It's Time For Us To Call a Code Green

by Clayton Kazan, MD

We all know about the various codes they call in the hospital: Code Blue, Code White, Code Pink, etc.  We have even made up a few codes of our own, aka Code Brown.  But, not enough of us know about Code Green.  It's not a new name for patients on 4/20 or from Colorado or California.  It's about recognizing the leading cause of active duty death in our First Responders...suicide.

I have come to believe strongly that we train ourselves and our EMS brothers and sisters the wrong way.  When I look back on my training as an EMT (and Medical School and Residency), I received exactly zero training in mental resilience and zero preparation for the calamities I would bear witness to.  In fact, my department followed a now discouraged practice of forcing us to see a psychologist for a debriefing after any traumatic call.  Hopefully none of your departments still require critical incident stress debriefing since we now know that forcing it upon our folks can be counter-productive.  But, what can we do, because we need to do something...the data is staggering.

According to the Firefighter Behavioral Health Alliance (FBHA), from 2014-2016, there have been 374 suicides among active duty firefighters, compared with 268 Line of Duty Deaths (LODDs).  This data likely understates the problem, since data for suicides is shared voluntarily while LODDs are reported mandatorily to NIOSH.  Research has shown that first responders' rate of suicidal ideation is 10x that of the general public, while firefighters' rate is more than 12x.  The risk of suicide attempts is 13x higher for first responders and 30x higher for firefighters.  The risk of successful suicide is more than 2.5x that of the general public.  And, unfortunately, the data is not much better for us Medical Directors because Emergency Physicians also have an increased risk of suicide, though not as bad as the first responders.

I think that the problem boils down to 2 cultural issues we need to face.  First, we need to reconsider the whole way we think about the horrible things we experience.  We all carry with us the memories of the horrific tragedies we have cared for, the mistakes we have made, the times we have been threatened or assaulted, and we have all experienced having to suppress our emotions for the sake of moving on to the next patient.  We see things and experience emotions, quite often, that the lay public never experiences.  No matter how resilient you may be, these exposures leaveboth temporary and permanent impressions upon your soul.  

What do we do to prepare our folks during their training, and how good are we at monitoring our crews throughout their careers?  The military, faced with a suicide epidemic, has incorporated resiliency training to soldiers preparing for deployments, and they have seen some decrease in post-traumatic stress disorder (PTSD).  While EMS has embraced many military technologies and practices into everyday care, resiliency training has lagged behind.  There are many healthy ways we use to cope every day, including the tight comeradery among us.  Many of our departments, mine included, have incorporated Peer Health Counsellors, Chaplains, and access to Psychologists, but it is still largely dependent on self-referral.  Unfortunately, beyond the comeradery of our profession, the culture also includes some worrisome practices.  Substance abuse is high, especially with the work hard-play hard mentality.  The same comeradery that binds us can lead folks that need help to be afraid to ask for it because they are afraid of being ostracized, thought of as weak, of being laughed at, or of being fired.  And so, they laugh at our jokes and sit quietly during our stories, and they begin to isolate themselves.  After all, they signed up for this, and working in EMS becomes more than your profession.  It becomes who you are, and what if you don't know if you can continue to be who you are anymore?  

The other cultural problem that we need to face is the way we treat errors.  This is not unique to EMS and is true throughout the practice of medicine.  I think that we all tire of the analogies to the airline industry, but the success of their cultural change around safety has been remarkable.  In my own department, if we avoid serious mistakes 99.99% of the time, then we will still commit 36/year...a number that most critics would argue is far too high.  But, can anyone really expect even that level of performance from human beings?  We need to get out of the cycle of our name, blame, and train approach to performance improvement.  No system punishes its way to greatness.  In fact, only a poorly designed system would ever allow a single, unchecked mistake by a provider to lead to a patient catastrophe.  Our culture of punishing for mistakes only leads to their concealment for fear of reprisal, and so our system remains stagnant rather than getting safer.  We set such unrealistically high expectations for our folks, that the guilt of a mistake reaps a terrible toll on our folks, and they practice in fear.  In the words of Jeff Skiles, the lesser known co-pilot of the USAir plane that landed in the Hudson River, "It is vastly more important to identify the hazards and threats to safety than to identify and punish an individual for a mistake."

