Dealing With Downtime

      I should warn you that I find it hard to relax. Just ask my wife. She'll tell you that my idea of a vacation is a to-do list, a half-finished manuscript and wireless Internet. Now would be a good time to feel sorry for her.

   When I swapped my office for an ambulance in 1992, it felt good to get out from behind a desk (and even better to shed the suit and tie). No more factories to manage, budgets to balance or sales to solicit. My goal was to work in a hyperactive 9-1-1 system where I could run calls constantly.

   That didn't happen. After a few months in the field, I had a much more realistic view of EMS: many hours of downtime punctuated by moments of medical madness. I envied coworkers who had mastered the hurry-up-and-wait mentality.

   What do we do between calls? Not much, according to a 2008 EMS Magazine survey. Over half of the 211 respondents listed watching TV, snoozing or goofing off with coworkers as their favorite on-duty pastimes. Only one third of the participants claimed they often engaged in other work duties or training when idle.

   I've had partners who treated downtime as mini-vacations. They felt they were being paid to answer alarms, not wait for them. Each call was a discrete mini-shift; anything else was time off.

   Does it matter how we manage downtime? Yes, if we view our work as cyclical rather than as intermittent. On either side of emergent responses are preparatory and recovery phases that help us maintain a state of readiness. We can't control chief complaints, but we can take ownership of idle time and treat it as a strategic resource.

   Consider the following pre- and postcall activities.

VISUALIZE THIS

   Some aspects of EMS don't translate well in polite company. For example, I'm reluctant to characterize an unstable patient as "good practice" to anyone not in this business, and I'm not going to initiate dinnertime conversation about how the second cardiac arrest of the day usually runs more smoothly than the first. But really, rather than exhibiting apathy or cynicism, these remarks merely contend that prehospital skills are honed through practice.

   I won't waste your time by rehashing studies that correlate performance to experience. That's a tautology well within the realm of common sense. A much greater challenge is to determine how much practice is needed to maintain prehospital proficiency.

   An interesting example of such research is a 1998 Swiss study of anesthesiologists' endotracheal intubation performance. Eleven first-year residents needed an average of 57 attempts to achieve a 90% success rate. Even after 80 tries, two physicians still required assistance to correctly place a tube. In many EMS systems, ALS providers would wait a decade or more to gain that much experience.

   How frequently do you need to successfully intubate to maintain confidence and competence? What about other invasive and diagnostic procedures? Do you get enough reps on real patients in your EMS system? Does your agency offer supplementary training facilities and equipment?

   Suppose you want to work on your technical skills, but Resusci-Randy, Torso-Timmy, STEMI-Steve and all their synthetic soul mates are entombed in a locked (of course) training room. You could try to convince the new guy that a Jamshidi needle doesn't hurt much ... or you could consider a performance-enhancing technique known as mental simulation.

   Defined by social psychologists Shelley Taylor and Sherry Schneider as an "imitative mental representation of an event or series of events," mental simulation can be either a process- or outcome-driven game of "what if"--i.e., we can either visualize the steps needed to reach a certain goal, or imagine fulfilling that goal. Research shows the former is more effective, and that there's a link between imagery and performance.

   How does this apply to EMS? Even without manikins and their bionic accessories, we can close our eyes, visualize a megacode, train wreck or almost any medical scenario, and "see" the steps we'd take to achieve a positive outcome. (Warning: Do not attempt mental simulation while operating machinery that makes holes in things, or while trying to have a meaningful conversation with your spouse.)

   I always use actual cases for mental simulation. There is science to support this. In Brain Rules, author John Medina reveals that "the final resting place (for long-term memory) is also the region that served as the initial starting place." If you want to recall how to do something, try to reconstruct the environment where you first learned it.

   I know I'm doing a good job of visualizing challenging scenes when my pulse quickens and I start to feel the same tension I would on a real call. I find myself assessing the "scene," reviewing treatment options and "practicing" skills. All that's missing are CEUs!

EXPRESS CHECKOUT

   This shouldn't surprise you, but I'm rather particular about how I prepare an ambulance for a call. No, I'm not talking about a custom paint job, stainless steel hubcaps or night-vision goggles. I just don't want to be surprised by, say, an empty O₂ tank when my patient's perfusion is fading faster than the job market.

   I discovered the importance of checklists when I was earning my pilot's license in the late '70s. There were too many "no-go" items to remember while preflighting an airplane. Forget one, and you could find yourself in a very heavy glider.

