Saturday, December 29

The hour is late

Recently a close friend asked why we even try.  Why do we try so hard to achieve all the goals we have been chasing?  Who cares?  Isn't there someone else who can fill in what we're doing better?


No there isn't.

If there was something better that could be done, we'd be doing it.

This forum used to be updated every few days, some days even multiple times a day.  My duties have consumed my time, heart and vision.  Previous posts about not being able to change the system have turned into meetings that are changing the system.  For every crazy story I try to tell, I read an actual chart that mirrors my edited version and the tale can't be told.

We're on the verge of some major opportunities in my system and that seems to be monopolizing my time.

Go figure.

13 months ago my priorities changed and this therapy experiment has suffered.  It was created for one purpose and one purpose only and that was to serve as a pressure release valve.

Boy did it ever.

But the pressure might be too high this time around.  The troubles aren't with those in charge of the system, or the system itself, but within myself.  My dreams of an EMS 2.0 world were destroyed by regulators, bureaucrats and the realities of a for profit system only to be rebuilt by a single EMT doing the right thing despite our policies to the contrary.  Our late night discussions in Baltimore, Vegas, Houston and other places all build into a mural of a future for our Profession only to be sidelined by technical issues and personnel conflicts.

We were dreamers.  We looked at a future that was built around quality patient care, not realizing the first question would be "how are you going to pay for all that?"

I checked...the Police Department has yet to post a profit.

It isn't an uphill battle we in EMS are fighting, it's an all out war.  There are those who wish to take over, give up, concede, demand even take a seat on the fence and wait to see who wins to declare their allegiances.  We can get frustrated, rant, moan and complain or we can give 100% to the one thing that matters:


The patient.


My posts may slow, my twitter may stagnate, but only because I have a chance to make a difference for more patients and I'm taking it.

Join me?


Thursday, December 20

I got mental health counseling, I wasn't crazy

Three is a stigma in America that if you seek out someone to talk to about your mental health you are crazy, not normal, weird, not to be trusted, ill.

That can't be any farther from the truth.

Case in point: Me.


Years ago I thought I had something wrong with me.  I've spoken briefly about my OCD issues in this forum and kept it light hearted.  In the wake of recent events I feet it necessary to mention that seeking out psychotherapy isn't a bad thing.  It's actually a sign that someone is willing to deal with what they think are their demons.

Think keeping your feelings inside is manly?  "Suck it up pussy!" Yeah, good luck with that.  The absolute worst thing you can do is shut down and ignore your mind's reaction to events.

Even worse, I learned, is when your mind draws a correlation you're not aware of and to deal with it suddenly must adjust other elements of your life.

That is the basis of Obsessive Compulsive Disorder.  It's funny to see it depicted in movies as a desire to triple check that a light is off or the washing of hands for seemingly no reason, but the subtlety of the illness can almost literally drive you mad.

Have you ever seen a picture on a wall that is not level?  Have you ever wanted to fix it?  Not in your house, but someone else's house?  Or an office? Or even on TV?  Seems silly, right?  Now imagine you not only want to fix HAVE TO.  It has to be fixed and if you can't fix it it sticks in your mind for days or weeks.

Have you noticed the rings of water left behind by your water glass at a restaurant?  I sure did.  So much so that I had to place my glass back directly on top of the same ring every time.  HAD TO.  I didn't want to, but if I didn't I had to fix it and if someone else wasn't doing it I noticed and it bothered me.

Once at a restaurant my OCD noticed that the little sugar packet holder was not in the center of the table.  I subtly (or so I thought) adjusted it and a friend put it back with a smile on his face.  Then I put it back and he moved it off center again.  I was immediately angry.  For nothing at all, and yet because it HAD to be in the center of the table, just HAD to.

The worst part was that I had no idea WHY I felt this way and it led to frustration, stress, even to anger some days.

I finally reached out for help.  I was lucky that my union bargains to ensure I have access to mental health care.

I didn't know what to expect. Doctor's in white coats with orderlies in high collared white jackets who run through the halls but suddenly walk calmly when they find me?  Am I going to be medicated?  What can they possibly do to fix me?


Turns out all we did was talk.


I met with a psychotherapist once a week and all we did for an hour was talk.  She had hot water and I was encouraged to bring tea to sip. Her office was comfortable with table lamps, couches and chairs and I could sit, lay down, stand, whatever I liked.  We talked about anything and everything from favorite TV shows, music, family, life, and only on a few occasions did we discuss my need to rearrange the magazines in the hallway outside her office.  Although I suspect she misarranged them just prior to my arrival to gauge my progress.

Over weeks we finally reached an odd correlation between an event in my past and the onset of my symptoms.  My mind had been worrying about something so fiercely that it was doing it's best to alter my surroundings to deal with it.

Literally the day after that realization I began to notice all the little things I used to do.  What seemed perfectly normal suddenly felt forced, unnatural.  The way I always HAD to roll up used sugar packets and place them into the half opened creamer packet now seemed like someone else made me do it.


My reason for sharing is that psychotherapy, therapy, talking about things, feelings etc is not a bad thing to do.  If you think something might be "off" and you have access to someone who knows what to talk about, please seek them out.  They understand what you are going through.  You are not the first, you will not be the last, but I guarantee that if you ignore it or think it is manageable on your own you could reach a point of no return where you will begin to damage your life and the lives of those around you.


While my experience was with a low level form of a disorder, there are those who suffer from far more complicated mental health issues.  They need attention and help far more than I did and ignoring their condition or if thinking that dumping them in with the "normal kids" will help you are sorely mistaken.  It can be done but should be done after evaluation by a mental health professional.


Call it TMI, call me crazy, call me a fool, but I got better.  I can walk right past a pile of magazines and not care that it's a mess.

But then again, should I be worried I still notice?  I say no.  My OCD is a valuable tool when company is coming over and we need the house cleaned up fast.  Point is I got therapy to deal with the compulsion, which is what was causing the disorder in my life.  But I'm still slightly obsessive.  I leave you with this observation:

"Obsessive behavior is when the toilet paper absolutely positively must come off the roll in only one direction and in your house you will change it before using it.  Compulsive is changing it at a friend's house."


If you or someone you love is struggling with something you think is out of their control, help them reach out to resources in their community.  They will not grow out of it, it isn't just a phase or a form of grieving, it's something that can benefit from an expert.


Thanks for letting me share.



Friday, December 14

20 Children

The most amazing thing about a blog is that you can take a full day's worth of frustration, anger and confusion and just let it out.  I wrote an angry diatribe that ended with just under 8000 words.  I blamed the left, the right, the shooter, the community, the family, myself and a host of other groups before I learned that it took getting all of that out to realize the truth:

Shit happens.

It's not discounting what happened or an insult to the community recovering from this act, but a realization that no gun, no government, no policy or plan from any politician, priest or partner could have prevented a man from believing that such a selfish, cowardly act could solve anything.

Some people needed intervention long ago.  Some people have access to devices that can kill large numbers in short times.  Sometimes they're the same person.

Some people will default to their core beliefs instead of dealing with what happened.

Few will learn from it.

Will you?

Write a letter about your feelings and destroy it.  It helps.

Hug your kids again, it's been a rough week.


Wednesday, December 12

Back in service

Put Medic 99 back on the board.


HMHQ was hit with a Tabnabbing attack.

In layman's terms, I got phished.

In terms grandma can understand I got tricked into giving out my login information.


Tabnabbing is a tricky, and scary, thing.  THIS link will take you to an article that explains it as well as giving you a safe example.

Too afraid to check the link?  OK.  it goes like this:

A site like mine with reasonably general security settings based on shareware code gets a bit of code added to it by a hacker.  The code simply waits until you open the page, then tab away.  When the information that another page has been opened goes past, the tabnabber switches my blog to look like a login screen for something like gmail or ebay.  You tab over thinking you had it open and got timed out.  So you log in.  As you do the code nabs your login info, keeps it and then immediately sends it along to the site you're trying to log in to.  As far as you know everything is fine.


The giveaway, thankfully, was when their code caused the tab for HMHQ to become a drug ad.  As soon as I realized they were logged in as me and locked me out I called Setla and down went HMHQ.


We wanted to make sure this install was clean and knew exactly what had happened before going back up, hence the delay.  Thanks for coming back.


Needless to say I now only keep tabs open that don't need a login ESPECIALLY email, bank and social media.  This also prompted me to revisit my stellar passwords.


Back to the action soon,


Friday, November 30

Station Tour + Fire Safety + Training = OCFA Doing it right

You new folks may or may not know why they call me the Happy Medic, but for this post you need a refresher on the Angry Captain.

The Angry Captain was a name given to my father, a retired Fire Captain, because of the way he handled logistics when the USAR team was deployed.  He was a stickler for receipts.  Long story.

But long before he was the Angry Captain, he worked at a firehouse in Orange County, CA.  He was assigned to this house during the years I decided to seek a career in the fire service.  I rode along on Engine 4 as an Explorer and the crew there became my second family as well.


When the Orange County Fire Authority posted this video to their Facebook page I was curious to see what other agencies are doing for inter-Department training using video.

