I had hit what I now know as rock bottom in February of 2014. I hadn’t gotten out of bed other than to use the bathroom for over a week. I hadn’t showered in days. Food was out of the question. To top it all off, I hadn’t been sleeping much, or if I did it was during the day. Nightmares haunted me whenever sleep dared to come.
Many of us have families to look after. Our main goal is to be able to go home safe and take care of them. Scheduling and responses are, what I see, as the two biggest issues with the way we treat today’s EMS industry.
The modern EMS system as we know it has come a long way from it’s humble roots of simply being a transport service for the sick and injured to multi-tiered system capable of performing procedures that were once reserved for Physicians only. With all the change that has occurred over the years, we still have a lot of work to do. And I’m not talking about the care delivered in the system, I’m talking about taking care of our people.
It wasn’t too long ago where just about every single call we were dispatched on was an emergent (lights and sirens) response. At the small service where I worked at the time, I very distinctly remember the day the regional dispatch center finally started to triage calls into emergent and routine responses, my service being the first in the entire region to respond to that first call. At the time, this seemed to almost be an insult to the industry, but it strangely made sense. Although the systems has it’s flaws (mainly the person on the 911 line) it does, largely, work out. However with all the questions being asked by the dispatcher and science now behind the reasons why we respond the way we do, there are still some major flaws in the system; and these flaws are putting our lives at risk for no good reason other than some random statistics and risk factors that have absolutely no place in the response scheme. Does every single person you pick up with abdominal pain end up with an aneurysm? I didn’t think so.
A major determination in how we respond is how much information is available at the time of call. Unfortunately with a majority of calls detailed information is not available. This can be due to a variety of reasons such as a uncooperative or inebriated caller or the call coming for a second or third-hand source. So the typical rule of these responses is to make them emergent just simply based on the lack of information. But this also begs the question “how much information do you really need in certain circumstances?”. Are dispatchers competent enough to make an educated decision on how best to choose the response priority? I think they are, and they need to be allowed to do so without fear of being cut down by a bureaucracy supporting often vague, unrealistic statistics. So I’ll spell this out simply. If someone calls 911 stating they are drunk and wish to go to detox and hang up before all the questions can be asked, it is an emergent response. If the police request a transport for a mental health crisis and that is all the information available, it is an emergent response. This may seem like a fairly trivial, small amount of what we do in EMS, however anyone who has worked in the industry for any period of time can tell you otherwise. Despite advances in the 911 call taking system, there are still agencies out there that choose to disregard any type of prioritizing responses. Another example of inappropriate responses, particularly in the commercial sector is facilities exaggerating or overstating the complaint of a patient or their situation. We had serviced a facility for years that did exactly that. They would call two services with an “emergent” transport so naturally both services would respond as quick as possible. This often included crews getting out late or having to punch in early without properly checking their equipment. The only problem was, the service who showed up first got the transport. This facility willingly putting our lives at risk just so they could get the fastest time possible for the transport. And I speak from experience when I say that a majority of the time, there was actually nothing emergent about the patient’s condition. This was simply a measure of clearing beds for them. Fortunately for me, my administrators caught on to this game and quickly put an end to it - well at least for that facility. We still have facilities that refuse to take certain times for no justifiable reason - and I’m not talking about a four hour time either. Just like every EMS system, we have our abusers - and often the worst offenders are other medical facilities like nursing homes and dialysis centers. Shady Acres Nursing calls commercial company “A” looking for a time to transport a patient to the ED for something non-emergent like “abnormal lab values” or a blocked G-tube. They are unhappy with the time of an hour so they call 911 knowing they will get an immediate response from the very same company. This also taxes the systems who have separate 911 and commercial systems by causing backup but more importantly an unnecessary risk to the lives of the responders. We also have our share of “chronic inebriates” who use the system every day and in no way, shape, or form require an emergency response. Is it really worth the risk of losing people just to save a few minutes here and there? Is it worth having a vehicle involved in an accident for someone who is medically stable and just wants a ride or meal? I’m not asking you to evaluate the worth of another human asking for help, I am asking you assess the risk to yourself that is often unnecessary. Ask your boss the next time you see him/her if they think you are worth changing a protocol or allowing a dispatcher to make a common sense judgment.
