Leadership (was: My Safety...)

[Guest guest]

Comments inline...

Mike

> I think that there may not be as much training on: YOU CAN'T HELP

> IF YOU CAN'T GET TO YOUR PATIENT or YOU CAN'T HELP IF YOU ARE

> CONCERNED ABOUT YOUR OWN SAFETY. " Scene safety " are just a couple

> of words and not a clear intentioned thought process in teaching

> new EMS folk.

And there's a difference between an initially safe scene turning

unsafe and an initially unsafe scene being made safe. That's a LONG

discussion for another time...

> I think we need to be more concerned about how much the violence

> has made our job that much harder, and think about those issues. I

> do believe there needs to be some kind of relevant instuction on

> what the company feels is the way to deal with a violent patient.

> This way the employee understands when the company will stand

> behind you and when the company will stand behind you.

There needs to be a frank and open discussion between provider

safety, patient safety and the concept of abandonment. Additionally,

there needs to be a serious evaluation of the level of " public

safety " your organization provides, and in which modalities it

operates. In that regard, policy is key - having a clear, consistent

set of policies that set out the responsibilities of medical

providers with regards to safety will go a long way towards create a

sense of safety consciousness in medics. QA'ing calls for safety

issues can be very, very difficult because it's not often documented,

or correctly documented. Training, if any, must be tailored to the

expectations your organization has set forth for its providers - when

to intervene, how to intervene, when to disengage and call for backup.

If you look at law enforcement and use of force training, many things

are changing. Gone are the days when cops are taught to be the solo,

hard-charging butt-kicking folks they once were. Now officers are

encouraged to wait for backup (LAPD has a policy that officers will

not contact subjects when alone, LASD has a policy that prevents

officers from " splitting up " in foot chases to chase separate bad

guys, etc.) and slowly escalate use of force. As a result, violent

encounters seem to be RISING as the offenders understand that cops

are more on the defensive. " Hard-charging " cops are seen as

aggressive, now, rather than " just doing the job. "

EMS starts at a disadvantage in terms of this mindset - EMS providers

are almost assuredly seen as " defensive " - nobody expects EMS

providers to tackle fighting subjects and handle actively occurring

violence - but it's something that EMS providers do encounter. EMS's

core issue, however, seems to be " what now? " Most providers are

completely untrained to monitor situations for threats and changing

violent dynamics, and all too often end up running for cover when the

fit hits the shan - abandoning the person they were caring for until

the scene is made safe again.

There is no middle ground and no magic bullet (no pun intended) - but

there does seem to be an opportunity to educate EMS providers on the

dynamics of violent encounters and that would seem to include a basic

set of defensive strategies designed to protect the provider, protect

the patient and extricate all involved from a worsening situation.

> Leadership doesn't start in the middle it starts at the top.

I disagree. Leadership is cultivated from the bottom-up. If you're

not making leaders, you won't have leaders in the future. Leadership

must be a priority for all involved and must be ***demanded*** by

field-level providers, rather than accepting simple " management. "

Companies that have no leadership should have no employees... it's

that simple.

I am consistently amazed by medics who will work in POOR working

conditions and somehow rationalize it with terms of " it's not that

bad " or " it could be worse. " That's MANAGEMENT mentality - not

LEADERSHIP. And it's what we've told medics they're worth - it's

where we've allowed the expectations to be set. We all know them -

folks who work in conditions that shouldn't be tolerated or may be

illegal (OSHA violations, etc.) yet do whatever is asked of them just

to " keep a job. "

The " great " agencies out there have one thing in common -

leadership. They empower medics to make choices, back them up when

the do so within prescribed frameworks, and expect them to " learn

above, train below " when it comes to their job responsibilities. On

a personal note, this is why I'm so disappointed in Austin/

County EMS - they moved from " leadership " to " management " - ask any

medic who's been there more than 5 years about RMS and you'll get an

inkling of what I mean. It's also why I'm impressed with on

County - they promote a culture of leadership (and no, I don't have

an application pending with them - no sucking up). I've noticed that

most smaller services, ESPECIALLY fire-based ones, at least

understand leadership. Just ask Rinard, the NFA, etc. how many

hundreds of EMS providers are on their waiting list for EMS

leadership classes... I'll bet you get laughed at. I'll bet there's

no waiting list.

