Thursday, January 28

Hey Board of Supervisors, You're Remembering the Wrong People

The San Francisco Board of Supervisors have unanimously approved a "Day of Remembrance" for a man shot and killed by Police after harming another person with a knife and threatening to do it again.

The day will be July 22nd, what would have been his birthday.

They must, since the cast has been set, immediately announce April 9th and August 14th as Days of Remembrance for my friends Lt Vincent Perez and Firefighter/Paramedic Tony Valerio who died in the line of duty following a fire June 2, 2011.  Vince died that day, Tony 2 days later.  You can remember them on either of those 2 days also.


January 13, 2003 I was working when Mindy Ohler died in the line of duty.  Where is her day of remembrance?


Or how about I remind you of the night I was working the ambulance when a sea of blue flooded into the trauma center escorting a stretcher carrying murdered SF Police Officer Issac Espinoza?  That was April 10th 2004.  His then toddler daughter is probably old enough to hear your excuse for remembering a criminal instead of her hero father.  Where is his day of remembrance?


Dismiss it as "Liberal San Francisco" all you want but this is a slap in the face to the firefighters and police officers who have stood in front of these law makers and said "I'll put my life in harm's way to protect you" now being pushed aside to honor a criminal.


What this day of remembrance tells me is that if I want to be recognized by the local law makers I shouldn't learn CPR, take my turnouts to work, earn a badge and patrol the streets, I should just go stab someone and threaten police.


Here's a list of more people who deserve a day of remembrance more than the criminal being honored.  Here's another one. I am sorry that a human being died.  I wish SFPD had other methods of dealing with armed criminals, but those issues are separate.  I'm not challenging the manner in which he was killed, I am challenging that we are honoring him and not others who made the ultimate sacrifice to protect people instead of hurting them.


On July 22nd I will not remember this criminal or speak his name, as I have not here, instead I will share stories about my friend Tony and Mindy and Issac the Policeman with my children so that they will grow up remembering people who matter instead of the random folks some law makers think are important.




Tuesday, January 19

the Crossover Show - Episode 38 - How not to Get Tazered

Your heroes are back and better than ever (which isn't really saying much, I know).  This week we fire up the internet's only Fire, Police and EMS podcast to bring you a discussion about a Michigan man tazered by Police at the scene of his father's death and how a combination of family planning and verbal de-escalation could have been beneficial.

We also discuss MC's sudden fascination with the height of noted thespian Jake Gyllin...giliyn...damn...Maggie's brother and how there's a whole podcast devoted to mysteries just like this one.


Don't forget you can support the Crossover Show by visiting and don't forget to rate the show on iTunes!


Have a listen:  EPISODE 38

Sunday, January 10

the Crossover Show - Episode 37 - What Makes a Good Chief?

crossoverlogo300Do you know a cop’s cop? How about a firefighter’s firefighter?

Do they have what it takes to run the department? Or are the two mutually exclusive?

In this week’s episode, HM and MC talk qualifications. Not pedigree or talking points, but real honest-to-goodness requirements for the head position in any of the three disciplines.

Can a Chief in one of the three disciplines just walk into the Mayor's office, bang a rock on the desk and get results?  Is a "My way or the highway" mentality healthy?  Where is the line between Supervisor and Administrator and why isn't a good Supervisor automatically a good Administrator?



Saturday, January 9

Johnny and Roy lied to me - I write receipts

I was watching some episodes of Emergency! for an upcoming presentation and I began to notice something.

Johnny and Roy lied to me.

All those years watching Squad 51 wandering from rescue to rescue, to Rampart and to the station I wanted to be there with them.  I wanted to hang out at the table in the morning, chat with Chet while he and Marco cleaned the fittings on the engine.  I wanted to wear my helmet all the time and watch the cops do the same and stand nearby while I worked.

However, there is a HUGE part of EMS that Johnny and Roy never even mention, let alone complete.


Not 1 PCR is completed.


Folks call for help, help is delivered, then they go away.

Turns out that is what I like best about the show now.  It isn't the rescues that always seem to go perfectly (as soon as Truck 110 shows up). It isn't Chet's bad jokes or Mike Stoker's ability to follow the Squad up the street, it was doing the job, then leaving.

It got me thinking.  Are we writing Patient Care Reports or are we preparing receipts?

No ER in my 20 years has ever even looked at my PCR, even when my daughter came in on an RN IFT car the PCR never made it to her chart.  We have created laws, policies and guidelines that are remarkably strict on what MUST be included in a PCR, but is it really just to document patient care?  If so, can we streamline it to actually address care?

As CQI for years I was tasked with confirming that the care in the field matched the policies.  I can say, unofficially, that it did overwhelmingly.  There were no documented medication errors, but since the author was the one to make any errors, would they really not fix it in the document?  No, most issues were clerical, not clinical.  The formatting of the report existed simply for oversight and review, statistical reporting and, most importantly to the organization, billing.

Next time your charting takes longer than your patient contact did, think back to Johnny flirting while Roy listens to the radio and wonder how we got from there to here.

Wednesday, January 6

Defining System Abuse - A Response to Ambulance Chaser

In his self described musings Ambulance Chaser, both a Medic and a Lawyer, brings up some great topics we seem to kick around but never want to dive into.


Recently he wrote about system abuse in EMS:

"System abuse.  That’s a term we commonly hear in EMS.  And as soon as we start talking about system abuse, the talk invariably turns to EMS providers’ favorite solution for system abusers.  Namely, the idea that EMS providers should be able to refuse transport to system abusers."  You can read more at the link above.

