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AMPA
The Power of Communication
As winter winds down, spring always feels like a time for new beginnings. Something about watching the first buds form on the tree, followed by the beautiful array of colors as blossoms come into full bloom stirs thoughts of anticipation about what opportunities lie waiting to be discovered. These opportunities may be found in your hometown or possibly in a new location. They may be professional or personal. Two common sayings—“Timing is everything” and “Location, location, location”—come to mind as I mention several upcoming opportunities to seek new beginnings or to challenge yourself to broaden your network of individuals with the common language of critical care transport by ground or air. Please mark these upcoming opportunities:
There are many factors with which a member (or non-member) bases a decision to join an association. Determining how many resources to place on areas such as advocacy, representation, knowledge transfer, business benefit, etc., is a significant challenge faced by any association leadership team. Developing a strategic plan that encompasses short and long term goals helps prioritize allocation of limited resources. As our community has grown, the list of initiatives has also grown.
A major resource that associations rely on is the work of volunteers and staff. Yet the committees, special interest groups, sections, and AAMS staff are struggling to find enough dedicated volunteers to help with the efforts identified by the membership as important. A call for volunteers goes out in every publication and verbally at every opportunity for face-to-face interaction. I wish I could find the magic formula that would bring in the amazing talent I know lies out there in the community.
One comment heard from time to time is “It's the old guard” making decisions for the community. Well, in a small way that might be true, partly because there are so few people willing to step up to the plate and get involved. This so-called “old guard” remains passionate about the community and the mission it serves. I have had the opportunity to meet many people around the world who share this same passion and who could make a huge difference on a national and international level in the many facets involved with the transport of the critically ill and/or injured patients. Interested? Call AAMS at (703) 836-8732 or visit www.aams.org.
One of the objectives a good communicator has is to inspire people. This is a challenge the AAMS leadership faces with so few opportunities to meet face to face. All I can do is try the power of words, and that assumes people are actually reading the messages. We are all inundated on a daily basis with so much written communication; it is no surprise that we need to prioritize what to read. The membership tells us that we are still not reaching the masses necessary to make informed decisions about key drivers to move the association forward as our community evolves and grows. That tells me we have not exhausted all possible venues to reach you, which means the message to get involved is also not resonating loud and clear.
I am making a formal request to the membership to share ideas on alternative methods of communication that will meet your needs—not only to disseminate information but also to provide input to AAMS on a regular basis. In other words, we must find the ability to provide two-way communication in an accessible, intuitive, economical, and effective manner. These methods must also have the ability to reach the masses on a moment's notice to respond to potential advocacy issues that would benefit from a quick response. Please visit www.aams.org and send your suggestions to any board member or AAMS staff.
Let me share an example of communication challenges as I'm writing this column. The week after this column is due to the editor, a volunteer group representing the various membership segments will meet to address the evolving business models in today's and future transport programs. However, to meet the publishing deadline for the March/April issue, information from this task force cannot be shared in this format until almost 5 months after the fact. The importance of utilizing multiple forms of communication becomes obvious with this one example.
Please take another close look at your program's safety culture and make sure it incorporates the simple concept of the 3 Cs: communication, complacency, and consistency. Before losing her battle to cancer, Michelle North broke down the sequences leading to a fatal helicopter crash during one of her safety presentations and pointed out how a break in one of those three Cs almost always contributed to the crash.
An important project supported by a FARE grant has just kicked off, led by Dr. Ira Blumen, with participation from the professional associations, aviation operators, manufacturers, and regulatory agencies to perform a root cause analysis of over 100 crashes using NTSB reports. The team is working closely with representatives from the Joint Helicopter Safety Analysis and the Joint Helicopter Safety Implementation Teams and using their analysis tool to ensure consistency and accuracy in the findings. Through this research and analysis, concrete recommendations will be made for interventional strategies and recommendations to make the helicopter EMS community safer. Thank you, in advance, to the group of volunteers who will put in a significant amount of time and deliver an important contribution to achieve Vision Zero.
