job. Yes, we’re warned that we’ll see blood and guts and gore, but we’re not told that we are going to feel helpless on a regular basis, or that we’ll be scared we hurt a patient or made them worse. We’re not taught about how different this job can be from normal jobs, and how hard it can be for spouses and other family members to understand what we go through.
Aside from stressful calls, we’re exposed to higher rates of assault, vehicle crashes, and workplace injuries than many fields, which can add to the trauma.
We seem to have higher rates of depression, anxiety, and substance abuse, although it is unclear why.
We work in a very macho field and we’re supposed to be the helpers, not the ones that need help. There have also been reports of people being suspended or fired after admitting they have a problem. That combination helps create a huge stigma against admitting any sort psychological problem and asking for help.
We have more knowledge about lethal means of suicide.

Q: Okay, so let’s contrast EMS against some similar fields. Other first responders like fire and police, or medical personnel like doctors and nurses, all seem share most of the qualities you listed. Are they in the same boat? Or is there anything that puts us at greater risk compared to them?

A: Other first responders like fire and police are in the same boat. In fact, we don’t separate EMS numbers from fire service numbers because the employee base is so entwined. There are almost no fire departments out there who don’t do any EMS at all, so it is tough for us to draw a line as to who counts as EMS and who doesn’t. Just because an agency doesn’t transport doesn’t mean their employees/volunteers aren’t exposed to the same trauma. If you can’t draw the line at transport versus non-transport, where do you draw it? In the long run, it becomes almost impossible to separate people out. With police officers it is easier, but their suicide rate is on par with Fire/EMS. I believe that in 2014 there were over 140 reported police suicides.

As far as other medical professionals go, we do know that doctors do have a high rate of suicide, to the tune of 46 per every 100,000 (for first responders we’re looking at about 30 per 100,000). We don’t know what the suicide rate is for nurses, PAs, or NPs, but we wouldn’t be surprised to learn it is also high.

This is purely supposition on my part, but I do think we are particularly susceptible, because EMS is less developed than other medical fields. Nurses and doctors have well-established professional organizations representing them at the state and national levels. EMS is much more fragmented. The one big difference we’ve especially noticed with nurses and doctors compared to EMS is that many states have license preservation programs in place for RNs and physicians, but not for first responders. That is, if they have a mental health or addiction issue, their state may have an official program in place to help them keep their license while getting help. Few (if any) states have a similar program for first responders. EMS doesn’t have that kind of well-organized advocacy yet.

Q: I expect many of our readers aren’t familiar with license preservation programs. What are they and what are the possible ramifications when we lack one?

A: My answer is based on the states I’ve lived in. From what I understand, most states have such a program set up for either doctors and/or nurses. Basically, the state has recognized that nurses and doctors spend considerable time and money to obtain their licenses, and that it is in everyone’s best interest to keep them on the job, rather than automatically revoking their license. Here is an example of how it would work: say a nurse starts diverting narcotics. She self-reports her behavior to her employer and to her state licensing agency. She will likely be suspended or fired from work, but if the state has a license preservation program her license will only be suspended. The licensing board will then review the case and outline what the nurse has to do to get her license reinstated. They may require her to complete a treatment program, attend weekly counseling sessions, and submit to monthly drug tests. As long as she meets those requirements, she can keep her license.

The issue with lacking a license preservation program is that it creates an atmosphere of fear. People will avoid seeking help for anything they think could possibly cause their license to be suspended, since they have no way of knowing the outcome of that. No license means no job, and unless you want to move to another state, you’d have to come up with a new career fast.

Q: In the absence of such programs, is there a real possibility that EMS providers can lose their jobs or even their certifications merely for reporting mental health issues? In other words, no diversion or actual violations, just the typical paramedic suffering from depression, anxiety, or PTSD?

A: This question is difficult to answer because it is based on the idea that people are routinely reporting their mental health issues to the employer or the state. Unless someone is seeking to use Worker’s Comp or other employment benefits for a mental health issue, there is no reason to be reporting routine treatment to anyone (unless it is required, like with some communicable diseases). Someone wouldn’t report that they’re being treated for asthma or hypertension to their employer or state licensing board, so why would they report depression or PTSD? Employment benefit issues aside, in absence of diversion or actual violation it really doesn’t make sense for anyone but the person and their treatment team to know anything.

Such programs are generally more reactive than proactive, although in the ones I’ve looked at it is strongly encouraged to self-report issues/violations before they are caught by an employer. In fact, at my employer you’re much more protected if you self-report to the EAP than you are if you get caught.

I think that no matter what the reality is, having programs like these make it so that people don’t feel like they are backed into a corner once they develop an issue. We don’t want people feeling like a situation is hopeless, we want them to be able to see there are options.

Q: I imagine that in most cases, “reporting” occurs in the circumstances of a worker’s compensation claim (i.e. asking the employer to pay for mental health services), or perhaps when an employee needs to take time off work.

In the real world, I expect some employers are inclined to be less than supportive about these types of requests. Are they sometimes refused? Are employees sometimes asked to “prove” that their condition is work-related? Is there a legal framework mandating employers to provide these services and accommodations?

A: We answered earlier that Worker’s Comp claims or using other employment benefits are the instances an employer is most likely to learn that someone is having issues. It is difficult to answer a straight “yes” or “no” to any part of this question. No one has sat down and studied how often requests like the above are made, how often they are granted, how often they are refused, and if the response to such a request is affected by the type of employer or the state the employee is located in. We don’t know how often time off requests for mental health conditions are granted or refused, or how often they are granted or refused compared to other time off requests at that same employer. We could come up with anecdotes of both positive and negative outcomes, but there is no data.

What is and what isn’t covered by Worker’s Comp will vary from state to state and employer to employer. We do know that there are states where psychological conditions are not covered for anyone, or are only covered for certain jobs, and the employer has no control over that. It’s not uncommon for Worker’s Comp claims to be investigated no matter what kind of claim it is, so we would not be surprised if people filing a claim related to a psychological issue would be subjected to some questioning. Just ask anyone who has filed Worker’s Comp for a back injury or knee injury. Worker’s Comp tends to be difficult no matter what.

Furthermore, people who have had to take time off for physical injuries will tell you that on top of their injury being investigated and questioned, they likely also had to jump through hoops in order to return to work. Fitness for duty evaluations, physical agility tests, etc. Because of the differences between state laws and agency policies it is very difficult to know if mental health conditions are being treated differently at a significant rate.

As for accommodations, that is even more complicated. Under the Americans With Disabilities Act (ADA) employers are mandated to provide reasonable accommodations for employees that have disabilities. Now, how many first responders do you know that are willing go through that process, and then admit to their employer that they have a disability that needs to be accommodated? Additionally, first responder agencies are in a tough spot when it comes to accommodations because this field is so unpredictable. Agencies can’t ensure that you’ll never run another pediatric cardiac arrest, or never have to respond to a certain address again. If someone has an anxiety attack while responding to a call, or on scene of a call, is taking them out of service going to be considered reasonable? Probably not. Accommodations get very complicated very quickly.

