Doing The Right Thing

Last week, several EMS friends and colleagues asked me to look at the recent Kentucky case on EMS liability. Obviously, as a lawyer, my first and foremost answer is always going to be “it depends.” I’d also remind you that even appellate cases are incredibly dependent on the facts of the underlying case and the law in the relevant jurisdiction. If you’d like an in depth analysis of the case or how your organization can learn from this case, get in touch with me. I answer legal questions for a living, ya know?

Having said those disclaimers, though, there are a few things that stand out to me and bear discussion.

First and foremost, it’s quickly glossed over that the medics in question didn’t check their monitor and possibly not even their equipment. There’s no record of the daily check on either in this case. And the monitor failed to defibrillate when it needed to. As my torts professor at Texas Tech University’s School of Law used to remind us, “If there are damages, you must pay.”

Second, the court does an in depth analysis of the medics using the Active 911 phone app to navigate (incorrectly, no less) to the call when the policy manual for the department requires the use of the map book. By operating outside of department guidelines, the medics lost their qualified immunity at least under Kentucky law, under this set of facts. More on that to follow. I’d note two things, though. First, especially in rural or rapidly growing communities, maps are remarkably inaccurate no matter the source. Second, while I don’t have the trial transcripts, a good lawyer might have developed testimony to state that the Active 911 phone app does indeed constitute the use of a department approved map. Active 911 isn’t something people can just randomly download. The department has to subscribe to the service and it’s typically integrated into the Computer Assisted Dispatch (CAD) system.

So this all leads up to a long standing belief I’ve had — and it covers both the mapping issue and the equipment check issue. Namely, if you make it easier to do the right thing, people (typically even including your worst EMS providers) will do the right thing.

Over the years, I’ve encountered many such policies and processes that make it difficult for field providers to do the right thing — to the point that people either don’t do the right thing or don’t do anything at all. I’ll illustrate with a few examples over my nearly twenty years as an EMS professional.

Case # 1 – rural EMS system is worried about compliance and creates lots of policies and processes. One of those processes is to go with a system called Operative IQ for truck and bag checks to be completed at the beginning of each shift. Operative IQ in and of itself isn’t a bad platform. Like any IT solution, it’s all in the implementation. But this truck and bag check takes nearly 45 minutes — and double that time if there’s a spare truck quartered at your station. In other words, guess how many medics did a proper check of 45 plus minutes versus clicking through most things except the ones they deemed important or that required an actual number to be entered?

Case # 2A – As I call this, this is the story of the bags. I was at one rural EMS service that had a large Thomas pack on every ambulance. This was probably the heaviest bag I’ve ever carried in my EMS career. (Heck, if you want to use this bag for a physical fitness exam for new or current employees, let me know. I can hook you up with their chief.) The bag had a full assortment of trauma supplies, a D cylinder of oxygen, various oxygen masks, a complete set of intubation supplies, assessment supplies, and a full panoply of IV supplies. In other words, the bag had everything except one thing. Namely, any medications at all. Where were the medications at this service? Well, they were in a cabinet in the ambulance. Loose. (Except for the small amount of controlled meds which were in a small metal lockbox.) Again, guess how many crews took in the bag? Virtually none. To the point that the bag rarely even got checked. (By the way, did I mention that there wasn’t even an inventory or stocking list so you’d know what you’re supposed to have?) All but the least informed and laziest EMS clinicians know that it’s usually best to bring the gear to the patient and try to stabilize before transporting. But when you have a bag that makes it impossible to do so, you end up with 2 alternatives, both of which are bad. Option 1, just take the stretcher and get the patient in the ambulance. (At this service, this was VERY common with the BLS crews, who’d often resort to the funeral home days of EMS with throwing the patient on a stretcher and driving fast.) Option 2 was to bring in the Thomas pack and go back and forth to the ambulance getting the medications you needed from the shelf. Insert your favorite Benny Hill or Keystone Cops clip there.