It's a great tool for standardizing station tours as well as working in home fire safety tips and I recommend it for anyone who ever gets visitors.

OCFA Station Tour Video from Orange County Fire Authority on Vimeo.


So much has changed to that house I almost didn't recognize it, kind of like seeing someone living in your childhood home long after you moved out.

Does your agency have a standardized tour or does the junior member have to wing it?


Thursday, November 29


I am a big skeptic of putting the 2 people with the least ability to assess a situation in charge of the system's response to a reported emergency, but until we change things they can only code what they are told, right?  And the caller is never, ever, EVER, wrong.  Especially when describing technical rescue.



A caller is reporting he has fallen over 50 feet and is unable to walk.



I had to read it twice too.  First party caller has fallen 50 feet, unable to walk.  Should be unable to do most things after that fall, especially when he would have hit the ground at a decent pace, then suddenly stopped.  Stranger things have happened, right?

The dispatch rounds out, after us in the engine, the truck, medic, Battalion Chief and Captain, with the Rescue Squad.  Further questioning suggests the patient is trapped.  Never before have I wanted the TV version of EMS to be true so they could patch me directly through to the caller and figure this all out.


Arriving on scene my firefighter and driver are grabbing some hand tools and a long spine board when we all look around the address for a second, an old habit of sizing up burining buildings.  None of the surrounding structures, trees, even light poles are more than 20 feet off the ground.

Something doesn't smell right.

The balance of the assignment arrives as we head inside, ready to treat trauma.

We found drama.

A middle aged man is sitting on a chair still on the cell phone with the call taker, no apparent injuries.  He is inside a single story building and the folks standing around him seem confused as to why so many firemen have arrived.  The rest of the units are cancelled as we begin to learn the tale of the "long fall."

This gentleman tripped on the sidewalk and would like to know who he can complain to after we take him to the hospital.

"Why would you goto the hospital?" I asked, already knowing it was a mistake.

"For my injuries, of course.  I must be hurt if the ambulance took me in.  I'm on disability already and can't be expected to get around on my own all the time." Was his response as his cell phone rang.

The caller on the other end wants to speak to "whoever is in charge over there" and I LOVE these calls so as the EMT confirmed the appearance of non-injury I spoke to the patient's wife who also heard what our call taker heard.

"He says he fell 50 feet!  He needs to be taken to a hospital or something, he could die!"

"Sir?" I was embarased it took me this long to put 2 and 2 together, "Where did you trip on the sidewalk?"

"50 feet up the block!  I couldn't walk!  Go look at that crack!"

He kept giving the distance TO the fall, not OF the fall, hence all the confusion. GIGO.

After refusing to listen to our reassurances that an ambulance ride was not only unnecessary but would end up costing HIM money, he was taken to the local ED "to get checked out."

While loading up the gear the engine boss decided to go have a look at the crack in the sidewalk that could end up being a killer.  About 25 feet up the sidewalk we saw a slightly raised seam that someone could indeed trip over.

So we taped it off.

Tragedy averted.


Sunday, November 18

Move up or move over

In a recent post I mentioned my service is using CAD data to monitor just how busy the EMS Division is when addressing calls for service.  All of this is gearing up towards a State mandated increase in market share without (so far) an increase in staffing or units available to staff.


Knowing how busy you are is crucial in any business, that's how the supermarket knows how many checkers they should need at 5pm.  Yet you've never seen all 24 check stands open have you?  There is a buffer built into most operations, a surge capacity if you will, that anticipates a need for more than the usual compliment of people and supplies.


Trying to anticipate that surge is the job of our in house statistician.  Yes, we have one.  She determines the need, designs the staffing models and anticipates surge.  She's the one who says we need 19 ambulances on Friday night, not 18.  her models are all built on her understanding of how the system reacts to calls for service.


She and I have many conversations where I explain EMS systems and she explains stats and we slowly come down to realize we're using the same word to describe 2 different things.  The wife and I have this problem all the time.


We're both tearing through data looking to find where we can squeeze another 10% of the market share of responses out of an already taxed system.  We're looking at what we're calling the logistics gap, or when a rig is staffed but not available for a call because they are getting checked out or returning to base close to the end of shift.

We're also looking at their posting patterns or lack thereof) to determine if we really are sending the right unit to cover a post.  Maybe we could move someone else and save time, fuel and misery?

We're also looking at the way we use our non ambulance EMS resources, our engines and Captains to maximize the availability of transport resources.

In a perfect world, my regulator will change one sentence in their policies and I can flex 3 more non emergent transport vehicles already deployed into service.  Change one more sentence and we can better serve the homeless population while simultaneously drastically decreasing ED overcrowding.  I have said before, EMS holds the key to ED overcrowding.  So many solutions are just waiting for the 40 year old rules to change.  But proving that those rules need to be changed has to be supported with data that can be confirmed, recreated, and stamped approved by someone who knows what that means.  I am not that guy.  But I know who is.


There is no switch to flip to make it work better, we all know that, but I have a good relationship with the people who do the wiring.  Our dispatch data folks, the Dept data folks, the statistician, everyone has been very receptive when I came in asking for our police designed CAD to spit out EMS metrics.


You can sit in the cab and complain and I can sit in an office and complain but until we provide solutions that will work and can be verified, we will continue to stagnate as a profession, content with the status quo because no one is stepping forward to help us.

You are the change your system is looking for.  Get involved or get your bags packed.  I've got 18 years left and I'm not taking them sitting down.

Tuesday, November 13

Ellerbe may be ahead of his time

DC FEMS Chief Kenneth Ellerbe unveiled a plan for EMS redistribution in the Nation's Capital and it is getting some nasty comments online and from the local Firefighter's Union.

I can't necessarily comment on Ellerbe's reasoning for his move, since I don't know what it is, but I can tell you that he's WAY ahead of his time.  I just think he doesn't know it yet.

You see, DC FEMS will be down staffing ALS transport units from 0100 to 0700, a time when calls for service are drastically less than the daytime hours.  On the surface, it makes perfect sense.  Cut extra resources when they're not needed.  If it can be done and still meet the demand for quality ALS transport, great.  If it can be done while still meeting all the guidelines set forth by the local EMS regulatory agencies, great.  (Now our UHU calculations come in handy, don't they?)

But what happens when your calls for service are ALS?

Ellerbe's answer is to staff up that ambulance for the transport with one of the 21-25 ALS engine resources and 7 ALS supervisor units.   That also makes sense, until that fire engine is doing something else, like already transporting an ALS patient.  Forget being on a fire or an alarm or rescue, these resources will be BLS as their extra member attends another transport.  now units are scrambling to pick up medics at hospitals or BLS ambulances are out returning medics to their company.

My agency could consider such a move in the future, but it will be doomed for failure because of the high call volume of seemingly ALS calls as defined by the local EMS regulatory agency.  Without decreasing the number of patients, we can't decrease the number of transports.

If DC FEMS can also flex their ALS Supervisor resources to augment the system of transports, they will also soon run out and someone from the engine will need to return their buggy to the hospital or the BLS unit give them a ride back to their buggy parked back at the scene.  More time will be spent returning units than responding in many cases.


Ellerbe's plan is ahead if it's time, but as far as I've been able to find it will not be as efficient as it needs to be.

Why you ask?

Because it needs to be coupled to a "Respond Not Convey" program, or as we call it on the street, the Paramedic Initiated Refusal.  Refusing transport to certain patients who do not need it is the relief DC FEMS needs to better serve the population.  So long as every stubbed toe and runny nose that wants transport gets it, you will continue to have 4 person ALS engines or ALS supervisors at the scene of incidents waiting for an ambulance.  We call it "Medic to Follow" and it is the number one drain on our system. "But Happy, that's a BLS run!" Not if they used the magic word "Chest pain" to get triaged faster.  And we all know that NEVER happens...right?


With the sudden interest in the Community Paramedic model, many systems will have to address the issue of Respond Not Convey if they want to increase services without increasing resources.  I would love nothing more than to deploy our fleet of ALS supervisors to handle community paramedicine, but we're dealing with an increase in call volume and market share.  And we have less than HALF the amount of ALS supervisors DC FEMS deploys.


Ellerbe's plan seems like a slap in the face to some, but I see it as a new way of deploying resources.  Thing is, it will work.  That is until a second call comes out.  Then a third, then a fourth and next thing you know Engine 99 is sitting on the curb IFO the clinic awaiting a second engine to respond with a medic so the BLS unit idling at the scene can transport.


Just a gentle reminder: These views are my own, not those of the SFFD, the City or any one else, just me.

Thursday, November 8

How busy are you?

How do you measure an EMS system?

Cardiac arrest survival rates?  Profit? Market share?


How can one system accurately compare themselves to another?

I was tasked earlier in the year with a seemingly simple question: "Are we busy? How busy?"


Um, yes and um, a lot?


Many systems use a measurement of Unit Hour Utilization (UHU), or a numerical value of how much time you spend doing EMS stuff.  This number can then be compared to others since it uses two basic measurements.  Those measurements are Hours Staffed and Time on Task.