Q: Interesting. So despite these challenges, the problem is clearly an urgent one. What steps can field staff take to prevent and manage mental health issues, whether for themselves or for their colleagues?

A: Resiliency, and building resiliency factors, seems to be a key to helping prevent mental health issues from arising, so everyone should review what resiliency factors they have and work on building upon them. People also need to be able to recognize signs of decline in themselves, such as worsening sleep, increased drinking, and anger issues. For co-workers, the biggest thing is not to be afraid to say something to someone if you think there is a problem. Asking someone, “Are you thinking of suicide?” is not going to put the idea into their head — so if you’re concerned, ask.

Something else that is important is reducing the stigma around mental health in general. Don’t make jokes about “BS psych patients” or complain that psych calls are a waste of time. This contributes to the stigma and makes it harder for people to admit they have their own problem.

Q: What other points do you want do make on this important topic?

A: We need to keep talking about this and keep the conversation going. Changing how mental health is addressed is going to involve changing the culture, which is going to take time and effort.

For people who want to get involved there are several things you can do. Speak up if you hear someone speaking negatively about mental health, whether in the context of our peers or our patients. If you hear about a suicide, please report it to either Code Green or to the Firefighter Behavioral Health Alliance. All reports are confidential and we do not disclose information without permission.

If you know of a first responder–friendly mental health professional in your area, let us know so we can add them to our resource database. It may not seem like much, but this kind of stuff is incredibly helpful to us and to the cause.

Visit the website of the Code Green Campaign to learn more, read personal accounts, and see else what you can do to help.

A Saga of Spurious Spines

There’s a story we’ve all been told. It goes like this:

A person suffers a traumatic injury, usually a minor one, like bumping their head or crunching their fender in traffic. Afterwards, they appear fine, without deficits or any great pain. Ambulance and hospital personnel are unimpressed. But all of a sudden, our seemingly-well patient makes some slight movement — maybe he turns his head — and instantly collapses to the floor, unable to move. He is paralyzed forever, and it’s all because of the unstable spinal injury that you missed.

You heard this cautionary fable in EMT or paramedic class. They tell it in medical school, in the emergency department, and on the trauma wards. It goes back decades. And it makes sense, right? Even a layperson would agree that if the structure of the spine is damaged, the cord it protects will become vulnerable, just like how you’re not supposed to poke the soft spot on a baby’s head.

In fear of this event, we go to great lengths to prevent it. We wrap collars around our patients’ necks, we tie them onto boards, we strap and tape and secure. If their spine can’t protect the cord, by golly we’ll protect it instead, at least until somebody definitively proves that there’s no injury. Which there usually isn’t. But still.

Here’s the trouble: practically nobody has actually seen this phenomenon of mechanical instability occur. For real; the next time somebody mentions it, ask if it’s happened to them. No, they’ll say; but my partner’s cousin’s babysitter saw it a few years back. And if you bother to track that person down, invariably you find that the case either never occurred or has become terribly dramatized through the telling. Steve Whitehead calls it the “Sasquatch event.”

So does this happen at all? After all, many things in medicine that make sense aren’t real. Indeed, doubt has grown lately as to whether our spinal immobilization precautions are effective, and we’ve become more aware of the harms associated with them; as a result, backboards have become increasingly vilified in recent years, and “selective immobilization” algorithms have been accepted in some areas. But there’s been less attention to the question of whether the disease itself is real or a myth, and I wanted to know.

So we went and looked. With the help of four folks smarter than me — Domenic Corey, NREMT-P; James Oswald, B.Emerg Health (Paramedic); Derek Sifford, FP-C; and Brooks Walsh, MD, NREMT-P — we canvassed the literature as far back as possible to dig up any actual, confirmed, peer-reviewed reports of this event. And we just published our findings in the journal Academic Emergency Medicine. Check it out. (And also check out the accompanying editorial by spine connoisseur Mark Hauswald, who you know from “that Malaysia study.”)

I won’t spoil the results, but let me put it this way:

Despite looking across 50+ years, we found few examples.
Most of them weren’t very impressive.
Even fewer occurred in the EMS setting, and none of those were the classic, sudden event you’ve heard about.

So the next time your buddy mentions this unicorn, tell him you don’t doubt him, but that he should write it up for the journals — because it’ll be the first one, and that’s publishable.

This has been an exciting project for another reason. From start to finish, this paper was the child of two parents: the FOAM and EMS communities. Of my four co-authors, I knew three of them exclusively through the web, and have only met two, yet we share interests and passions enough to collaborate on a project that took us over a year. Moreover, every one of us is either an EMT or paramedic, most of us still working actively in the field (although in a few cases we’ve accumulated some other titles too). In fact, had this reached print a few months sooner, the fanciest initials of the lead author would be EMT-B, and that should tickle you.

So never let it be said that the nonsense in this profession is invincible, or that we can’t be the ones to exorcise it. We can fix our own problems, and if we spent more of our energy on moving forward rather than complaining, it just might happen sooner than you think.

Murder by Checklist

Reader Steve Carroll passed along this recent case report from the Annals of Emergency Medicine.

It’s behind a paywall, so let’s summarize.

What happened

A young adult male was shot three times — right lower quadrant, left flank, and proximal right thigh. Both internal and external bleeding were severe. A ~~physician bystander~~* tried to control it with direct pressure, to no avail.

With two hands and a lot of force, however (he weighed over 200 pounds), he was able to hold continuous, direct pressure to the upper abdomen, tamponading the aorta proximal to all three wounds.

Bleeding was arrested and the patient regained consciousness as long as compression was held. The bystander tried to pass the job off to another, smaller person, who was unable to provide adequate pressure.

When the scene was secured and paramedics arrived, they took over the task of aortic compression. But every time they interrupted pressure to move him to the stretcher or into the ambulance, the patient lost consciousness again. Finally en route, “it was abandoned to obtain vital signs, intravenous access, and a cervical collar.”

The result?

Within minutes, the patient again bled externally and became unresponsive. Four minutes into the 9-minute transfer, he had a pulseless electrical activity cardiac arrest, presumed a result of severe hypovolemia. Advanced cardiac life support resuscitation was initiated and continued for the remaining 5-minute transfer to the ED.

The patient did not survive.

When the cookbook goes bad

The idea of aortic compression is fascinating, but I don’t think it’s the most important lesson to this story.

Much has been said about the drawbacks of rigidly prescriptive protocol-based practice in EMS. But one could argue that our standard teachings allow for you to defer interventions like IV access if you’re caught up preventing hemorrhage. Like they say, sometimes you never get past the ABCs.

The problem here is not necessarily the protocols or the training. It’s the culture. And it’s not just us, because you see similar behavior in the hospital and in other domains.

It’s the idea that certain things just need to be done, regardless of their appropriateness for the patient. It’s the idea that certain patients come with a checklist of actions that need to be dealt with before you arrive at the ED. Doesn’t matter when. Doesn’t matter if they matter.