So, what are the answers?  We need to educate ourselves and our folks about the warning signs of our brothers and sisters in crisis.  We have to educate them early in their careers and renew it often, and we need to maintain a culture that encourages members in crisis to step forward.  We must build layers into our systems to protect both our patients and our caregivers, because no individual error should ever lead to catastrophe.  That way, the crews on the front lines can step forward and help us build a safer system rather than practicing in fear of making a catastrophic mistake.  Lastly, let's mobilize behind the critical work of organizations like the Code Green Campaign, FireStrong, etc. and make sure that our folks all know that they are out there.  

We must all remember that we are all vulnerable to mental illness.  The burden of our deceased brethren was not unique to them.  Sometimes it just takes one bad experience to put us over the edge.  It happens to folks in the beginning, middle, and end of their careers, and it can progress rapidly.  There are often warning signs, and there may be an opportunity to intervene and get them the help they need.  What sets them apart is not their circumstance, it's that we did not recognize their crisis and respond to them in time.  Suicidal ideation is a treatable illness, and suicide is preventable.

Please check out these excellent and important organizations:

Code Green Campaign

Firestrong

The ER system is a sinking ship, EMS can be part of the solution.

By Clayton Kazan, MD, MS, FACEP (@clayton_kazan)

The ER system is a sinking ship, EMS can be part of the solution.

In the late 1960's, most pre-hospital care was provided by primary care physicians.  As hospital care became more sophisticated and Emergency Medicine began to develop, the focus began to shift to transporting patients to hospital Emergency Departments, and EMS began to provide emergent treatment in the field as an extension of the ER.

But, the pendulum has swung way back.  85% of ED patients are discharged home, and, while many of those patients benefit from an ED work-up, there is also a large subset of patients presenting to the ED that could be worked up in other, less costly arenas.  Research from ACEP has shown that the vast majority of patients that present to the ED are justified to be there, but that just does not jive with my experience over the past 15 years. 

The problem is that the needs of the healthcare system and the financial incentives of the hospital/ED physicians are not aligned.  The healthcare system needs minor patients to be managed in a cost-effective manner, but ED budgets and ED MD salaries are driven by census.  I used to try to educate my patients on the appropriate use of Emergency Services, but it is a fruitless endeavor to try to educate millions of Americans, and it lacks any financial incentive for the stakeholders on the hospital side.  Instead, ED census continues to rise faster than new beds can be added, reimbursement per patient is falling, and the only answer is to improve ED bed efficiency.  But, efficiency has its limits, and, unless financial incentives are realigned, the ED system as we know it is a sinking ship. 

The ideal hospital ED needs to be reconsidered, and triage needs to be able to route patients along a spectrum of tracks.  We cannot expect patients to stop coming to the hospital, but patients with less acute problems can be triaged to the appropriate level of care, including Fast Track, Urgent Care, and Subacute Care.  Emergency Departments can be much smaller and can be a service line in a spectrum of services offered by the hospital.  Until financial incentives are realigned however, there is no incentive for hospitals to stop routing all patients through the ED, and board certified resuscitationists will continue to bill to see patients that could have been managed in a less expensive venue.

If EMS systems do not evolve, then we are part of the problem and are destined to go down with the ship.  This death spiral begins with increasing ambulance wall time and ED diversion.  But, unlike the ED system, the EMS system is financially incentivized to change its practice.  The mobility of our service puts us in the position to offer community based medical care unlike any current hospital or healthcare system.  Payers are highly incentivized to reduce the cost of unnecessary EMS transport and ED visits, and they are very open to working with us on innovative new models.

We need to stop viewing ourselves as EMS providers and start viewing ourselves as delivering mobile healthcare, with EMS being a service line in a spectrum of care we can offer.  Physician Assistants and Nurse Practitioners can be utilized to provide simple interventions in the field setting and redirect patients back to their medical homes.  In addition to contacting patients through the traditional EMS system, we can also partner with payers' nurse advice lines to evaluate patients that cannot wait for next day appointments.  While none of this is cheap, it is far cheaper than our current practice of EMS transport and ED visits, it saves EMS resources for true emergencies, it can reduce ambulance wall time and diversion, and it can provide a better patient experience.  Payers can also partner with us to provide urgent follow-up resources, which are far more cost effective and sufficient for many of our patients.  There are may ways that different departments are using mobile healthcare resources in innovative ways to reduce hospital readmissions, perform safety checks on high risk patients, etc.

This is the biggest watershed moment in EMS since John Gage and Roy DeSoto went to paramedic school.  This is our opportunity to become a stakeholder in the future of healthcare delivery rather than just an extension of the Emergency Department.  This is our time to become an indispensable provider of cost effective mobile healthcare. 

