Tuesday, March 22, 2011

Where's My Pizza?

It's 8:00pm, and you've just gotten home from a long day at work.  Add the commute, and you're exhausted.  You have no energy left to decide what to make for dinner, or to make it.  It's take-out again.  Fortunately, there's a place down the way that makes great pizza.

You call in your order, a large pie with pepperoni and mushrooms, and sit down to relax for a few minutes.

Sure enough, within a short period of time, you see the pizza delivery car pull into your driveway.  You go to the door, counting out the cash to pay him, anticipating the hot, melted cheesy goodness of your pizza.

But when you open the door, there he stands. With no pizza box.
"Hello," he says, with a smile on his face. "Did you order a pizza?"
"Yes," you tell him. "Where is it?"
"Oh. Sorry. I don't have your pizza. I'm just here to make sure you are the person who ordered it, and to get some information from you so that the correct pizza will be delivered. It should be here soon."

He asks for your name, your birthday, the correct address, what, exactly it was that you ordered.
While you answer him, puzzled about why he is even asking, you see several more cars pull up in front of your house.  People wearing the uniforms from the pizza place get out.  Some stand in the yard and talk to each other.  Others start to put out traffic cones, and direct traffic around the now crowded street.

None of them have your pizza.
You're getting hungrier.
And more confused,
And even angry, a bit.

But they all seem so nice, you don't want to complain.

Still. You ordered a pizza, and have every right to expect to get it!  You might order a dozen wings to go with that pizza, but you didn't order a dozen PEOPLE to show up all over your lawn!!

For a person who lives in a rural community that has an all-volunteer fire department that is also a non-transporting EMS agency, I think this scenario is very much like what it feels like sometimes.

When a person calls 911, what are they asking for?  What do they expect to get?
They expect an ambulance that will take them to the hospital.
But in a rural area, what do they often get?

Whatever they get, it isn't that.  It isn't what they think they ordered.

As much as we want to help people, and as good as we are at being EMTs, the flat out truth is this:
We don't have, and will NEVER have, what they asked for in the first place.
We are not an ambulance service.
We cannot take them to the hospital.

So, you might ask, and some people DO ask, why are we even there?!?

There are several reasons.

One is that sometimes, what people WANT, what they EXPECT, and what they NEED, might not be exactly the same thing.
They might want and expect to get a ride to the hospital.
But they might collapse and need CPR.

In that case, we aren't what they planned on, but we can provide, in a timely manner, what they actually need.
That one is pretty clear cut.

But what if it isn't that obvious?  What if it's a relatively minor thing, where what they need is to go see a doctor?  What, then?  Or what if it's a case where they believe that EMS is ONLY about a ride to the hospital, and don't know that we can begin treatment in the field for a wide variety of things?  Or what if all they really need IS a ride to the hospital?

Why ARE we there?!?

As a BLS, or ILS, first response agency, what can we provide to our patients, our customers, BETTER than the ALS ambulance that backs us up?  What can we do that makes it worth our being there?

I think there are several things, and I think we need to focus on being very, very good at those things.  For our patients, for ourselves, and for the ambulance crew.

A list, in no particular order.  I'm sure it is not all-inclusive.  It's just the things I've been thinking about lately.

1. A very quick response in a true emergency.  
What are the emergencies where a quick response matters?  Clearly, anytime there is CPR required.  Someone who is choking.  Serious bleeding.  And look- these are BLS things, yes?   Right in our skill set.  So what should we spend a lot of time practicing?  CPR. Bleeding control.  And more CPR.  Maybe we should consider taking advantage of the variety of tools out there that can improve CPR.  From simulation practice, to timers on scene.

2. We can gather information that will help the ALS crew do their jobs better and sometimes faster.  The more we know, and are able to communicate to the medics, the more quickly the patient can get what they wanted in the first place: on their way to the ER.  The better we take advantage of the time on scene before the ambulance arrives, the less time the ambulance needs to stay there. So we need to practice assessments, we need to practice taking vital signs, and we need to practice an excellent, clear and concise, transfer of care. This includes accurate, legible PCRs.