As we bring in a new season, please remember to take a moment to stop and appreciate the people in your life who help keep you grounded in what it truly important to your essence. We, of anyone, should abide by the saying “Life is short” as we have all seen, on one too many an occasion, someone's life cut short for reasons that make no sense. Sometimes we are given another chance to reevaluate our priorities after we have faced a close call. Stop, smell the roses, take in the sunrise or sunset, and let people know how important and special they are. Please do not take for granted that the opportunity will always be there.
Sandy Kinkade, President
AMPA
A Different Look at Medical Errors
First off, knowing that this Forum column will be published in March, I must remind you to consider attending two upcoming conferences sponsored by AMPA. First, the Critical Care Transport Medicine Conference in San Antonio, sponsored conjointly by AMPA, ASTNA and IAFP, will occur March 31-April 2, 2008. The 2008 CCTMC again promises to be an outstanding conference for the value, with numerous quality speakers from the sponsoring organizations. The final closing session of the 2008 CCTMC will be a lecture by Dr. Russell MacDonald titled Adverse Events & Errors—Using Evidence to Mitigate Risk. I have no specific knowledge what Dr. MacDonald is going to talk about, but I am looking forward to it, like most of us should be, in this continuous “Zero Error” goal that exists in medicine at this time.
The second conference is AIRMED 2008 in Prague from May 20-23, 2008, with AMPA and AAMS sponsoring a 1 day preconference. If you have the remotest possibility of attending this meeting, make it happen as it should be outstanding.
I recently read a book, How Doctors Think, by Jerome Groopman, an oncologist in Boston who has published several books in both the scientific and lay press. Groopman undertakes a formidable task: the analysis of thought processes that doctors use and the errors of thought that can create trouble for doctors and patients. In order to do this, he interviews and quotes many experts in epistemology and the psychology of thinking, as well as several subspecialties in medicine. Many of these opinions seem somewhat scattered and undeveloped, but their ideas do make sense, especially in the task of reaching a correct diagnosis for a specific patient. Groopman seems to believe the old adage: “The three essential components of correct treatment are diagnosis, diagnosis, and diagnosis.” As a result, this book focuses on how doctors think in making diagnoses and the mistakes we make in diagnosis, especially of rare disorders.
(Consistent with this view, malpractice insurance carrier data demonstrate the allegation of failure to or delay in diagnosis leads to the majority of malpractice claims in primary care and non-procedural specialties.)
Groopman tries to create taxonomy to classify physicians' mental errors. He does this by naming and discussing phenomena such as search satisfaction (the tendency to be satisfied with the first diagnosis that comes to mind—especially true for most of us who work in emergency medicine and critical care transport, where we have relatively little time with our patients and are expected to move quickly), the hazard of overvaluing algorithmic thinking over the more usual and often more successful pattern recognition, and the problems that he calls availability and anchoring: “Availability means the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind. ‘X's diagnosis of subclinical pneumonia was readily available to him because he had seen numerous cases of the infection over recent weeks.'” (We tend to re-diagnose what we have seen in the most recent past—e.g. influenza during the winter, viral gastroenteritis, etc.).
Anchoring is a “shortcut in thinking where a person doesn't consider multiple possibilities but quickly and firmly latches on to a single one, sure that he has thrown his anchor down just where he needs it to be. …your mind plays tricks on you—confirmation bias—because you see only the landmarks you expect to see and neglect those that should tell you that in fact you're still at sea. Your skewed reading of the map ‘confirms' your mistaken assumption that you have reached your destination.”
Now, what does this have to do with AMPA and our roles as medical directors of critical care transport systems? As I mentioned above, we all work in environments where we are expected to act quickly and get our patients from point A to point B efficiently and safely. The majority of our patients, whether they start at a pre-hospital scene or at a referring medical facility, have a presumed preliminary or known diagnosis. We all have treatment guidelines or protocols that, for the most part, need to start with an assumed diagnosis. We train our clinical crews to recognize certain signs and symptoms and then expect them to institute treatment algorithms that will hopefully benefit the patient. But (and I doubt I am the only medical director that has experienced this), sometimes our crews are led down a pathway because of an initial wrong diagnosis by someone else (many times a physician) and then enter and institute treatment modes for that diagnosis. This may continue once the patient arrives at the definitive care facility as the “anchoring” term describes above.