Let's say you're on Medic 99 for 12 hours. 12 is your denominator, since you spent 12 hours on the rig.  Your time on task is defined slightly differently from place to place, but the standard definition is any time you spend responding to, at the scene of, transporting from or at hospital following a call for service.  This total becomes your numerator.  So let's just say that on your 12 hour shift you ran 5 calls for a total time of 7.25 hours.  That means 7.25(time on task)/12(hours staffed) is a UHU of .60.  Quite busy indeed.

But I learned very quickly this is not a complete picture of the shift.

You see, you didn't magically appear in service when you came on duty, you had to get the rig checked and fueled.  Then at the end of your shift you had to return to base and try to get the rig squared away for the next shift.

We refer to this time as the "Logistics Gap" or the amount of time we are paying you to do what should have been done already.  On average this can take 30 minutes at the start and end of a shift.  Now your 12 hour shift feels like an 11 hour shift.  That increases your UHU from 7.25 hours in a 12 hour shift to 7.25 hours in an 11 hour shift, or a .68.

That's even busier.

But STILL not accurate.

What about all that post moving?

We spent months trying to get our servers to spit out CAD data that tracked post moving, but the language just didn't understand what we were trying to do.  Adding up all the post moving time gives us an idea of how much time we are paying you to drive around instead of sitting still eating, going to the bathroom, studying, etc.


Applying that total, let's say it's a whole 60 minutes per shift, brings our UHU to 8.25 (7.25 time on task plus 1 hour post moving)/11 hours (12 hour shift - logistics gap) or .75.


From a .6 to a .75 is a HUGE difference!  If you are only tracking your UHU Actual, or the Time on Task/Hours paid, you are not getting an accurate picture of how busy your crews really are.


The best part of tracking these 3 values is that you can track them separately and add them up in a simple table.  Now when you introduce a new inventory tracking system that reduces restocking time, the impact can be measured and compared to previous days.  Or if a new software program at dispatch makes post moving less efficient, we can track it and break it down.


If your reports can be configured properly you can then measure each rig, each hour, each area of your district to see who is busy and how busy they are compared to others.


My agency is in the middle of gearing up for an expansion of market share and trying to figure out how busy we will be at different staffing levels is a breeze.  Just add a few rigs to the mix and rerun the math.

Yup, that's what I do now.

So, how busy are we? That's a secret. ;P

Tuesday, November 6

Control V

We have become a cut and paste society.  Not just us social media savvy kiddos either, oh no, no.  In a time when the conclusion that shapes your opinion has already been authored, why not just copy and paste it as your own?  Who will notice?


Probably me.


And not just because I can access all the same resources you can when you did the original search for your opinion, but because I have grown up on this technology and can spot certain abnormalities that many don't.

Yes, I have these powers.

I can see the difference between MS Word 97 Times New Roman 12pt and MS Word 2003 TNR 12 pt when printed.  It looks the same on the screen and had you cared to standardize your document, maybe it wouldn't have been so obvious.  How do I know this? I've done the same thing before, but caught it in time.  When copying references to cite on a page, most folks copy and paste, resize and move on, not even noticing the font is different.

So what does this tell me about your abilities in the field to which you are professing knowledge?  That I should be highly suspect and investigate ALL aspects of your findings.  And that's when I get frustrated.  Nay, UnHappy.

There have been few documented cases of me being honsestly UnHappy.


Trying to trick me?  Try harder.

Monday, October 29

My EMS Expo Schedule

I've been getting messages on Twitter, Facebook and in the old fashioned email inbox (who uses email anymore?) about when to wear the kilts at Expo, will I be at the ZOLL booth as usual and how much are autographs going to be this year?

(Always free for you Dave Konig)


To answer all your questions would take more than 30 seconds and I don't have that kind of time, so I'll answer them all right here, right now.


Sadly I am unable to attend this year's drunken romp through another City EMS EXPO.  This would have been 1 too many trips far, far away this year and with the new gig at work, time off gets complicated.


However, Mr Grayson has arranged for the 30th (tomorrow) to be kilted day at EXPO, possibly creating a tradition born last year in Vegas when we kicked off KTKC.  I will be kilted in solidarity here at HMHQ.

Learn bunches, network bunches more and let your liver know just what you think of it.  I would humbly ask that all my blogging peeps stop by the ZOLL booth to say hello and check out the Z series monitor, it fits in your pocket and updates the patient's social media accounts as to their condition.  No, really, go take a look!


In all seriousness I'm going to miss all of you this year and hope I can make Baltimore (oops, DC) in the spring for EMS Today.

Lift a pint for me!

2012 World Series Champion San Francisco Giants

Great series Giants!  See you on Wednesday for the parade!

Saturday, October 27

If chest pain was treated like C-spine

Johnny is 72.

His brother and father both died of cardiac related issues.  He is currently feeling fine, no complaints, but was found near an energy drink, rare steak and a little blue pill.  The man sitting next to him has similar history and is experiencing an Anteriolateral STEMI.

Everything around Johnny is screaming that he COULD be having a cardiac event that we can't see, that he can't feel, and that we'll be liable for if we don't "treat him."


"Absurd" you say?

"We'd assess him and only treat him if he had signs or symptoms."



If you are required to strap a curved spine to a flat board based on how a person was found, then you should be required to treat Johnny for the MI he is surely experiencing based on his history, current situation and the fact that someone right next to him doing the same things is having an MI.

We seem content to compartmentalize our treatment based on the little boxes in the protocols.

As practitioners we must strive to use our assessment skills and tools to determine a patient's condition and need for treatment or transport.  Focus less on the looming lawyer myth you've been sold by the anchors and do what your patient needs.

In this situation, we don't even need to bother Johnny unless he asks.  Based on his history and environment he deserves a "You OK?" and his friend deserves your attention.

Evidence based medicine has slowly begun to trickle into EMS and we have to wait for it to make it all the way to the bottom where that cold, flat board that hurts our patients sits because of everyone's fear of the "one" that might get away.

Is Johnny on the track to an MI?  Surely, but that's no reason to make him worse now.

Saturday, October 20

That is not a late run

A trend has spread through EMS that is causing a bit of a ruffling of panties in my neck of the woods. If the term ruffling of panties is upsetting to you relax, it's accurate.

I hear a lot of "We got a late call" both in the yard and online as a reason folks dislike their shifts. Every shift seems to claim they are always held over because of a late call, that the next shift never has to hold over, it's not fair, IT'S NOT FAIR! Then they jump up and down from foot to foot in a tantrum which causes the bunching panties mentioned earlier.

Complaining in EMS is remarkably easy. We apply anecdotal observations skewed by our own bias and apply it to everyday. Suddenly getting a call 35 minutes before the end of your shift is a late call and being sent to it is an affront to all things holy.

In response to just such a statement recently I was sucked into a common EMS Manager response that had me actually catching my words just before they left my mouth.

"Back in my day..." was how the sentence was going to start, but I was just able to catch it before I lost all credibility.

But then I stopped. It likely looked like a stroke, but the phrase was easy to say, yet lacked the true meaning I wanted to get across.

"You were closest, you got the job. You are assigned to the ambulance until 0300, not until 0230." I went on to describe methods they could use to check the ambulance and plan their off duty chores in the 106 minutes they were on post prior to the "late call."

I then told a war story about the call at 825, 25 minutes AFTER my sift was over and when I had been ordered by the Battalion Chief that I was not to leave my post until relieved. That the call ended up being a transport to Saint Farthest and that I didn't return to the firehouse until close to 10 AM. They were unimpressed and still held on to the belief that they should get some wiggle room at the end of the shift to "wind down and restock."

The film version of me delivers the speech far better than I do but the point gets across that we are on duty to answer calls for service and make bad days better. Sometimes that means we're a little late getting home.

Sometimes we have to spend a few extra minutes doing this work that we have chosen, taking the time to do it right instead of half assing it just to race back and disappear, upset that we asked you for a little something extra. Especially when we're paying you extra to do it.

A late call is a call that comes in AFTER your shift has ended folks, plain and simple. if you are due off duty at 0300 and dispatch gives you a code 3 call guess what? You have another chance to do something for someone who might need it. Be thankful it's not the other way around.

Wednesday, October 17

Pre-Requisites for the Chicago Rescue Squad?

Many Fire Departments have strenuous and extensive requirements to make their rescue squad.

In NBC's new show Chicago Fire, apparently all you have to do is have worked as an EMT in San Francisco.

Taylor Kinney as SFFD EMS EMT Probie Glenn Morris in Trauma




Taylor Kinney as Lieutenant Kelly Severide on NBC's new show Chicago Fire


Not bad, SFFD EMT to CFD Lieutenant in 3 short years.

Also interesting that both Departments seem to have such lax rules regarding rugged facial hair.


After this show is cancelled what do you think Kelly will return as?

Tuesday, October 16

Of Blankets and Discipline

A very eye catching story has been circulating for a few days involving everyone's favorite EMS system to hate, Detroit and a Paramedic who claims to have been reprimanded for giving a blanket to a person who was cold after a fire.

I was waiting to comment until the Detroit EMS Administration commented.  Let's just say I'm glad I wasn't holding my breath.

