Today’s guest post comes from a connoisseur of fine motorsports and prehospital care: Ryan Ziegler (@momedic9019). He shares the struggles and roadblocks he has come across in trying to bring progress to his department–something I think the vast majority of us can relate to. It’s important to remember that you’re not alone in these struggles and this is really why we started EMSPOCUS– to support and connect those who want to provide the best patient care possible. Without further ado, Mr. Ziegler:
If you are like me and have been in the fire service long enough, you’ve probably come to understand, and perhaps embrace, the idea that change can be very hard, sometimes impossible. We often like to think we are all high performing services, the best of all worlds, with a “can do” attitude. But in reality, many of us are probably way behind the times. While emergency and critical care medicine utilize an evidence based approach, we still find ourselves citing the idea that, “that’s the stuff for the doctor to worry about” or “we’ve done it this way for a long time. It works, no need to change.” Sit around the firehouse table, and bring up the idea of something really on the bleeding edge of medicine, especially one that’s never seen the inside of a typical ambulance setting, and heads will explode.
You’ll likely be laughed at by the no-hair/ grey hair types, looked at strangely by some others, and possibly asked questions by the younger ones who are smart enough to know that this isn’t 1970’s and the days of “load and go, two amps of bicarb for all ditch medicine” are gone. Those are the ones to target when trying to bring a new concept to light.
For those of you reading this, you are likely aware of the FOAMed community. Those of us who are know of the late Dr. John Hinds. I’d known of him through Twitter, and related to his passion for motorsports medicine. He gave a groundbreaking talk during the opening plenary at SMACC Chicago. Go and familiarize yourself with Crack the Chest, Get Crucified, you’ll be left in stitches, and hopefully very inspired.
Though I only got time to share a small amount of conversation and one beer with him, I considered him to be a mentor, someone whom I long to be like. Not because of his celebrity FOAMed appeal, but because he had the foresight to see what he wanted through an acerbic wit to drive the point across. It just made you listen, think, and realize that he might not be wrong. His passion was magnetic; he made you a better clinician without trying. Within the aforementioned talk, he discussed four types of people you will come across when trying to push medicine ahead.
In my experience in trying to move my own system forward with simple things, I’ve absolutely encountered them. I’ve had some successes, but it’s been a tough go. This brings me to the real meat of this blog post. And the obvious reason you are here, if not just blind curiosity:
Prior to my time at SMACC Chicago, I never once considered the idea of POCUS with any seriousness. Early in my career, I’d worked at a local urban hospital, and had seen giant, clunky ultrasounds used by some ham-handed residents. Often this was done in vain attempts to place subclavian lines or IJ’s without any assistance from the attending, who was busy grinning in the corner as they made feeble attempts to identify the correct vessel on a murky screen. I never, ever considered this to be a skill I’d ever have in the back of a truck, let alone MY truck. Hell, I’d never even thought there would be a useful need for one. I’m great at IV’s, have sound clinical judgment skills to know why my patient is hypotensive, and when a pneumothorax needs to be decompressed. I based this all on my experience, and education from people who I assumed were knowledgeable enough to put us in a position to act decisively, and without question and not lead us down the wrong path. A number of years later I found myself in a position with a patient where I wasn’t sure if I was looking at PEA or a perfusing rhythm during a code. A quick call to our OLMC and a bolus of dopamine later, we had clear ROSC. It was at that point that I knew there was a better way. There had to be. Once again, I looked at the FOAM world to show me the way and I found it. Could we really be trained to do an ultrasound to evaluate the heart? I looked a number of videos, and it was clear to me that it wasn’t difficult. That’s about the time the FAST became mainstream… eventually I began to take some interest in what that would mean for our trauma patients, but still couldn’t fathom how we could fit a huge ultrasound into a truck, let alone train, afford, and maintain proficiency.
I was shocked that I’d somehow been unaware of this. Immediately, I began looking into how we, a small fire based EMS agency, could incorporate it into our daily work. Suddenly my eyes had been opened and a whole new world sat in front of me. And somehow, as I approached this subject with some of my crew, I was met smack dab with, “What? Ultrasound? We would never use that,” regardless of who I talked with. Some wanted to know what we would use it for, and after explaining, many would reply with, “Yeah, I guess, but it’s not going to change anything” or, “that’s not in our scope, we can’t diagnose anything in the field anyway…”
I walked away from all of these chats with an overwhelming feeling of despair and discouragement. Here I was with a tool that’d I’d now seen with my own eyes to help us make appropriate interventional decisions. Granted, I wasn’t delusional enough to believe that every single person in my department would look at it with the same fervor that I had. I began a conquest to put a proposal together to define pricing, use, and education. I spoke with reps from all of the major manufacturers. I quickly realized without a substantial buy-in and investment, there was no way to make this happen in a reasonable timeframe. We would need to show the benefit to the patient and our decision making process before I could even think about going to our city council to ask for $60,000 in capital investments. So, I decided to find the evidence showing the benefit to paramedic ultrasound…. I searched, and searched, and searched. Much to my chagrin, and having found the end of the internet no less than three times, I resigned myself to the fact that a sizeable volume of data and science simply didn’t exist. Sure, some places were using it, and since then, more agencies have added it to their toolbox, realizing that this has a huge benefit in destination determination and intervention timing. But the science was slow. I still didn’t have enough proof to push this forward.
