Fifty Thoughts on Fifty Years

Many believe Johnny and Roy represented the beginning of EMS in America. While Emergency! probably did more to advance public knowledge of EMS than anything prior, our profession was already developing. My role models as a child were Skip and Wes, the rescue squad members who starred from 1958–60 on Rescue 8. While the care they provided was primitive by today’s standards, they were consummate professionals who provided excellent service based on common sense, ingenuity, and compassion. 

At the time rescue squads were developing around the country. Training largely consisted of standard and advanced first aid, yet efficient emergency care was provided in many communities. Much of my early training, beyond first aid certifications, came from these “rescue men.” I became an EMT at the end of 1971, two months before Johnny and Roy hit the streets. The county where I lived was already providing ALS care, and we had the benefit of learning from those early providers. The county where I went to college and spent more than 20 years of my career did not have ALS until 1978. I credit those first seven years of BLS with providing a firm foundation that made me a more effective advanced provider. 

After five decades it is time I finally commit to writing much of the “wisdom” I have accumulated over the years. These are just my personal thoughts and observations; it won’t hurt my feelings if you disagree. Any resemblance to individuals is purely coincidental, as this writing is a composite of what I have experienced. 

1. If you want to be good at this, learn to create molehills out of mountains. There will be plenty of folks around you trying to do the opposite. 

2. There are four parts to a good provider: 1) knowledge and ability, which you must constantly strive to improve; 2) common sense, which will help you figure out things that aren’t in the textbook; 3) the ability to keep your head on straight when the time comes to perform; and 4) a good attitude, a lack of which can negate the other qualities in an instant. 

3. Develop a broad pair of shoulders that are slightly beveled to allow stuff to run off. Even when everything is done correctly, outcomes may be predetermined and not always happy. 

4. There are supervisors who will demand respect. That cannot happen. You can demand obedience, but you have to command respect. Demanding obedience generally reflects poor management. 

5. There is a saying that you should never criticize a man until you have walked a mile in his moccasins. That is good advice, but a corollary should remind you to never forget what they felt like on your feet. Too many higher-ups feel having been there and done that, even years before, is adequate justification for criticism of actions that differ from their ideal. 

6. Your first priority is always yourself. You are the only person with whom you must spend the rest of your life. On the other hand, while taking care of yourself, making a priority of caring about and treating other people well leads to a life well lived. Be especially cognizant of the subtle slide from caring and compassionate provider through compassion fatigue to burnout. 

7. Your next priority must be your patient. Working in their best interest will make you a better provider. You are then obligated to your partner, providing they do not go astray of morals or professional ethics, and next to maintaining the highest standards of your profession. Your final obligation is to your organization, and that should be a two-way street. 

8. With economic fluctuations, I have often heard people say they are lucky to have jobs. What many employers overlook is that they are often luckier to have certain people as employees. Consider whether you’d want to be a patient in your own system. 

9. I would love to attribute this quote, but it is not mine, and I received it third-hand: “You can take great employees, highly trained and motivated, and place them in a lousy organization, and the organization will always win.” 

10. A well-run agency will be guided by the principle that it only has one real asset that matters: its personnel. Does management support its personnel or sell them out the minute an issue arises? 

11. The single worst problem I have seen over my years in the business is inbreeding, when an agency solely develops and promotes personnel from within, often with in-house training and certification at all levels. When you hear “This is the way we do things here,” be very concerned about becoming part of a dysfunctional “family.” Try to ride with various agencies during your training—as a provider you can learn both good and bad habits from almost every agency and colleague you encounter. 

12. Watch out for dysfunctional agencies that analyze or postpone changes to death. 

13. Leadership has vision and looks to move forward while management often looks back and tends to fiddle with what and who it has. Be open-minded and forward-thinking. 

14. Want a simple way to demonstrate leadership? Catch people doing something right and let them know. Too many managers do the opposite. 

15. Create a culture where employees feel free to report errors. If employees are more worried about being reprimanded than fostering improvement, progress may be stifled. 

16. When errors occur attempt to narrow down causes. If a lack of guidance exists, creating a guideline or protocol may be required. If the issue is lack of proper understanding, training and education may help. If actions are deliberately contrary to expected norms, some degree of attitude adjustment is indicated. Ensure the punishment fits the crime and is based on established policies applied to all. 

17. Many years ago I was told there are two kinds of people: tractors and fields. Fields just lie there and eventually get plowed under by the tractors. Strive for something. 

