Q: What is your capacity and role at Brewster Ambulance right now?
JB: I'm 45 now, and I started with Brewster when I was 19. When I work clinically, I primarily work in Quincy as that's where I live. I do many other things in addition to my clinical responsibilities because I have other experience. I average about three to four shifts a month and I work in education. I am involved in Continuous Quality Improvement (CQI). I primarily focus on Middleboro and its contract as we are contractually obligated to provide CQI data and share it with the EMS committee. We work with a company that provides a computer algorithm to review cases. It will then queue me to say, "Hey take a look at this one." I review it, make notes, and go over it with the crews. If the crew does everything they should do, I don't see any notices. I participate in all of the new hire orientations and teach them hard equipment training, mechanical ventilation, the cardiac monitor and infusion pump. I have done extensive training and teaching on mechanical ventilation, so it’s a perfect fit for me.
For the last 17 years I've worked for New England Donor Services. I've been involved in the management of organ donors and assist the doctors in recovering the organs if necessary. That's my full time job, usually I work about 45-50 hours a week.
Q: what prompted you to pursue a career in EMS?
JB: Like many medics of my generation, watching the TV show Emergency. I tried traditional college for a year and decided to come home and then began my EMS career from there. I enrolled in the EMT and Paramedic program at Northeastern, finished in '93, and once I was credentialed I started working in Plymouth. The commute was far, so I worked in Weymouth for a few years and then I worked a combination of Boston and some Dedham. I also used to work on a non-transporting truck out of the old Hyde Park Avenue location where I was based for a number of years. I was with the company through the MedTrans buyout and then the transition to AMR. So I've known the family for 26 years. I started in March 1992 working as an EMT while I was in paramedic school.
Q: What changes have you noticed over the last three decades?
JB: We certainly have many more paramedics now than we did back in the day. The company is bigger now than it was back then, but there just weren't nearly as many medics. The City of Boston had two trucks on the overnight. Brewster had more ALS coverage in the Town of Weymouth than the City of Boston did, which is a little mind boggling. There were times when the City of Boston had staffing issues so they had someone call out, and we ended up covering half of the city in addition to all of the other things we were supposed to do, simply because there weren't that many medics back then. There were only three paramedic programs within driving distance: Northeastern, Cape and the Islands and Quinsigamond Community College. Those were the only options for medic training.
There was a huge influx of, "Hey, we need more medics and more medic training programs. More oversight and more accreditation in there." For example, I remember working with the Medical Director at Beth Israel Deaconess, where we had some requirements to get on the phone or radio within ten minutes of patient contact for ALS patients, regardless of whether we needed advice from them or not. So that has changed quite a bit. We went from standard limb leads to pacing capabilities to 12-lead capabilities. We added new medications and new treatment options. We also added CPAP—which has drastically changed—and how we take care of patients in heart failure.
It's funny because I remember working for George before and having a relationship with him. I haven't worked full time ins EMS since 1999, but when I came back to Brewster, it just felt like it was home—like I'd never left—even though the company has changed dramatically. Still a lot of the same people are involve, from Mark's father, George, his brother, George, and many others. There were a whole ton of people who were part of the original success who are currently here now in one capacity or another.
People don't realize that a lot of George's brothers were involved in the business back then, yet none of them are involved now. I remember working with his brother Richie, his brother Mike, and it was truly a family operation then; it began with his family before that, it's just moved a generation down.
Q: What are some of the things you are noticing about the new people coming into EMS field?