It’s this reasoning: “If I deliver a trauma patient without a collar, vital signs, and two large-bore IVs, the ER is going to tear me a new one.”

In other words, if you don’t get through the checklist, that’s your fault. But if the patient dies, that’s nobody’s fault.

From the outside, this doesn’t make much sense, because it has nothing to do with the patient’s pathology and what might help them. It has everything to do with the relationship between the paramedic and the ER, or the paramedic and the CQI staff, or the paramedic and the regional medical direction.

Because we work alone out there, without anybody directly overseeing our practice, the only time our actions are judged is when we drop off the patient. Which has led many of us to prioritize the appearance of “the package.” Not the care we deliver on scene or en route. Just the way things look when we arrive.

That’s why crews have idled in ED ambulance bays trying over and over to “get the tube” before unloading. That’s why we’ve had patients walk to the ambulance, climb inside, and sit down, only to be strapped down to a board.

And that’s why we’ve let people bleed to death while we record their blood pressure and needle a vein.

It’s okay to do our ritual checklist-driven dance for the routine patients, because that’s what checklists are for; all the little things that seem like a good idea when there’s time and resources to achieve them. But there’s something deeply wrong when you turn away from something critical — something lifesaving — something that actually helps — in order to achieve some bullshit that doesn’t matter one bit.

If you stop tamponading a wound to place a cervical collar, that cervical collar killed the patient. If you stop chest compressions to intubate, that tube killed the patient. If you delay transport in penetrating trauma to find an IV, that IV killed the patient.

No, let’s be honest. If you do those things, you killed the patient.

Do what actually matters for the patient in front of you. Nobody will ever criticize you for it, and if they do, they are not someone whose criticism should bother you. The only thing that should bother you is killing people while you finish your checklist.

* Correction: the bystander who intervened was not a physician, but “MD” (Matthew Douma), the lead author, who is an RN. — Editor, 7/22/14

Glass Houses: Suicide in Both Seats

Of all the skills we’re called upon to wield without adequate training, care for psychiatric complaints tops the list. In particular, it’s a rare shift when you don’t handle a person — whether on the initial emergency response or a subsequent interfacility transfer — who has thought about, or even attempted to commit suicide.

Probably because these patients aren’t very medically exciting and can be challenging to deal with (due to varying degrees of cooperativeness), many of us aren’t big fans. We also tend to have a cynically individualistic sort of streak, which says that deep down, patients are responsible for themselves. If someone wants to be healthy and they get unlucky, we’ll help out. But if they can’t be bothered to try, we can’t be bothered either, and if they’re actively trying to hurt themselves, surely we have better things to do than interfere with natural selection.

But before we throw stones, we should probably understand the disease we’re discussing. Just like you can’t treat CHF without grasping its pathophysiology, properly treating the suicidal patient — or even deciding not to care — demands knowledge before judgment.

Depression itself is hard to grasp from the outside. This easy walkthrough may shed some light, but if you haven’t been there, you probably shouldn’t pretend you understand it. Nevertheless, it’s one of those conditions that invites amateur opinions, because it seems like the sort of thing we all know something about.

Maybe depression is too loosey-goosey; maybe it’s better if we stick to concrete facts, yeah? And there’s nothing more concrete than suicide. Let’s talk about suicide.

Start by reading through this article at the Daily Beast. It’s long, but it’s real good, and you may start to change your mind about a few things by the end.

For instance, in 2010, in the developed world where we have good statistics, suicide killed more people in the prime of their life (ages 15–49) than anything else. Read that again. Of all the terrible insults we study and treat, from gunshots to heart attacks, car crashes to cancer, suicide was more deadly than every single one. Over a hundred thousand suicide deaths that year. Almost a million across all age ranges. Every murder, every war, every natural disaster you read about in 2010 — throw them all together, and they still don’t equal the number of suicides. There were probably even more that weren’t reported, and even that’s just the successful suicides, of course; those that were attempted but didn’t quite succeed make up a much larger group, perhaps twenty-five times larger. (Yes, 25 times.) And there are more and more every year.

When we talk about CPR, we often talk about quality of life. When a 98-year-old bed-bound dementia patient dies, we might ask whether we should jump through hoops to save them; even in the best possible case, they’re not going to return to a very long or very fruitful existence. But when the 20-year-old college student drops dead on the lacrosse court, we want very badly to bring him back, because if we can he might live another 70 wonderful years.

Well, the people committing suicide are the second kind. They’re often middle-aged, middle-class folks who could be happy and live long — if they can get past their illness. But dead people won’t get past anything.

Of course, we see a lot of depressed people, and most of them won’t kill themselves even if they’ve thought about it. Figuring out who’s most at risk of taking that step is a worthwhile goal, and the Daily Beast article describes three risk categories that you may find useful:

Those who feel alone, that they don’t belong anywhere
Those who feel like a burden to others
Those who have the willingness and capacity to go through with self-annihilation

Who feels alone? Everybody, at times. We need connection. Married people kill themselves less often than the unmarried, twins less often than only children, mothers raising small children almost never. Sometimes those who seem to have everything in life may have the weakest connections, which is why they say that money doesn’t equal happiness.

The life-saving power of belonging may help explain why, in America, blacks and Hispanics have long had much lower suicide rates than white people. They are more likely to be lashed together by poverty, and more enduringly tied by the bonds of faith and family. In the last decade, as suicide rates have surged among middle-aged whites, the risk for blacks and Hispanics of the same age has increased less than a point — although they suffer worse health by almost every other measure. There’s an old joke in the black community, a nod to the curious powers of poverty and oppression to keep suicide rates low. It’s simple, really: you can’t die by jumping from a basement window.

When nothing ties you down, when nobody cares what happens to you, what’s stopping you from shuffling off into the abyss? “I’m walking to the bridge,” one note said. “If one person smiles at me on the way, I will not jump.” Did you smile at your last psych patient?

Who’s a burden? Anyone who’s not achieving, contributing, responsible for something or someone. The unemployed, the chronically cared-for, those with debilitating diseases or intractable poverty. We do this job because we like taking care of people, but that means there’s always someone being taken care of, and nobody loves being on that side of the equation. Some people will go to their graves rather than add to the work or worry of those around them. A few will send themselves there.

Finally, who’s actually willing to end their own lives? It takes something special to close the deal, a particular resolve; no living creature’s natural instinct is to die. Even if you have the desire, it’s not easy to pull the trigger. It’s those with the gift or the learned ability to follow through with difficult deeds, the “athletes, doctors, prostitutes, and bulimics . . . All have a history of tamping down the instinct to scream.”

Think about those categories. None of those are particularly insane thoughts to have. All it takes is their juxtaposition, and suddenly, something unthinkable becomes a very real possibility. Honest. It happens hundreds of thousands of times every year.

Suicide in EMS

“Well, what the heck,” you’re thinking. “That’s nice, but I’m not going to fix them, so why do I care? I’ll bring ’em where they’re going and say good luck; God and the doctor can take care of the rest.”