18. Keep in mind that a call is not your emergency, while also remembering it is probably the worst day in your caller’s life. 

19. Be leery when you see the words studies have shown. One of my favorites is that the use of lights and sirens only saves a few seconds. Where? When? I have responded in areas with 70 mph highways where traffic passed me and also ones with traffic signals that can be red for up to 2½ minutes. Assuming 15 seconds to stop and proceed safely, it seems to me L&S could save up to four minutes on a half-mile run with two of these intersections. On the other hand, the vast majority of transports should be routine and nonemergent. 

20. Speaking of emergency driving, it’s probably the most dangerous and potentially lethal part of the profession. The main purpose of lights and sirens is to keep you moving at a steady speed, not to race and stop continually. Give those folks around you time to recognize and react. 

21. That big mechanical siren may seem cool, but the electrical system on your vehicle probably has a different opinion. If you have one, however, holding your foot to the floor does not make it better heard out front or more effective. 

22. Electronic sirens have been around for over 60 years, and so have the basic tones of wail and yelp. The constant up-and-down wail tends to travel forward the best, while yelp bounces around intersections well, and the change of tone often gets attention. Any other tone added over the years is pretty much a waste of output to give an impatient provider something to play with en route to a call. 

23. Formal uniform shirts, especially with metal attachments, are not necessarily comfortable or conducive to good care. Looking like a slob does not project the image we seek either. Many agencies have switched to high-quality and attractive polo shirts that have all needed information embroidered right on, resulting in a professional yet practical outfit. 

24. My early career was spent in Cadillacs and Type 2 conversion vans. Then came Type 1 and 3 boxes that somehow grew to even larger medium-duty trucks, because we supposedly needed the added weight capacity and storage space. Despite all these advances, we still predominantly transport one patient at a time, but with lousier-riding vehicles that often have less leg room and maneuverability. 

25. Now that we have so many larger trucks, do your people get to ride around in circles all day because a computer program determines an allegedly better place to be? Dynamic deployment has some response benefits, but there are many detriments to being in a cramped passenger compartment for hours. 

26. While having objective classifications of severity can be beneficial, there are shortcomings. My favorite example was an alpha call for a “catheter problem.” Our response time was in excess of 20 minutes, and we finally arrived to find an incredibly pale and diaphoretic patient clutching her groin. She was markedly hypotensive and bleeding from a cardiac catheterization puncture a day earlier. 

27. One of the best enhancements to vehicle warning and safety came in the form of LED lights. Then some folks decided we could mount dozens of them per vehicle and make them flash in multiple patterns. Take a good look: Do your “dancing LEDs” present a pattern that is easily followed and conveys its intended warning, or are they merely a light show? 

28. Be careful with absolute rules. If your rules say providers should not exceed posted speed limits by more than 10 miles per hour and something bad happens while they’re going 11 over, they are automatically violating a policy and potentially adding liability. 

29. The golden hour and platinum 10 minutes are great guidelines to remind us that severe trauma is fixed in the operating room, not the field. On the other hand, if it takes 12 minutes on scene to provide better care that will potentially reduce morbidity and mortality, that’s more valuable than the time you’ll spend writing your explanation for the extra two minutes of scene time. 

30. Your provided equipment might include the cheapest stethoscope available. Once you learn proper auscultation and differentiation of lung sounds, a good stethoscope becomes an invaluable tool that is also useful in obtaining an accurate blood pressure. 

31. Use your senses to do a good assessment. All your nifty and expensive diagnostic equipment does not take the place of a proper history and physical. Feel and assess pulses for rate, quality, and regularity. Think of PEA—a monitor rate does not necessarily equal a pulse rate. Auscultate lungs upper and lower, anterior and posterior, left and right, and listen directly to skin, not through clothing. By the time you hear rales in the upper anterior lobes (the common site for shortcut assessments), it is probably too late to matter. 

32. Your patient is almost never five minutes from care. Do not use proximity to your receiving facility as an excuse for shortcuts. The better question is, “How long will it take until this intervention can be done in the hospital?” 

33. The corollary to the above is that unstable patients generally require urgent care in an operating room or specialty lab. Do not waste time with non-lifesaving interventions that might delay definitive care. 

34. As care has evolved, so must our operations. Most calls are not life-threatening emergencies, and a quiet, uneventful transport to the receiving facility is indicated. Talk to your patients during that ride—their well-being is more important than your tablet. 