The poor agencies hand them a cookbook, don't have a set of policies

in place other than " show up in uniform and do what dispatch tells

you, " and expect medics to do nothing but " follow orders " from folks

who have no leadership training, skills or ability and instead are

relegated to " managing " those below them, often using punitive

" stats " and " write-ups " as the only form of on-the-job training,

counseling and education.

Mike

[Guest guest]

Chopped out everything except the part that ws relevant to my comments, which

are in-line, below:

Leadership (was: My Safety...)

> Leadership doesn't start in the middle it starts at the top.

I disagree. Leadership is cultivated from the bottom-up. If you're

not making leaders, you won't have leaders in the future. Leadership

must be a priority for all involved and must be ***demanded*** by

field-level providers, rather than accepting simple " management. "

Companies that have no leadership should have no employees... it's

that simple.

Which takes us back to the " training = vs = education " discussion. It

frequently takes a person quite some time (as a person in any endeavor, not

merely in EMS, that is) to recognize the difference between management and

leadership. I'd bet that many of our newbies in their early-20s, less than 5

years out of Paramedic school, don't realize that they're being managed, rather

than lead. I wonder if part of the burn-out problem in EMS has less to do with

the number of incidents a medic sees during a shift and more to do with how the

medic's bosses treat him/her during that shift.

I've also seen, as I'm sure many of you have, upper echelons of agencies who try

to control the information their employees receive (specifically regarding EMS

management, leadership, and generally everything that ISN'T drug-pushing,

squiggly-line-reading ambulance-driver stuff) and who define their own levels of

performance. It's the " this is a well-run agency because I'm the boss and I say

it's a well-run agency " mentality. If an agency head admits that his/her agency

is not well managed or well lead, s/he is admitting that s/he has a problem, and

humility of this nature is seldom seen in my experience.

I am consistently amazed by medics who will work in POOR working

conditions and somehow rationalize it with terms of " it's not that

bad " or " it could be worse. " That's MANAGEMENT mentality - not

LEADERSHIP. And it's what we've told medics they're worth - it's

where we've allowed the expectations to be set. We all know them -

folks who work in conditions that shouldn't be tolerated or may be

illegal (OSHA violations, etc.) yet do whatever is asked of them just

to " keep a job. "

And you forgot the " I'm not going to say anything because there are 300 people

standing in line to replace me " mentality. I've worked there, and I know you

have too, Mike. I'm older and wiser now, but when I was working in those

conditions I was in my mid-20s, less than 5 years out of school, " well-run

because I say it is, " and didn't have any idea that I needed to be lead rather

than managed. The irony of my example is that by that point in my life, I had

attended ***fire service*** leadership courses through my volunteer fire

department and had done 6 years in the Air Force during which time I had

completed several NCO leadership courses. For crying out loud, the Boy Scouts

taught me better leadership skills than I've seen in some agencies. I should

have known better.

phil

________________________________________________________________________________\

____

Looking for earth-friendly autos?

Browse Top Cars by " Green Rating " at Yahoo! Autos' Green Center.

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[Guest guest]

The intention of the first statement is that EMS folk need additional training

on what to do when the scene turns unsafe. #1 being to be able to assess the

actual scene safety to determine if it may become more violent enroute with the

patient. This is not being taught nor can it by your normal EMS Instructor

(unless they have the background i.e. Law Enforcement or Military Police

training)

I would tend to agree that company policies do need to be made clear. That was

the point to my post. Most companies have not addressed these concerns in the

past nor do they until the horse has left the barn.

EMS and the medical professionals all over are at a disadvantage because they

see themselves as the " defensive " person. Understanding green, yellow, and red

postures will move toward being more able to take care of patients and assuring

the abandonment of patients will not happen.

Leadership does start at the top. It cannot start in the middle. The point of

my comment on leadership was that the company and its management need to be the

ones to let the troops know how far they can go to accomplish the job yet still

be employed if the decision to use other measures to protect the patients, thier

partners or themselves has to be made.

Empowerment is a great thing, but empowerment is insubordination without the

management setting the boundaries.

