Good morals I define as a desire to preserve personal honor, preserve the dignity and sacredness of human life, respect the personal boundaries and belongings of others, etc, and to act in a way that is right and always erring in the desire to do the right thing. Understanding how morals effect behavior is called ethics. The terms “morals” and “ethics”  are not well understood by the layman, so it is a common misconception that they are the same thing.

So frequently lately there have been awful stories in the news about those in emergency services who breach those morals and act in a way that is not ethical. Taking pictures of patients in compromising positions, speaking in a way in public that would degrade others, stealing the property of those we are sworn (usually but not always) to protect, and generally acting in a way that would breach their trust of us, are just to name a few instances where negative morals have ruined careers and by extension, lives.

We live and work in a society that is seemingly out of control. We should know, we are on the front lines of it. Crimes that were unspeakable and carried a serious stigma are now more and more common place, to the point they lose the stigma.

How does my commentary on the state of society relate to emergency services? Well, we are part of it. We were talking on EMS Garage a few weeks ago regarding an EMS LT in FDNY that got canned for posting derogatory comments to Twitter. I made the comment when we discussing teaching “electronic ethics” to students that we have to assume that the people that we are teaching have a translatable set of morals that mold well to our collective ethos. Increasingly this is not the case. In a society that teaches that everything is relative, we are failing to provide a steady guidepost as “pillars of the community.” People that were the standard are now no longer the standard.

The reply to my comment was that maybe we need to be more selective in who the industry as a whole allows to “make it.” I believe that we can’t legislate morals in terms of rules and regulations, but gone are the days of people knowing what is right and what is wrong so we are forced, as organizations to legislate. Invariably, we end up legislating every aspect of a person’s workday. This is where we transition from trusting our people with knowing what to do, to trusting them with nothing. A workplace without trust in our line of work is, in my experience, not a place worth working in.

Can we teach morals and ethical behaviors? Maybe. I believe that organizations should have the right to define was is and what is not procedurally correct, but to undo what a person has been taught all their life about what is right and re-define right and wrong to them is outside of our scope of practice. I believe that the people we bring in should already be able to join our collective ethos.

Then we get our first run.

Then that excitement fades a little.

I watch our competent, entry level paramedic deploy their skills for the first time which usually results in a rehash of an old saying they learned in school:

“IV, O2, monitor”

C’mere junior, let me tell you how this REALLY works…

It’s not really their fault though, some schools (all but one that I’ve seen) don’t teach clinical decision making starting with the basics first. They teach paramedic students paramedic stuff, and predictably they over-emphasize the ALS. But it’s not EVERY run that we use ALS skills, so should we be teaching paramedic students how to use basic skills?

I think so. I think that yes, even though paramedic students should have a strong foundation in the basic before becoming paramedics I realize that this is often not the case or even desirable by many organizations, paramedics should be strong EMT’s first.

In another thread, paramedics are often held to organizational standards or perceived standards (read “culture”) that promote over-kill, inappropriate treatments, or “cookie cutter” medicine that results when adherence to the protocol book is placed above good (and appropriate) care.

The primary cause of these situations is called “reduction of liability” but in the same line don’t see that when we make an attempt to reduce liability we cage effective providers and praise poor providers. Personally, my protocol compliance statistics suck, but I deliver excellent care. Does my stat reflect my care? No. Do I make mistakes. Of course.

Somehow though, as in any organization that attempts to reduce their liability, when quantifying what “quality care” is ineffective providers are often the highest in the statistics for compliance. Why?

IV, O2, and monitor

I’m getting at that we should get away from such instruction and actually raise our bar. I would say that we don’t teach to skill sheets which promote checklist medicine and give the knowledge of what certain procedures are and why they are necessary. If we are going to use skill sheets, we should rate skills that require a checklist and not starting it with “given a scenario…” Any person with a pulse can perform a trauma and medical assessment, they teach it in the most basic of CPR and first aid classes.

It takes a real clinician to prescribe a procedure and know why.

A lot. I’ve read 6 books since the start of the new year and I still have several more to wade through.

I recently read Atlas Shrugged in about a week. At several points I reflected upon the organizations I belong to and work for. One glaring example stuck out.