As we attempt to organize and author evidence-based guidelines and treatment algorithms for patients we encounter in the critical care transport arena, I feel we need to be careful that we don't further encourage “cookbook” medicine and be challenged with ways we can train our crews (and ourselves) that we can live with the uncertainty of a diagnosis not yet made but still respond to a patient's individual suffering and are satisfied with the care we give them. After practicing medicine for over 20 years, I still have some trouble telling a patient or their family I don't know what is going on with them. I think it has a lot to do with me knowing that they want a definitive answer and my ego being bruised that I don't know everything—but it is better than telling them something that they grasp on to and later is proven to be wrong.
Kurt Kroenke of the University of Indiana has been studying symptoms for the past 30 years and has told us that currently, in the best medical hands, for about 30% of the patients who present to doctors with symptoms, the diagnosis is never understood. Some of these patients simply get well before we can figure out what is wrong, many have functional illness, and some of them have diseases that have not yet been identified. (I am not sure I feel better or worse after I read this!)
While not a view espoused by most in the patient safety and quality of care arena (where it's believed that unexplained clinical variation leads to adverse outcomes), Groopman provocatively distrusts best practice guidelines, algorithms, and, in fact, evidence-based medicine as strategies that limit our thinking by leading us into premature and less creative diagnoses. He urges us to become more aware of our own mistakes and to know where we have erred in the past because that will most likely be where we will err again. He believes that it behooves each of us clinicians to know our weak spots and to watch carefully for them. A challenge for us, as medical directors, is how we teach this to our crews while also expecting them to follow our treatment guidelines and algorithms.
Groopman, in an epilogue, tells patients how to help their doctors think better and avoid errors. “The first detour away from a correct diagnosis is often caused by miscommunication.” Groopman suggests that the intelligent, helpful patient can ask, “What else could it be?” and “Is there anything that doesn't fit?” “Is it possible I have more than one problem?” In my experience, one of the most frequent complaints I get as a medical director is when one of my crewmembers “questions” a referring physician's or pre-hospital provider's opinion or recommendation. One way we can teach our crews to possibly overcome this is to ask the above questions as “intelligent, helpful clinical crewmembers” (hopefully in a non-confrontational, non-ego bruising manner).
Michael Brunko, President
ASTNA
Creatures of Habit
After another long cold winter, I'm excited that spring is just around the corner, bringing warmer and longer days. Spring brings us the opportunity to travel to beautiful San Antonio to attend the Critical Care Transport Medicine Conference (CCTMC). If you've never attended CCTMC before, I strongly encourage you to try and make it this year. For those who have attended before, I'm sure you will agree that CCTMC is an excellent clinical conference with a personal feel, and we hope to see you there again this year. CCTMC is sponsored conjointly by AMPA, ASTNA, and IAFP and will take place March 31-April 2, 2008.
For me personally, spring is my favorite time of the year. Watching the world come back to life and turn green makes me feel re-energized and hopeful. I especially enjoy watching the birds busily go about making their nests in anticipation of raising their young. Every year, a pair of robins start to build a nest on the light fixture above my back door. As much as I hate to do it, I have to tear the nest down in order to use my porch. Remorsefully, I take the nest down, all the while apologizing profusely to the birds as they sit in the tree squawking at me. If I don't cover the fixture, the birds will immediately start re-building the nest. They always end up making a new nest in the evergreen tree, and I wonder why they just don't start with the tree in the first place. They are certainly determined creatures of habit.
Just like those two robins, I think most of us are creatures of habit, which isn't always a good thing, especially in our line of work. Habit or complacency can cause us to take things for granted; accepting the day to day routine, unaware of some potential danger, defect, or the like. How do we prevent or minimize complacency? If I knew a sure-fire way to answer that, I could quit my day job!
THE AVIATORS' MODEL CODE OF CONDUCT (AMCC) reminds us “to prevent complacency, maintain constant situational awareness, adhere to checklists, conduct mental rehearsals, review accident and incident reports, conduct self-critiques, asking the question ‘what if?' and focus on improving your training regimen” (http://www.secureav.com/Comment-AMCC-III.c-Training.pdf). These recommendations certainly apply to our medical crews as well.