As a Quality Manager I see this differently than most line medics might.  On the surface a medic was doing the right thing giving a blanket to a cold person.  It's what we do most: Make bad days better.  We all know most of the attaboy letters don't involve medicine but instead note demeanor and comfort measures.

Seems like a non starter.

However, it seems there were some policies in place, whether you agree with them or not, regarding dispensing agency property.

Take a deep breath...I'm getting to my point.

Most Vice Principles have a list of trouble makers who are just under the disciplinary surface and are watching them like a hawk waiting for a reason, any reason, to bust them on a black and white policy violation.

I don't know enough of the facts to pass a decision regarding the blanket, but I can tell you that if this was brought to my desk I'd ask how we solved all the other problems to be able to spend time on this.  If there had been a decision to reprimand based on the Rules and Regulations, in my experience, there is more going on than meets the eye.

I wander the halls looking for my borderline crews to screw up on something so I can have a chat with them, sure, but more often I'm wandering looking for any chance to talk with them about how things are going.

This could have been a policy enforcement or the straw that broke the camel's back.

Let's just hope the camel doesn't need a blanket.

Friday, October 5

A quiet weekend in the City

Some boats in the bay...

America's World Cup

More boats...
Fleet Week

Air traffic ticks up a smidge...

Blue Angels


Hardly Strictly Bluegrass

A bit of sport...
Cincinatti Reds at SF Giants MLB Playoff Game

Buffalo Bills at SF 49ers NFL Game


Should only triple to population for a few days, all 33,000+ hotel rooms are booked, and I wish my weekend cars luck.

Tuesday, October 2

You Make the Call - Handcuffed

Man it sure has been awhile since we fired up the ol' You Make the Call Machine here at HMHQ, but I thought it's finally time to get back on the posting circuit.


For you new people, I post a situation, you answer it based on your local policies.


Dispatched in the first response vehicle of choice for your agency, the local PD has detained a man who assaulted another person.  The other person is receiving care from your partner and is stable, bleeding controlled and has agreed to transport.  PD presents you to the window of the patrol car where you can see a superficial laceration to the forearm just distal to the left elbow.  There was a small drip of blood that appears to be dry, no other injuries are obvious through the window.

After repeated pleas the officer agrees to open the door and remove the patient but warns that he became violent when they took him into custody.  He stands and allows a brief primary and secondary exam and you note no other deformity or injury.  He is refusing vital signs, treatment and transport in colorful language, but denies alcohol or drug use.  When asked if he understands the risks of refusing assessment and treatment he replies in the affirmative and states his reason for assaulting the man and the police is his business, not yours.


Is he able to refuse service?  If so, who signs the form when PD tells you there's no chance of him removing the cuffs to allow for a signature?


You Make the Call.

Thursday, September 27

Kicking it...Kilted

Last night was our fundraising event at a local piano bar.  I won't say how much we raised yet, but it was more than we could have hoped for!

Here's a pic of me hogging the microphone as MC fawns.

On a scouting trip through the community we happened upon a few guys watching football and having a few drinks.  When we came into the bar in our kilts they immediately began discussing it with us.  One fellow approached us and seemed extra curious about our motives.  I explained we were raising money for charity at an event in the area in a few weeks and told them to talk to their doctors.

He gave me his card.

His name is Steve Haworth and he happens to be the owner of Charity Auction Fundraising an expert in getting folks to part with their cash for a good cause.  He works with the Grammys, Justin Timberlake, Jay-Z...and now Kilted to Kick Cancer.  We had a couple of things we scrounged together from Alt Kilt's generous donations  but Steve wanted to show us how impressed he was with our dedication to the cause.

Steve brought with him, and donated for auction, a night in San Francisco, dinner and a show as well as a day trip to wine country, with driver, for 4 people.

These items both went for considerably less than they usually do simply because of our limited audience, but I intend on getting Steve in front of bigger and bigger audiences as KTKC moves forward.

That Bar will also be donating a portion of the proceeds from last night and was more than accommodating to us and even donated a gift card to the night.

The Prince Charles Pipe Band sent over a couple of bagpipers willing to help out for a beer and a T-shirt.  we even got them both on stage at one point and had dueling bag pipes!

Also a special thanks to Chief Picard from the San Ramon Valley Fire Dept Pipes and Drums for kilting up and wandering the neighborhood playing his bagpipes to drum up attention.  Then he and his lovely wife stayed to bid on and win an auction item!  Congrats Chief!


The total from the fund raiser will be donated to Blue Cure Foundation.  We've arranged with Ambodriver to have that total added to our fundraising totals for the contest since BlueCure wasn't able to get us the tracking links on time.

Oh, and one more thing, we got video of Motorcop dancing to Proud Mary in his kilt.  Want to see it?  DONATE!  I also gave my very best shot at a highland reel.  The wife, a former (and possibly future) competitive Scottish dancer said I did great.  So there.

Less than 72 hours left to donate folks!  If you aren't kilted support a blogger who is!

Thursday, September 20

Want to see me wash and wax MC's bike for a month?

Well, Kelly informed me recently that I'm lingering in the bottom 5 of fund raisers this year and that I should be embarrassed to be associated with the organization trying a little harder to solicit donations.


Motorcop, fellow co-founder of KTKC, chimed in by reminding me that his own fund raising has put me in my little medic place and I should just curl up and cry reached ever so slightly above my own.


Was it something I said?

Something I didn't say?


I know Kelly has a big EMS audience and MC a big cop audience...but where are all the firefighters?

If Kelly and MC out fund raise us we'll be in third place behind the ambulance drivers and the fuzz.  I can't accept that.




I offer a Kilted Challenge to my readers:

If I out fund raise MC I will wash and wax his motorcycle once a week for the entire month of October wearing a pink T-shirt.  MC will be allowed to photograph this event and I will post the pic in the top of the sidebar of the blog for the year.


Donate early / donate often!


Saturday, September 15

5.11 Tactical Duty Kilt Review

Back on April 1st 5.11 Tactical, a well known manufacturer of Police, Fire and EMS gear posted a video and a link to a new product, the Tactical Duty Kilt (TDK).

To me it was a well produced and conceived April Fool's Day Joke.  Why on earth would someone need a Tactical Kilt?

In the days and weeks that followed, many online tried to order the great looking kilt from the great company, but the product page listed that it was not available to be ordered.  Instead, one would need to sign up to be emailed when the product was available.

The price - $59.99


Your average starter basic cotton kilt goes for 3 times that.


I ordered 3, one for me and one for the Angry Captain and the Mrs dad.

They arrived yesterday and at first I was skeptical.  The kilts arrived as if they were made in a factory, not hand made from my favorite company Alt Kilt.  Saying Alt Kilt is high quality is like saying Neil Armstrong once went on a walk.  My bar was set pretty high on this one and the folks at 5.11 did not disappoint.

A quick note on 5.11: They could have simply posted a link saying it was a prank, or raised the unbelievable price of $59 bucks, or even skimped on the quality and blamed it on the price.  They stepped up and sent out a great product I wish I could order more of.


The Design:

The TDK is a non-traditional kilt, made of rip stop fabric so tough I had trouble getting my kilt pin in the apron.  The seams are clean and tight and the front angled pockets are perfect for cash so often falling out of cargo pockets when i sit down in other kilts.  The cargo pockets are attached with 4 snaps and can be removed, leaving only the velcro closure covering the snaps, a clean design.  Within the cargo pockets are 3 subdivided areas advertised as for magazine storage for shooting, I'll let AD or MC comment on that but mine fits my phone PERFECTLY.  No more is my phone again wandering a cargo pocket or buried in a sporran.


The belt loops are centered on the front and include a badge tab, but only accommodate up to a 1 3/4" belt.  The front apron includes a hidden snap for modesty and will keep the kilt from flying open on a windy day.  It also serves when sitting, allowing a first time kilter to be comfortable and learn how to sit properly before going all out on a tartan kilt.


The Style:

The pleats are few.  A traditional kilt has dozens of pleats, the more contemporary kilts have more, this one gets by on the minimum.  The pleats are what allow the kilt to move with you instead of being a mini-skirt.  The snaps and material go well with the low slung cargo pockets, putting my extended arm right in them no problem.  The front pockets, again, are a great touch and take the comfort of this kilt above others I own.  The snaps make it easy to get into and out of, but I like the look and feel of buttons better.


The TDK is an excellent starter kilt for three reasons:

1.  The modesty snap allows for wearing without a kilt pin and can get you less nervous about a gust of wind landing you on the sex offender registry for exposing yourself at a youth soccer game.

2.  The pockets don't require a sporran.

3.  The price of $59 means anyone can get started and have a basic item for September or whenever undies just don't seem like the thing to wear.


The Drawbacks:

1.  It is so contemporary some hard core kilters may not consider it a "real kilt."  Their problem.

2.  It's no longer available.


5.11, I think, took a hit in the pocketbooks on this one.  They charged $59 for an easily $200-$300 kilt considering the materials, hardware, design and creativity it took to consider the kilt an active duty garment.