We formed the EMS Committee several years ago to try and turn the tide on a lot of organizational rot, several of us noticed it and with some blessing from higher up we formed the committee with the purpose of making change. It ended up collapsing on us, not for lack of our desire, but because those of us that thought of a solution faced push-back from those that had something to lose from us gaining ground. They always seemed to be the people that hated the idea of their people being any more than pawns, and that our rightful place was droning on without any regard to the safety or well being of ourselves or our co-workers, or our patients.

So, we went on strike. The committee hasn’t met in over a year. We discuss ideas amongst ourselves but we rarely share them with any one else.

I’ve been asked to help with several different projects, or to volunteer for various things. I’ve refused outright (mostly) because I refuse to assist an organization that doesn’t basically have my best interests at heart. None of my counterparts have either. The one time I DID volunteer, I basically figured it was either get a favorable outcome or risk being forced into a position I didn’t want to be in, so it was more of a matter of self preservation than a true interest in helping the organization get along. As a result of the lack on input from any level, there hasn’t been any serious direction. Old projects and ideas are being repeated, seemingly in an attempt to redefine insanity.

So why John Galt? We’ve been told that we should simply tolerate the lowest common denominator and accept that whatever high ideals we set that they will inevitably be lowered to accomodate those that don’t have the ability to meet them because “it’s not fair.” It’s not fair to the public that we have to give them the lowest common denominator and it’s not fair to those that seek to be better that they have to be held back by those that can’t achieve for some reason or another. Just like John Galt, the minds that powered the organization through one of the greatest expansions in it’s history have decided that their best effort isn’t worth what is being offered. Lots of those minds are looking for an out, and several have found them.

We’re on strike.

Dear Manager (or Chief)-

I have been in emergency services a long time, beginning many years ago as a volunteer firefighter, culminating as a full time career firefighter and paramedic. Throughout my career, I have seen different services with different problems. Usually, all of those problem result from having to put people into a system. It is a proven fact that any time you introduce people into a system, there will inevitably be problems.

I spent 4 long years walking college halls learning the skills necessary to be a professional engineer, which gives me an interesting look at how systems integrate and operate. You could say that I see every patient as a complex network of interlocking systems that require specific conditions to operate. I also see how our system operates, and despite my best efforts and the efforts of many others to introduce effective and more efficient processes and procedures to that system to make it both user friendly and operator friendly, we have been rebuffed at every turn by those that see the thinking man as a hindrance to their desired plan, and their egos.

I have offered many suggestions from myself and others that would fix our in-service education and training programs, but because the desire of a certain few to keep their little fiefdoms in order to secure their future of never returning to field work again, they have gone unheeded. Somehow, what I suggested years ago is now a suddenly needed idea. Those that desire to hold on to their power, choose to ignore the problem and shovel the responsibility upon field providers to get the necessary training and education on their off days, which defeats the purpose of “in-service training” doesn’t it?

We’ve recently had logistical issues on items that require strict control, and the knee-jerk response has been to implement yet another step in the daily examination of those items, and change the forms that crews use, and change the packaging of those to “tamper resistant.” I hate to say it, but anyone looking to steal those items could easily defeat the new system, just as easily as the new system. You will never eliminate the problem, and the future of the present system is such that those controlled items will end up in the hands of far off supervisors that will never make the scene in time to utilize them and deny patients those necessary items. What has transpired to fix the system will ultimately hurt patient care. I made a clinical decision based on how difficult it was to utilize those items just the other day, when it may have made a difference, the risk of being accused of something and subject to investigation because I did the right things is not a worthwhile risk. Once again in this case as well, solutions were suggested in the proper form to the proper people and those ideas went unheeded because of the egos of a few or keeping it simple was too simple, even though it accomplished all the tasks and met the necessary requirements.

Everything that has been suggested as fixes has been sent to a committee, and I have learned that the value of “committees” in this organization is where good ideas go to die. Most of these “ideas” though aren’t new ideas, more than likely they are the solutions found by other organizations that worked. The idea that we need to “field test” all new equipment is purely ridiculous, and often the equipment that is field tested is too expensive, heavy, fragile, or cumbersome to actually use. This leads to a considerable strain on personnel when we are constantly trying new things that will never be implemented just to once again satisfy someone’s desire to pad the stats or the resumes.