We've heard all this stuff before, but can you honestly say you have your head in the game 100% of the time? Do you always follow and adhere to those checklists? Do you maintain constant situational awareness, even when you are caring for a critically ill patient? Do you speak up when you get that feeling that something is not quite right? Is there a true safety culture at your program, starting from the top down? Does your program promote air medical resource management (AMRM), and if not, why? Does your program endorse and support the AAMS Vision Zero initiative (http://visionzero.aams.org)?
Last year, ASTNA asked its members to complete an online safety survey. Members were requested to complete questions that focused on safety trends, issues, and challenges facing transport nurses. The results will be presented at CCTMC by Michael Frakes, Kevin High, and Jackie Stocking. Stay tuned for more on this survey, but you may find the results unexpected and surprising.
As we go forward with this year, please make safe practices the top priority during every shift, every transport, every day and demand that your coworkers do the same. We have a duty to take care of ourselves and each other. Remember…it's better to be prepared a thousand times than to die once!
Karen Arndt, President
IAFP
A Day in the Life
The alarm goes off at 0430. Have to be at work at 0550 for the 0600 shift. Groan. At the gym by 0500 for a quick aerobic workout. The weight issue again, ugh. Rush home, shower, shave, and kiss the family goodbye. ALWAYS kiss and say goodbye—and most importantly, say, “I love you.”
Head for work thinking about daily duties. Idly and somewhat morbidly wonder if I will die today. Quickly banish that thought and say a small prayer as I arrive at the base. The South Texas morning is gorgeous. What a great day to fly!
Nightshift crewmembers are stumbling out of their bunks and grouse that they were up all night. “So what?” I tease. “I will be up all day.” Being in a pre-caffeinated state, they fail to find the humor in that. They quickly come around, though, and relay last night's calls—two trips to the border for cardiac patients, one GSW DOS, a multi-ship scene call for an MVC in the county, and a neonate team transport. They were busy.
My partner arrives, and we quickly fall into the daily duties. First things first—coffee, then narcotic count. Out to check the ship. Looks good. The day is rapidly warming up as we help the A&Ps wash the aircraft. Night shift obviously did not leave any live bugs in Texas last night!
We set off to complete other chores, but the standby tones sound for a county response, unknown trauma. We climb in the aircraft, power up, punch in the coordinates, and wait. And wait. Then we wait some more. Knowing the responding agency, we know that they have a good way to travel before getting on scene. A slight breeze gently rocks the aircraft, and I find myself nodding off when the “go” tones sound. The pilot fires up the aircraft, and we launch into the early morning sky. We all comment that we have the coolest job on earth.
As we arrive on scene, there is organized chaos. Infant CPR in progress. The baby has a large hematoma to the forehead, bruises in various stages of healing, and had “fallen” sometime around the time I was at the gym this morning. EMS has done a great job; they have a pulse back. We continue resuscitation and fly the baby to the trauma center. Grim faces take over care. Man, my job sucks.
The rest of the day is filled by calls. A man falls from the roof of a house trying to put up Christmas lights; a teen is hurt by driving too fast and blowing through a stop sign; a man with incredibly huge ST elevation in leads II III AVF walks into a local ER.
We are still writing charts when the night shift walks in and pays me back for abusing them this morning. We tease each other without mercy, but underneath it all is a true camaraderie. These are good people.
As I get home and hug my son tightly, I can hear my wife on the phone. She is an organ transplant coordinator, and she is making arrangements for the donation of the organs from the child we flew this morning. She will be up all night working the case. I tuck my son in bed with me this night and set the alarm for 0430.
Many of you have had similar days or even worse. There is great joy in what we do, intermingled with tragedy. We get busy with our daily lives and careers, and it is difficult to find time for anything else.
The IAFP board members are all working paramedics. They respond to calls, function in administrative roles, go to school, spend time with their families, and somehow still manage to find time to achieve greatness with their volunteer work. I am truly honored and humbled to work with these individuals.