Fair enough. But I have a homework assignment for you.

Find that guy at work. You know the one. His nickname is “Doc” or “Papa.” He’s been doing this for twenty-plus years, since the days when ambulances were dinosaur-drawn wooden wagons. Ask about the other old-timers, the endless sea of faces he’s worked with over the years.

He’ll have good stories. Tons of them. Partners and coworkers and crazy SOBs. Hijinks were had, shenanigans performed, laughs all around.

But then ask what happened to those guys.

Because a lot of the time, they’re not running around on the ambulance anymore. Ol’ Doc is the exception. They’re not semi-retired, spending their afternoons fly-fishing and golfing. They didn’t jump careers to become bankers or meteorologists.

They’re dead. Or maybe in jail. Or shot robbing a 7-11 for $13. Or they were committed to a psych hospital so many times nobody knows what happened to him. Maybe they overdosed. Living on the street. Living who knows where.

And yes, some of them committed suicide.

Seems a little rich to judge your psych patients when, the way the odds go, you’re probably going to be the next one.

I suppose you could argue that EMS was different back then. Russ Reina talks about the time when most “ambulance drivers” were people who couldn’t find a job anywhere else, drifters and ex-cons. Not like now. Now we’re all as well-adjusted as Mr. Rogers. Right?

Yeah, sure.

Let’s be real. A lot of the people doing this job can’t stay employed even in our own dysfunctional field, and would never stand a chance anywhere else. Drug abuse and PTSD are common. And our social support networks often don’t extend past a partner or two.

Do we belong anywhere? Maybe you do in the police or fire service. But those of us who enter private EMS usually don’t last long before being sucked into a loop of working more and more overtime until we no longer have hobbies, no longer spend time with friends, no longer travel or expand our horizons. If we have spouses, significant others, or family, we neglect them. If we don’t have those relationships, we sure as hell don’t develop them from the driver’s seat of an ambulance. The last step — which doesn’t take more than a few years — is when we start to view every one of our patients as a nuisance. Burnout takes away the last string tying us to other people; if patients aren’t worth helping, aren’t hardly people at all, then the circle of humans in our life may become no larger than our uniform belt.

Are we a burden? In many cases, that shoe drops when we find ourselves off the clock. If our life has become the ambulance, what happens when we lose the ambulance? Your company goes belly-up. We piss off the wrong boss and get tossed out on our ass. Or, inevitably, we get injured. Suddenly, the only reason to get out of bed in the morning is gone. Sounds nice at first, but you realize quickly that having nothing to do actually means you’ve got no reason to be alive.

And are we afraid of dying? Who could be less afraid? We spend every day minimizing death, trivializing the human condition, ingraining a culture that teaches we should be able to order nachos after bandaging a burn victim. We drive fast; we laugh at seatbelts. Sometimes we snort cocaine and have sex in ambulances. (No, not you. But you know who.) There’s nothing beyond the pale for an EMT. Including pulling the trigger.

So is suicide a big deal? Yes. Should we try to understand it? Yes. Does it matter for us? Yes.

But more importantly: do we get to judge it? Do we get to pretend we’re above it? Are the kind of people who attempt it so bizarrely pathological that we’re nothing like them?

You can decide. But you only get to say that if you’re willing to say you don’t care about a disease that kills more healthy patients than anything else. Willing to write off hundreds of thousands of people every year.

And willing to say you don’t care that your partner could be next. Or your boss. Or yourself.

Check out The Code Green Campaign for mental health support for EMS. — ed. 1/17/15

Preparation vs. Improvisation

I have a new partner who called me obsessive once.

“Eh?” I asked.

“Everything has to be just so. When you come in you make sure the collars are organized and facing the same direction, you fold over the ends of the tape and stack it in a certain order, you make sure the handles on the bags are easy to grab…”

“I’m not obsessive… have you seen my car?”

“Well, you are here.”

And it’s true. When I show up in the morning, I do my damnedest to ensure that all of our equipment is as stocked, ready, and prepared as possible. I’m the guy who checks the integrity of the air-filled gaskets on the BVM masks, and considers two spare O2 tanks one and one none. If my blood pressure cuffs aren’t labeled, I label them, and I ensure my map book is turned to the correct page.

And all of that may sound funny, because everybody knows that one of the hallmarks of EMS is improvisation, the ability to adapt to unusual situations and “make do.” If you’re juking around at a chaotic scene and discover that you haven’t got any splints, or your stretcher strap is broken, or your patient is dangling over the side of a balcony and needs to be boarded, you see what you have and use your noodle and make it work. Not long ago I saw somebody apply pressure to a laceration on top of a patient’s head by tying a bandage to both stretcher rails and rubber-banding it over their skull like a bow-and-arrow. Why not?

We find a way. So why am I so anal about being prepared while we’re still standing on solid ground?

The fact is, in this job, things are going to go wrong. They just are. And you’re going to handle them the best you can. But if too many things go wrong, the situation may reach a breaking point — your capacity to “adapt and overcome” is not infinite.

Have you ever read a book or watched a show about a major disaster? Plane crashes, reactor meltdowns, bridge collapses. What they have in common is that numerous intelligent people usually foresaw the possibility of such an event, and so they designed systems and safeguards to prevent it from happening. When disaster happens nonetheless, it isn’t because one thing went wrong. It’s because five, six, twelve things went wrong. The backups to the backups to the backups failed. More problems occurred simultaneously than anybody expected..

In this job, too, the only time when feces hit fans is when problems accumulate. It’s not that the patient was sicker than you expected. Or that the stairs were rickety and covered in snow. Those are a nuisance. It goes from whoopsie to trainwreck when you didn’t bring your stairchair and your suction. Then when you go back, the chair falls open while you’re walking, and as you try to fold it you trip over your untied laces, and when you finally get inside you realize the suction canister is missing a cap and won’t hold pressure. And then once you get the patient extricated they’re already unconscious, but you can’t find any Yankauer tips in the truck, and by the time you do they’ve stopped breathing…

See? With this job, even at the best of times, the line between well-in-hand and circling-the-drain can be pretty slim, and once you’re on that slope it’s hard to recover. The only way to stay safely in control is to create a buffer, and that means doing everything you can to prepare yourself when you have the chance, because you won’t always have a chance. If you don’t bother dotting your I’s and crossing your T’s before you enter the mix, then when things inevitably go wrong, the sum of those unhingings may be too much to handle.

Consider your emergency responses. It’s a safe bet that you’re going to drive past the address, or turn the wrong way, or get caught behind the world’s slowest schoolbus. Something is going to cause problems, whether it’s your dyslexic partner who confuses Gable Street with Bagel Street, or you forgetting the apartment number three times in a row. But that’s just a small delay. It won’t be a real problem unless you also stopped to pee before leaving the base, or forgot where your boots were, or had to spend five minutes backing out of where you parked. In that case, you already burned through your margin for error, and now when the unexpected (but inevitable) comes along, you’ve got no slack left.