I tip my helmet to 5.11 for going through with this order fulfillment and having them out (almost) in time for the Kilted to Kick Cancer events (coincidence?).  Like I said, they could have told us it was a joke and we would have laughed and been bummed.  Now I'm bummed I didn't order more.  If it ever goes for sale again, I'm in.


The 5.11 Tactical Duty Kilt is a top quality product for the price and was well designed to boot.  Well done.



Thursday, September 13

A #KiltedChallenge!

Mr Kelly Greyson, @ambodriver, has a blog audience I would kill for.  Well, maybe maim, for...OK, I'd give someone a good dutch rub for.

Point being, when Kelly wants to spread the word he can.  And when it came to Kilted to Kick Cancer he was not good enough with just raising awareness.

However, Kelly has the rest of us at a disadvantage.  He has a larger audience than me so has a better chance at getting more donations to his site.  Turns out Kelly is also up against folks with a bigger audience than his.


As a result Kelly has "stooped" to "cheap" tricks to raise funds for Prostate Cancer Awareness Month.  He offers challenges so that if a certain dollar amount is reached he'll do or post something degrading all for a good cause.


I have dubbed these stoopings "Kilted Challenges."

Not to be outdone, I challenged noted KTKC co-founder Motorcop to don his knee high Motorcop boots with his kilt.  He scoffed at first, then a facebook post found a possible $50 donation to see the pic.




Kilted has a benefit night coming up on September 26th at a local bar and Mr Ted Setla will be there with his camera recording the event.


I offer the following #KiltedChallenge:


For $100 total donations to my fundraising site with the name "Scotsman" I will stand up in front of the crowd and recite the Scotsman Song.

For $500 I'll do it with a blue silk ribbon you know where.


Wadda ya say interwebs?  Can we raise some money for cancer research or what?

Click on the image above to be redirected to the Prostate Cancer Foundation collection point and enter your name as Scotsman to be credited to this challenge.  OR you can always drop a few bucks as anonymous, or yourself, the important thing is that you get checked.

Monday, September 10

"Daddy, did you win this hat?" A Daughter Learns of 9/11

My 6 year old is a quick learner.

She was dusting the shelves in our living room as a chore when she moved a few books as she always does.  But this time she noticed something on one of them.

"Your buddy looks sad.  Daddy, did you win this hat?"

She was pointing to the cover of one of the two September 11th books I keep on that shelf.  On the cover is a firefighter holding an American flag with a leather helmet on it, not unlike the one they see I wear (wore) at work.  The shield says 343.
We stopped the chore and sat down to look through the books.  She had heard the term "twin towers" and had seen the "343" before, but I began telling her about the bad men in the airplanes and how daddy's buddies (their term for firefighters and paramedics) went to put the fires out.

The images of the towers collapsing had an impact on both of us and she asked how many buddies got hurt.


I was starting to get emotional.

"Tell me about them?" she asked.

I flipped to the page with an ambulance in the rubble and shared the story of Paramedic Carlos Lillo on Medic 49 Victor.  Then I turned to Chaplain Mychal Judge and showed her the picture burned into my soul.  We looked through another book with photographs of all the firehouses who lost members soon after and saw Ten House.  I told her I had been there and seen Carlos and Mychal's names on a beautiful sculpture.

The impact of that day was not completely understood, I imagine much the same way Pearl Harbor is lost on recent generations. But her questions and my being able to relate on a personal level to the photos from that day will help her understand the human toll when it finally clicks exactly what happened that morning.

And because we take the time to learn their stories and share their stories they will not be forgotten.  Their names shall be spoken long after they, and we, pass from this earth.

Forget the bumper stickers and memorial T-shirts and learn a story, any story, there are hundreds to choose from.  Learn it, learn from it and share it.

Only then have you never forgotten.

Tuesday, September 4

CalFire Air Ops up close - VIDEO

Our good pal Dylan, noted BlogStalker, childhood Explorer Scout friend and Chief Programmer at GasdaSoftware got a surprise while out back the other day:


CalFire was responding to a slow moving fire that proved difficult to access on Sept 3rd.  It was on site of the Concord Naval Weapons Station, a deactivated WWII munitions depot primed for development if anyone can figure out how to remove all the ordinance. While we could smell the smoke at HMHQ Dylan, from Gasda Software, had a far better vantage point.  I'd be curious to hear the pilot's thoughts about all the kids at the edge of the pond.


And yes, that's a separate helicopter.


Thanks for the video Dylan!

Monday, September 3

1 in 6

1 in 6 men will be diagnosed with Prostate Cancer.  1 in 36 men will be killed by it.


Do you know your risk factors?


Regular readers of the blog will know that September is Prostate Cancer Awareness Month and we're getting Kilted to Kick Cancer.  If you're sick of hearing about it, get checked and come back in October when everything turns pink.


Prostate and Testicular cancers got a bad rap in days gone by.  They were considered old men's diseases and were filed on the to do list after "file nails with weed whacker." No one wants to talk about thier testicles with other men...unless we're comparing size, then it seems to be OK.  We're weird that way...and it's killing us.

But in recent decades something interesting has happened.  Younger men are being diagnosed with the old men's diseases.  Research even suggests that the old men who were diagnosed could have been diagnosed earlier.

Enter well known cyclist Lance Armstrong and his very public battle with testicular cancer.  He's not an old man, yet required drastic intervention to battle his cancer.

Then friend Russel from Hybrid Medic is also diagnosed with the old men's disease.

Motorcop found the story of Gabe Canales, who's doctors ran a PSA (the blood test that detects elevated levels of hormones indicative of an enlarged prostate) by accident and discovered his prostate cancer.  Gabe was in his 30s.  He took that experience and founded BlueCure an organization focused on preventing cancer and living a healthy lifestyle.


Cancer is all around us folks, but some organizations would like you to think theirs is more important than others.  One such group went so far as to trademark a common slogan used to organize people.  We at Kilted to Kick Cancer want to shine a light on male specific cancers because men still think they have a risk of developing breast cancer and will walk miles and miles with prostate cancer without even knowing it.  Imagine 60 men walking in October, pink from head to toe, each with their wives.  Odds are 10 of those men have prostate cancer.  Less than 1 breast cancer.  When will the walk to raise money for prostate cancer research be?


Well, as soon as you organize it.


We can't just sit on the sidelines and watch the multimillion dollar charities do what they want, we need to recognize this threat to men and act.  We've done amazing things for the pink, let's do something for the blue, the children, the cancers that seem to be less sexy than the boobies.


A quick note on the multimillion dollar charities.  I'm not a fan.  I would prefer donating to a local group, but there are so few.  I avoid donating to Jerry's Kids.  Kilted to Kick Cancer links to a number of charities that need your support to continue their efforts.  Some are small, some are huge, paying the board of directors million dollar salaries.  Again, I am not a fan.

That's why we're building our own charity from the ground up.  You can support us by donating to your local cancer groups using your time, your resources, your money.  Spread their info on social media, trumpet their cause at your church, their are so many other ways of fighting cancer than grabbing for your credit card.

If you can help with a donation, make sure you use one of our links so the big boys see what kind of reach we have.  If you can't help with a donation, find a local charity that needs help, it doesn't need to even be for cancer, get kilted and get involved.  When folks ask about the kilt, tell them their risk factors.  Coach little league kilted, wash cars for the high school band kilted, go to the game kilted.  We just need to raise awareness.


But as Kelly pointed out, awareness isn't enough.


We raised a lot of money last year and hope to raise even more this year, but those conversations with men who raise their eyebrows at their risks is what it's all about.  And even better, when you meet a survivor who asks, "Where were you 20 years ago?"


Let us not look back in 20 years and wish we had done more.  The time is now.  Get Kilted, Get Checked!


Friday, August 31

Happy Medic turns 4

It was 4 years ago today that a frustrated, stressed, borderline meltdown firefighter and Paramedic sat in front of a computer and began a therapy experiment.

It has fizzled, flown, soared even, and at other times consumed my time at the cost of ignoring my family.


This little blog helped me recover from the feeling that I was going to die and wondered why I only got hurt instead.

This blog took me to England,


To Baltimore,

To places I never dreamed.


But here, when HM smiles back at me from the homepage, I remember when it was more about therapy and less about EMS.  Now it is more about EMS and less about therapy, but when I feel stressed or need to unwind, I know that the keyboard is waiting and HM will say what needs to be said to make things right.


Thanks for stopping by these last 4 years and I hope you'll keep coming back.

Happy Birthday, Happy.



Monday, August 27

Out of Left Field

Sometimes we forget who we're up against.

Sometimes the system is indeed rigged against us from the start.

But how can you win if the other party refuses to even play the game?


The term "blind sided" was used in a meeting today, much to my surprise.  You could even go so far as to say that I was blind sided by this blind side.

It was a jolt of reality back into my EMS 2.0 world that not all of our enemies lie within.  Some are just skirting along the outside of EMS, providing valuable services, only to pounce on ideas they find threatening.

Only problem is, I don't see it that way, not sure I ever will.

I've had almost a year to figure out this whole politics thing and I still just don't get it.  I don't care who had the idea, or who gets credit, I need some things to just happen.

