One Step Forward, Two Steps Back – Focus People

Another great episode of EMS Office Hours accompanied my workout today, and of course it stimulated some thoughts.  Here are some of them:

First, more isn’t always better.  I know some people who love the AutoPulse, but they have no idea how many patients walk out of the hospital after having it put on.

Josh mentioned the disconnect between EMS managers and street-level providers.  It seems like we promote people who don’t want to take care of patients anymore and/or are hungry for power.  That’s a bad combination.  In the ED’s I see the big shot doctors and nurses, who have their own offices and are quoted on the news, occasionally perform the roles of regular staff members.  They seem to enjoy treating patients, so I don’t know where our disconnect is.

Finally, much of the discussion was based on the different treatment available in different communities.  In 2008, the Eagles published a paper outlining some performance benchmarks. Some of the highlights include:

If a pulmonary edema patient does not get CPAP and NTG, their EMS system failed.

If a NRB and BVM are all that’s available for a patient with bronchospasm, their system failed.

If a STEMI patient does not get a 12-lead ECG, ASA, and direct transport to a PCI center, even if they did not tell the dispatcher they were having chest pain, their system failed.

If a patient seizes all the way to the hospital without getting a benzo, their EMS system failed.

This does not cover everything, and the Eagles acknowledge that, but it’s a start.  Now is the time for us to educate the public about what is available from their EMS system, to demand that systems measure how often that treatment is delivered – and not delivered- when it should be, and to publish the differences between systems.  Knowing what to measure, and being transparent about it, is the key to fixing this mess we’re in.

Another fine job guys, well worth the listen here.



  1. Jim Hoffman says:

    Thanks Bob, good points and thanks for that link.

  2. Skip Kirkwood says:

    I think you overlooked a substantial group of people who seek to advance in EMS, Bob. In fact, i think you overlooked several. The one that I want to talk about are guys (and gals) who love EMS, who are committed to quality patient care, who believe that they can make things better from one or more rungs on higher up on the ladder.

    Once they get a step or two up, though, they find out that their organization, like so many EMS organizations, is too small to do anything but survive. They see that there are just enough people to keep the organization functioning in a survival mode, and that their organization is filled with people who either don’t want to be there, or who say that they don’t want to be there, or who act like they don’t want to be there. And there isn’t money to do anything “outside the box,” or to stand on principle and perhaps put some contract at risk.

    As far as the disconnect of which you speak, I’ll address that one, too. That ED physician or nurse director has a full staff, and is usually in an organization that is well above the survival mode. So he (or she) doesn’t move from crisis to crisis from 0700 – 1900, wishing for a short break so that he could go out and return to what he really enjoys doing…..which is conveniently right outside the office door.

    The EMS supervisor – manager – director has to leave the office, wait for a call to happen, and then actually “get there” – or commit himself to a full shift (maybe 12, maybe 24) away from the office, unable to be called away, with the aforementioned crises piling up. The calls happen in semi-random locations, and at semi-random times (they’re not usually stacked up waiting in a convenient centralized location like ED patients).

    As president of NEMSMA, I get to talk with a lot of “promoted” medics, ranging from first-line supervisors to CEOs. None of them I talk with sought advancement because they didn’t like taking care of patients or because they sought power (except perhaps the power to help make EMS better). Theirs is a frustrated lot, and many wish for the breathing room to actually go run some calls and forget about budgets, politics, and employee unhappiness for a while. I have a good friend who was “car 2” in a pretty good-sized EMS system. Frustrated with al of the above, he voluntarily went back “on shift” and, since he was used to working long hours anyway, now makes far more as a senior field person (and once again eligible for overtime) than he did in his management position. And he has fun taking care of patients, and being responsible only for himself and his partner.

    The performance measures you describe are good ones – and there are more on the way!

  3. emspatientperspective says:

    Thanks for your comment, Skip. As usual, you provide great insight.

    My comment about supervisors was not meant to be a generalization. On the podcast Josh mentioned something about supervisors that reminded me of some of my experiences. There’s a group of supervisors I’ve worked under at past employers who display a consistent set of behaviors that I wrote about. As field providers, they complained about going on calls that don’t meet there definition of an emergency, which includes elderly cardiac arrest patients, going to nursing homes, or being called for drunk patients.

    They openly admit that they want to be promoted to avoid going on calls, and then manage people who enjoy going on them. When supervision isn’t all it was cracked up to be, they start complaining to their subordinates about how miserable they are. One frequently described it as being the “meat in the shit sandwich,” as they complain about their supervisors and other subordinates.

    This seems to be a common complaint, and Thom Dick has frequently written about it. You won’t find these supervisors involved with NEMSMA, or doing much of the work they’re supposed to do.
    To be fair, they never had any formal supervisor training. I also do not see the promoted doctors and nurses who no longer want to care for patients. The attitudes just seem to be different.

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