Medicine in Public: Messaging is a Core Skill in EMS Education

Sabina Braithwaite, MD, MPH, NRP, FACEP

The current EMS Fellowship curriculum emphasizes clinical skills needed to be a competent EMS physician.  In addition to medical knowledge, prehospital patient care, and systems-based practice, there are milestones for team and patient centered communication. These milestones focus on communication between EMS physician and EMS providers, EMS physician and patient, but do not expressly focus on communication between EMS physician and the public in general.

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But unlike many other subspecialities of medicine, EMS is largely performed in public venues, now under the ever-watchful (and recording) eye of social media.  When taking care of complex patients in a complex system, it is guaranteed that bad things will happen. When that day comes (and it will), EMS physicians must be prepared to be questioned privately, in public, on TV, in front of a county commission hearing, and who knows where else, about what their role in the EMS system is and why that bad thing happened. 

Knowing this, we must make sure to prepare postgraduate EMS physicians with  additional communication skills that are at best under-emphasized in the current curriculum.  These skills are absolutely central to success as an EMS physician specifically, but also more broadly in any administrative role taken on.

One of these key skills is “messaging.”  A message is a brief, value-based statement aimed at a targeted audience that captures a positive concept.  This means that even when addressing a negative subject, the message should be positive.  Without a firm grasp on messaging, it is pretty easy to get into trouble in any of a number of ways when bad things happen.

So how do you become effective at messaging?  Here are my Top 6 tips: 

1.      Proactively work to get a positive public image.  This isn’t too hard to do: EMS are the “good guys” that help people in need.  But get that positive message out in front of the public, the funders (county / state government), and whoever else needs to know BEFORE the bad thing happens.  Develop a positive relationship with your print / TV media so they know they can call on you for facts when “it” hits the fan.  Get a reputation as an accessible expert who is part of a large team of folks there to help the public.  Volunteer to do a piece on heat exhaustion in the summer when it gets hot, pool safety for Memorial Day weekend, etc.  Every TV station in the land does those same pieces every year, and they will love you for not making them hunt someone down.  That way when you almost inevitably end up in front of a microphone / camera on a bad day, at least you will have done it before under non-confrontational circumstances.

2.      Always force yourself to write down the two or three bullet points that are the major message you want to get across.  You have time to do this no matter what, and it will keep you focused so you don’t wander off down some rabbit hole.  Have a “hook” that you can go back and rephrase, reiterate and come back to during the interview to emphasize your point.  Remember the KISS principle (Keep It Simple, Stupid).  Have a couple strong facts to support your points.  Anticipate the negative questions you will likely be asked and have an answer ready.  And shut your mouth and stop making sounds when you have made your point.  Resist the urge to over-explain.

Example:  Your system plans to start field cease resuscitation for OOHCA.  The public’s biggest concern will be that patients aren’t getting as high a level of care as they would if they were in a hospital [negative].  So create a positive message:  We want the public to know that we are taking a new approach to cardiac arrest similar to other progressive EMS systems [of course your system is progressive, right?], and we are now bringing everything the patient would get in an emergency department right to your home, where a whole team of professionals will try to help your loved one survive neurologically intact, starting with the dispatchers who will help you start CPR, which is one of the most important factors in helping your loved one survive ….. [you get the picture, team effort, everyone is there to help you, we are bringing it all to you, your job is to do CPR when we tell you, etc. Then explain when you will transport patients to the hospital.]

3.      Tell a story that illustrates your point.  This works particularly well with legislators and government officials, because it makes it personal and helps explain the problem or issue in a way people can relate to.

Example:  when explaining change in approach to cardiac arrest to the county commission, do a demo of your new “pit crew” approach, bring a survivor along, and tell them how many more people are surviving and going back to work (not a nursing home in diapers!) because of the great teamwork approach your system is using.  

4.      Be energetic, authoritative, and human.  Don’t hide behind doctor-speak - use straightforward language.  You know your stuff – show everyone!  For in-person interviews, be very mindful of the nonverbal messages you send and be sure they are in sync with what your voice is saying.  If doing a phone interview, stand up and walk around, it gives your delivery more energy and inflection.  Be sure the interviewer knows your name (spelling), title, and role in whatever you are being asked to comment on.  Feel free to educate them on what a medical director is / does, and also feel free to offer them some questions they can ask you when you are doing a public relations-type piece, so it is more likely that your major points will get across. 