Studies have been conducted nation-wide on the risks and benefits of responding emergently to calls for help and they overwhelmingly show that EMS providers are far more likely to die in a transportation related accident than in any other way. From the distractions inside the cab of the ambulance, to increasingly sound proof cars and distractions inside opposing vehicles, driving in emergency mode is increasingly more dangerous. Another killer of EMS professionals? Driving while tired and falling asleep at the wheel. EMS publication outlets feature one of these incidents about every month across the country. We know it happens, now why isn’t anything done about it?
Although various agencies have different schedules based on what the company or department deems out of need there is one thing in common: a majority of shifts are designed to kill or at least limit your ability to respond to stressors and lead a normal life outside of EMS. It is an inescapable reality that there is a need for us on a 24/7 basis, though this reality should not keep administrators from using common sense tactics to ensure coverage.
Though not as common as it once was, but incredibly deadly is the 24 hour shift. This is commonly used in agencies who seek to reduce staffing while still being able to cover the bare minimum needs. OSHA mandates that any shift over 16 hours requires sleeping accommodations. But how much sleep do you actually get? My personal experience with the 24 hour shift has been mixed at best. Typically it was a few broken hours in between calls. Mix in making sure your vehicle and equipment are ready for the next run and paperwork and the situation only gets more grim. Studies on this topic have shown that broken sleep is actually worse than no sleep; something that is often impossible for most people after the 16 hour mark. Researchers equate being awake for 16 hours to having a blood alcohol level of 0.08% which is legally drunk. So what is the solution to this problem? It’s quite simple, no more 24 hour shifts and no shifts longer than 12 hours. It is up to the administrators to ensure the safety of their people and this certainly includes making sure those who have to go out and do the work are fit for duty; not on the cusp of falling asleep at the wheel or making a treatment error that costs a patient their life.
Another fairly recent phenomena is the use of software to build schedules based on call volume or need. Unformed professionals all over the country who have taken a crash-course in software development have been creating programs that are intended to identify needs of the agency and fill them as the software sees fit and they are just as eager to sell it; damn the consequences. While this practice works in theory and in “the numbers” it can be just as detrimental as a 24 hour shift. Working odd hours that defy any sort of healthy sleep pattern, particularly the early morning hours, is detrimental in more than one way. These administrators have now become blind to the fact that the people working these shifts are actual people; they have lives and families outside of the EMS community but are finding it increasingly more difficult to function inside of a normal society and maintain a normal home life. What is the divorce rate of EMS providers? I’ll let you google that. The reality is the a majority of EMS spouses do not work in the industry or work typical hours so they are unfamiliar with the feeling of not being able to achieve restful sleep but still having to push on with life. You will often find that your administrators work typical hours or have some variety of set schedule that allows them to obtain the restful sleep that we all require. And it's with good reason: they should be sound of mind to make judgements that affect the organization and it's employees. The big question is: why can't that be at least partially extended throughout the organization?
I worked a rotating shift for many years and I can honestly say, beyond the shadow of a doubt, was the most detrimental shift work I have ever done. It has been almost a year since I worked that rotation and my sleep cycles are still completely erratic. Just as soon as you get used to working days, you switch to nights. Just as you get used to working nights, you get switched to days. There are a number of reasons why agencies opt for these shifts but largely it is because “we’ve always done it this way”. Rather than use this need-fulfilling software to justify at least semi-normal working hours, they use it to justify the needs of the agency weather that is in a decrease in staffing or payroll. But at what cost should the administration finally admit that putting arbitrary numbers over the needs of it’s employee base isn’t worth it anymore?
Should the turnover rate be the judge of it? Should those in the organization have a say in how they are scheduled? Should we just wait until we have enough fatal accidents or treatment errors that the liability falls solely on the employer? And don’t tell me it’s about proper customer service either. With the advent of electronic scheduling for the commercial groups and the simple idea of creating an overlapping shift there is absolutely no excuse for sacrificing the employee for getting the call done. Late or early calls will inevitably always happen; it’s just part of the industry. I don’t think anyone who works in EMS always expects to be out absolutely on time, but I think they do expect to be close to it unless there is a reasonable event that requires late work.
All of this builds on the stress of the industry. We take your wellness seriously. You should too. At the end of the day you have to be a person who is able to protect and provide for yourself and your family. Administrators should be actively assessing the stressors and risks involved in your schedule, how you respond to calls, and how it relates to your home life, your wellness and your safety. If they are not, then it is up to you to be asking why and advocating for yourself. It is important for your health, mental wellness, and just as important for the community we serve to see that we are also well served.