In my role, very few decisions are actually within my control.  I do research and pass the info along.  If it gets rejected, I research more.  I've had my preconceptions busted more than a few times, comes with the territory.  But there is this perception that others see my actions as more for me than the system.

I just don't get it.


Some things come from out of left field, but that's all based on the assumption that what we're expecting was in left field to begin with.  My surprise came from the bleachers behind left field, caught my on the jaw and knocked me to the floor, blinking, wondering what just happened.  I had a ceiling do that to me once.  Once.


I'd love to say "never again!" but when you don't know what to expect, how can you prepare?

Wednesday, August 22

When a complaint is a cry for help

I absolutely LOVE answering the complaint line here at HQ.  Not HMHQ, my real HQ gig.  The complaint line at HMHQ never rings.  :P


Many may not want to hear the public rattle on about how we stole tens of thousands of dollars from their wheelchair or lifted a priceless piece of art the last time we were called code 3 for a spoon stuck in the disposal, but I LOVE it.

My pencil jots notes as I listen to the complaint in it's entirety never once asking for clarification.  I get the entire story out and make sure they say everything they want to say.  90% of their complaint is usually because they want to be heard, not because they have a legitimate complaint.  They want to hear that it's not cool that they don't have as much stuff as I do or that spoons fall into my disposal all the time.  The venting is the powerful process here, I should know, right?


However, every now and then I get a call from someone unclear on the concept.



Not sure that heading still fits, but we're almost 4 years into this thing, why change now?  A woman has called me requesting the ambulance crew who transported her 2 days ago be fired.




Her story goes a little something like this:

The ambulance crew was late, rude and refused to help her.  They didn't carry her into the ER and refused to give her to a nurse.  The ambulance crew then pointed at her and make remarks that I won't repeat here.  Her language was colorful and hurried while I made notes and pulled up the chart from that day.

When she was finally finished I assured her I would look into her claims and explained the process.  While I was doing so I returned no records of a her being transported that day.

"Could this have been yesterday?" I ask seeing her name pop up on another day, then another.  In fact the software we use turns grey days blue if a patient is contacted on that day.


There are more blue days than grey.


I also notice that today is blue so I pull up the chart.

While I'm doing so she continues on that after the rude evil paramedics left she collapsed and had to spend 2 days in ICU.  She then described the pile of bills she is already receiving.

I noted her concerns for the file and asked the only question I needed to ask:

"Were you transported to St Closest today at 10 AM?"

"What? How do you know that? That's a violation of my privacy!  How dare you access my medical record without my permission!" a brief pause... "Well?"

"Ma'am, if you'll permit me.." and I restated her clinical concerns and her destination concern, and the claim that she was not delivered to a nurse, all of which is directly connected to her medical record.  And although I had no way of confirming her identity, no PHI was exchanged and clearly she knows most of the fleet and they know her.  As I scan a few of the charts looking for patterns of behavior I find what I'm looking for.

Most of the crews are using her statements in quotes and they match almost to the word:

"Patient states she will file a complaint if not transported to Saint Farthest, Saint Farthest is on divert, patient ambulated away angrily with steady gait."


When I asked if she had been transported to her facility of choice and if the Paramedics had actually been rude to her, she began the back track.  She didn't really want them fired, maybe just talked to, or even just mention that she was not pleased with the level of service she received.  Then we talked for a good 20 minutes about her medical conditions and her use of 911.  I offered a few contact numbers for local resources and even threw in a few breathing exercises for relaxing after a long day as an urban outdoorswoman.  She thanked me and in the end apologized for taking my time.

"That's why I'm here, Ma'am.  If my Paramedics ever do anything you don't like you call me right back, OK?"


That was in January.

Today I noticed her name on a chart where she was transported for a chronic condition, but the colorful language was gone.  I had to go back and check the name to be sure.

Her blue squares have decreased significantly since and I'd like to think I had something to do with that.  It wasn't a rapid response car, or an advanced skill set, it was taking the time to listen and offering support.


Try it.

Sunday, August 19

The end of the EMT-Basic?

I have always hated 2 terms in EMS but until I can get everyone to agree on just calling us "Paramedics" and assigning skills and licensing on a National level, I'm kind of stuck.

At a recent class a colleague mentioned how he hated the term "EMT-Basic" because it sounded too much like "EMT-Minimum."  This is the absolute minimum set of skills we think you need to be able to identify a life threatening emergency, intervene as indicated and arrange for a more educated assessment and treatment.


Another term that always dig sunder my skin is when we slap the word "Advanced" on the side of our ambulances.  Advanced compared to what?  To the basic?  To the minimum?  Current Paramedics are the advanced version of the minimum required.  Well, 3 is more advanced than 2, but it will never be a 10.


So how do we achieve the pinnacle of Professionalism with these outdated inaccurate terms chained to our ankles?

How is it that someone can be content with a certificate or license that uses the term basic?

Imagine you have a plumbing problem in your home and call the plumber.  The person arrives identifies themselves as a Plumber-Basic.  Perhaps they are trained and experienced to handle the problem, but what is our confidence level in that person?  Low, right?  Now what if he arrives and says "I'm an advanced plumber"?  We feel better, sure, but what if he simply arrived and said, "I'm a plumber, what's the trouble?"


As an EMT-Basic I hated having to rely on someone else to come help me with my patients, yet I refuse to seek out additional education above the level of Paramedic because I like where I am.  I get that not everyone wants to raise to the next level, I'm one of those folks, but I wonder if we're setting ourselves up for most of the problems we're experiencing.


EMT-Minimum and EMT-More than Minimum.


We need to get one name and stick with it guys, or this stratification will never end.  Paramedic - Level 1?

But Level 1 is basic, no?  Meets only the minimum.

How about EMT and Paramedic for now and we'll work on the details later.  The National Registry introduced the non EMT Paramedic requirements, that's a good first step.  Can we do the same for EMT-Basic? Just drop the basic part?  Can we at least do that?  I don't like the term technician, but in looking at the standards for EMT-Basic in this country, the term is accurate.


What do you think?


Tuesday, August 14

Overheard at the National Fire Academy

I finally took some trusted advice and put in for an EMS Quality Management class here at the National Fire Academy in Emmitsburg, MD.  Well, it's not A class, it's THE class.

And I am loving it.

The different levels of experience and system types in the room lend for a giant melting pot of ideas.  Folks are actively sharing, borrowing and down right stealing ideas.


Sound like anything we've been striving for?


There are a few anchors in my class though.  Not the anchors that drag EMS down, but the anchors that recently realized they were doing so and are working hard to reverse the damage they have done.  There are young bucks like me, middle managers from the deep south and more than a few Chiefs from the northeast.

I'm referred to as the guy from the Wrong Coast.

Cool by me I suppose.

The lessons I'm learning here directly relate to my current (part of anyway) responsibilities at the CQI office and I am absorbing as much as I can.  And not a single clinical scenario to be seen.  There is something refreshing about an EMS class that, whenever patient care differences arise, we are reminded "That's later" in this particular process.


This class is all about managing the quality of the system, looking ahead to spot trouble before it happens and realizing that if there is a problem, it is useless blaming the employee.

Yes, it is the system to blame.  The system that let them skate by, let their skills falter, let them hit the streets knowing full well they were ill prepared for what was coming.  All we did was wait too long to do something about it.  "No, Justin, Medic Bob is an idiot."  Then what are we for letting him still touch patients?


This class is all about designing the processes to do just that, intervene as soon as an issue arises and solve the problem starting with the simplest solution, not necessarily something that has been done before.  A new breed of instructor lives at this level of EMS Admin instruction, one that looks for solutions not in intubation success rates and response times, but quality of a system as a whole.  A 5 minute response time and 99% first pass intubation rate is useless if your average patient in pain goes too long without relief.


But I heard something today that really made me realize that EMS 2.0 is not is here.


A student was sharing the fact that they were barely able to attend this class because their Chief was worried they would take the class, learn how to do things right and then leave.  The instructor stopped the class and said, "Tell your Chief he should be more worried that you don't seek out education...and stay."


I'll let that marinate.

Saturday, August 11

Attention all companies and units in the field

We have a fellow member in distress.


Please do what you can to show your support.  Especially with September and the wave of pink in October, we seem to focus more on the lost than on those we can help right here, right now.


I've never met Valerie.  Don't need to know her to help, other than that people I know and respect need help helping her.


Wednesday, August 8

Post about our site and win a prize! - Seems Legit

I was going to let this one go and chalk it up to a bad decision.

A couple of weeks ago I got an email from a popular clothing and gear manufacturer to review one of their products.  Not uncommon.  I frequently get requests to review gear, host a guest post about an online EMT class etc etc.

They're all form letters likely sent to any email address that relates to a blog.


I've been asked to review helmets, boots, socks, you name it.  If the company sends me an honest email and meets my requirements, I review the product, write my honest review and post it.


99 times out of 100 the solicitation is bogus and often includes terminology reserved for Nigerian Princes.

"Please to review our new item!" etc etc.


When a company I respected reached out asking for a product review, I was curious to hear what they had in mind.

