Dealing With Downtime

How should EMS providers spend their downtime when not running calls?


      I should warn you that I find it hard to relax. Just ask my wife. She'll tell you that my idea of a vacation is a to-do list, a half-finished manuscript and wireless Internet. Now would be a good time to feel sorry for her.

   When I swapped my office for an ambulance in 1992, it felt good to get out from behind a desk (and even better to shed the suit and tie). No more factories to manage, budgets to balance or sales to solicit. My goal was to work in a hyperactive 9-1-1 system where I could run calls constantly.

   That didn't happen. After a few months in the field, I had a much more realistic view of EMS: many hours of downtime punctuated by moments of medical madness. I envied coworkers who had mastered the hurry-up-and-wait mentality.

   What do we do between calls? Not much, according to a 2008 EMS Magazine survey. Over half of the 211 respondents listed watching TV, snoozing or goofing off with coworkers as their favorite on-duty pastimes. Only one third of the participants claimed they often engaged in other work duties or training when idle.

   I've had partners who treated downtime as mini-vacations. They felt they were being paid to answer alarms, not wait for them. Each call was a discrete mini-shift; anything else was time off.

   Does it matter how we manage downtime? Yes, if we view our work as cyclical rather than as intermittent. On either side of emergent responses are preparatory and recovery phases that help us maintain a state of readiness. We can't control chief complaints, but we can take ownership of idle time and treat it as a strategic resource.

   Consider the following pre- and postcall activities.

VISUALIZE THIS

   Some aspects of EMS don't translate well in polite company. For example, I'm reluctant to characterize an unstable patient as "good practice" to anyone not in this business, and I'm not going to initiate dinnertime conversation about how the second cardiac arrest of the day usually runs more smoothly than the first. But really, rather than exhibiting apathy or cynicism, these remarks merely contend that prehospital skills are honed through practice.

   I won't waste your time by rehashing studies that correlate performance to experience. That's a tautology well within the realm of common sense. A much greater challenge is to determine how much practice is needed to maintain prehospital proficiency.

   An interesting example of such research is a 1998 Swiss study of anesthesiologists' endotracheal intubation performance. Eleven first-year residents needed an average of 57 attempts to achieve a 90% success rate. Even after 80 tries, two physicians still required assistance to correctly place a tube. In many EMS systems, ALS providers would wait a decade or more to gain that much experience.

   How frequently do you need to successfully intubate to maintain confidence and competence? What about other invasive and diagnostic procedures? Do you get enough reps on real patients in your EMS system? Does your agency offer supplementary training facilities and equipment?

   Suppose you want to work on your technical skills, but Resusci-Randy, Torso-Timmy, STEMI-Steve and all their synthetic soul mates are entombed in a locked (of course) training room. You could try to convince the new guy that a Jamshidi needle doesn't hurt much ... or you could consider a performance-enhancing technique known as mental simulation.

   Defined by social psychologists Shelley Taylor and Sherry Schneider as an "imitative mental representation of an event or series of events," mental simulation can be either a process- or outcome-driven game of "what if"--i.e., we can either visualize the steps needed to reach a certain goal, or imagine fulfilling that goal. Research shows the former is more effective, and that there's a link between imagery and performance.

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