Administration and Leadership, Columns, Commentary

Lessons on Partnerships in EMS

Issue 2 and Volume 43.

Lessons on working together from a constant companion

I lost a great partner in December; perhaps the best I’ve ever worked with.

He was strong and smart; he was always ready and eager to go to work (early); he was a quick and eager learner; he loved being a mentor to others; he took pride in his appearance and uniform; he loved working with and calming the fears of children, the elderly and the infirm; he always followed orders and suggestions presented to him; and he performed in accordance with protocols and standard operating procedures. Most importantly, he was in constant sync with me—mentally, visually and audibly. He knew from a look or a hand signal exactly what equipment I needed him to retrieve, what I needed him to do, and where there was danger we needed to back away from.

The partner I lost was my 6 ½-year-old, loyal, well-trained, majestic, 130-lb. Bernese Mountain therapy dog Bernie. He was diagnosed with cancer in early December, and my wife and I made the decision to put him to sleep and send him to heaven because we didn’t want him to suffer for one minute.

It was one of the toughest decisions I’ve ever made in my life. I was devastated, and I probably will be forever.

During the first few days of my grief, I sat and reflected on all the good Bernie did while attached to my hip at visits with his squad of fellow therapy dogs at the San Diego Veterans Hospital.

He was a respected celebrity at the hospital and many other places he went with me, and he had few faults.

OK, so he peed on a hallway wall in the hospital twice. It was an action that, by rules of the Love on a Leash therapy dog training approach, required that Bernie and I leave the hospital immediately, so we both knew what “we” did wrong.

It was humiliating for me both times it happened. I may have been embarrassed, but as we exited the hospital, Bernie kept looking up at me as if to say, “What? I own that hallway and love walking down it every time we visit.”

Aside from those incidents, he was exceptional—so I gave him a pass and didn’t chastise him. I considered it my fault, not his. I was the trainer who failed to prepare him for those visits. From that point on, I restricted his fluid intake the morning we visited the hospital, and made sure I walked him several times before each visit, so his bladder was empty.

Bernie died too soon but, during my reflective period, I had time to think about all of the other great partners I’ve had during my 45 years as a paramedic. I wanted to share those thoughts with you here.

If you lead by example and mentor your assigned partner, you’ll find that they assimilate knowledge and begin to act as you do. Photo A.J. Heightman

Partners in EMS

I’ve had countless partners, not all equal and not all perfect. I worked in volunteer and paid systems and didn’t always have a choice of who my partner was.

Oddly, and perhaps not too wisely, EMS is a profession where most of us don’t get to request or bid for stations, districts or partners. In the fire service, it’s rare to find an engine or ladder company crew that hasn’t been working together as a coordinated team for years. This is the same in most aeromedical systems and law enforcement/tactical teams.

In EMS, where we often don’t know who our partner is until we arrive at work. We don’t really work with partners; rather, we work with associates—other individuals in our profession who have received similar training, but who we don’t truly know because we haven’t worked with them regularly.

Consistency is an important concept that we know is beneficial in cardiac arrest and trauma resuscitation. It’s also important in scene management and partner relationships. Consistent and repetitive experience with someone puts you in sync with them educationally, personally, mentally and physically.

It’s hard to keep in sync and know how a partner will react under stress, what their strengths and weaknesses are, whether they know how to master and assemble items in your ALS and airway kits, and whether they will have your back during a dangerous call, if you don’t really know them.

A Cohesive, Coordinated Relationship

The word partner in most EMS systems is a misnomer. The assignment of partners is often random; you’re not strategically matched or paired with someone. Merriam Webster’s definitions present a great perspective of what a true partner represents. A partner is:

>>One associated with another especially in an action;

>>Either of two persons who dance together;

>>One of two or more persons who play together in a game against an opposing side;

>>A person with whom one shares an intimate relationship;

>>A member of a partnership, especially in a business; and

>>One of the heavy timbers that strengthen a ship’s deck to support a mast.

I’ll use Bernie’s traits and training to illustrate how you can work in a more cohesive, coordinated manner with associates so they meet your expectations, understand your operating modes and, most importantly, keep you in sync and safe on calls. I believe it all starts with an awareness and basic knowledge of your colleagues.

Often you hear from others that “A.J. is a fast, careless driver” (true), or, “A.J. never misses an IV or ET tube insertion” (not true).

Their reputations (or warning signs) precede them and give you advanced knowledge of them. If you know their known or perceived strengths and, more importantly, weaknesses, you can work to adjust your relationship.

In some cases, your seniority, reputation and known strengths in EMS enable you to be the lead (Alpha) and exert your expectations.

In other cases, particularly where the person has an attitude or lack of respect for you, you can first try the soft approach and discuss the way you like to operate on calls and come to an operational agreement— before taking calls.

If that approach doesn’t work, it can make for a long shift (or career!)—unless you dig your heels in and insist that certain actions be taken on the way to a call, or after an uncoordinated call in a debrief discussion. (Never in front of a patient or their family!)