What they had in mind was no where close to what I expected. [my edits]

"Hi, [ no name...sure giveaway]


[a person you've never heard of] had initially emailed you [no they didn't but it seems like you missed it, right?] to to [poorly proofread, I mean who wrote this? Me?] let you know that we [we who?] have teamed up with [a company you respected] for a giveaway! [company] is the leading provider for law enforcement and tactical gear  and wanted to see if you would be interested in blogging about an experience that you have had using a [company] product. If you have not used [company], that's okay too! You could also write about a product that you are interested in using. We are doing a [companyBag and yes, the lack of a space between the company prize and the word Givaway is a ... giveaway---->]Giveaway with lots of great stuff for the best blog writers!


If you are interested please a post [again with the proofreading!] about your experience/write about a product that you're dying to try~!


To Qualify the Requirements are:

1. 300-500 words

2. This must be 100% unique and original content

3. 1 link to the main webpage ([company website])

4. 1 link to the product that you have used or would like to try out ([hint hint, here's a product we likely want to push])


When you have posted this article, please email  me and provide me with the URL so that you can be entered in the contest.


This giveaway will start Wednesday July, 11th and the winning blogger will be selected on August 31, 2012. We will enter in the URLs and randomly choose a winner. The winner will be contacted via e-mail no later than September 14, 2012. When you are contacted I will ask for all your info as to where to mail the [company prize, which is never explained] prize giveaway!


We wish you the best of luck!! And we hope that you decide to be a part of this amazing giveaway!


Good luck,

[another person you've never heard of]"

An email address not affiliated with the company reached out in Nigerian Prince fashion to ask me to review a product and write a blog post about it.

But wait!  There's more!

If I meet the qualifications listed below I could be entered in a contest with other bloggers to win a prize?  All I had to do was review a product I had never touched, write a 300-500 word review and post a few link backs within my post to be entered to win?


I made a snarky comment on facebook soon after and dismissed it as a fly by night internet PR firm's idea of drumming up site traffic.


Then I got an email today reminding me to get my post up soon to be considered for the contest:

"This is just a reminder about the [manufacturer deleted] giveaway contest. Time is passing by quickly! We know that sometimes there is so much to do that you don't have time to write a lengthy post. So for those of you interested but don't have the time, we have a different option that you can do to enter into the giveaway! Please email me for further details. For those that want to take a stab at it yourself, below are the requirements!

Thank you for you time and I wish you all luck!"


No I didn't email them to get a likely canned "guest post" nor will I.  Heck, part of me wants to send this in as my entry to their "contest."


Some companies understand the blogger, some go the less expensive route and hire a company or a 10th grade intern to dream up ways to drum up traffic.

Sorry, guys.  If you were aware of this you lost big points in my book.  If you didn't know about it, you lost even more.  Either way this is a letter in your file and I hope one of your folks sees this and thinks, "Oh crap, was that us?"


I will refrain from mentioning the manufacturer, but if you follow me, you already know.


Monday, August 6

Forensic Gastronomy

Field intubations are tricky.

Anesthesiologists like to talk about first pass rates on 12 hour fasted chemically sedated patients in a well lit room at table height.  Dude, if you miss those something ain't right.

We know from experience hitting the doors of the ED with a dirt covered ET tube holder and a solid ETCO2 waveform is a badge of honor.  Heck, hitting the door with good chest rise and a BVM is just as nice, but when we begin to relate the difficulties in clearing, securing and then ventilating through a challenge airway, some Docs seem to shake their heads at us as if we were telling them a tale about being chased by a giant dragon.


One crew recently decided to bring some evidence with them to the ED.



A local skilled nursing facility seems to have been feeding a dead man.



First engine on scene requests a Captain and transmits CPR in progress.  The engine medic notes extreme difficulty in clearing the oropharynx of a dry mush-like substance, grey in color, which seems to ooze more as soon as some is scooped out.

Ventilations are not even useful and a few abdominal thrusts are performed which seem to clear most of the blockage.

The patient is pulseless so chest compressions are started and it seems to be helping.  Not seeing a chance to get the airway clear enough for the BVM ("Emesis too dry and chunky for suction") the ambulance medic has a grand idea:

Attempt laryngoscopy and suction the tube of the contents.

First attempt yields a placement and no air movement is noted, so they pull it and are almost shocked to see a perfect core sample (their words, not mine) of what is blocking this airway.  The decision is made to use a KING LT and hope most of the blockage is now inside the withdrawn ET tube.


The BVM moves air, the chest rises, and they're off the the ED to explain this airway.


When the ED Doc seems not too convinced the airway was as difficult as they described, the Medic produces the ET tube from earlier and describes the various layers of foods that were lodged in the trachea.

Core sample intubation.  You heard it here first.

Saturday, August 4


Stress and worry moved into the office next to mine a few weeks back.

There was no precipitating factor, no big event, just all of a sudden I was upset, felt overworked and seemed to be missing my family more and more.

Work was getting complicated.

Life seemed never ending, always something we needed to do this week, weekend, next week, coming up.

It seemed as if I was drowning.

Often a break from the blog helps, but it didn't this time.


It was a facebook update and a call from a friend that put my reality in check.  Both stories have the same arch villain.




A co-worker found herself under the knife and a classmate needed help when his father-in-law deteriorated rapidly.  The phone call started, "Justin, I didn't know who else to call..."

My problems not only went away I felt bad for thinking I was in trouble in the first place.  We let the little things begin to drag us down.  Each problem a piece of straw, slowly building without notice until we begin to buckle from the weight.


Only in my case I had a small handful of straw I put there on my own.  So I shook it off.

I am alive, I have my health and my family is healthy.  The rest is icing.


Get checked.



Tuesday, July 10


I was told recently that I have paid my dues in EMS and have the right to speak my mind.

Funny, my check never cleared.

I've been:

  • puked on,

  • peed on,

  • gotten ROSC

  • called a code on scene

  • carried limbs

  • carried dead limbs

  • extricated patients

  • extricated bodies

  • carried those who can not walk

  • carried those who could

  • been hurt in a fire

  • helped those hurt in a fire

  • laughed at jokes that are not funny

  • told those that are worse

  • run 23 jobs in 24 hours

  • been an entire paycheck without a call

And yet I don't feel that I have paid my dues.

I talk a lot.

I write a bit.

Haven't done much.  Really.

AD says some medics have 1 year of experience repeated 20 times, I wonder if I am falling into that category.

I'm going to be taking one of those famous blogger breaks, where I try to ignore the interwebs machine and get my own house in order.

See you on the other side, Ray.

Saturday, July 7

Just because it's right...

...doesn't mean you can do it.

We've had some confusion around the yard as to just what we're supposed to be doing when it comes to assessing the car rather than the patient.
We all know to assess the patient, not the car, the patient, not the monitor etc etc.

At a recent training evidence was presented that contradicts our current protocols as set forth by our regulators.
It seems a number of folks took that training to heart and are trying to apply it to the patients they encounter in the field.

Problem is, the treatment, or omission of treatment in this case, is causing trouble for me in the CQI office since I now have to talk to folks about doing the right thing and breaking the rules.

First a note on one of our favorite terms: mechanism.

Motor vehicles today are designed to crumple, absorb energy and disperse it around the passenger compartment. This design allows for a great deal of damage to be incurred prior to the passenger, if properly restrained, is injured. This is the reason that recent CDC wording of field trauma triage criteria specifically mentions intrusion into the passenger compartment. Your protocols and policies likely have a similar clause.
The problem is when the protocols and policies start making assumptions about the possible damage to the car and how it relates to possible damage on the patient, then prescribes treatment based on the car, not the patient.

Rollovers used to be a big deal. If everyone is belted chances are they're self extricating before you get there and strap their curved spine to a flat board. You know...just in case.

Even more frustrating is when you finally convince the patient that the hospital will take careful care of them in case they have a back and neck injury only to arrive to a triage nurse removing the collar, performing the same assessment you did, then removing the board if your treatment was based only on mechanism.

Even worse is when you convince them to be seen at the trauma center based on damage to their car, only to see them moved to the hallway prior to your chart being board, no collar.

I asked a few of my crews to think of the worst Paramedic they had ever seen and if they would want that person "clearing" C-spine injury in the field on them. The point set in that most of us can barely get our noses out of the cookbook long enough to do a complete assessment now. Those folks have no future in EMS if I have anything to say about it.

So what to do?

Attend the meetings of the groups that make the rules. Get on the agenda and speak. Bring research, evidence, examples from other systems already doing what you want to do.
You get a lot more attention when you bring in a multiple page presentation on Community Paramedics rather than complaining in the yard that we need more training to be able to do more.

Follow the policies. If they aren't what your patient needs, lobby to change them. Don't ignore them in the field or your next patient may suffer when you're on suspension and that medic you despise has to treat them.

Which is worse?

Monday, July 2

Summertime in the City - Why does hypothermia have to be therapeutic?


"Coldest winter I ever spent was a summer in San Francisco" - Mark Twain

"Don't believe everything you read on the internet" - Abraham Lincoln

"Quotes are stupid" - Some idiot


Summertime is here and I for one am glad.  Glad that I get into my car in the high 70s and get out in the City somewhere in the high 50s.