35. Is your “airway bag” pregnant? We used to carry enough supplies to care for a patient on scene, often in multiple smaller bags. Then along came the “super” trauma bags where, much like our vehicles, we decided to carry a lot more stuff just in case. Split your equipment and take better care of your backs, elbows, and knees. 

36. Do something good for your patient, but don’t try to do everything. Just because a guideline allows you to perform an intervention does not mean you must or even should. 

37. Always be an advocate for your patient. This includes after your arrival at the ER. Until someone else assumes care, the patient is your responsibility (not always legally, but certainly ethically). 

38. Some things do not belong in patient compartments. Turnout gear and air packs that have recently seen toxic environments may not be good for you or any immunocompromised patients. Your personal items and food also do not mix well with pathogens. 

39. I really miss the prebilling days. In my fire-service days, we were a tax-supported agency that was prohibited from billing for transport. By my next professional life, I was sticking pieces of paper in front of patients to sign that they often didn’t read or couldn’t understand. The short version was usually, “This allows us to release information to bill your insurance company directly.” There was an awful lot of Unable to sign due to… Yes, crackdowns on this may lead to reimbursements being questioned, but it’s about the patient. 

40. There have been a lot of studies on automatic CPR devices, with varied outcomes. From my experience, some are simpler to apply than others and more easily applied to some patients, often due to size and position. Once properly applied, however, the newer generation of devices seems to be far more consistent on a moving target than manual methods. 

41. There has been much controversy over prehospital intubation. Experience leads me to believe that in the hands of an experienced provider, intubation, where patient parameters are easily monitored, still affords the best airway control for respiratory emergencies. On the other hand, endotracheal tube placement may interfere with good compressions in cardiac arrest. My reasoned logic for cardiac arrests is to begin immediate, uninterrupted compressions; rapidly apply pads and deliver prompt defibrillation if indicated; then insert a supraglottic airway and deliver asynchronous breaths while carefully avoiding overventilation. 

42. Avoid patient refusals. The patient usually called for a reason. In most cases that should result in transport. 

43. Treat your patient like a family member. Humor is great to keep things light. Many of my calls were like rolling Seinfeld episodes. 

44. Accreditation may be a positive move for an agency. Make sure you meet the same standards all year long. I have seen agencies ensure that they cross all their Ts and dot all their Is in the weeks leading up to an inspection, only to revert back their usual operations immediately following. 

45. The best way for providers to know if they made the correct choices is through proper feedback. The single most important piece of information to learn from is the admitting/discharge diagnosis versus the presumptive field diagnosis. 

46. Some time ago I spent several days in the hospital and then rehab with a family member and made a few observations. About half of all providers seemed competent, and about half appeared to really care about their patients. Unfortunately, combining these led me to calculate that maybe as few as one in four presented as a competent and caring provider. I imagine similar ratios exist among prehospital providers. Be better than that. 

47. In this era of scientific evidence, be concerned with misleading statistics. Nobody will ever see 50% overall survival rates from cardiac arrests—claims of extremely high rates are often based on witnessed arrests with bystander CPR and shockable rhythms with AED use. While you are focusing on cardiac arrests, remember we also save lives through timely interventions such as CPAP, prompt diagnosis and appropriate transport of CVA and STEMI, and proper triage and transport of trauma. These are a larger part of our business, and not everyone has them down pat. 

48. CPAP is one of the best tools we have to make an immediate difference in patient outcomes. Once it became available I never had to intubate another CHF patient with acute pulmonary edema. Keep in mind that intubation and a ventilator are often a one-way trip. Try to have an adjustable device or options available, as many COPD patients will do well with lower pressures than those suffering from CHF. Also, if you have not figured it out by now, start at lower pressures and let the patient initially hold the mask themselves. After they adapt strap the mask on and adjust the pressure. 

49. If patients have become an inconvenience to your workday, it may be time to change professions. Do not blame them for your bad attitude—support them. 

50. “You who are on the road must have a code that you can live by; and so become yourself because the past is just a good-bye.” Graham Nash wrote these lyrics when EMS was more of a concept than a reality. The words are also printed in my high school yearbook. They were good advice back then and remain sound principles to live and work by today.  

Lew Steinberg, MPA, NRP, has been involved with EMS since 1971 and is still certified as a firefighter, paramedic, and instructor of many disciplines. He is a former fire chief and besides the prehospital environment has worked in both the emergency department and outpatient surgery settings. Reach him at ffpmlew@bellsouth.net.