   The need for orderly preparation is similar in EMS. First, learn what supplies you require and what equipment has to work to minimize the chances of disability, death or destruction. Next, secure critical items in a state of readiness. Finally, give yourself permission to customize your work space--a little. Standing an E tank upright in the center of the cabin just to be closer to it would be like arming an F-16.

   Here are some critical items to consider including in your preshift checklist:

• Airway supplies and equipment: Is the laryngoscope bulb tight and bright? Did the preceding crew replace that 8.0 tube? Do you have an extra stylet? Is the #4 Mac blade submerged in an ED slop sink, or is it in your tube kit? You get the idea.
• Oxygen: When I was a probie, I was taught to replace portable D cylinders when they read below 1,000 psi. I was also told to attach EKG electrodes to the temples of gullible patients. But I digress. A thousand psi of oxygen at 15 lpm in a D cylinder lasts less than 10 minutes--probably not long enough to package and transport any patient whose ventilations you are assisting. Would you rather change that tank after encountering cyanosis, or before?
• Monitor/defibrillator batteries: At the very least, initiate the "user test" option. This will impose a small load (e.g., 10 joules) on the batteries. Even better, charge your unit to the manufacturer's recommended setting for defibrillation, then discharge safely. If you get a low-battery warning, swap the offending energy source. You'll extend the life of your batteries if you recondition them monthly.
• EKG paper: I know what you're thinking: Real medics don't need a static tracing to interpret a rhythm. Fine. Try explaining to an ED attending physician why you cardioverted a patient presenting asymptomatically. There's an easy solution: Change the spool when you see that red streak on the border of the strip.
• EKG electrodes: How many do you need? Three? Six? Twelve? Multiply the leads you apply per patient by the number of unstable patients you might treat consecutively before you have a chance to restock. Add one set for bad luck.
• Dressings: Question: How many 4x4s does it take to control arterial bleeding? Answer: How many do you have? Keep a big, thick trauma dressing close.
• Cervical collars: Unlike ponchos, life vests and ski masks, one size definitely doesn't fit all. A "no-neck" collar on a "regular" patient is strictly for show.

BRAIN DRAIN

   No hard sell is needed to convince EMS responders to eat. The issue is what we eat, and how much. The top priority during downtime is to nourish the brain.

   Gluttons for sugar and oxygen, our brains comprise only 2% of our body weight, but demand approximately 20% of our energy. Brains are so dependent on sugar that they can't activate more than 2% of their neurons simultaneously without exhausting glucose supplies and causing syncope. However, we have to balance the type and timing of sugar we consume to avoid a glucose roller coaster that can impede our performance.

   Think about conscious hypoglycemic patients you've treated. Signs such as confusion, agitation and lack of coordination can be attributed either to low blood sugar or to the sympathetic nervous system's attempt to correct that condition. Dextrose is a quick but temporary solution. Maintaining mental dexterity for more than an hour or two requires complex carbohydrates that don't cause the pancreas to secrete so much insulin that blood glucose is rapidly depleted. "Brain-friendly" foods such as fresh fruit, unsweetened cereals, grains, vegetables and dairy products help prevent sugar highs and lows that can interfere with prehospital care.

   What about that bag of Halloween candy in the ready room that's calling your name? You can slow the metabolism of a sweet snack by satisfying your craving during or immediately after a more substantial meal.

   Speaking of snacking, it's healthier and more realistic for EMS providers to consume smaller portions more frequently than to gobble heavy meals between calls. We burn fat more efficiently and minimize the impact of stress on our digestive systems by distributing our intake.

TACTICAL NAPPING

   Like many of you, I've done time on the night shift. The most difficult part of those assignments for me wasn't the health, family or lifestyle issues accompanying an act so unnatural as working overnight; it was trying to stay awake at 4 a.m.

   My employer had no respect for circadian rhythm--our biological drive to sleep when it's dark and awaken when it's light. If we were caught napping, we could be subjected to counseling, or even termination for repeated transgressions. The logic, as I understood it, was that the job required nonstop wakefulness, day and night, because there was always something productive that could be done. Perhaps so. According to researchers, though, sometimes the most constructive use of downtime is sleeping.

   A NASA study found that pilots who were allowed 26-minute naps enhanced their performance by 34%. The literature documents similar cognitive enhancements, lasting more than six hours, after only 45 minutes of sleep. Also, for those of you working overnight, even a 30-minute nap helps combat the degradation in memory, attention span, quantitative skills and logical reasoning that are signs of sleep deprivation.