EMS does not at this time require any type of managerial training to become a

supervisor or for that matter manager of an EMS service. This needs to be

required.

As for your last paragraph, " NOT IN MY ORGANIZATION. "

Mike wrote:

Comments inline...

Mike

> I think that there may not be as much training on: YOU CAN'T HELP

> IF YOU CAN'T GET TO YOUR PATIENT or YOU CAN'T HELP IF YOU ARE

> CONCERNED ABOUT YOUR OWN SAFETY. " Scene safety " are just a couple

> of words and not a clear intentioned thought process in teaching

> new EMS folk.

And there's a difference between an initially safe scene turning

unsafe and an initially unsafe scene being made safe. That's a LONG

discussion for another time...

> I think we need to be more concerned about how much the violence

> has made our job that much harder, and think about those issues. I

> do believe there needs to be some kind of relevant instuction on

> what the company feels is the way to deal with a violent patient.

> This way the employee understands when the company will stand

> behind you and when the company will stand behind you.

There needs to be a frank and open discussion between provider

safety, patient safety and the concept of abandonment. Additionally,

there needs to be a serious evaluation of the level of " public

safety " your organization provides, and in which modalities it

operates. In that regard, policy is key - having a clear, consistent

set of policies that set out the responsibilities of medical

providers with regards to safety will go a long way towards create a

sense of safety consciousness in medics. QA'ing calls for safety

issues can be very, very difficult because it's not often documented,

or correctly documented. Training, if any, must be tailored to the

expectations your organization has set forth for its providers - when

to intervene, how to intervene, when to disengage and call for backup.

If you look at law enforcement and use of force training, many things

are changing. Gone are the days when cops are taught to be the solo,

hard-charging butt-kicking folks they once were. Now officers are

encouraged to wait for backup (LAPD has a policy that officers will

not contact subjects when alone, LASD has a policy that prevents

officers from " splitting up " in foot chases to chase separate bad

guys, etc.) and slowly escalate use of force. As a result, violent

encounters seem to be RISING as the offenders understand that cops

are more on the defensive. " Hard-charging " cops are seen as

aggressive, now, rather than " just doing the job. "

EMS starts at a disadvantage in terms of this mindset - EMS providers

are almost assuredly seen as " defensive " - nobody expects EMS

providers to tackle fighting subjects and handle actively occurring

violence - but it's something that EMS providers do encounter. EMS's

core issue, however, seems to be " what now? " Most providers are

completely untrained to monitor situations for threats and changing

violent dynamics, and all too often end up running for cover when the

fit hits the shan - abandoning the person they were caring for until

the scene is made safe again.

There is no middle ground and no magic bullet (no pun intended) - but

there does seem to be an opportunity to educate EMS providers on the

dynamics of violent encounters and that would seem to include a basic

set of defensive strategies designed to protect the provider, protect

the patient and extricate all involved from a worsening situation.

> Leadership doesn't start in the middle it starts at the top.

I disagree. Leadership is cultivated from the bottom-up. If you're

not making leaders, you won't have leaders in the future. Leadership

must be a priority for all involved and must be ***demanded*** by

field-level providers, rather than accepting simple " management. "

Companies that have no leadership should have no employees... it's

that simple.

I am consistently amazed by medics who will work in POOR working

conditions and somehow rationalize it with terms of " it's not that

bad " or " it could be worse. " That's MANAGEMENT mentality - not

LEADERSHIP. And it's what we've told medics they're worth - it's

where we've allowed the expectations to be set. We all know them -

folks who work in conditions that shouldn't be tolerated or may be

illegal (OSHA violations, etc.) yet do whatever is asked of them just

to " keep a job. "

The " great " agencies out there have one thing in common -

leadership. They empower medics to make choices, back them up when

the do so within prescribed frameworks, and expect them to " learn

above, train below " when it comes to their job responsibilities. On

a personal note, this is why I'm so disappointed in Austin/

County EMS - they moved from " leadership " to " management " - ask any

medic who's been there more than 5 years about RMS and you'll get an

inkling of what I mean. It's also why I'm impressed with on

County - they promote a culture of leadership (and no, I don't have

an application pending with them - no sucking up). I've noticed that

most smaller services, ESPECIALLY fire-based ones, at least

understand leadership. Just ask Rinard, the NFA, etc. how many

hundreds of EMS providers are on their waiting list for EMS

leadership classes... I'll bet you get laughed at. I'll bet there's

no waiting list.

