People Care

This is the best book any EMT can own.

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

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

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

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

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

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

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

Helping

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

Carolyn Delaney

Not too many people know about Joe Delaney anymore.

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

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

His claim to fame was something different.

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

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

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

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

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

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

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

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

But then there’s Joe Delaney.

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

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

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

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

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

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

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

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

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

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

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

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

Good Partners

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I recommend these basic rules:

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

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

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

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