I read in a book of essays on leadership by Christopher Kolanda that such an organization that doesn’t value to reward or elevate it’s best examples and brightest minds to serve as an example to others, will find that those people will leave as soon as the opportunity presents itself. I find myself, a hold out to the idea that eventually things will improve, looking down the long line of things to come and deciding that perhaps I need to leave as well.

Sincerly

Disgruntled Employee

People that once served as people to look up to, occupiers of the walls of boys and girls rooms as examples to aspire to, get disgraced every day. I spent hours reading about the falls from grace of some of baseball’s recent great players, Chad Johnson and Michael Vick from the NFL, and (begrudgingly) Joe Paterno. I’m almost afraid to get too attached to any particular star because they turn out to be some sort of cheater, a jerk, or just plain ignorant.

The recent example of Lance Armstrong would seem to serve as another lesson that there is no one we can trust. I could go on and on with recent examples: Roger Clemens, Barry Bonds, Mark McGwire, Sammy Sosa, etc. All sports figures who have achieved great athletic feats but have been accused (and several found guilty) of using performance enhancers.

Without speaking to their guilt or innocence and thinking upon a greater picture, what does this say about our culture these days? Could the answer be as simple as “do whatever it takes to get ahead”? Given recent examples and speeches and politics, it seems that way. Do we really want to be teaching our kids to cheat to win or do we need to be teaching them that honest play and hard work will reward them? It’s a difficult concept to instruct without mentioning so many failures.

It’s hard for me to think of a way to teach my son the difference between right and wrong without destroying the hope that someone out there can do it well without having to cut corners and still instill some sort of virtue. It would appear that most people that are good but don’t cheat display an extreme hubris. That arrogance eventually gets them into trouble.

I can’t help but wonder if we have lost all our heroes, and when one does come along, we hardly notice or even care.

“Respond to a report of man on fire…”

“What is this? A Denzel Washington movie..” you grumble as you take your seat in the ambulance.

The MDT is no less helpful. “On fire…… 30yom…..” it reads.

Pulling up to the scene, you see no fewer than 3 police officers running around, and the engine sent to help you has stopped in front of a house, that is still smoking. The police officer stops you. “Yeah, he’s in there. It’s… uh, pretty bad. He’s burned all over.”

The open door shows the scene out into the street. A charred body lies in the front room of a house. “Oh great,” mumbling as your partner pulls the ambulance out of the way of the soon to be arriving full response. You both grab on the cot as you roll it up to the house to find half of the engine crew already working on your patient.

The smell of burnt flesh permeates the air. The paramedic on the engine looks vainfully for an IV while his assistant secures a non-rebreather to the burned face of your victim.

Visually, the rest of the scene is about as unappealing as the odor. The patients face is burned, and soot is visible inside the airway. The patient is completely naked, presumably the clothes have been burned away. The skin over the hands and feet has burned and flaked away, revealing the bleeding under layer of skin. Looking down to the ground, bloody tracks are noted where the patient had walked. The skin on the shoulders and arms has also burned away, revealing the freshly exposed ink of tattoos. Surprisingly, your patient is still breathing.

The crew covers the patient in a burn sheet. You decide to lift the patient on a backboard because using any other method would cause more pain and more irritation of the skin layers. The backboard is covered in a burn sheet, and the patient is lifted on to the cot and taken back to the ambulance.

In a better environment, the vain hunt for IV access continues, and is abandoned due to the lack of any landmarks. IO access is considered, but the swelling has progressed so quickly that now even the IO landmarks are not palpable. You continue the high flow oxygen and dismiss the engine crew to go back to firefighting duties.

You gather as much information as you can before the airway becomes unmanageable, but, to your surprise, it’s in great shape. The patient gives you an address not consistent with where the scene was, and mentions something about gas.

Your monitor manages to catch some vitals on the quick ride to the burn center:

BP: 150/86
HR: 138, sinus tachycardia
RR: 22, inspiratory wheezes noted with slight crackles

Stay tuned for Part 2

The IAFF local in my hometown recently changed their bylaws to prohibit active members from working as firefighters or paramedics in a volunteer or part time capacity. Lots of emotion on this topic on both sides. I tried to summarize the root of the issue.

Check it out over on YouTube, and subscribe to my channel!

http://hereandnow.wbur.org/2012/08/07/emergency-response