The poor agencies hand them a cookbook, don't have a set of policies

in place other than " show up in uniform and do what dispatch tells

you, " and expect medics to do nothing but " follow orders " from folks

who have no leadership training, skills or ability and instead are

relegated to " managing " those below them, often using punitive

" stats " and " write-ups " as the only form of on-the-job training,

counseling and education.

Mike

Danny L.

Owner/NREMT-P

PETSAR INC.

(Panhandle Emergency Training Services And Response)

Office

Fax

[Guest guest]

> The intention of the first statement is that EMS folk need

> additional training on what to do when the scene turns unsafe. #1

> being to be able to assess the actual scene safety to determine if

> it may become more violent enroute with the patient. This is not

> being taught nor can it by your normal EMS Instructor (unless they

> have the background i.e. Law Enforcement or Military Police training)

So your assertion is that normal people can't tell when a situation

is going bad? That there's no series of verbal and non-verbal clues

that can be taught to determine this? I'd disagree, and so would

authors like Malcolm Gladwell, Gavin de Becker and researchers

working on this very " aptitude " around the world. I think, given a

good set of criteria, that we could train for violent clues in much

the same way we teach patient assessment, and in the same way we use

base knowledge synthesis to build that " gut instinct " that is so

crucial to building a good medic.

> I would tend to agree that company policies do need to be made

> clear. That was the point to my post. Most companies have not

> addressed these concerns in the past nor do they until the horse

> has left the barn.

>

> EMS and the medical professionals all over are at a disadvantage

> because they see themselves as the " defensive " person.

> Understanding green, yellow, and red postures will move toward

> being more able to take care of patients and assuring the

> abandonment of patients will not happen.

Why not? It's certainly possible to train on. Do we just believe

it's not possible, or are we not interested?

> Leadership does start at the top. It cannot start in the middle.

> The point of my comment on leadership was that the company and its

> management need to be the ones to let the troops know how far they

> can go to accomplish the job yet still be employed if the decision

> to use other measures to protect the patients, thier partners or

> themselves has to be made.

> Empowerment is a great thing, but empowerment is insubordination

> without the management setting the boundaries.

I think we're agreeing in different terms. Insubordination, in and

of itself, isn't necessarily a bad thing if an employee is being

given an illegal, immoral or unethical directive from a supervisor -

it can indicate a problem with the supervision, not the employee.

That said, clear policies, procedures, chains of command and

responsibilities along with training on all of the above can go a

long, long way and is very often neglected until/unless a problem is

noted, and then it's corrected through negative reinforcement of

concepts. That's not a great way to train, nor to learn.

> EMS does not at this time require any type of managerial training

> to become a supervisor or for that matter manager of an EMS

> service. This needs to be required.

I agree. I don't know what the actual requirements are in the fire

service, but I know that TCLEOSE requires a " New Front Line

Supervisor " course for new supervisors, and a " New Chief's Course "

for new police chiefs or other agency administrators. EMS could do

the same - require attendance at TEEX's program within 2 years of

being made supervisor at an agency...

Mike

[Guest guest]

Fresh out of residency I had many concerns about being sued and certainly

practiced defensive medicine. Then, as an ED medical director I began to get

pressure from the other side. Hospital administration was pushing us to move

patients through faster and I was dealing with an increasing number of

complaints about charges for tests that were not necessary. Then, in a

moment of enlightenment, I decided that I would do what was in the best

interest of the patient and damn the lawyers. In the overall scheme of

things, I would rather explain my reasoning to an Ellis County jury than

continually order tests where I knew what the results would be before they

were done. This is what I ask a medical student when they want to order a

test or procedure. I ask, " How will this change your treatment? " I want them

to remember that these are diagnostic tests a not simply something to be

done to please a Philadelphia lawyer. I then again found the part of

medicine for which I originally entered the profession. My length of stay

went down, my cost per patient down, and patient satisfaction went up.