Most partner/crew interactions and expectations should occur at the start of a shift as you check out your units in advance of you first call.

As a volunteer paramedic, I covered every Sunday evening for my department and occasionally had a different driver or crew that signed up to be with me.

I set the tone by making sure everyone knew where all equipment, drugs, supplies and safety gear were located and who was assigned to do what on a call: Airway management, IV and drug set up, equipment retrieval, charting, etc.

Be Aware of Strengths & Weaknesses

In any system, particularly volunteer systems, there are newbies; strong EMTs; EMTs who can’t yet take the lead on calls; and trainees who are there to observe and learn.

You need to know who can lift, who can’t, who has a back problem, who can’t tolerate an SCBA mask, who’s allergic to cats (in case the patient has 10 of them in their home) and who gets motion sickness on long rides to a hospital in the confines of the patient compartment.

You then have to work with and mentor them all in a different manner. If you don’t, your stress level will increase and your effectiveness as a team will decrease.

Be Ready & Eager To Work

Whenever I asked Bernie if he was “ready to go to work,” he took on a new persona and went into work mode: Focused and professional in all respects. There was no playing or wandering.

You and your partner need to set the tone by arriving at work early, neatly dressed, and doing a proper debriefing with the crew that had your rig and response area the previous shift. It not only tells them you’re eager to go to work, it also shows that you’re eager to learn if there were any vehicle problems, system abusers or zones/streets/addresses that you need to watch out for.

Teach Your Partners

Your shifts will go more smoothly if you inject a little knowledge. Update or review a few clinical or operational tidbits with your partner or crew members.

For example, “Hey, did you hear about the positive results ‘A’ shift is having since we started using mechanical compression devices and head-up CPR? It’s really working.”

Or, on the way to a call at a known address, say: “I know this patient and she gets really upset if you talk down to her or invade her space.”

Lead by Example

EMS is a craft. You can teach your partners and associates how to master the craft when you lead by example. Many providers fail to realize or accept that we’re social workers and ambassadors. If you hold the hand of someone’s dying grandmother, or talk softly and sincerely to a frightened child, you’ll find that your partners will see the benefits to your approaches and use them in the future.

Follow Protocols & SOPs

Partners not only know their protocols and SOPs, but orchestrate and perform them in the proper order. In the old days, when calcium chloride was the last drug in my cardiac arrest protocol (used when all the other drugs and therapy was exhausted), I had all the fire and police first responders trained to go get the litter because we were done on scene and ready to move. As soon as they heard the words “calcium chloride,” they immediately knew how to react.

And, for processes to be effective, they need to be followed. Ignoring the delivery of consistent compressions during a code in favor or administering epi or placing an ET tube has been shown to reduce our effectiveness in resuscitating patients.

So, if you have a partner who won’t follow your lead or your agency’s protocols, and insists on doing it “the old way,” you need to have a polite, professional one-on-one with them to explain the new way and try to steer them in the right direction.

If that approach fails, it’s incumbent on you to bring their resistive attitude to your superiors. The life of a patient can be impacted, or lost, in the future.

Follow Directions

My partner Bernie was trained to respond to my voice and, more importantly, my eye and hand movements. I could walk him with one finger on his leash. He watched me and gauged my foot speed and direction, and turned when I did.

I could point to a down position and he would immediately stop what he was doing and lay down so a small child could pet him. I could wave my hand and he would go to a safe location in a patient’s room, stay away from hazards such as an escalator or open manhole cover, or retrieve an object I pointed to in a certain way.

These are essential traits for partners and associates to have.

When you find an oxygen tank left empty from a previous call and ask another crew member, “Please go get another O2 tank,”—and give a firm, distinctive look to that crew member—you shouldn’t have to answer why or explain the problem in front of a family member.

More importantly, when you’re at a domestic violence or assault call and you see a weapon on the table or a sense a potentially dangerous situation, you should immediately establish eye contact with your co-workers and alert your partner.

Mentor the Mentors

If you lead by example and mentor your partner, you’ll find that they assimilate knowledge and begin to act as you do. I learned from every one of my partners when I worked on a part-time basis with a small, elite group of paramedics in the very busy city of Allentown (Pa.) EMS system. Because there were so few of us and we ran non-stop on calls every shift, I knew their every mood, skill and expectation. I also learned their unique skills and techniques, approaches to patients and, their unique senses of humor.

I absorbed their best traits and was mentored by each of them. This approach is contagious, and can result in others learning from you down the road.

Conclusion

My beloved Bernie is gone from this earth, but his legacy and spirit live on because I raised my 2-year-old Bernese mountain dog Charlie alongside him. As a therapy dog in training, Charlie assimilated and picked up most of Bernie’s solid traits. He learned from him by example.

You can have a similar effect on your associates and partners by following what Bernie taught me, and allowed me to share with you.