Case # 2B – This is how you do it right. I worked at an EMS system on the far outskirts of Houston. They had their challenges – namely, try being the third crew member at a station with only two bedrooms and virtually no options to eat away from the tiny kitchen in the station. But the one thing they perfected was their bag design. First, the cardiac monitor’s pouches also held aspirin, nitroglycerin, and a glucometer. There was a trauma bag with everything to manage a traumatic injury (aside from pain medications) from bandaging and splinting supplies, IV supplies, “Stop the Bleed” type devices, and some basic assessment supplies. There was also a pediatric bag with the pouches color coded with the Broselow tape colors. But my absolute favorite was what they called the “ALS bag” that went in on every call. The bag had IV supplies, airway supplies (including endotracheal tubes and iGel devices), and medications. Better yet, the bag had two plastic cases in them. One was a case with all of the medications and supplies needed to handle an allergic reaction up to and through anaphylaxis. The other case (of a different color) had all of the medications and supplies to handle a hypoglycemic emergency. Finally, the spare medications in the ambulance were in a bag that could easily be removed from the shelf to handle an extended resuscitation or to treat a patient who needed more medications. In short, there was no reason you couldn’t bring the right supplies right to your patient each and every time. Oddly enough, while this service had its challenges, not bringing gear to the patient’s side was rarely, if ever, an issue.

Case # 3 – There are volunteer EMS organizations that issue bags (stocked at the appropriate certification level) to their members for them to respond to calls. That’s a great idea especially in areas where an EMS response may take a few minutes. But if you issue out bags and supplies to people, they need to know what they’re supposed to have AND be able to get the bag restocked without significant heartache or hassle. Otherwise, you end up with members either responding without the items they need to care for a patient or they don’t respond at all because they don’t believe they have what they need to respond. Anecdotally, we can see those things happening either by runs made by members or when a member turns in a bag that’s chock full of expired supplies and medications. How do you fix this? Step one is to make it easier to access the supply room. Step two. Organize the supply room and make the supplies easy to find. Bonus points if you have eager leadership who has taken ownership of the supply issues. Extra bonus points if the supply room now has all of the items that were on back order for eons now easy to find. (The gentleman I’m speaking of is my current EMS hero for this.) Step three. Make the supply/stocking list easy to access. Said current EMS hero recently made the organization’s protocols easy to access via a phone app — and the app includes the supply list for the bags. Speaking purely hypothetically, I know of at least one attorney/paramedic who now has a bag stocked to specifications and with the current meds.

In summary, most people are in emergency services, public safety, or healthcare because they want to help others. And most of those people know that they need to do the right things in order to help others. Most of us also have a relatively low BS tolerance. What does that mean? Procedures and policies that don’t work get ignored or there’s malicious compliance. That undermines respect for the organization, the leadership, and the procedures and policies that DO work. Further, when the bad thing happens (and it will), the lawyers have a field day. Even if the actions (or inactions) of these providers didn’t cause the bad outcome, there’s enough doubt to give a jury (or an insurance company) reason to question what really happened. It’s also a huge hit to the department’s reputation and the profession’s reputation as a whole.

For the leaders (whether formal or informal) in organizations, take a good look at your policies, procedures, and processes. See if they reflect reality. See how much of a “BS factor” there is to each and every one. Revise or even remove the ones that don’t make sense. And when you finally get to something that’s workable, hold people to account. Even if there’s not a negative outcome. Especially if there’s not a negative outcome. As we know, “just culture” doesn’t look at the outcome, it looks beyond that. On that note, when you bring someone in to talk about a violation, ask how and why it happened. Don’t immediately assume malicious or malevolent intent. The explanation might actually solve an underlying problem that you were never aware of. If it’s a department fault, fix it. If it’s an individual fault, remediate them or use the appropriate discipline. A policy that’s unenforced or not applied is a policy that a plaintiff’s lawyer will have a field day with.