In short, you can be the best in the world at rolling with the punches, and in this job, you ought to be. But that doesn’t mean you shouldn’t also try to be prepared to the point of obsessiveness. One lays a foundation for the other, and when you habitually have both to work with, you can handle whatever comes your way; if you’ve only got one, you’ll be lucky to get through your shift.

The 10 Easiest Ways to Violate HIPAA

Leave paperwork face-up on the dashboard or front seat.
Leave your computer unsecured wherever the hell you please.
Tweet a picture of the badass MVA you just did, with a victim obviously identifiable to anybody who reads the news (“A car struck a tree on Route 421 today, driver Jim Smith was rushed to the hospital…”).
Tell everybody about the celebrity you just transported.
Tell everybody about the coworker you just transported.
Crack jokes and make comments about the patient you just dropped off while in the elevator, or in the public ambulance bay outside — usually while the patient’s family is eavesdropping.
Post a Facebook status about the crazy shooting you ran, sharing intimate details about the patient who was probably the only person shot in your town that day.
Leave paperwork in the truck at end-of-shift.
Let a facesheet (demographics page) escape into the wind as you fruitlessly chase it down the street.
Answering curious questions about the patient’s status or destination from the random person on scene, I’m not sure who that is, probably just the nosy guy who lives downstairs.

Clinical Judgment: How to Do Less

It was around 11:00 AM when we were called to a local skilled nursing facility for a hip fracture. The patient was a 61-year-old male with mild mental retardation and several other issues, who’d fallen last night while walking to the bathroom. He was helped back to bed with moderate hip pain, and the staff physician stopped by to check him out. A portable X-ray was performed, which the physician interpreted as showing a proximal femur fracture as well as an associated pelvic fracture. This was communicated to us via a scrawled note and a cursory report.

The patient was found resting comfortably in bed, semi-Fowler’s and alert. He had no complaints at rest, although his pelvis and left femoral region were mildly tender and quite painful upon movement. No deformity was notable and there was no obvious instability. His vitals were stable and he was generally well-appearing, in no apparent distress. He denied bumping his head and had no pain or tenderness in the head or neck.

We gently insinuated a scoop stretcher underneath him, filled the nearby voids with towels and other linen, and bundled him into a snug, easily-movable package. Then we gave him the slow ride to his requested emergency department, a teaching hospital in town just a few minutes away.

We rolled into the ED and were lifting him into bed on the scoop when a young man entered the room, bescrubbed and serious-looking. I gave a brief report. As the words “pelvic fracture” left my lips, his mental alarms started visibly beeping and flashing, and he hurriedly asked, “What kind of pelvic fracture?”

“We don’t know. All we’ve got is the radiology note, which doesn’t say much.”

“Okay, but pelvic fractures can be a big deal. It could be … ” he sucked in air, “… open-book. There could be a lot of bleeding.”

I stared at him. “Well, sure. But he’s been stable since last night, and has a basically normal physical with no complaints at rest. He’s not exactly circling the drain.”

He didn’t seem to hear me as he briskly approached the patient and began poking him and asking questions. While we pulled our stretcher out of the room, he asked, “Does your neck hurt at all?”

Now that the patient had been stuck on a scoop stretcher for over twenty minutes, he thought for a moment and then shrugged. “Sure.” The doctor immediately ordered the placement of a cervical collar.

As we escaped, he was on the phone to the SNF, and the last thing I heard was him berating them with his urgent need to know exactly what type of pelvic calamity the patient had suffered.

What was the failure here? It was a failure of clinical judgment.

Clinical judgment is a phrase which means different things to different people, and often its meaning is so nebulous (much like “patient advocacy“) that it sounds good while saying nothing. But most would agree that it means something like this: the ability to combine textbook knowledge and personal experience, applying them intelligently to the current patient’s situation to yield an accurate sense of the possible diagnoses and the costs vs. benefits of possible treatments. In other words, it means knowing what the patient’s probably got and what to do about it, which is the heart of medicine anyway. So what’s all the fuss about?

In reality, when clinical judgment is mentioned, what’s often meant is something specific: the wisdom to know when something’s not wrong. Much of medicine is about planning for the worst, ruling out the badness, and looking for the unlikely-but-possible occult killer that nobody wants to miss. As a result, we often act as if nearly everybody is seriously ill, even when they probably aren’t.

On a practical level, most complaints — from chest pain to the itchy toe — could conceivably represent a disaster. Anything’s possible. So if we want to truly adopt perfectly mindless caution, we should be intubating every patient and admitting them directly to the ICU so that we’re ready when their skin melts off and their eyes turn backwards.

But we can’t do that, and we shouldn’t. So how do we know when to do a little less? Clinical judgment.

Clinical judgment is the acumen to assess a patient and say, “I think we’re okay here. Let’s hold off on that.” It’s what you develop when you have both the knowledge and experience to understand that a person is low-risk, and that certain tests or treatments are more likely to harm than to hurt them. That doesn’t mean that nothing will be done, or that more definitive rule-out tests will not occur, but it means you’re not freaking out in the meanwhile. It’s a triage thing.

Put another way, imagine the patient who you’re placing in spinal immobilization, or providing with supplemental oxygen, or to whom you’re securing a splint. They ask, “Look, I don’t much like this; do I really need it?” Well, I don’t know, rockstar — does he? If you’re simply acting on algorithms, reflexively doing x because you found y, then you really don’t know. How important is that oxygen? To answer that, you’d need to truly understand the benefits versus the potential harms, which means having a strong grasp of the mechanism of action, familiarity with the relevant literature (including the pertinent odds ratios, NNT and so forth), prior experience with similar patients, et cetera… only with that kind of knowledge do you really understand what’s happening. In essence, the patient is asking for the informed element of informed consent, something he’s entitled to, and you can’t provide it if you don’t have it yourself.

But when you do develop that depth and breadth of knowledge, you gain a special ability. It’s the ability to do less. When you truly understand what you’re dealing with, and more importantly, what you’re not dealing with, you can titrate medicine to what’s actually needed and stop there. Along with the knowledge comes the confidence, because you don’t merely know, you know that you know; in other words, you don’t need to take precautionary steps merely because you’re worried there might be considerations you don’t understand.

When it comes to withholding anything, even the kitchen sink, you might ask, “isn’t there risk here?” And strictly speaking, there is risk. But you can set that bar wherever you want. The important thing to grasp is that “doing everything for everyone” is not the “safe” approach; overtriage and overtreatment are not benign. All those things you’re doing have a cost. They may cause real harm. Even at best, they cost time and money, and subject the patient to unnecessary discomfort and inconvenience. We’d like to minimize all that whenever possible.

So, we return to the gentleman with the pelvic fracture. Strictly speaking, fracture of the pelvis has the potential to be life-threatening; certain types of unstable fracture can cause massive bleeding, along with damage to nervous, urinary, and other structures. So a textbook response to “pelvic fracture?” might be to treat it as a high-risk trauma.

