Valuable Lessons Learned at EMS World Expo 2015

Ed's Note: Mark Your Calendars! EMS World Expo 2016 is scheduled for October 3–7 in New Orleans, LA. Visit EMSWorldExpo.com for more information.

Despite it being my first time in Las Vegas, the content at EMS World Expo 2015 was more than enough to keep me off the strip and in the convention center—and not just because they had doughnuts on the salad bar.

On Wednesday afternoon I was able to drop in on parts of two all-day pre-conference sessions being led by two of the smartest Daves in EMS.

First, I watched Dave Page and Heather Davis discuss how to use scenarios to help students develop psychomotor skills and prepare for practical exams. Page, a paramedic and educator in Minnesota who was recently named director of the Prehospital Care Research Forum, was telling the dozens of educators in the room that practical training needed to be as realistic as possible. That included encouraging students who weren’t the “lead” to still speak up.

“We have to inculcate that culture in which everyone is responsible,” Page says.

Page and Davis also emphasized the need to stop students and point out their errors immediately, instead of waiting until the end of a scenario.

“We don’t want to reinforce it, so we stop them and correct it,” Page said.

Scenarios also needed to reflect real life and test medical procedures and communication and empathy, Davis said. 

One of the highlights of my time in the workshop was when the educators in the room were asked to develop a scenario and then run some local EMT students through it. Seeing the look on the students’ faces—they had thought they were at the class to serve as patients, not to be tested—made me glad not to be the ones being watched by EMS instructors from around the country. But it was a great experience to watch a teaching scenario and then evaluate the performance of the educators, not the students. It’s something we need to do more—educators need to study, innovate and adapt their practices as much as practitioners do.

Improving Performance

Speaking of innovating and adapting, I snuck out of the first workshop and joined the EMS leaders who were discussing performance improvement with Dave Williams. Williams is a former paramedic who now consults with EMS agencies and other healthcare entities, helping them with quality improvement. 

While at times improvement science can seem overwhelming, Williams explained it in a way that made sense. He also explained that we are often too busy trying to find a perfect solution or fighting over whose ideas are better. 

“People spend a bunch of time trying to come up with good ideas instead of just putting them all down,” Williams says, arguing that it’s easier to sort the good from the bad after brainstorming. 

Similarly, organizations often look for perfect solutions and fight over whose idea to use rather than testing them on a small scale to see if they actually work. Instead of implementing untested solutions across entire organizations, ideas can be tried on a very small scale, Williams says. If they work, they can be tried again on a slightly larger scale. If they don’t work, testing the ideas still validates the person who proposed the idea and sometimes provides lessons that can be applied to other innovations.

Starting small in EMS means testing a process on one patient, or with one crew or shift, and then maybe trying it with five crews, then more, and so on. Williams described the “Plan, Do, Study, Act” cycle, and used a simple quiz (available here) to demonstrate the importance of trying to disprove theories and ideas, rather than always just trying to prove they work.

The Impact of Stress

While the effect of stress on the long-term health of EMS providers has gotten more attention lately, we often ignore the impact that stress has on our day-to-day decision making during emergency incidents. In a fascinating and standing-room only session, Maine EMS educator Dan Batsie presented evidence showing that our ability to function is hindered by the stress that naturally occurs on critical incidents. Fortunately, he also gave us some tips on how to prevent that stress from negatively impacting our patients’ and our own safety.

Some of that stress comes from the expectation—from ourselves, our peers, and the community—that we will be able to help in every situation. The need to act sometimes compels people to act without thinking through the consequences. 

“I think these are the most dangerous words in EMS: ‘Just do something’,” Batsie says. “This is when accidents happen. This is when people get hurt."

Batsie described the physiological changes that occur during stressful situations, such as critical incidents. Decreased fine motor dexterity, tunnel vision, reduced cognitive processing abilities and auditory exclusion are just some of the evolutionary adaptations that help humans escape dangerous situations but harm us when we are trying to treat patients and stay safe on scenes.

“Our body doesn’t distinguish a lion from a critical baby,” Batsie says. “It just says ‘Fear. Anxiety.’”

Batsie argued that EMS education needs to more realistically mimic some of these stressors, so we can learn to adapt to them. He gave an example of a class he was teaching when he had asked some other paramedics to rush into the room with an infant manikin, interrupt the course and scream for help. Even he was caught off-guard when it happened, having forgotten he had asked them to do it—and some of the students froze, unable to respond to the situation.

Other methods of dealing with this stress include teamwork and crew resource management, checklists, and breathing exercises. Simply recognizing the impact that stressful situations have on your body and your brain will help.

“I don’t care how good or how skilled you are, this stress is waiting for you,” Batsie says. 