As for those of us who aren’t in a leadership role, we need to let leadership know when something doesn’t work. Better yet, have a proposed solution. Hopefully, you’re in an organization that will take action on your concerns – whether making changes or providing insight as to how/why the changes can’t happen — or the current system actually works.

If you’ve made it this far, thanks. If I can be of help to you or your organization, I do make house (or station) calls.

Texas EMS Conference 2023 Postmortem

Well, it’s the week of Thanksgiving and for most people that means
turkey.  For me, Thanksgiving has always been stressful – mainly due to
family issues.  But therapy has helped with that.  (Mostly kidding,
y’all.) For me, this week has always been about the Texas EMS Conference and
all that means.  This is my nineteenth year taking care of Texans, first
as an EMT and now as a licensed paramedic. (For those of y’all reading this who
aren’t from Texas, the licensed paramedic thing is one of those weird Texas
differences – just like no beans in chili. For Texas EMS, we’re also special in
being a true delegated practice state and have no state protocols or scope of
practice.)

This has been one of my best years at conference ever. There were a couple
of minor lowlights.  The keynote speaker was a very generic motivational
speaker you could hear at any corporate conference, but I suppose that’s okay
too.  Also, lunch on Monday could’ve been better.  (Food wise,
there’s a really strong, albeit underrated, BBQ option just around the corner
from the Austin Convention Center.

2023 has been a year of growth and change for me in both my legal practice
and my EMS passions.  Being at the Texas EMS Conference has really brought
some of those changes home to me.

First and foremost, I am coming to recognize my own worth to this profession
based on my experience and education. Case in point.  I had a good friend
come to me about the challenges they’re facing at their department and
describing the recent promotional process.  (For what it’s worth, I think
I did pretty well on the exam questions.)  The discussion then changed to
a part time position with that department and where and how I’d fit in. Not
that long ago (maybe even six months ago), I’d have started working out the
details of a start date and such.  Not this time.  First and
foremost, I’ve got two excellent EMS homes that are giving me room to grow
personally and professionally with the goal of helping both of these
organizations get even better.  Second, I don’t need to drive a
significant distance if I really want or need to get on an ambulance. I
explained exactly that.  If they want me to come on board, it’s going to
involve me helping them advance and progress doing the things that I can do
that maybe their current staff doesn’t yet excel at – risk management,
education, clinical management, training, and organizational development.
I’m rapidly approaching the point in my EMS journey where the opportunity to
lead, advocate change, and develop my colleagues is what drives me much more
than running calls. In the spirit of full disclosure, I STILL love running
calls – even more so if I’m with a newer provider.  Watching them grow and
learn is as fulfilling as getting a good call, just in a different way.

The conference has also brought more personal recognition of my changing
roles in my EMS career. I attended classes that were directed to my roles as
the opportunities arose. I’d have never thought that I’d attend or enjoy a
class on electronic charting software. But the class couldn’t have come at a
better time as I’m evaluating software choices at one of my departments. It was
a huge confirmation when the issues I’d identified and been working through on
my own. Attending classes like that and learning about other topics that I want
to bring back to my departments gave me a whole new understanding of why chiefs
and officers attend conferences. It’s not about getting a vacation or about
taking the opportunity away from the field staff.  It’s for us to learn,
network, and bring back things to the entire department. Sometimes, with
limited budgets being what they are, the best return on investment is for
leadership to attend to improve the entire department. Now, whether the leaders
return with relevant knowledge to make better decisions for their organization
or share that knowledge with their team is an entirely different story.