But a patient with an unstable, severely hemorrhaging open-book pelvic fracture probably wouldn’t look like that. It would be evident; it would cause a number of apparent effects, such as pain and distress, shock signs, altered vitals, deformity or palpable instability. Except in bizarre cases or in patients who are clinically difficult to evaluate, big problems create big changes. While it’s true that we don’t know exactly what the X-ray showed, so one could theoretically argue for any conceivable pathology, there’s no question that the patient appeared stable, had remained unchanged for many hours, and had apparently been judged low-acuity after evaluation and imaging by his own doctor. In other words, let’s take it easy.

The question of spinal immobilization is another example. Strictly speaking, could we rule out the possibility of a cervical spine fracture? Well, no. Not without CT and MRI and even then who knows. But the fall was many hours ago, the patient was freely mobile and turning his head throughout that period, had no peripheral neurological deficits, denied striking his head or loss of consciousness, and quite frankly, had no pain until he spent twenty minutes with his head against a metal board.

It’s not often that you find a doctor more concerned about C-spine than an EMT. How did it happen here?

Despite the fact that we delivered the patient to a major tertiary center, it was nevertheless a teaching hospital, and the new interns had just hit the wards. While this particular clinician was undoubtedly smart and well-educated, at this stage he had about two weeks of experience behind him, and that is not conducive to providing judicious (rather than applied-by-spatula) care. He had neither the experience to know when to take it easy, nor the confidence in that experience to stand by such a decision.

We don’t want to take this concept to its extreme, which would involve doing very little for most of our patients. In the end, this is still emergency medicine, and emergency care will always involve screening for the deadly needle in the benign haystack. There’s also danger in simply becoming lazy and burned-out, and using Procrustean application of cynical “street smarts” to justify never bothering with anything. The real goal is to do the right things for the right reasons, no more, no less. And to get to that point, you have to put in some time.

Live from Prospect St: The Big Crunch (part 1)

It’s 4:00 PM on a gloomy Friday in Chandlerville, and you’re the technician for the A2, a dual-EMT, transporting BLS unit dedicated to the city. Chandlerville is a small town, but densely populated, and its numerous industrial districts are frequent sources of work. 911 dispatch is directly through the fire department, which also sends a BLS fire apparatus to assist on all medical calls; your company’s ALS is also available by request. You are equipped with finger-stick glucometry, glucose, aspirin, and epinephrine.

After a “man down” call that ended in a patient refusal, you’re now returning to quarters. Just as you’re beginning to back into the garage, a tone sounds.

“Engine 3 and Ambulance 2, respond to 2108 Coastal Rd, the Empire Shipping Company, for an MVA. That’s two-one-oh-eight Coastal Road, in front of Empire Shipping, for an MVA. Engine 3?”

“Engine 3 is responding.”

“Ambulance 2?”

As your partner flips on the lights and pulls out to the street, he speaks into the radio: “Ambulance 2 has 2108 Coastal Rd.”

“Time out 16:01.”

Coastal Road is a long connector that wraps around the edge of town, and you glance at the map book to confirm that the 2000 block will be near the very end, about as far away as you can get in Chandlerville. Engine 3 is stationed in that district, however, so they arrive within minutes.

“Engine 3 to Firecom.”

“Firecom answering.”

“We’re off at 2108 Coastal Road. Two-car MVA, car versus truck. Multiple injured parties and entrapment. Start an ALS unit and a ladder for extrication.”

“Engine 3, you have a car versus truck, multiple injuries with entrapment. Break. Ladder 3, respond to 2108 Coastal Rd for the MVA; Engine 3 is on scene and A2 is responding. Time out 16:04.”

A few seconds later, your company radio dispatches Paramedic 12 to the same address, after Chandlerville Firecom contacts them via landline. The P12 starts responding, but they’re coming from two towns away, with an ETA of 10+ minutes. The field supervisor also starts rolling from an unknown location to assist. 30 seconds later, Engine 3 updates that they have an injured adult and several children.

Now very awake, you reflect that the nearest hospital will be Chandlerville Memorial, a 3–5 minute emergent transport (10 minutes otherwise). The nearest large tertiary center, Bullitt Medical Center — a Level I adult trauma center and a designated pediatric ED — is 15 minutes emergently (25 otherwise). The nearest Level I pediatric trauma center, however, is the Children’s Hospital, which is also 15 minutes but in the opposite direction; they do not receive adult patients.

Ladder 3 arrives on scene momentarily, and you pull up a few minutes later. As you park and call yourself out, you observe a Ford sedan with its front left corner smashed in, two feet of its fender and frame crumpled. This is evidently the result of driving almost headlong into the side of an 18-wheeler. It appears that the driver swerved right to avoid the truck, undercutting its rear wheels and “submarining” itself; the damage reaches the passenger compartment, but there does not appear to be significant intrusion. The truck itself seems minimally damaged.

As you jump out, a firefighter waves you down. “We’ve got three!” he announces. “Mom’s in the driver’s seat; she seems really loopy, probably drunk. Her door is just dented, we popped it open. But her kids are over there.”

Twenty feet away, you see two young girls, around 4 years old, each in the arms of a firefighter. They are crying loudly and clearly upset, with no visible injuries. The mother is hidden from sight in the sedan. The driver of the truck is nowhere to be seen.

What are your initial steps for addressing this scene?

Who appears to be the first priority for care?

What resources will you need? Which, if any, should you cancel?

Continued in part 2 and the conclusion

Product Review: Shoes for Crews Maverick

About a month ago I was solicited over email by a marketing agent working on behalf of Shoes for Crews, a designer and vendor of its own line of work shoes and boots. They offered me a free pair of their boots — my choice — in exchange for a review on this site.

I was, at the time, extremely reluctant and uncertain about this. I have very little to offer as a blogger and “authority,” and the small service I do provide is largely predicated upon my credibility; in other words, I may not know much, but I try to be as honest, impartial, and accurate with the small amount of information that I do provide. Taking free swag in exchange for kind words seems like a slippery slope at best. It’s more important to me to be able to, in the future, recommend a specific product because it’s worked well for me — without anybody wondering if I’m getting a kick-back for it — than to benefit from occasional free goodies.

I eventually agreed under the clear and explicit terms that I would write exactly what I thought, with no prevarication or white-washing. If I liked the boots, I’d say that; if I had reservations, I’d share them; and if I thought they had no role in EMS, then I’d say that too, and in that case their marketing effort would be counter-productive. They agreed to this, which I suppose was a calculated gamble.

So here’s the review. I doubt that this company will be sending me more boots, whether or not they appreciate this post, but in the future the same type of situation may arise, so I’m very eager to hear any opinions — positive or negative — on this practice. Does it leave a bad taste in your mouth, and make you less inclined to run your eye over our next volume on drug interactions or pulsus paradoxus? Or do you find this sort of thing useful?

The Company

Shoes for Crews is not a new company, although they’re new to me; they’ve been around for several decades now. Their claim to fame seems to be their slip-resistant soles, which use a patented tread-pattern and material to allow high traction in dangerous environments like wet floors or oil splatters. Their line runs from slip-ons to high-top firefighting boots, and the general theme is similar to Red Wings — basically footwear for working folks who are on their feet all day and need both comfort and protection.