I have never had a malpractice suit. Not that I haven't made mistakes-I've

made plenty and will again. I just immediately tell the family (or patient)

what happened, explain why it happened, and explain what we are doing to

make sure it does not happen again. That defuses 90% of situations. People

mainly sue because they are angry.

EMS needs to learn the same lessons. While it is prudent to do the right

thing and document things well, it is important to put the patient first and

foremost. I hear EMTs and paramedics who want to do " things " in the field. I

will be the first to embrace a new " thing " if it really makes a difference

for the patient. I recently had a paramedic-a very bright person, in

fact-argue for doing troponins in the field (troponins can be done with a

drop of blood and a kit). His argument was that a positive tropnin would

help him route his patient to a cath lab. He had not, and would not,

consider it from a different perspective. There is a false positive and

false negative aspect of any test. What would happen if a patient was

diverted to an interventional facility for an intervention (based on the

troponin) and it was a false positive? What would happen if the patient was

not routed to an interventional facility because the troponin was negative

and later found to have ACS and was later transferred to the lab. You must

prove that the test will change your treatment-otherwise it is fairly

worthless.

Medicine is not black and white. Tests are not yes or no. It takes

education and experience. It takes time. Medicine is nothing more than

pattern recognition. The more often you see the patterns, the better you

are at recognizing them. I might not recognize a pituitary deficiency in a

child because I have seen so few. But, a pediatric endocrinologist has seen

a bunch and she recognizes it right away. Is she a better physician? No.

She has elected to study a particular area and do well. Some of us have

elected to be generalists (EM, FP, IM) and will recognize 95% of the

patterns. When we don't, we ask for help.

The legal system, though hated, plays an important role in health care. When

a patient is wronged, and somebody is negligent, and medical staffs and

hospitals don't intervene, then the patient's only recourse is the legal

system. There are certainly the " tough, smart lawyers " who use the less

fortunate among us to make their living. However, like all things, their day

of reckoning will come.

In summary, always act in the patient's best interest, document well, be

honest, apologize when you should, and you will again find the reason you

originally entered EMS.

_____

From: texasems-l [mailto:texasems-l ] On

Behalf Of Danny

Sent: Wednesday, January 24, 2007 8:50 PM

To: texasems-l

Subject: Re: Leadership (was: My Safety...)

The intention of the first statement is that EMS folk need additional

training on what to do when the scene turns unsafe. #1 being to be able to

assess the actual scene safety to determine if it may become more violent

enroute with the patient. This is not being taught nor can it by your normal

EMS Instructor (unless they have the background i.e. Law Enforcement or

Military Police training)

I would tend to agree that company policies do need to be made clear. That

was the point to my post. Most companies have not addressed these concerns

in the past nor do they until the horse has left the barn.

EMS and the medical professionals all over are at a disadvantage because

they see themselves as the " defensive " person. Understanding green, yellow,

and red postures will move toward being more able to take care of patients

and assuring the abandonment of patients will not happen.

Leadership does start at the top. It cannot start in the middle. The point

of my comment on leadership was that the company and its management need to

be the ones to let the troops know how far they can go to accomplish the job

yet still be employed if the decision to use other measures to protect the

patients, thier partners or themselves has to be made.

Empowerment is a great thing, but empowerment is insubordination without the

management setting the boundaries.

EMS does not at this time require any type of managerial training to become

a supervisor or for that matter manager of an EMS service. This needs to be

required.

As for your last paragraph, " NOT IN MY ORGANIZATION. "

Mike <paramedicop@ <mailto:paramedicop%40gmail.com> gmail.com> wrote:

Comments inline...

Mike

> I think that there may not be as much training on: YOU CAN'T HELP

> IF YOU CAN'T GET TO YOUR PATIENT or YOU CAN'T HELP IF YOU ARE

> CONCERNED ABOUT YOUR OWN SAFETY. " Scene safety " are just a couple

> of words and not a clear intentioned thought process in teaching

> new EMS folk.

And there's a difference between an initially safe scene turning

unsafe and an initially unsafe scene being made safe. That's a LONG

discussion for another time...