This week has really helped me realize how my EMS experience is changing,
and I think for the better.  During the conference, two EMTs from one of
my departments reached out to me with questions – one about how to document a
call and the other based on information they learned at conference.  After
the second one of these, I realized I’m now (whether officially or
unofficially) the one that gets the call when there’s an issue.  (And
there’ve been other calls/emails/texts this past year along the same lines.) In
other words, for better or worse, I’m feeling that my new roles now mean I’m
one of those people who get the call when something unusual comes up, whatever
the issue.  The recognition from others has been both humbling and
flattering.  And just as we feel unsure of ourselves as a new provider,
the feeling of imposter syndrome is even more intense as a leader, whether
official or unofficial.

Being a leader – or identified as one – means you feel different or at least
you should. Getting that email or text about an uncovered event gives me a
bit more of guilt than it used to.  And the “level zero” page has caused
me to change clothes and load my car up to go out and work.  If you’re not
feeling that same sense of obligation or responsibility, maybe a leadership
role isn’t right for you. Being out in the field, helping shoulder the load,
and setting an example by being present is what being a leader is about. Any
leader who doesn’t get that is no better than the volunteer EMT or firefighter
who’s just there to get the t-shirt.

I really felt the change in my age and role on Sunday – which is typically
the day that most of us wander around the conference exhibit hall to get free
pens and swag while we catch up with people we haven’t seen since the last conference.
Sometimes, we actively avoid some of the people we haven’t seen since the last
conference. Especially this year, I managed to rebuild a few bridges I might’ve
burned over the years.  I like to think
that those of us on either side of some of those arguments both grew.  At least, that’s what we told each
other.  But what really made me realize
my growth came from a new EMT I know who’s likely coming on board with one of
my departments. Like me, she’s a bit older and is going to volunteer while
deciding if EMS is the right path for her, including the possibility of
paramedic school. She asked if she could come up to the exhibit hall to hang
out.  I remember that same eagerness (and
I try to keep it going for both me and others) and encouraged her to come hang
out.  I made sure to introduce her to all
of the people I’ve known over nearly 20 years in and around EMS.  She’s already scheduled for a ride along with
a large urban third service EMS system as well.
She commented on how many people I knew and how willing I was to
introduce her around.  It’s called paying
it back.  And if you’re not doing it, you’re
part of why so many in EMS are worried about where the next paramedics and
paramedic leaders and educators will come from.

When I first got started in this field, I heard a lot of jokes about the people
who wear their uniforms to conferences.
And I assumed they were yahoos, yokels, and every other slang term for “Rescue
Ricky” out there. I made sure to avoid that by and large over the years. While
at our Texas conference this year, I noticed how many folks WERE wearing
uniforms or at least their department polo shirts or job shirts.  More importantly, some of these people were
presenting. And quite a few other people were walking around the conference
looking perfectly normal.  Having said
that, though, not everyone needs to wear a full dress uniform reminiscent of
Idi Amin.  If you are going to wear some
of your department’s uniform, whether fully or partially, wear it in a way to
reflect the obvious pride you have in your organization.  Tuck the shirt in.  And don’t be passed out drunk in the
uniform.  As for me?  I finally broke down and went ultra casual
the last day – jeans, a polo shirt, cowboy boots, and the zip up fleece from one
of my departments. I will draw the line at a radio, pager, utility belt, or a
dress uniform more suited to a Park Avenue hotel doorman.

My lecture on Monday confirmed that I’m on the right path.  While some of my usual conference friends
came, I couldn’t think of higher praise than seeing one of my current chiefs in
the room along with a former battalion chief that I used to argue with like
cats and dogs. That vote of confidence in my knowledge and my abilities spoke
volumes to me.  I hope I found myself
worthy of that trust. I’m just glad that I’ve been able to, at least in part, use
both my legal education and EMS experience to demystify some legal concepts and
give practical advice to EMS professionals and agencies.  FYI, I’ll travel.

Here’s hoping that conference was as rewarding for you as it was for
me.  And if you’re in EMS and haven’t
been to a major conference, it’s past time to go – and learn outside of your
own department.  On that note, some of
the best learning happens outside of the classroom sessions when you get to network
with others and see what others are doing.

 

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