Lately they seem to have been making a marketing blitz, possibly due to enlisting the help of the service that contacted me, and I’ve been seeing their ads everywhere. I even received a memo from HR at my job offering a company discount for their products. The social media angle has been aggressive (via Facebook, Twitter, and obviously blogs like this), and on some level I have to admire it. After all, it’s clearly working.

In my experience, boots for EMS fall into about three ranges. There’s the low-end range, ballpark of $40 or so, which is mainly low-cut shoes you find at Walmart or other generic retailers, intended for waiters and entry-level jobs. They can look good and seem somewhat serviceable for brief periods, but invariably they fall apart, sometimes catastrophically, after a few months. After that, there’s the mid-range, around $100, where the bulk of workhorse EMS and police boots fall — Bates, 5.11, Rocky, etc. These are good boots that wear well and last, perhaps, from 1–4 years depending on care and your tolerance for their final appearance. (All of my own boots have been this type.) Finally, there’s the high-end lines — Haix, Danner, and others — usually in the $200 range. These should last approximately forever, are built from high-end materials with scrupulous manufacturing, and ideally add an extra level of comfort.

Shoes for Crews seems to sit on the low end of the mid-range category. Many of their boots are in the $70–$80 territory, which is a pretty affordable boot if you’ll wear it for a solid few years.

The Boots

As I flipped through their collection, my first impression was that there weren’t too many styles that seemed suited for EMS. Typically our uniforms require black footwear that will take a polish, and I like a side-zip for easy ins and outs.

The models that seemed most appropriate included the Ranger; the Yukon; the Expedition; the Empire; and the Legionnaire. (None, sadly, included a zipper. Maybe next year.) Eventually, I settled on the Maverick, a recent release.

Here they are new out of the box:

First impression: well-built, good looking all-leather boots. They are relatively low-cut, but they are clearly boots and not shoes; here’s a comparison next to my 5.11 ATACs.

They do have a white-threaded stitching, adding a bit of accent against the black; however, it is barely noticeable and I doubt would run afoul of anybody’s uniform policies. After a few polishes it will probably fade completely.

The lacing system is a typical hiking-boot style, with hooks instead of D-rings for the top two pairs. This is supposed to make it easier to get your foot in and out, but to me it just adds to the lacing process and makes donning and removing them a bit of a chore. I also noticed a couple of the hooks get bent outward during regular use; they bent back easily, but it may be a common issue. Although I didn’t try it, I wonder if you could use a pair of pliers to fold them tightly in around the lace, converting them into semi-permanent lace-retaining tubes instead of open hooks.

Here’s the slip-resistant soles after some wear:

Slip resistance, although undoubtedly positive, is not exactly something I lay awake at night worrying about. However, I admit that these soles felt good, with solid traction on all surfaces including soapy washfloors and the occasional grease patch. They seemed to do well on loose soil as well, although I didn’t do much off-roading in them. They are also, for any aspiring ninjas, very quiet.

The uppers are all leather, without any nylon or mixed surfaces. Although it takes longer to polish, I prefer this look to a two-tone or “patchy” style; one does wonder how well it breathes in the heat, but I had little trouble on some reasonably hot days. They felt decent in the cold as well (it’s been a rollercoaster month), so for moderately extreme temperature ranges I’d give them a thumbs up.

The product page makes the fairly strong claim of “waterproof.” Many boots say water resistant and some say waterproof, but within the low and middle price ranges this usually means some kind of external treatment or half-hearted membrane that lasts a year or two at the most. I saw no mention of a Gore-Tex or similar liner on mine, so that may be the case here as well. However, they do have a gusseted tongue, and on moderately rainy days, as well as a leisurely test session of soaking them in several inches of bathwater, I noticed not one drop of moisture penetration.

This is how they look after about a month of use (every shift at work plus many days off):

So they’re reasonably durable. The leather is actually somewhat soft, so I have some concern for how it’ll hold up in the long-term; you notice one small cut already on the left boot. I gave them one quick shine when I first received them, and that’s held up well. The particular style at the edges also seems to help prevent scuffing the toe. The included laces do seem pretty frail, already looking a little scruffly after a month, and I’ve read reviews that others have had similar experiences; laces are easily replaceable, of course.

These have a composite toe, which I found quite light compared to steel toes I’ve used in the past. Combined with the lower cut, they’re overall not heavy boots, although obviously heavier than a soft-toed variant. The good news is that the toe is very roomy and never felt confining, which is something I’ve always experienced with safety toes; the box is built quite high, which is actually noticeable from the outside, giving a bit of a square, blocky look.

How about comfort? These are actually quite comfortable boots. Partly it’s because of the low cut (which makes driving particularly easy), but mainly they just feel like boots designed for humans to wear, unlike many uniform boots which seem primarily intended as ornate buttcaps for bipedal robots. They are quite rigid, with a steel shank and more arch support than I’ve ever had in a boot, and the feel of the heel and overall “stance” against the ground is very stable and comfortable. I feel better lifting in these than in my current boots, extremely stable while stair-chairing, and I could almost certainly wear these to the gym to squat, press, and deadlift without any difficulty. The collar is heavily padded, and although it took a few days before it stopped feeling noticeably stiff against my ankle (the only real break-in), after that it’s been perfect. The insoles are replaceable, too, if you have your own orthotics.

My two biggest gripes, in the end, are these:

The low cut. Every pair of uniform paints I’ve ever received has been (at least after a wash) laughably short, barely reaching my instep while standing and “flooding” embarrassingly whenever I bend my leg. As a result, wearing a low-rise boot like this makes the gap extremely noticeable; my pants almost don’t reach my boots even while standing. With properly-fitted pants, it wouldn’t be as bad, but I still feel that a medium-rise boot is a more professional look.
No zipper. I tried to adjust to this, but particularly on overnight shifts, it’s a deal-breaker; having to lace and tie these every time I pull them on, and reverse the process to get them off (even just to rest my feet for a bit) is like switching from a cotton T-shirt to a corset. It’s enough to make me wonder if I could buy a center-zip panel like Haix makes and lace it into the front, but I doubt it would fit.

Final Thoughts

So with all of that said and done, what are my take-away impressions of these boots?

They are generally well-thought-out work boots, very appropriate for their primary market (for instance, warehouse personnel, contractors, or repairmen), and with an overall pretty good quality. They are obviously not specifically aimed at the EMS/fire/police market, but there are not too many gaps (targeted “EMS boots” are usually bizarrely overbuilt, anyway), and the main difference seems to be one of feel. My quibbles with them are enough that they won’t be replacing my existing boots, but I will wear them occasionally, and in fact they make decent-looking off-duty shoes (my girlfriend approves). Moreover, I know many field staff who don’t mind, or even prefer, low-cut and zipperless uniform boots, and for them I do recommend the product. The value is good, and if you can find some sort of discount (and they seem to be falling from trees), all the better.