At home it's shorts and flip flops, at work it's jackets and glad we wear wool pants.  When I return home, however, to temps in the 90s we rethink the wool.

In a recent conversation with a respected hospital administrator the term "therapeutic hypothermia" was tossed around rather freely, as if saying it for the 500th time would win them a set of steak knives.  It seems the powers that be are interested in bringing some active cooling measures to the only recently mostly dead.  This was the result of a series of meetings I somehow never made it to.  Laziness one possibility, apathy another, or I could have been reading charts and yelling at people.

In our discussion of the merits of the term "therapeutic" we wondered if having to mention a treatment is good in the title is a red flag we'll look back on in the future.

"Try this therapeutic oxygen, it's amazing, but avoid that passive oxygen, it's no good."

Making people cold can apparently help them recover from a cardiac arrest.  I guess some papers have been written and some friends looked at it and agreed so it became the thing to do.  Trouble I have is the recommended window of initiation of treatment.  It seems that if we can get their heart beating on it's own again, then make them slightly cold within 4 hours and keep them there for 12-24, we can improve their chances of survival.

4 hours.

Our average transport time hovers in the teens and tack on a few minutes to get pulses back...let's call it 1 hour.

One full hour, 60 minutes from when the heart stops to when we hit the doors of the ED with pulses and a BP.  That leaves 3 hours to initiate CONTROLLED cooling in a CONTROLLED environment.

My conversation with the hospital rep then turned to the process that will be used to monitor the cooling efforts.  Thermometers perhaps?  Maybe, we'll see.

On a side note, we also have a problem with a little something called passive hypothermia wherein Erma Fishbuscuit drops a few tenths of a degree just by sitting in her drafty bay window, then we carry her out to the rig on a cold chair with a single wool (wool again!) blanket.  Then we have to get her all tucked in and cozy warm.  Makes sense.

But for her the hypothermia is not therapeutic, had she suffered cardiac arrest, then yes, but late for her dialysis, then no.

So what to do?  Hypothermia seems to be the next big thing, but I'm not sure the effects it will have in my system.  Could we get more people leaving the hospital without deficits from cardiac arrest if we focus on the weakest links of the chain of survival?  Bystander CPR, Public Access Defib and ED CPR quality? (See how I threw that in there?)


The conversation ended with a desire to see all policies and protocols require footnotes showing the research that supports the contents.  Then we realized half the manual would need to be discarded and laughed.  It wasn't a triumphant laugh, but more the kind of laugh when you realize your car was stolen.

As Clinical Supervisor I am tasked with ensuring my crews follow established policy and protocol while acting in the best interests of their patients.

But Justin isn't sure what kind of an impact making the recently deceased shiver will have.  On a cold summer's day in the City we could probably just leave the blanket off and get good results.


Saturday, June 30

Overheard in the Risk Manager's Office

The phone rings while I'm immersed in discussion with one of the field Captains.  A man is asking for help with an elevator.  I get all manner of complaint calls, so this one is a welcome change.

Medical Expert (ME) - "Sure I can help you"

Stair Phobic (SP) - "Yes, I need a copy of your stair ordinance that says how tall a building has to be before it gets an elevator."

ME - "Well, that sounds more like a building code question, have you been to City hall?"

SP - "Yes, but specifically I need to know where it says that you have to have an elevator for the paramedics."

ME - "That would be a lovely addition to the building code, but currently no such statute exists.  Why do you ask?"

SP - "Our elevator has been out of service for weeks and the building owner is taking too long getting it fixed, so I thought I'd remind him that the Paramedics will need it if anyone gets hurt."

ME - "If you're on the 30th floor and get hurt and the elevator is broken, we'll get to you and get you out if we need to, elevator or no."

SP - "But where does it say that?"

ME - "That's just what we do."

SP - "Do you train your people that?"

ME - "Of course."

Wednesday, June 27

Special Call Mobile Surgery 1, Mobile Surgery 2, EMS Surgeon 1...

A nice resource to have if your system is innundated by, oh I don't know, the shaking of the earth until everything falls down.  Especially in a City with water on 3 sides and only 4 trauma


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Saturday, June 23

9 Letters away from a solution - An EMS 2.0 update from San Francisco

I've been going about it all wrong.


Here I was scouring the laws, policies, regulations and statutes looking for a way to get alternate transport vehicles, like vans, SUVs and cars classified as ambulances.

Turns out all levels of regulation are quite clear on what an ambulance (the 9 letters, in case you're wondering) is.

It starts at the State level defining an ambulance (I'm paraphrasing these) as a vehicle modified to accommodate a stretcher and staffed by 2 people, at least one of them an EMT-1 and that meets all local standards for an ambulance.  So that kicks the details to the local EMS agencies.  I'm OK with that, let the communities decide what specifics they need.  Oh, but there is the 2 person standard and the stretcher part I need to change.

The California Highway Patrol has standards for a vehicle to be LABELED ambulance and allowed to violate certain aspects of the vehicle code by using red lights, siren and blocking the right of way etc.  It requires a forward facing red light, distinctive paint, a cot and 2 people.

Dang it.

Then the County Health Code breaks down an ambulance and a routine medical transport vehicle, both requiring cots and 2 people.  This is looking bad.  So far I have to change a state law, a vehicle code and a County Health Code.

The local EMS Agency is specific on the staffing requirements of a BLS and ALS ambulance, equipment for first response vehicles (do all ALS first response vehicles really need a long spine board?) and are also charged with certifying that all ambulances in the system comply to the standards.

I have a huge uphill battle if I want to start transporting people in something other than a 2 person ambulance.

Or do I?

What is surprisingly lacking in all the statutes I'm reading are 2 things:  The definition of a patient, and a definition of what a patient uses to get to the hospital.

It appears the automatic default is that a patient will go via an ambulance and vehicles carrying those 9 letters are well regulated, and for good reason.  But what about when we let folks refuse transport, then they climb in a car and go to a hospital anyways?  Is that drier violating the state law, vehicle code, County Health Code and local ambulance ordinance? Of course not, silly, it's not an ambulance.

It's not an ambulance.

I've been going about this all wrong.  A complete 180 is in order.  Instead of trying to wiggle my solution into a decades old understanding of 9 letters, we could simply exist without them.

This theory applies only to my pilot project of course, the 9 lettered certified ambulances are still meeting all local, state and applicable laws, but now imagine being able to call the company taxi and send the person who meets criteria in something not labeled ambulance and they get the care they need.

Won't someone think about the billers?!

Oh, I forgot to mention 1 little law that does go against my idea: Medicare part B.

Medicare part B is the legislation that looks retroactively and decides if the ambulance was really necessary and reimburses accordingly.  This is the main reason so many systems tell their practitioners not to walk patients to the ambulance like I do.  They're likely not going to pay you for that trip.

So why are we still making the trip in the most expensive, regulated manner possible?

Because of 9 little letters.

Medicare has strict definitions as to what makes a BLS and ALS ambulance and gives subscribers guidelines as to what is and is not covered for reimbursement, even being as specific as to where you are when we declare you dead.  Another reason some agencies transport all cardiac arrest patients.

Turns out the folks who would meet criteria for a retriage to alternate transport wouldn't be eligible to have Medicare cover the bill anyways.  So why not arrange for alternate transportation at far less cost?  It's a cost more likely to be recovered and freeing up the ALS ambulance to find another paying customer patient in need.


I was always told there was a big law somewhere telling us we had to do things a certain way.  And there is, if you want to keep doing things the same way.

There's still a lot of research required and permissions to get, but the biggest blockade to my desire to introduce alternate transport options is gone.

Just leave out those 9 magic letters.

Wednesday, June 20

Patch me through to the patient please

In one of the opening scenes of the disliked NBC series TRAUMA, the medics responding are wearing their headsets and suddenly begin speaking to the 911 caller.

"Oh, yeah...right..." was my first response too.

But think about it.  Imagine being finally able to put the caller in touch with someone other than the call taker.  What if the Paramedic or EMT responding was able to apply their education and experience to decide how the system will react to this patient.

It might become more efficient.

The call is received, the unit assigned, then the caller transferred to the practitioner assigned to respond.  They begin assembling facts that the little boxes of the priority dispatch and the untrained ears of the call taken can't identify.

"OK, so you have asthma, but this doesn't feel like an asthma attack, you just want some albuterol?" There is no code for that other than an asthma attack, but now we can downgrade the call and possibly save a life and time.  Who's life?  Not the caller's they're fine.  But the responders now travelling with traffic reduces the risk of accident.  The call that may come in with CPR in progress can be triaged ahead now that we have a more accurate idea of what's happening at the first call.

We've spent so much time designing systems to categorize, prioritize and automate dispatches we forgot to upgrade the callers and the call takers.  Instead of staffing dispatch with practitioners, why not just let me talk to the patient you're about to hang up on anyway to meet your target time.

I can begin to establish if that little code even matches what's going on, gage my response based on what the caller is telling me and save time in patient care for being ready for exactly what's going on.


We could ditch the codes and just dispatch based on their chief complaint.