5. The microphone is always on.  Corollary:  there is no such thing as “off the record.”  And remember, the 10-20 seconds that ends up on the evening news can be any 20 seconds out of the 5-10 minutes you talked, so don’t stray off message and have comments that can be taken out of context.

6.  Most importantly, KNOW YOUR AUDIENCE.  Be sure you are tuned in to station WII-FM – “what’s in it for me?”.  If you can anticipate what your audience wants to know / is worried about / can connect with and incorporate that information into your message, you can be sure that the message you think you are sending out is also the message they actually receive.  For the public, they want to know they are getting the best care possible.  For legislators, they want to know that the public isn’t going to complain to them, and that they can truthfully tell their constituents that public funds are being expended wisely, and possibly even that they have supported some fabulous thing that you are doing in your system that has improved patient outcomes.

EMS is a uniquely public specialty of medicine.  It is therefore of paramount importance that EMS physicians – in –training are taught how to navigate medicine in the public eye.   It not only has the potential to save them a lot of heartache, but also prepare them to be more effective advocates for themselves – and most importantly – the patients we serve.

Interested in learning more?

If you ever get the opportunity to go to the Media Training offered by ACEP at Scientific Assembly or at the Leadership meeting, definitely do so, it will really open your eyes and give you valuable pointers.  There also is considerable in-depth information on this subject in the chapter in the NAEMSP textbook Vol2 Ch15:  EMS Physicians as public spokespersons.

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EMS MEd Editor: Maia Dorsett

Now Is the Age of EMS: It is Time to Revolutionize Our Practice

David K. Tan, M.D.

            Growing up, one of my favorite TV shows was “Emergency!”  I suspect many of our readers with a few grey hairs share my fond memories of watching Johnny and Roy gallantly saving lives every week while receiving sage advice from Dr. Brackett and Dr. Early when they brought the patients to Rampart ER.  It is fascinating to watch the portrayal of the early paramedics and what was necessary to become the first physician surrogates during the birth of EMS.  Training was a few weeks long, online medical control was required to defibrillate VF patients, every IV started in the field required permission as well as a 24-hour follow-up report, and an EOA was considered their advanced airway. 

            Fast forward to today, and look at how times have changed!  We now expect paramedics to interpret Sgarbossa’s criteria on a 12-lead EKG and, in some locales, initiate thrombolytic therapy for it, perform surgical crics, calculate cardioactive pharmaceutical drip rates, and engage in community paramedicine as part of the continuum of medical care.  EMS no longer merely brings patients to health care.  EMS is health care.    We continually pile more and more expectations onto EMTs as well as paramedics, yet we still treat the profession as a vocational tech skill as opposed to a practice of Medicine.   Paramedicine is not skilled labor.  It is a medical practice deserving of the requisite training and education worthy of the trust that citizens place in our abilities and, more importantly, our aptitude for decision-making and critical thinking.  Such capabilities require an entirely new paradigm in EMS education, yet if anyone dares mention that paramedic licensure should be via a college degree pathway instead of a “certificate,” prepare for an onslaught of naysayers! 

            Something else that struck me about Johnny and Roy is that they had a personal relationship with their medical control physicians.  Dr. Brackett did not abrogate his responsibility to teach and mentor his medics to a staff member.  He spent time with them, taught them his approach to patient assessment, gave feedback to the crew, and imparted his sense of the sacred trust between a caregiver and the patient.  Merely by the tone of their voice over the radio, either party instinctively knew if something was awry or if a patient was going to be particularly ill or a situation particularly difficult.  EMS Physicians must find time to break away from the desk and jump on the box or the apparatus, respond unannounced on scenes as a resource and teacher, and spend time in the classroom imparting knowledge impossible to glean from books. 

            As such EMS agencies must recognize that EMS, as a practice of Medicine, requires a compensated physician, ideally board-certified in EMS Medicine, with the requisite time and infrastructure to realize the new reality of this unique practice of Medicine.  Government, from local to state, must support medical oversight including having a functional state EMS office and a state EMS Medical Director. 

            Now is the most exciting time to be an EMS provider in the age of Mobile Integrated Healthcare, recognition by the proverbial House of Medicine as a bona fide subspecialty, and the growth of evidence-based protocols and practice where EMS can actually influence hospital policy.  It is a quantum leap from where Johnny and Roy started, and we now must begin treating this new frontier with a new vision by demanding more from ourselves and each other. 

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