I’d love to hear from anybody else who’s tried these, or better yet, one of the other Shoes for Crews models; I’d suspect that many of them are pretty similar in the overall feel, but there may be some important distinctions.

Best of all, SfC has provided me with a coupon code for one more free pair of any of their products to give away to one of you lucky folks. EMS Basics isn’t exactly The Price Is Right, and we don’t do a lot of contests, but here’s what I’d like to do: if you’re interested in a free pair of boots, post to the comments below describing:

What boots you currently wear, and what you like/dislike about them
What features are important to you in a pair of uniform boots

I’ll pick a random winner from those who respond.

Tiny Monsters

Hand hygiene.

Wait, come back!

It’s not very exciting, which is one reason we don’t seem very impressed by it in EMS. Also, I have a theory that most prehospital providers (probably most people in general, with the possible exception of those who have taken a microbiology course and seen gross things) don’t really, on a visceral level, believe in germs.

Whatever the reason, we really drop the ball on this one. Walk into your nearest Mega-Lifegiving Medical Center, where the best and brightest are using the latest and greatest methods to save lives every day, and look at the hand sanitizer mounted to every wall. Look at the giant signs reminding everyone to clean their hands, cover their nose with their elbow, and lock themselves into an airtight bubble if they think they’ve got the flu. Watch nurses exit patient rooms wearing full-body gowns, eyeshields, respirators, and gloves. Then watch the ambulance crew wander in wearing week-old uniforms, touch everything, scoop up the patient like a sack of potatoes, heave him onto a suspiciously gray and drippy stretcher, and do just about everything but lick the doorknobs.

Admittedly, one difference between us is that the hospital makes its money in part based on metrics that include the number of nosocomial (healthcare-acquired) infections it sees. But maybe that’s a good thing. If our billing started depending on how many patients we infected, suddenly we might start believing in germs. Just a prediction.

Why should we care about universal precautions? For one thing, to stay alive. Not long ago I transferred a nurse between facilities. She was being admitted to a medical floor for a massive MRSA-colonized abscess on her cheek; it had been surgically incised and drained, and she was now beginning a course of antibiotics and further care. The cause? She’d idly scratched her face one day at work.

For some reason, I find this argument unconvincing to many of us EMTs and medics. I suspect that, as usual, we consider ourselves immortal. Whatever the case, if you find it compelling, go with it, but otherwise, try its mirror image: precautions keep your patients alive.

You may be a romping, stomping, deathless badass. You’re 18, you take your vitamins, and you’ve never been sick in your life. Staph tells stories about you to scare its children. But your patient is elderly, takes immuno-suppressant drugs, and has leukemia coming out of his ears. How’s his immune system? Do you want to find out?

He’s the reason that the hospitals have become so paranoid about cross-contamination — because this guy is right across the hall from a guy infected with Ultra-Virulent Pan-Resistant Skin Melting Brain Bleeding Disease, and it’s very, very easy for staff to touch one of them, then touch the other. Or touch the doorknob, which someone else touches, who then touches… etc. This is why hospitals are such dangerous places for sick people.

That’s why I’m not particularly paranoid about germs in my everyday life, but I try to bring a little paranoia to work with me. Because our patients may pass through many medical hands, but most of those hands are now climbing aboard the sanitation train. Yet the system is only as good as the weakest link, and especially when it comes to interfacility transfers, EMS may very well be that link. We wear the same uniform from patient to patient (if not from day to day), we don’t always replace linen or clean the stretcher, and equipment — never mind the ambulance itself — gets decontaminated far less often than after every call.

And perhaps, due to the nature of our work, some of this is necessary. We work in a more difficult and less controlled environment than the ICU, and maybe we can’t maintain exactly the same standards. (This argument is less convincing when it comes to non-emergent, routine transfer work, though — particularly when a patient’s infectious status is already known.) However, there are some things we can do that are easy, routine, and when introduced into our habits, create essentially no added work.

Number one is hand hygiene.

Whenever possible, I wash my hands after every call. It’s no burden. If I’ve delivered a patient to a hospital or other facility, I simply find the restroom (which I probably want anyway, because my bladder is the size of a grape) and wash. Many times a sink may even be available in the patient’s room.

The proliferation of waterless hand sanitizers, usually alcohol-based foams or gels, has given us an alternative to this. When there aren’t any sinks, it’s the only way. But I don’t like ’em. They leave a residue that’s palpable, and which smells — and if you’re planning on eating anything, tastes — foul. They are also, in many cases, literally less effective. Although alcohol and similar agents kill most microorganisms, they don’t kill all of them (Clostridium difficile and the norovirus being notable exceptions), and like all contact sanitizers, they disinfect but do not clean. Any gross dirt, grease, or other contaminants on your hands (and this includes particles that are “macro”-sized but still too small to see) can cover or encase microbes, preventing antiseptics from reaching them. Unlike contact sanitizers, washing with soap and water is an essentially mechanical process: you are physically rinsing contaminants away from your skin and down the drain. (All that the soap does is “lubricate” hydrophobic particles to make them easier to rinse off.) Some soaps now are “antibacterial,” meaning they contain a germ-killing substance as well, but it’s not clear that these do any better of a job for routine purposes, and they may contribute to drug resistant strains. (They do, however, leave a microstatic coating on your hands afterwards, which helps to keep things clean a little longer.) Either way, most soap in healthcare facilities does contain an antimicrobial agent. In any case, I use the waterless sanitizers only when soap and water aren’t available.

Proper handwashing isn’t hard, but since it requires mechanically washing each portion of skin, it helps to have a system or you can easily miss spots. If you’re scrubbing in for surgery or a similar sterile procedure, you’ll need a much more stringent method than I use — but you’re not going to practice that ten times a day. So I use an approach that hits essentially the whole hand with as few steps as possible. Once you have the basic pieces in place, you can then do it fast for a routine wash, or spend much longer on each surface if you know that your hands are funky.

Here’s how I like to wash. It may seem elaborate or awkward at first, but with a little practice it’ll become second nature.

The same method can be used with waterless sanitizer. In the past, frequent washing tended to dry out your skin and lead to cracks (great windows for infection), but nowadays most soap in the hospitals contains moisturizer to prevent this.

A few points to remember:

Washing is a mechanical process! Mere contact with soap doesn’t clean anything. If you didn’t rub an area of skin at least briefly, you didn’t clean it.
Use warm water. Cold is a less effective solvent, and hot abuses your hands.
If you’re also using the bathroom, consider washing before and after to avoid contaminating your… important areas.
Drying with a towel is part of washing: it helps physically clean the hands, and wet hands are microbe-magnets.
Although I don’t religiously practice the turn-off-the-water-with-the-towel technique, if you know that your hands were grossly contaminated, it’s a good idea; remember that whatever was on your hands before you washed is probably now on the knob.
In an ideal world, we probably wouldn’t wear watches. In the real world, just try to be aware that it’s a great shelter for contaminants, and find a way to clean it (watch and band) regularly.

Tag: self-protection