A few years later I found myself in the middle of the vendor hall in at McCormick Place in Chicago at SMACC. Philips unveiled the Lumify– and there I found the silver bullet. An app based device. I quickly made a video of the device, it’s use and abilities. I sent it off to my medical director with a “Can we have FAST exams now?” It was about as snarky as I could get as I’d been pushing this for years. The idea blossomed, and we suddenly found ourselves in a position to write this into our operating budget, and have this fabulous ability. Now, I’m not paid by Philips and I have no skin in the game; I just like their product. It’s simple, and the little bit I played with it, it appeared that it was the perfect tool. Naturally, I was excited. At our first combined education session after SMACC, I sat and chatted with our medical director. He was interested to hear about it, but we had months to go before Philips released it. Lucky for me, and us, he had an opportunity to use it at NAEMSP. He saw the benefit, and he was hooked. We knew that through their subscription model, we’d likely be able to amortize that money over four or five years much easier than purchasing our own, and worrying about service, breakage, and general outdated behaviors that come with all new technology. Together, we proposed the idea, and we had it all but approved. Then we had to win over the masses.
Grand. Should be easy. It had taken me a bit so many years ago, but I was shown the way by smart educators in fireman friendly formats. Short quick bursts of education, with pictures.
We like to think we are all visual learners, but for me it was the easiest way to understand the concepts at hand with such an unfamiliar topic. There was little doubt that if a simpleton like me could get it, there was no way some of the geniuses I work with wouldn’t understand as well. I had hoped that my passion would carry over, and the open-minded co-workers I have would embrace it with the same passion…
I was wrong. Dead wrong. I found myself in a position where I was lambasted for trying to bring POCUS to my service. So many people who had heard we were getting it, or at least planning to instantly brought vitriol to me, in the typical, firehouse fashion. Every day I was met with, “Oh, I heard we are getting ultrasound; what the hell do we need that for?” I’d usually argue, citing PEA, vascular access in the typical Wisconsinite, and FAST/EFAST exams. I’d argue that knowing how to make the next choice in our care of the sick patient, the ability to determine why the patient is hypotensive, the ability to get an IV instead of defaulting for an IO, choosing the right destination for our trauma patients… It was all of the things that you’d want POCUS for, all sound reasons to consider if you are willing to embrace it. But, I was shot down, I was told that it doesn’t fit our scope, we don’t need it, and that it won’t make a difference.
I struggle to understand their reasoning. I struggle to understand why they would be so resistive to a tool that can actually make a difference. Month after month, I’d listen to the masses complain about “not knowing”… Or “how am I supposed to know that”… I’d begun to use these arguments as fuel, as an angle to show the non-believers how one simple tool, and knowing abnormal from normal suddenly gives them the power to know. But yet, these still didn’t go the way that I had hoped, sure, some became less of a skeptic, but, you could see that it still gave them enough pause to not take a genuine interest.
Was it me? Was I the problem? Maybe I wasn’t showing them the right stuff. Was it fear of a lawsuit that would likely never come? Or, perhaps, they just didn’t care, and would resist something they had no interest in.
Suddenly, I realized that this was more than likely the case and regardless of how enthusiastic I was, or how much I showed them the way, it wouldn’t change reality.
This is the roadblock almost every 911 agency will face when instituting ultrasound. The speed at which medical care, and subsequently, pre-hospital care, is moving is much faster than the average provider can keep up with. I’ve found that you have to be dedicated to stay on the leading edge. If you aren’t, you won’t be aware of what is going on, what is coming, and what we need to be doing. And getting folks to be aware that this isn’t just some fancy, on the bleeding edge, “let’s do this to be advanced type idea,” is tough. As I sit and write this, agency after agency is beginning to look at it, some are adding it, and have realized that it’s the next “big” thing in pre-hospital care.
Yes. Bigger than 12 leads. Bigger than capnography. Bigger than well…just about every major invention that’s found it’s way into pre-hospital care to date.
For me, I’ve given up trying to win the hearts and minds of everyone. I’m going to go for the sure thing, the low hanging fruit. Sure, it may seem to be the lazy way out, but, in reality, it’s likely the most effective. It’s a bit like guerrilla warfare. Turn one person, or two, or three… Eventually you end up with enough providers who embrace the ability to provide really good patient care and more will follow.
I think this is the only way to promote change in a system like mine. A system that is so very much like everyone around us. Change is hard, but when outcomes can be positively affected, it’s change we must strive for. It’s a skill that must be done in the field. Point of care ultrasound is an EMS skill. It needs to be part of our core competencies at every level.
At the end of the day, if you are here and you’ve read what I wrote, know that you aren’t alone. Take the passion you have to make care better and turn it into whatever you need it to be to ensure the highest quality of care you can bring your patient. Those around you are likely easier to mold than we assume.