EMS providers should most certainly be able to refuse transport to system abusers, following a complete assessment, of course, but not in the way you think.

AC, as I'll call him, goes on to state what many already know, that EMS abuse is hard to identify and even harder to act on.  He makes good points that we need to first raise the education standards, thus raising the quality of the average provider, but there is a real solution to EMS abuse when we finally pull the sheet off of it.

Trouble is, the sheet is different sizes and shapes in many communities.


We all know the EMS abuser who calls 911 when they want their window shut.  No chief complaint, no medical condition, just an elderly woman living alone who can't reach the window.  She calls 911, uses the buzz words and knows your refusal speech by heart.  Is she abusing EMS?


Do we refuse her care?

Absolutely not.

Should we refuse her transport?

If she asks and has no need of it based on our assessment, why not?

When responding to these kinds of calls we need to begin to assess the surroundings, not just the patient and yes, she is a patient until your assessment reveals otherwise.  Is the milk in the fridge in date?  Is there a decent amount of food?  Are the bathrooms sanitary?  Is it possible that there is a living condition we can improve on this brief stay that will solve her problem without a 911 activation next time?  These are the questions we need answered, but too many folks will never consider it, they'll simply get upset they don't get to cardiovert someone and stomp away, leaving the problem right where they left it.


Chronic homelessness plagues my response district, with the most common call being "Man down, 3rd party caller."

An Engine and ALS ambulance are sent lights and sirens for a person sleeping.  Is this EMS abuse?

Nope.  Dude is just trying to get a nap in on the sidewalk when someone called 911 from a block away.

This is a flaw in the 911 system that values the call processing time over the information gathered on that call.  This is also why so many calls here start with "...for the code 3 Medical, unknown..."  Well, radio, just tell me what they told you and code it later.


The other side of the homelessness issue are those who call 911, lie to get a fast response, then seek out other services.  This is EMS abuse.  Knowingly activating the system without intent of care is EMS abuse.  We encountered just such a patient when filming Chronicle of EMS back in 2009.  She told 911 she had chest pains, got the fast response, then wanted to nap in the ambulance and the hospital, no medical complaint whatsoever.  Should I have been able to refuse transport?


Instead, because of policy and a misunderstanding of the word "liability" I was required, by law, to take her to a cardiac cath capable receiving facility.  That bed needs to remain open for someone who needs it.  AC mentions this trouble when he says he is afraid of the average provider messing up this privilege to refuse transport.  I agree to a point.  We let them drive the ambulance, right?  I'd say that is far more dangerous than refusing transport to those who an assessment finds will not benefit from pre-hospital care.

And since we're big on the blame game in EMS, let me tell you exactly who to get upset with:

The mirror.


We are the reason EMS abuse exists and the #1 cheerleader for it to continue.

We focus on merit badge classes that rephrase the same information from 20 years ago with the occasional paragraph about a major change we all suspected anyways.

We sensationalize the rare and ignore the mundane.  When was the last time your department held a ceremony with the 8 year old girl who used her inhaler properly, thus preventing the need for an ALS response?

We promise our young new hires lights, sirens and adrenaline, then get confused when they commit suicide following emotionally traumatic scenes.

Our training focuses on little boxes to fit patients into and rarely allows us to look outside those little boxes for solutions for fear of the Medical Director's rage and a loss of our 120 hour certificate from the local college.

Addressing EMS abuse must be a priority!

Our goal as EMS providers must be to answer calls for service and do everything in our power to identify the root cause of that call and take action to prevent it from happening again.  It is the same for a choking, cardiac arrest, abdominal pain and, yes, the toe pain at 3AM.

Folks don't call 911 to get their meds refilled because that is what they WANT to do, they do it because someone, somewhere failed to teach them about what they are taking and how to get more.  Be the solution.


The future of EMS doesn't have room for folks just running calls.  We are on the front lines of medicine and, as such, have an enormous responsibility to prevent as many 911 calls as possible.  Only with a reduction in non emergency calls can we begin to focus on advanced assessments and "respond, not convey" a remarkably successful program elsewhere in the world I saw first hand in England that flat out told people, "no, you're not getting an ambulance" then solved their problems in other ways.


So why won't it work?  Why hasn't it worked?

Well, in some places it is, and very well, but when the service you work for calls you in because your refusal of transport is below the company average, their priority is billing, not health care.


Ambulance Chaser is right to bring up EMS abuse and commenters on the post have varying opinions on EMS abuse, but it is indeed easy to define and address.  However, there can not be 1 solution for everyone, we need to pick and choose from other successful programs and see what works for our own communities.


We call it "Adopting best practices."

Saturday, January 2

the Crossover Show - Episode 36 - Perception vs Reality

crossoverlogo300In this, 2016’s very first episode, MC and HM talk about MC’s personal burr under his saddle: Perception and Reality.

If you’ve heard it once, you’ve heard it a thousand times, “Perception is reality.” The guys address this idiom through the lens of a (not really so) recent Chicago PD shooting.

On a side note, both HM and MC (along with their respective brides and families) wish you a Happy New Year!

MC and HM hope you’ve enjoyed the 36 episodes they brought you in 2015 and that you look forward to more entertaining and educational content in 2016!


And don't forget to visit our sponsorship page where you can become a patron of the show and help us keep it going!