JB: I think that their education has changed, some for the better, some for the worse. They have some great online audio video displays, many of which were not available to me when I completed my training. I think that some of it in part is what society has created, where everybody gets a trophy and they don't know what it feels like it to fail. My philosophy when I'm teaching new people is that I want them to fail because they will learn from those experiences. Now, I will step in if I think that the patient's at risk, but if it's a minor thing that won't harm the patient, I want them to fail. They will never forget those things. I think of all of the learning that I had to do with a lot of on-the-job training I learned so much more from my failures than my successes. I want to let them fail so they can learn from it and it's how I build my training programs. It doesn't have to be a clinical matter. It could be how they interact with a family, a patient or fellow colleague when they're getting or giving a report. It's okay when they make a mistake. I see that as something I incorporate into a lot my training in a variety of ways. I know a lot of the things that are included in our expectation of the job, but none of those were included in my initial training. It's a little frustrating when they add expectations because they don't add educational arms to that. For example, we talk about the mechanical ventilation. I certainly didn't know anything about that when I was trained 25 years ago. I had to learn it. I've seen a lot of different iterations of the AHA programs from how we change resuscitation from CPR to ACLS and a lot of it has changed for the better.
So I try to take my other experiences and try to bring it back to current providers—the current generation of providers. I learned from every patient encounter and I want to impart that information to people and make them better providers, whether in the transfer environment or 911 work. Both of those patients are very important and it's odd to me when people avoid interfacility transfers on the paramedic side. Those patients are typically much sicker. Some of these people in the ICU or ER who are on two pressors, their oxygenation poor and you're managing how to sedate them without dropping their blood pressure—there are so many things and those patients are so much more complex.
A patient is a patient, whether they're in the hospital, they need to go to a teaching hospital or they are in their house; they are still a human being and still need care. I just wish there was more interest in trying to stay in that line of work. It's much more fascinating. I'd rather take care of a patient that's like that. I don't want people to not feel comfortable taking a shift because they don't have the training, because the company will support the training.
I'd love to take that training and make it more readily accessible. One of the things I'm doing is taking a major piece of the didactic training that I do and puttin it online so that everybody can do it whether they want to do it on their couch or in the ambulance at 3:00 AM in the morning so they can review the basics in the environment that's somewhat friendly and get people to be more comfortable about it.
When there's an opportunity for improvement we try to make it known, such as doing impromptu visits at a base with the mobile simulator unit. We have a portable environment to review stuff and give them an opportunity to learn, or on a one-to-one basis say, "Hey, this is what I had trouble with," and get them the specific help they need. It's a combination of challenging patients, equipment failure (which is rare) and operator error. Because if you haven't used a piece of equipment for six months, you're likely not going to be very good at it. If you haven't seen a person who is sick like this, needed this piece of equipment, or you haven't touched this thing in a year, there's no way you're going to be good at it. It's not fair to anyone, including yourself and the patient.
Q: Anything else you want to add about what's coming next for you?
JB: I'm still doing a lot of training stuff. I'm hoping to be closer to home as I've done a lot of national and a small amount of international travel for training, and I'm getting tired of airports, so maybe I'll have more time to do these things once I get closer to home. On average I work between 15-20 hours a week, and considering I don't have a lot of free time, it's a fair amount. I'm also doing some teaching for CMTI as well.
I'd love to see for additional relationships between the EMS folks and the hospitals to continually develop. There are more opportunities for paramedics to evolve as clinicians after they've completed their training and to open up new ideas and new responsibilities, whether it's a trial with a new piece of equipment or relationship building. I would love to see some skill maintenance by crews getting in the operating room on an annual basis, to work with anesthesia to provide airways, to get into the catheterization lab so they can learn more about different interventions that are available to patients who have cardiac events. We've had some interactions with new procedures to take care of stroke patients with the folks at Boston Medical Center. I think those relationships are huge and I'd like to see those developed even further. There are a lot of smart people out there. If we could use those relationships, leverage them to help the delivery and service to the community, it would be amazing.
Some of the new procedures available are cutting edge, like removing a stroke from someone's brain in 30 minutes—they go from surgery to home in a week with little impairment. We need to know about these new options as they become available, and leverage those relationships so we learn which facilities are the best places to bring those patients. All of these hospitals are competing for patients by specialization, so it's important to know the best options of where to bring a patient. It's giving them more options because we know more about which hospital is excelling at a particular treatment or protocol. It would set Brewster Ambulance even further apart from any other provider. It'd be great to see, to have more opportunities to cultivate those relationships and even better care to patients.