> I think we need to be more concerned about how much the violence

> has made our job that much harder, and think about those issues. I

> do believe there needs to be some kind of relevant instuction on

> what the company feels is the way to deal with a violent patient.

> This way the employee understands when the company will stand

> behind you and when the company will stand behind you.

There needs to be a frank and open discussion between provider

safety, patient safety and the concept of abandonment. Additionally,

there needs to be a serious evaluation of the level of " public

safety " your organization provides, and in which modalities it

operates. In that regard, policy is key - having a clear, consistent

set of policies that set out the responsibilities of medical

providers with regards to safety will go a long way towards create a

sense of safety consciousness in medics. QA'ing calls for safety

issues can be very, very difficult because it's not often documented,

or correctly documented. Training, if any, must be tailored to the

expectations your organization has set forth for its providers - when

to intervene, how to intervene, when to disengage and call for backup.

If you look at law enforcement and use of force training, many things

are changing. Gone are the days when cops are taught to be the solo,

hard-charging butt-kicking folks they once were. Now officers are

encouraged to wait for backup (LAPD has a policy that officers will

not contact subjects when alone, LASD has a policy that prevents

officers from " splitting up " in foot chases to chase separate bad

guys, etc.) and slowly escalate use of force. As a result, violent

encounters seem to be RISING as the offenders understand that cops

are more on the defensive. " Hard-charging " cops are seen as

aggressive, now, rather than " just doing the job. "

EMS starts at a disadvantage in terms of this mindset - EMS providers

are almost assuredly seen as " defensive " - nobody expects EMS

providers to tackle fighting subjects and handle actively occurring

violence - but it's something that EMS providers do encounter. EMS's

core issue, however, seems to be " what now? " Most providers are

completely untrained to monitor situations for threats and changing

violent dynamics, and all too often end up running for cover when the

fit hits the shan - abandoning the person they were caring for until

the scene is made safe again.

There is no middle ground and no magic bullet (no pun intended) - but

there does seem to be an opportunity to educate EMS providers on the

dynamics of violent encounters and that would seem to include a basic

set of defensive strategies designed to protect the provider, protect

the patient and extricate all involved from a worsening situation.

> Leadership doesn't start in the middle it starts at the top.

I disagree. Leadership is cultivated from the bottom-up. If you're

not making leaders, you won't have leaders in the future. Leadership

must be a priority for all involved and must be ***demanded*** by

field-level providers, rather than accepting simple " management. "

Companies that have no leadership should have no employees... it's

that simple.

I am consistently amazed by medics who will work in POOR working

conditions and somehow rationalize it with terms of " it's not that

bad " or " it could be worse. " That's MANAGEMENT mentality - not

LEADERSHIP. And it's what we've told medics they're worth - it's

where we've allowed the expectations to be set. We all know them -

folks who work in conditions that shouldn't be tolerated or may be

illegal (OSHA violations, etc.) yet do whatever is asked of them just

to " keep a job. "

The " great " agencies out there have one thing in common -

leadership. They empower medics to make choices, back them up when

the do so within prescribed frameworks, and expect them to " learn

above, train below " when it comes to their job responsibilities. On

a personal note, this is why I'm so disappointed in Austin/

County EMS - they moved from " leadership " to " management " - ask any

medic who's been there more than 5 years about RMS and you'll get an

inkling of what I mean. It's also why I'm impressed with on

County - they promote a culture of leadership (and no, I don't have

an application pending with them - no sucking up). I've noticed that

most smaller services, ESPECIALLY fire-based ones, at least

understand leadership. Just ask Rinard, the NFA, etc. how many

hundreds of EMS providers are on their waiting list for EMS

leadership classes... I'll bet you get laughed at. I'll bet there's

no waiting list.

The poor agencies hand them a cookbook, don't have a set of policies

in place other than " show up in uniform and do what dispatch tells

you, " and expect medics to do nothing but " follow orders " from folks

who have no leadership training, skills or ability and instead are

relegated to " managing " those below them, often using punitive

" stats " and " write-ups " as the only form of on-the-job training,

counseling and education.

Mike

Danny L.

Owner/NREMT-P

PETSAR INC.

(Panhandle Emergency Training Services And Response)

Office

Fax