3. There may be things we can do to prepare the environment. Make sure the dog is in the back room. Clear a path to the patient.  Sometimes, clear a path to the house. Have someone direct the ambulance crew in to where we are.  And put things back where they were afterwards.  Some of this can be done by other fire department members, not just by the EMTs.

4. Once we have transferred care, we can become excellent assistants to the ALS crew.  We can help get the patient on the stretcher, help get the stretcher into the ambulance, carry bags, clean up any trash, collect up any used gear, etc.  Make sure everything that needs to go with the ambulance, does.  Let the medic focus on, and be in charge of,  the patient care.  For some reason I don't understand, some people seem to have a problem with an ALS crew "taking over patient care." Well, duh.  That's why they are there!

5. We can assist in the ambulance, if necessary, and we have any required training to do so.  This may include spiking the IV fluids, setting up for an IV, helping get the patient on the monitor, etc. Or it may be doing compressions all the way to the hospital. This means learning to become part of the ambulance crew, on the fly.  See #7, below.

6. We can be a familiar face to our patients- they are our friends and neighbors.  This may include going out into the community and making connections, so they meet us before they need us.  It includes remembering them if we see them more than once.  It includes treating them like friends and family, with care and consideration.  One of the MOST important things we can do, where we can really excel, is in this category.  We can establish a rapport, and let them know that we are there to care for them.  We also need to be sure they know, and can trust, that we will treat them with respect, and will not share their personal information with anyone.  This is important anywhere, and critical in a small town.  Some things are easier when we are people they know, and some things are harder- and we need to navigate both.

7. We can introduce them to the medic, by name, so it's not a total stranger suddenly taking over.  And we can reassure them by our words, attitudes and actions, that we believe the medic will take good care of them, that they will be in good hands.  This part includes creating relationships with the ALS providers, so that we DO believe in their quality of care, and CAN introduce them personally.  It also means that the medics need to be able to trust US, and they can't do that, if we never work with them, never ride with them, never talk to them outside of a call.

8. Even if we do all this, and do it impeccably, we still aren't what most patients expect. There is a role for public education about what EMS is about, what the different crews do, and why sometimes it seems like so many people show up at their door.  We used to have to do a lot of pub ed about this because our rescue vehicle was a recycled ambulance, so it looked just like one, and people were frequently confused about why TWO "ambulances" would show up, and why we wouldn't ever put them in ours.  I can't blame them.  It WAS confusing to someone who didn't know that we didn't all come from the same place. How would they know, if we don't tell them?

The reality is that way out here, when someone calls us, we are never going to have their "pizza."
We need to be sure that we can deliver something of value.
I want our customers to know that when they order a pizza, not only will they get an excellent pizza, but before they get it, someone will come and set the table, warm the breadsticks, and pour the wine.  I want them to feel like they are getting a four course meal, with an excellently trained, courteous and efficient wait staff, for the price of take out.
We might even wash the dishes afterwards.

Figuratively speaking, that is. :-)


  1. I loved this post! I work on a paid ALS ambulance as the basic and we run with non-transporting volunteer FDs. We get asked all the time why there are so many people on scene when "all I need is an ambulance." Sometimes the volunteer FDs really get in the way (especially when they don't want to hand off care of a BLS pt to me, since I am the same level of care), but they can also be great. My favorite company to run with is such because besides being competent, they always make sure to help us, carry our bags, open doors for us, not rush in when we arrive on scene at the same time to make pt contact first (even though they should handoff to us as soon as we get in, 10 sec later)...

  2. Being non-transporting has got to be rough. We transport BLS, and take along the medic if we need ALS level of care in our rig. Sometimes, we turn the whole job over to the ALS crew if we are running ragged, it is off hours whne we don't have a lot of people available (daytime work hours), or it is just best for the patient. Still, we too sometimes show up with what appears to be 'too much stuff' or too many people. We are getting better at this and trimming our responses through better training. However, a cardiac call still draws a lot of attention because working a code takes many hands and there is plenty to do.
    Somewhere in there is a balance between Public education and our own training and organization. Depending on your county (geography) you may also be dealing with response and travel times which can play a significant role in how you organize.
    Another good post!