RSI “Time-Out”

Another way to prevent stress from causing medical errors was presented by Kevin Collopy, a paramedic and educator from North Carolina, in his session on taking a “time-out” prior to rapid sequence intubation (RSI). The time-out approach is similar to what is happening in operating rooms in order to prevent wrong-site surgeries and other medical errors.

For an RSI, Collopy suggested taking just 30 seconds to pause and go over a checklist with the entire team prior to starting the procedure, which involves sedating and paralyzing a patient prior to intubation. The checklist included ensuring someone was keeping an eye on the patient’s pulse oximetry levels, having suction and alternative airways ready, and other important preparations.

Although there was skepticism when Collopy rolled out the idea of a pre-RSI time-out and checklist in his agency, eventually it caught on. He followed the advice I had heard earlier from Dave Williams and tested the concept first before making it part of the protocol. 

“We had to go through changes in the process,” Collopy explains.

The testing process allowed for input from the providers in the field who would eventually be using the checklist, so it also gave them a chance to be a part of its development. Collopy felt that involvement helped develop buy-in. While the data is still early and the sample size small, Collopy showed that first-attempt intubation rates and overall airway management have improved.

Professionalism in EMS

Switching to a less clinical topic, I stood in the back of the room during a packed talk on professionalism from Ray Barishansky, state EMS director in Connecticut. Barishansky facilitated a discussion with the audience on what it means to be professional, ranging from appearance to attitude.

Telling a story from his days as an EMT in Newark, NJ, Barishansky recalled a night when he had a patient ask if another provider could treat him instead.

“People can sense when you’re empathetic,” Barishansky says. “And they can also sense when you lack empathy.”

One of the most interesting parts of the talk came when he discussed the people who work at the fish market in Seattle. Several years ago, an observer noted the attitudes of the employees there—who spent all day surrounded by large, slimy, smelly fish—and developed a business philosophy around them. Yet they always appear to be having fun—and more important, the customers are having fun.

“We choose our attitudes,” Barishansky explains. “They put all of their attention into making every customer service interaction enjoyable.”

Professionalism also includes doing everything we can to protect our patients and our communities, so I also attended a moving session on ambulance safety with Brian Lacroix, president of Allina Health EMS in Minnesota, and Noah Smith from the National Highway Traffic Safety Administration (NHTSA) Office of EMS.

If you missed their session, or even if you were there, be sure to check out the articles they wrote for the September issue of EMS World: A Profound Impact and A National Perspective on Ambulance Crashes and Safety. After reading the articles, it was a thrill to see one of the Allina paramedics in the audience who was involved in a horrible ambulance crash last year. While his recovery has been remarkable, we need to do everything we can to ensure that others don’t have to go through what he has 

As often happens at conferences like EMSWorld Expo 2015, there is so much great content, and I couldn’t attend it all. While I listened to Lacroix and Smith talk about the importance of properly seatbelting our patients and ourselves, Ed Racht—the chief medical officer for AMR and one of my favorite speakers—spoke about leadership in the room next door. So I sent one of my colleagues to bring me back some nuggets of wisdom.

“There’s tremendous leadership value in knowing and understanding the contemporary issues in EMS,” Racht says before delving into some of the critical issues facing EMS today.

Although I was not able to attend the session, I think these words from Racht are important. While sessions on professionalism and leadership often cover issues like attitude and accountability, the most critical aspect of being a professional and being a leader is continuous learning. To be a leader in EMS, you should be reading about EMS every day. Not just the crazy headlines about overturned trucks and animal attacks, but also peer-reviewed studies. If you think what you learned in EMT or paramedic class is enough, or you refuse to accept that some things we considered tenets for decades may have been wrong, you can’t be a leader.

I was honored to speak at a session with two leaders in EMS who understand change. In a session on response time as a performance measure, I introduced doctors Alex Garza and Jay Fitch. Garza spoke about the culture that EMS helped create by telling everyone to call 911 for emergencies—but then not educating the public on what an emergency actually is. Fitch spoke about the politics of response times. In many places, it costs several million dollars to decrease response time by adding ambulances and personnel, yet we are often more willing to do that than to spend much less on training and protocols for dispatchers or a good quality management system—both of which can help ensure we are getting the right resources to the right patient in the right amount of time.

In the airport, waiting for my flight back to Washington, I overheard another EMS World Expo 2015 attendee talking about how energized he was to return home and make some changes based on what he had learned. While getting your continuing education hours and having a little fun are both great bonuses, this is what conferences like EMS World Expo 2015 are really all about: sharing new ideas and inspiring leaders at all levels to make EMS systems better.

Michael Gerber, MPH, NRP, is an instructor, author and consultant in Washington, DC. He is also a paramedic with the Bethesda-Chevy Chase Rescue Squad and previously worked as an EMS supervisor for the Alexandria (VA) Fire Department. Gerber has experience as an EMS educator and quality management coordinator and has presented original research at state and national EMS conferences. Reach him at mgerber@redflashgroup.com.