Author鈥檚 note: In my last column, I wrote about how one minor clinical mistake or misdiagnosis can lead to a bias cascade or compounding errors that result in a bad outcome for the patient. In this one, I鈥檒l talk about how a series of rationalizations of 鈥渢hat鈥檚 the way we do things here鈥� can lead to disastrous results for the EMS system.
鈥淭hat鈥檚 not how we do things here.鈥�
That objection was spoken by one of my paramedic students in a recent class. It wasn鈥檛 a challenge, merely a statement that he was unfamiliar with the concepts I was discussing. His entire concept of an EMS system was based upon his personal experience in a system that was dysfunctional on its best days, and hopelessly broken on every other day that ended in Y. Whether it was response time standards, unit hour utilization, QA/QI, continuing education, protocol development, standard of care or whatever, I got similar responses.
- 鈥淭hat鈥檚 not how we do things here.鈥�
- 鈥淭hat鈥檚 not in our protocols.鈥�
- 鈥淲e鈥檇 never get orders to do something like that.鈥�
- 鈥淲e don鈥檛 have that drug in our formulary.鈥�
- 鈥淭hat will never work at our agency.鈥�
It happened so often that I had to remind myself to stop saying, 鈥淚t doesn鈥檛 matter how screwed up things are here, this is a state exam you鈥檒l be taking, and for those of you who aspire to NREMT certification, you鈥檒l be tested on national standards, which are considerably higher than your state鈥檚.鈥�
I struggled at advocating treatment and performance standards to a class who grew up in a system when the performance standard was, 鈥淗ave a pulse and a patch, show up however you鈥檙e dressed and take the patient to the hospital.鈥�
Agents of change
One day in class, as I was explaining the actions and indications of inotropic drugs, a student raised his hand and said, 鈥淵eah, but we don鈥檛 carry dopamine or dobutamine. All we carry is norepinephrine. Why do we have to learn drugs we鈥檒l never carry?鈥�
My answer was, 鈥淛ust because they鈥檙e not in your protocol, doesn鈥檛 mean you shouldn鈥檛 know them. They鈥檙e on the state exam, and they鈥檙e useful drugs that you should know how to use.鈥�
鈥淓ven if they鈥檙e not in our protocol?鈥�
鈥渊别蝉.鈥�
鈥淚f they鈥檙e so good, why are they not in the protocol?鈥�
I had heard enough. I asked the entire class, 鈥淒o any of you ever wonder why your protocols are so restrictive and your drug formulary is so limited?鈥� I was met with shrugs and blank stares.
鈥淏ecause the medical directors who wrote those protocols think you鈥檙e too stupid to learn any more. And you have given them no reason to think otherwise.鈥�
I went on to point out that the average career span of an EMT is 5 years. In recent years, a majority of new EMTs leave the profession within 1 year, and if they can last longer than that, they could reshape the culture of their agencies.
鈥淚f all of you graduate, do you realize you will have more than doubled the number of paramedics in this region?鈥� I exhorted. 鈥淲ho else is better suited to be agents of change? Don鈥檛 be like the paramedics you鈥檝e seen, be better than that. Be the paramedics the next few cohorts can aspire to.鈥�
That got through to them. I abandoned the lesson plan at that point and we spent the next 2 hours discussing how their EMS system was broken and why, and what could be done to fix it. The only rule was, nobody could say, 鈥淭hat鈥檚 not how we do things.鈥�
Tolerance stacking
In the class, we had a student who held a PhD in an engineering discipline. I had him explain to the class the concept of 鈥渢olerance stacking.鈥�
He went on to explain that a single part of a machine could be technically within the maximum tolerances allowed for that part, but if other parts of the machine were similarly machined 鈥� within parameters but only just so 鈥� that eventually the combination of shoddy tolerances would make the entire machine fail.
I went on to explain the concept of 鈥渘ormalization of deviance,鈥� in that if you accept deviations from the standard often enough, that deviation becomes the new standard. I explained it a little more scatologically: 鈥淚f things are crappy long enough, people began to think that crappy is the way it鈥檚 supposed to be.鈥�
EMS has a critical staff shortage, so anyone that has a pulse and a patch can get a job.
Because the primary job qualification is now a pulse and a patch, poor performance is accepted as a cost of putting meat in the seat.
Since we鈥檙e hurting for people, minor deficiencies in performance and minor instances in misconduct get ignored as a cost of doing business. Employers become afraid to fire anyone for anything but the most egregious of offenses.
If you do fire someone, employers are reluctant to give bad references to other prospective employers because they misunderstand how much information they can share, and the bad employee gets a job at a new agency. The cycle continues in what respected EMS leader and advocate Job Politis calls 鈥渃ross-pollination of a**holes.鈥�
The minor deficiencies and mistakes become the new standard, and what was once considered a major mistake is now a relatively minor one.
The good employees at an agency, the ones who held themselves to a higher standard, see what is accepted now and ask themselves, 鈥淲hy do I bother if this is what earns a paycheck here? They gave this idiot a signing bonus, and I haven鈥檛 gotten a rise in 3 years.鈥�
So rather than bring the new employees up to their standards, they either leave or lower their standards to that of their less-dedicated peers.
Eventually, you wind up with an agency or entire system who has no idea what quality EMS looks like, and the members of it say things like, 鈥淭hat鈥檚 not how we do things here.鈥�
Tolerance stacking caused the system to fail.
Become the destination for new grads with talent
The process can be reversed. Instead of that signing bonus to fill an empty seat with the guy who has been fired from multiple other agencies, devote that money to pay raises to your best employees. Show them their efforts are not unappreciated.
They鈥檒l be happier and more loyal to your agency. They鈥檒l stick around longer. You may spend more money on overtime in the short term, but eventually you鈥檒l be able to fill those empty seats with the right people, not just the available ones.
Quicker than you鈥檇 think, your agency becomes the destination for new grads with talent; a place filled with happy and well-paid employees, fierce and passionate ambassadors of your way of doing things, where job openings are a coveted rarity.
Your agency becomes the place where everyone wants to go and siphons off all the best people from the agencies who didn鈥檛 have your foresight. Those agencies either improve their standards to remain competitive, or they fail. Eventually, the entire system grows around you to become the place where the best paramedics come instead of the system they flee.
Tighten your tolerances, and your machine will start working again.