Because we are all working paramedics, we know the challenges you face in your jobs on a daily basis and the challenges our industry faces. Our board represents you and our industry on a national level.
We have many exciting projects in the works to represent you on a national level. The National Paramedic Survey is one of many. Data obtained from this survey will be utilized to improve our industry. This project is a tremendous undertaking involving multiple organizations and individuals. Watch closely for results.
Come and see us at CCTMC in March. We will be actively working on many other projects—come see what we are doing for you. Take some time out from your busy schedule and meet your board. You will find many things in common with them.
We are in an extremely exciting time for the IAFP. 2008 and on will see continued growth for our organization. Come get involved and grow with us. Please contact us at www.flightparamedic.org or come see us at our booth at CCTMC.
Greg Winters, President
NEMSPA
Crystal Palace or House of Cards
Since the time man began to build shelters, references have been made to both a “house of cards” and to “crystal palaces.” What can we take from these references, and how can we use these lessons to improve our programs? Let's look at both structures and then closely examine our program to see which structure we work in.
A house of cards is a reference to a building that is thrown together with little regard to longevity, stability, or safety. Ancient cultures described this type of construction as being on shifting sand. The lack of a firm foundation allows the structure to shift and fall apart. These structures are relatively quickly erected and, on first sight, may be quite appealing. It is often hard to distinguish a house of cards from a crystal palace without doing some investigation.
Another adage that parallels this is, “The grass is always greener on the other side of the fence.” When we look at what someone else has, it may look better than what we have, but that doesn't mean we are seeing things as they truly are.
A crystal palace is the epitome of what is desirable. These are the best of the best and kept by royalty and the elite. The palace is erected on solid ground or bedrock so it is stable, safe, and protective. The entire structure is centered on quality.
You may be asking what this has to do with air medical services. Since 2000 there have been several companies profiled by news programs for financial scandals. Companies such as WorldCom and Enron were considered crystal palaces in the business world and thought to be above such scandal. These scandals rocked the communities around them and impacted thousands of lives. The scandals prompted the federal government to enact a special set of laws known as the Sarbanes-Oxley Act of 2000. These laws established a governance standard for publicly traded companies. While some companies within the air medical services are publicly traded, this is not the point I want to make here.
The point I wish to make is that governance is a part of what we do. The recent ordeal with operational control is an example of how we are held accountable for governance and how the FAA can and will enforce our requirements. Along with the rights we are given to conduct air medical operations, we have the responsibility to provide safe, efficient transport to those we serve. We are responsible for oversight of our programs, not just flight operations. This governance includes the safety programs we use to protect our employees, ranging from meeting OSHA requirements to developing our own aviation and ground safety programs. When we develop these programs, we need to develop quality programs on solid foundations so they withstand the test of time and meet the highest standard.
Once a quality program is established, it must be continually evaluated and perfected to meet the changing environment in which it is used. Constant attention must be paid to ensure our programs don't just look good, they actually work. If they don't, we have to establish ones that do. Without governance no crystal palaces can exist.
I remember two questions that were asked of the class when I attended the safety course. We were asked by the commander of the U.S. Army Safety Center, “If a unit does not have an accident, is it because it is a safe unit?” The second question was, “If a unit has an accident, does that establish the fact that the unit is unsafe or has no safety program?” Think hard about these questions and take those thoughts into account when you look at your programs. There are many tools available for anyone who wishes to develop positive quality programs. The SMS tool kit from the IHST is one of those tools. If you need help identifying tools or where to obtain them, ask questions.
NEMSPA is another resource. We welcome your questions and stand ready to assist. Don't simply mimic a program without close inspection. Don't model your program after one that ends up being a “house of cards” program. Sarbanes-Oxley rules were developed to protect the rights of shareholders and stakeholders. For most of us personal responsibility serves as our regulation; however, if we shirk this responsibility, it may not be long before there are laws enacted to protect us and those we interact with.
I urge each of you to examine your program and the governance of it. If upon close inspection you find a house of cards, consider upgrading, repairing, or completely rebuilding the palace you and your customers deserve.
Gary Sizemore, President
PII: S1067-991X(08)00005-9
doi:10.1016/j.amj.2008.01.002