   I've been known to go horizontal on a ready-room recliner while watching M*A*S*H reruns through half-open eyes. I stay awake (barely) because I'm afraid of two things: unemployment and the sluggishness I feel when I wake up. The latter, known as sleep inertia, can adversely affect cognitive function and manual dexterity. The longer we sleep, the more we're affected by sleep inertia.

   Is there an ideal nap interval? A National Sleep Foundation study found that 10 minutes of snoozing provided the greatest benefit without any adverse impact of sleep inertia. Other research recommends 20-45 minutes of napping for optimal performance. Any longer than that, and it becomes much harder to wake suddenly in a functional state.

EXERCISING YOUR OPTION

   We know that exercise improves long-term memory, reasoning, attention, problem-solving and abstract thinking. Also, a 2008 Taiwanese study revealed that physically active people have better coordination than sedentary subjects. EMS providers need all of these qualities to excel at prehospital care.

   To address vigorous exercise as a lifestyle issue would be outside the scope of this article. Besides, I have to admit that I'm more of a spectator than a participant in strenuous activity when I'm off duty. Let's focus instead on channeling restlessness toward precall preparation.

   Stand up. Walk around. Wash an ambulance. Sweep the bays. A little activity can help you prepare mentally and physically for your next patient.

POSTCALL CLOSURE

   Sometimes we complicate EMS unnecessarily. Automated patient-care reporting systems that aren't flexible enough to record real-time data are one example. Another is ambulances configured with little regard for how we actually work in back. We could devote an entire article to either of these aberrations. However, since the topic here is downtime, let's focus on a worthwhile postcall activity that could use some simplification: acute stress relief.

   I'm not a big fan of CISM. I found it inflexible, with confusing rules about when to speak and what to say. Even the name--Critical Incident Stress Management--sounds too regimented to me.

   I'm not the first to question the effectiveness of CISM. In a 2006 poll by the British Psychological Society, post-trauma counseling was voted the third-worst "idea on the mind" ever, behind prefrontal lobotomy and the chemical imbalance model of mental illness. The author, Dr. Christian Jarrett, cited 16 studies showing that "psychological debriefing after a trauma definitely does not work, and in fact probably increases the risk of post-traumatic stress disorder."

   EMS author Bryan Bledsoe, who has commented at length about the danger of customs based on anecdotal, rather than quantitative evidence, characterizes CISM as a "poster child for pseudoscientific practice." Bledsoe recommends "resiliency-based strategies" that mitigate stress before and after critical incidents. "What most people need in a stressful situation is information," Bledsoe says. "Provide accurate information as soon as possible."

   Doesn't this sound like an appropriate, occasionally emergent use of downtime? Who better to offer psychological first aid to stressed-out EMS personnel than coworkers? We shouldn't demand dialogue from our ailing colleagues; just be available when questions or concerns arise.

   When I participate in conversations about difficult calls, I try to focus on three Rs:

   Review: After a stressful event, victims should have an opportunity to express thoughts and emotions. The participants, timing and agenda should remain flexible. According to above-mentioned studies, sooner is better than later, and peers are frequently helpful. If you weren't involved in the critical incident but find yourself in an after-action forum, your first priority is to listen. Don't try to impose structure on the discussion or compete by adding war stories of your own. Eye contact and an "open" posture (e.g., arms unfolded, legs uncrossed) are helpful.

   Reinforce: As you listen, try to recognize elements of the story that are consistent with your own experience. Perhaps you've encountered a scenario similar to the one being described, or experienced some of the same feelings. Look for opportunities to validate concerns you're hearing with brief expressions of empathy. Be supportive, but don't patronize the speaker(s) with trite homilies. If you can't think of anything positive to say, keep listening.

   Relax: Your goal isn't to "cure" victims, but rather to facilitate a decrease in tension, even if it's only temporary. There is no generic timetable for resolution of anxiety; people handle stressful events in different ways.

   I'm no expert. You should consult one if you or someone you know might be suffering post-traumatic stress. Your agency can help by offering individualized professional counseling.

PREPARE TO CARE

   The cyclical nature of EMS demands conscientious allocation of resources before, during and after alarms. Effective management of downtime can be as important to your agency as vehicles, equipment and staff. More important, your patients benefit from a not-on-my-watch mentality that, between calls, prompts the question, "How can I best use this time?"

   I promise to ask myself that again--as soon as I get back from vacation.

   Acknowledgment: All the sources cited below were helpful, but the author wishes to highlight John Medina's Brain Rules as a particularly enlightening work.

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Mike Rubin, BS, NREMT-P, is a paramedic in Nashville, TN, and a member of EMS World’s editorial advisory board. Contact him at mgr22@prodigy.net.